1. Re-audit of Microvascular Free Flap Monitoring Clinical Audit Department November 2011 Head and Neck Practice Development Unit

2. Aim The aim of the audit is to assess whether a reduction in flap monitoring intensity has affected flap health.

3. Objectives The objectives of the audit are to: assess compliance with the local Trust guidelines, assess flap health and flap failure rate, identify possible contributory factors to flap health, provide an evidence base for flap monitoring guidelines, provide yearly results for flap monitoring.

4. Standards Local Trust Guidelines: - Microvascular Free Flap Monitoring

5. Criteria CriteriaTarget All patients with a microvascular free flap should have 1 hourly monitoring for the first 48 hours. Exception: Consultant request 100% There should be a further 4 hourly flap monitoring for the next 120 hours. Exception: Consultant request 100% Following the above, there should be further flap monitoring daily. Exception: Consultant request 100%

6. Methodology Data was collected via a case note review for patients who had a free flap between 1 st May 2009 and 31 st December 2009. Patients were identified using the Head and Neck Oncology database. A total of 40 patients were included in the results. Results were compared to those of the previous audit carried out in 2008.

7. Results

8. Demographics N40 Overall (2009): Mean - 65 yrs Median - 63 yrs Range - 40-92 yrs Overall (2008): Mean - 59 yrs Range - 34-88 yrs

9. Smoker N40 If smoker, how many per day n16 (2009): Range – 4 - 40 Mean - 18 Overall n20 (2008): Range – 5 - 30 Mean - 15

10. Alcohol N40 If drinker, how many units per week n24 (2009): <20 = 7 21-40= 7 >41= 8 Not stated= 2 Overall n31 (2008): <20 = 15 21-40= 7 >41 = 9

11. Donor site N40 If other, please state where, n1: Pectoralis Major * In 2009, 1 patient had a graft taken from the radial forearm and DCIA

12. Flap monitoring per protocol? N40 20092008

13. For those who did not follow the protocol, what was in the case notes? 2009 (n3): Not completed for 5 hours Not requested in the case notes 1 proforma had no information stated 2008 (n5): Flap monitoring every hour for the next 24 hours Flap monitoring not to be done as instructed in the operation notes by the SpR 3 proformas had no information stated N40 Flap monitoring per protocol?

14. Flap location N40 * In 2008, 30 patients had more than one flap location * In 2009, 33 patients had more than one flap location

15. Implantable doppler used? N40 If yes, were was it used n6 (2009): Artery= 4 Not stated= 2 Overall n11 (2008): Artery = 4 Artery & Vein = 1 Not recorded = 6 * In 2009, 1 patient had no information documented in the case notes so this question could not be answered.

16. External (hand held) doppler used? N40 20092008

17. Flap monitored according to guideline? N40 If no, what was the change to protocol? 2009 (n13): More frequent monitoring = 6 Less frequent monitoring = 3 No flap monitoring charts = 1 Not stated = 3 2008 (n1) More frequent monitoring = 1

18. At what stage did the monitoring stop? N40 * In 2009, of those ‘not stated,’ 4 cases were due to missing charts or only 1 day was available in the notes

19. Were there any changes to the flap N40

20. Changes to flap documented N40 * In 2009, 4 patients had more than one colour change * In 2008, 6 patients had more than one colour change In 2009, 17 patients had a change in flap colour. The results are below:

21. Changes to flap documented cont… Hours post-op No. of patients (2009) n3 No. of patients (2008) n13 <24 hours 49 24-48 hours-1 49-72 hours-- >72 hours-2 Not stated-1 * In 2009, 1 patient had more than one refill change N40 Change in RefillChange in Texture Hours post-op No. of patients (2009) n3 No. of patients (2008) n8 <24 hours 24 24-48 hours11 49-72 hours-1 >72 hours12 * In 2009, 1 patient had more than one texture change

22. Changes to flap documented cont… Hours post-op No. of patients (2009) n10 No. of patients (2008) n3 <24 hours 63 24-48 hours3- 49-72 hours-- >72 hours-- Not stated2- * In 2009, 1 patient had more than one temperature change N40 Change in TemperatureChange in Implantable Doppler 2009: No patients had an implantable doppler 2008: 4 patients had changes <24 hours= 3 72> hours= 1

23. Conclusions 1. Lots of minor variations in colour, (temp) etc. 2. None of the variations linked to flap failure during this audit. 3. Future audits need to make this more statistically explicit.

24. Recommendations Further audit of 40 retrospective free flap patients. Continuation of current practice.

25. Discussion Links with H&N oncology database / current published evidence regarding flap survival rates at Aintree / nationally. Flap monitoring chart filing issues. Flap temp section? Daily flap check? Lifestyle data?

26. Action Plan (from recommendations or discussion) Is there a need for a Re-audit  if yes D ate of Re-audit  /  /  Changes in practice/ systems or protocols Changes made  Planned Changes  Person Responsible Date to be Implemented 1. Re Audit 40 retrospective patients in 2012 H&N PDUSept 2012 2. Discuss suggested changes to data capture with H&N Directorate / Audit Department H&N PDUSept 2012

27. References 1.Flap monitoring after head and neck reconstruction: evaluating an observation protocol J.C. Devine, L.A. Potter, P. Magennis, J.S. Brown, E.D. Vaughan Journal of Wound Care 10(1): 525 - 529 (Jan 2001)10(1) 2. Factors that influence the outcome of salvage in free tissue transfer. Brown JSBrown JS, Devine JC, Magennis P, Sillifant P, Rogers SN, Vaughan ED.Devine JCMagennis PSillifant PRogers SNVaughan ED 3.Salvage outcomes of free tissue transfer in Liverpool: trends over 18 years (1992-2009). Ho MWHo MW, Brown JS, Magennis P, Bekiroglu F, Rogers SN, Shaw RJ, Vaughan ED.Brown JSMagennis PBekiroglu FRogers SNShaw RJVaughan ED 4. Guidelines on Micro-vascular Free Flap Monitoring. 1st Edition Regional Maxillofacial Unit Aintree University Hospitals NHS Foundation Trust Lead author: Paul Banks, Deputy Ward Nurse Manager, Ward 29