Transcript Title of Audit Author Date of presentation

Re-audit of Microvascular
Free Flap Monitoring
Head and Neck
Practice Development
Unit
Clinical Audit Department
November 2011
Aim
The aim of the audit is to assess whether a
reduction in flap monitoring intensity has
affected flap health.
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.
Standards

Local Trust Guidelines:
-Microvascular Free Flap Monitoring
Criteria
Criteria
All patients with a microvascular free flap should have 1
hourly monitoring for the first 48 hours.
Target
100%
Exception: Consultant request
There should be a further 4 hourly flap monitoring for the
next 120 hours.
100%
Exception: Consultant request
Following the above, there should be further flap monitoring
daily.
Exception: Consultant request
100%
Methodology

Data was collected via a case note review for
patients who had a free flap between 1st May 2009
and 31st 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.
Results
Demographics
Number of Patients
Male (26)
Female (14)
14
Overall (2009):
12
Mean - 65 yrs
10
8
2
2
4
0
Range - 40-92 yrs
4
6
2
Median - 63 yrs
6
7
5
7
5
Mean - 59 yrs
Range - 34-88 yrs
2
34-45
Overall (2008):
46-55
56-65
66-75
76+
Age (Years)
N40
Smoker
2008 (40)
2009 (40)
20
20
18
50%
Number of Patients
16
14
12
16
15
40%
38%
10
If smoker, how many
per day n16 (2009):
Range – 4 - 40
Mean - 18
12
30%
8
6
4
1
2
2%
8
8
20%
20%
Overall n20 (2008):
Range – 5 - 30
Mean - 15
0
Not Stated
Non-Smoker
Ex-Smoker
Current Smoker
N40
Alcohol
2008 (40)
2009 (40)
30
31
78%
25
Number of Patients
If drinker, how many
units per week n24
(2009):
24
20
60%
15
<20
=7
21-40
=7
>41
=8
Not stated = 2
10
5
0
9
4
4
10%
10%
Not Stated
23%
Non-Drinker
Overall n31 (2008):
3
5
<20
7%
12%
Ex-Drinker
Current Drinker
= 15
21-40
=7
>41
=9
N40
Donor site
2008 (40)
2009 (40)
23
Radial Forearm
10
ALT
Fibula
2
Scapula
2
Other 1
9
8
5
DCIA
19
1
If other, please state
where, n1:
Pectoralis Major
Not Stated 1
0
10
20
30
40
Number of Patients
* In 2009, 1 patient had a graft taken from the radial forearm and DCIA
N40
Flap monitoring per
protocol?
2009
2008
Yes, 36,
Yes, 35,
89%
87%
N/S, 1, 3%
No, 3, 8%
No, 5,
13%
N40
Flap monitoring per
protocol?
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 location
2008 (40)
2009 (40)
35
Oral
35
24
Blanchable
33
6
Muscle
External 2
4
3 1
Not Stated
0
10
20
30
40
50
60
70
Number of Patients
* In 2008, 30 patients had more than one flap location
* In 2009, 33 patients had more than one flap location
N40
Implantable doppler used?
2008 (40)
30
If yes, were was it
used n6 (2009):
32
80%
29
25
Number of Patients
2009 (40)
Artery
73%
=4
Not stated = 2
20
Overall n11 (2008):
15
Artery
10
5
=4
Artery & Vein = 1
11
Not recorded = 6
27%
2
6
5%
15%
0
Not Stated *
No
Yes
* In 2009, 1 patient had no information documented in the case notes so this question could not
be answered.
N40
External (hand held) doppler
used?
2009
2008
No, 34,
84%
No, 33,
82%
Yes, 7,
18%
Yes, 1,
3%
N/S, 5,
13%
N40
Flap monitored according to
guideline?
2008 (40)
2009 (40)
40
Number of Patients
35
If no, what was the change to
protocol?
39
98%
30
2009 (n13):
25
20
More frequent monitoring
=6
26
Less frequent monitoring
=3
65%
No flap monitoring charts
=1
Not stated
=3
15
10
5
0
13
1
1
2%
2%
Not Stated
2008 (n1)
33%
No
More frequent monitoring
=1
Yes
N40
At what stage did the
monitoring stop?
2008 (40)
2009 (40)
30
30
Number of Patients
25
75%
27
68%
20
15
10
5
0
9
6
23%
15%
Not Stated
1
3
3
7%
7%
1
2%
2%
3
4
4+
Number of Days
* In 2009, of those ‘not stated,’ 4 cases were due to missing charts or only 1 day was available in
the notes
N40
Were there any changes to
the flap
2008 (40)
2009 (40)
25
Number of Patients
20
15
23
17
13
10
10
8
5
3
0
Colour
Refill
3
Texture
3
Temperature
4
Implantable
Doppler
N40
Changes to flap
documented
In 2009, 17 patients had a change in flap colour. The results are below:
2008 (23)
2009 (17)
16
Number of Patients
14
12
16
14
10
8
6
6
4
4
2
5
4
2
2
0
<24
24-48
49-72
72>
1
Not Stated
Hours Post-Op
* In 2009, 4 patients had more than one colour change
* In 2008, 6 patients had more than one colour change
N40
Changes to flap
documented cont…
Change in Refill
Change in Texture
No. of
patients
(2009)
n3
No. of
patients
(2008)
n13
No. of
patients
(2009)
n3
No. of
patients
(2008)
n8
<24 hours
4
9
<24 hours
2
4
24-48 hours
-
1
24-48 hours
1
1
49-72 hours
-
-
49-72 hours
-
1
>72 hours
-
2
>72 hours
1
2
Not stated
-
1
* In 2009, 1 patient had more than one texture
change
Hours post-op
* In 2009, 1 patient had more than one refill
change
Hours post-op
N40
Changes to flap
documented cont…
Change in Temperature
Change in Implantable Doppler
No. of
patients
(2009)
n10
No. of
patients
(2008)
n3
<24 hours
6
3
24-48 hours
3
-
2008:
49-72 hours
-
-
4 patients had changes
>72 hours
-
-
<24 hours
=3
Not stated
2
-
72> hours
=1
Hours post-op
2009:
No patients had an implantable
doppler
* In 2009, 1 patient had more than one
temperature change
N40
Conclusions
1.
2.
3.
Lots of minor variations in colour ,
(temp) etc.
None of the variations linked to flap
failure during this audit.
Future audits need to make this more
statistically explicit.
Recommendations


Further audit of 40 retrospective free
flap patients.
Continuation of current practice.
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?
Action Plan
(from recommendations or discussion)
Changes in practice/ systems or protocols
Changes made 
Planned Changes 
1.
Re Audit 40 retrospective patients in 2012
2.
Discuss suggested changes to data capture with
H&N Directorate / Audit Department
Is there a need for a Re-audit 
Person
Responsible
Date to be
Implemented
H&N PDU
Sept 2012
H&N PDU
Sept 2012
if yes Date
of Re-audit //
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)
2. Factors that influence the outcome of salvage in free tissue transfer.
Brown JS, Devine JC, Magennis P, Sillifant P, Rogers SN, Vaughan ED.
3.Salvage outcomes of free tissue transfer in Liverpool: trends over 18 years (1992-2009).
Ho MW, Brown JS, Magennis P, Bekiroglu F, Rogers SN, Shaw RJ, Vaughan 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