Association of a Lean Surgical Plan of the Day With Reduced Operating Room Time for Head and Neck Free Flap Reconstruction

Impact of Preoperative Multidisciplinary Conference on Head and Neck Reconstruction Outcomes

INTRODUCTION

Head and neck oncologic resections with microvascular reconstruction are lengthy and complex procedures with inefficiencies in the operating room (OR) associated with increased complications and higher costs. Multidisciplinary care has become increasingly used to provide improved care for complex patients; however, the potential role of this has not yet been studied in head and neck microvascular free flap procedures.

METHODS

Patients between 2016 and 2022 treated before and after implementation of the conference were included. Primary outcome was total procedure time (TPT). Demographics, operative details, and postoperative complications were also collected.

RESULTS

233 patients were included in the preconference group and 330 in the post-conference group. Preconference mean (SD) age was 61.6 (12) years versus 62.9 (12) years in the post-conference group. The post-conference group was associated with shorter mean (SD) TPT (629 [117] vs. 719 [134] minutes), less mean (SD) estimated blood loss (ESD) (230 [201] mL vs. 306 [211] mL), fewer prolonged lCU stays (>1 day), and fewer returns to the operating room (RTOR). The post-conference group was associated with TPT ≤9 h (p < 0.001) on multivariate analysis. Factors associated with TPT greater than 9 h include history of head and neck radiation (p = 0.003), bony reconstruction (p = 0.05), stage IVa (p = 0.009), and stage IVb cancer (p < 0.001).

CONCLUSIONS

Implementation of the multidisciplinary conference in head and neck surgery was associated with reduced TPT and reduced OR return. Our study suggests preoperative planning conferences may improve surgical efficiency and outcomes in head and neck oncologic resections with microvascular free flap reconstruction.

LEVEL OF EVIDENCE

3 Laryngoscope, 2024.

Less is more: Exploring neoadjuvant immunotherapy as a de-escalation strategy in head and neck squamous cell carcinoma treatment

Head and neck squamous cell carcinoma (HNSCC) constitutes a significant global cancer burden, given its high prevalence and associated mortality. Despite substantial progress in survival rates due to the enhanced multidisciplinary approach to treatment, these methods often lead to severe tissue damage, compromised function, and potential toxicity. Thus, there is an imperative need for novel, effective, and minimally damaging treatment modalities. Neoadjuvant treatment, an emerging therapeutic strategy, is designed to reduce tumor size and curtail distant metastasis prior to definitive intervention. Currently, neoadjuvant chemotherapy (NACT) has optimized the treatment approach for a subset of HNSCC patients, yet it has not produced a noticeable enhancement in overall survival (OS). In the contemporary cancer therapeutics landscape, immunotherapy is gaining traction at an accelerated pace. Notably, neoadjuvant immunotherapy (NAIT) has shown promising radiological and pathological responses, coupled with encouraging efficacy in several clinical trials. This potentially paves the way for a myriad of possibilities in treatment de-escalation of HNSCC, which warrants further exploration. This paper reviews the existing strategies and efficacies of neoadjuvant immune checkpoint inhibitors (ICIs), along with potential de-escalation strategies. Furthermore, the challenges encountered in the context of the de-escalation strategies of NAIT are explored. The aim is to inform future research directions that strive to improve the quality of life (QoL) for patients battling HNSCC.

Improving Operating Room Efficiency in Otolaryngology-Head and Neck Surgery: A Scoping Review

OBJECTIVE

One minute of operating room (OR) time costs $36 to 37. However, ORs are notoriously inefficient. There is growing literature on improving OR efficiency, but no formal review of this topic within otolaryngology has been performed. This study reviews and synthesizes the current literature on improving OR efficiency within otolaryngology.

DATA SOURCES

MEDLINE, EMBASE, Web of Science, CINAHL, Cochrane Library, preprints.org, and medRxiv were searched on November 4, 2022.

REVIEW METHODS

Published English studies were included if they reported on metrics for improving OR efficiency within otolaryngology. There were no publication date restrictions. Articles were screened by 2 reviewers. Preferred Reporting Items for Systematic Reviews and Meta-analysis reporting for scoping reviews was followed.

