The importance of ward-based education in the postoperative assessment of free flaps

Abstract

Background: Despite the theoretical and practical advantages of adjunct-based free flap failure detection, the introduction of ultrasonographic techniques has not changed free flap failures rates and their use remains secondary to clinical assessment. Our study aims to develop an educational framework to improve the confidence of nursing staff caring for free flaps, with an emphasis on early detection of flap failure, thereby improving postoperative outcomes. Methods: Nursing staff in intensive care units and surgical wards caring for free flaps completed standardised questionnaires either before or after an educational seminar detailing clinical and Doppler assessment of free flaps. Differences between cohorts were summarised descriptively with frequencies and percentages. Overall confidence scores for pre-education and post-education cohorts were compared. Results: Overall, 173 responses were collected. Most staff were from intensive care units (n = 114) and almost one-third completed surveys following the educational intervention (n = 51). Microsurgical ward staff had more experience in the postoperative care of free flaps than intensive care unit staff (29% vs 18% had experience caring for > 50 free flap cases). Confidence in assessing a free flap by clinical, implantable Doppler or external Doppler ultrasound was universally increased among ward staff compared to intensive care unit staff (p ≤ 0.007). Altogether, 51 per cent of intensive care unit staff had never identified a failing flap compared with 35 per cent of ward staff. Education increased confidence in managing and escalating failing flaps unanimously. Most failing flaps were identified by clinical assessment alone or combined with adjunct-based methods (94%). Conclusion: This study demonstrates that the provision of targeted education for nursing staff, both in intensive care units and on surgical wards, is useful for increasing confidence in the clinical assessment and early detection of free flap compromise. Increased confidence and improved clinical assessment may allow for early intervention and improved salvage rates for a threatened free flap, thereby improving patient outcomes.