RESULTS

The search yielded 9316 no-duplicate articles; 129 articles were included. Most of the studies reported on head and neck procedures (n = 52/129). The main tactics included surgical considerations: hemostatic devices, techniques, and team/simultaneous approaches; anesthetic considerations: local anesthetic and laryngeal mask airways; procedure location considerations: procedures outside of the OR and remote technologies; standardization: equipment, checklists, and personnel; scheduling considerations: use of machine learning for booking, considering patient/surgeon factors, and utilizing dedicated OR time/multidisciplinary teams for on-call cases.

CONCLUSION

The current literature brings to attention numerous strategies for improving OR efficiency within otolaryngology. Applying these strategies and implementing novel techniques to manage surgical cases may assist in offloading overloaded health care systems and improving access to care while facilitating patient safety and outcomes. Anticipated barriers to implementation include resistance to change, funding, and the current strain on health care systems and providers.

Unveiling the Impact of Lean Leadership on Continuous Improvement Maturity: A Scoping Review

Purpose

Lean Management (LM) is a process improvement approach with growing interest from healthcare organizations. Obtaining a culture of continuous improvement is a primary objective of LM, and a culture of continuous improvement indicates a mature LM approach, and here leadership plays a central role. However, a comprehensive overview of leadership activities influencing LM maturity is lacking. This study aims to identify leadership activities associated with continuous improvement and, thus, LM, maturity.

Methods

Following the PRISMA guidelines, a scoping literature review of peer-reviewed articles was conducted in twenty healthcare management journals. The search provided 466 articles published up until 2023. During the selection process, 23 studies were included in the review. The leadership activities related to continuous improvement maturity were identified using the grounded theory approach and data coding.

Results

The analysis highlighted a total of 58 leadership activities distributed across nine themes of LM leadership. Next, analysing leadership activities concerning the different maturity levels revealed three maturity stages: beginner, intermediate, and expert. Based on the findings, we propose a framework that guides suitable leadership activities at the various stages of LM maturity. The framework provides leaders in healthcare with a practical overview of actions to facilitate the growth of the LM approach, and the related propositions offer academics a theoretical basis for future studies.

Conclusion

This review presents the first comprehensive overview of LM leadership activities in relation to continuous improvement and LM maturity. To enhance LM maturity, leaders are encouraged to consider their leadership style, (clinical) stakeholder involvement, alignment with the organizational strategy, and their role in promoting employee autonomy.

Team Consistency in Reducing Operative Time in Head and Neck Surgery with Microvascular Free Flap Reconstruction

OBJECTIVE(S)

To evaluate the impact of consistent surgical teams on procedure duration in head and neck free tissue transfer, and to evaluate the length of stay and readmission rates with consistent teams.

METHODS

A retrospective chart review of head and neck microvascular reconstruction by a single surgeon between August 2017 and November 2021 was performed. Procedure duration, wound complications, length of stay, and 30-day readmissions were analyzed. One circulating nurse (CN) and surgical technologist (ST) were considered "consistent" due to their prior work with the primary surgeon. All others were considered "ad hoc." Teams were "Consistent CN + ST," "Consistent ST," "Consistent CN," or "Ad hoc." Procedure duration between groups was compared via analysis of variance. Multivariate linear regression was performed to predict procedure duration.

RESULTS

A total of 135 patients were included. Age, sex, and American Society of Anesthesiologists status did not significantly differ across groups (p = 0.963; p = 0.467; p = 0.908, respectively). The mean procedure duration was 339.3 min and differed significantly across all groups (p = 0.006, Cohen d = 0.32). Compared to the Ad hoc group, consistent teams demonstrated significant reductions in mean procedure duration (Consistent CN + ST: 58.4 min, p = 0.001, Cohen d = 0.67; Consistent ST: 51.6 min, p = 0.013, Cohen d = 0.61; Consistent CN: 44.5 min, p = 0.031, Cohen d = 0.52). Controlling for other factors, the ad hoc team predicted increased procedure duration on multivariate analysis ( β 57.38, 19.92-94.85, p < 0.003). Wound complications, length of stay, and readmission rates did not differ significantly across groups (p = 0.940; p = 0.174; p = 0.935, respectively).

CONCLUSION

Consistent CN and ST improve operative efficiency in head and neck-free tissue transfer. Future studies may evaluate the impact of team consistency on complications, physician burnout, and health systems costs.

LEVEL OF EVIDENCE

3 Laryngoscope, 133:2154-2159, 2023.

Improving Quality and Value in Head and Neck Reconstruction

Multiple advances in surgical techniques, technology, and perioperative patient care have revolutionized head and neck reconstruction over the last 40 years. Concurrent with these advances, health systems, patients, and payers have become increasingly focused on value and quality, owing in part to rapidly increasing health care costs. However, there is no consensus on how to define value and quality in the realm of head and neck reconstruction. This review focuses on the past, present, and future of quality improvement efforts in head and neck reconstruction.

The Use of Dissemination and Implementation to Improve Multimodal Analgesia in Head and Neck Surgery

OBJECTIVES

To optimize the delivery of multimodal analgesia to patients undergoing major head and neck oncologic surgeries.

METHODS

Pilot study included patients enrolled to receive either scheduled acetaminophen and as-needed opioids (control group) or scheduled acetaminophen, gabapentin, ketorolac, and as-needed opioids (experimental group). RCT, a hybrid type 1 effectiveness-implementation pragmatic trial, was designed to test the effectiveness of the intervention. Arm A received scheduled acetaminophen and as-needed opioids. Arm B received scheduled gabapentin, ketorolac, a regional nerve block at the free tissue donor site, scheduled acetaminophen and as-needed opioids.

RESULTS

Pilot: Thirty-one patients undergoing major head and neck surgery were enrolled. Mean MMEs administered in control group (n = 15) was 251.60 mg (SD = 224.57 mg); mean MMEs in Experimental group (n = 16) was 195.78 mg (SD = 131.08 mg), p = 0.401. LOS was 8.0 days in control versus 7.0 days in experimental group (p = 0.054). RCT: Interim analysis for safety and futility was planned during trial's design after 30 patients (n = 14 Arm A, and n = 16 Arm B). Mean MMEs administered were 135.1 mg in Arm A, (SD = 86.0 mg) versus mean MME of 51.3 mg in Arm B (SD = 43.3 mg, (p < 0.05)). Given clear superiority results, the trial was prematurely terminated. Functional pain scores, LOS, and complications were similar between the arms (p > 0.05). Variability of mean MME was compared before and after implementation of the management protocols: SD in RCT#1 was 181.46 mg versus 124.6 mg in RCT#2.

CONCLUSION

Multimodal analgesia significantly reduced the need for opioids in patients undergoing major head and neck surgery.

LEVEL OF EVIDENCE

1, Randomized Clinical Trial Laryngoscope, 133:S1-S11, 2023.

Designing an evidence‐based free‐flap pathway in head and neck reconstruction

Background

The use of autologous free‐tissue transfer is an increasingly utilized tool in the ladder of reconstructive options to preserve and restore function in patients with head and neck cancer. This article focuses on the evidence surrounding perioperative care that optimizes surgical outcomes and describes one tertiary center's approach to standardized free‐flap care.

Data Sources

This article examines English literature from PubMed and offers expert opinion on perioperative free‐flap care for head and neck oncology.

Conclusion

Free‐flap reconstruction for head and neck cancer is a process that, while individualized for each patient, is best supported by a comprehensive and standardized care pathway. Surgical optimization begins in the preoperative phase and a thoughtful approach to intraprofessional communication and evidence‐based practice is rewarded with improved outcomes.

Efficiency of microvascular free flap reconstructive surgery: An observational study

OBJECTIVE

We aimed to assess operative workflow and efficiency in microvascular free flaps via a direct observational study based on Lean principles of quality improvement (QI).

METHODS

Observers monitored the workflow of twenty-three free flaps. Pre-operative preparation and surgical duration was recorded with supplemental data provided from our institution's surgical tracking database. Traffic patterns of operating room (OR) staff were documented as "entries" and "exits" from the OR and classified by role and the reason that the entry or exit was required. Patient data was obtained via chart review.

RESULTS

The mean surgical time was 9.0 h. Approximately 20% of OR time was dedicated to the pre-incision process, averaging 1.6 h per case. One third of entries and exits occurred during this period. In total, 180.2 surgical hours were observed during which 6215 "entries" and "exits" occurred. The mean number of entries and exits per case was 270; the most common reasons were supplies and communication. No association was observed between elapsed surgical time or total number of entries and exits with post-operative infection rates.

CONCLUSION

Comprehensive observational workflow studies of free flaps are challenging to execute due to lengthy procedure times. At our high-volume institution, a significant portion of OR time is devoted to the pre-incision period, largely due to inadequate supply availability and pre-operative communication. These findings will serve as a foundation for QI interventions at our institution, while our observational model provides a broadly applicable framework for assessing surgical efficiency.