AHNS029 - IMPLEMENTING A PREOPERATIVE QUALITY IMPROVEMENT PROTOCOL FOR GERIATRIC HEAD AND NECK CANCER PATIENTS RESULTS IN DECREASED UNPLANNED READMISSIONS
Resident physician UC Davis Department of Otolaryngology Sacramento, California
Background: Head and Neck cancer incidence is increasingly driven by cases diagnosed in the geriatric population. Geriatric patients are more susceptible to delirium, falls, and deconditioning in the post-operative period, resulting in greater functional decline, delayed recovery, and increased dependency. Increased length of stay, unplanned hospital readmission and increased dependency status burden the health care system. The American College of Surgeons released a Geriatric Surgery Verification Quality Improvement Program, but there are currently no guidelines specific to preoperative care of the geriatric head and neck cancer patient.
Methods: A quality improvement (QI) initiative was implemented for all head and neck cancer surgical patients on 10/01/2020 at a single tertiary care institution. Patients were selected into the QI initiative if over the age of 75 and undergoing surgery requiring greater than a 48-hour admission. This study assesses length of stay, unplanned 30-day readmission, and discharge location in patients who received this QI initiative (post-initiative group) compared to an age-matched historical cohort (pre-initiative group). In this QI initiative, all patients filled out a pre-operative modified geriatric assessment, and the patient and their identified caregiver received a personalized preoperative phone call explaining their upcoming surgery, inpatient stay, and post-operative expectations. A week prior to the patient’s planned surgery, a “Geriatric Email” was sent to the multidisciplinary inpatient team (nursing, phyisician and dietary teams) alerting them of the expected admission and pertinent information obtained in the pre-surgery assessment. Upon admission, a geriatric order set focused on tenants of geriatric health, such as: decreasing delirium events, nutrition supplementation and avoiding deconditioning was created for this QI initiative and exclusively utilized for these patients.
Results: 30 patients underwent the QI initiative between 10/01/2020 and 06/01/2021. There were no significant differences between the pre- and post-initiative groups’ demographic variables including age, gender, surgeon, primary site, cancer stage, radiation history, or free flap at time of surgery (Table 1). There was a significantly decreased rate of 30-day unplanned readmissions in the post-initiative (16.7 %) versus the pre-initiative (40.0%) cohort (p < 0.04). Discharge to home was improved in the post initiative group, with a higher rate of skilled nursing facility discharge in the pre-initiative group (26.7%) versus the post-initiative group (10.0 %) (Table 2). There was no significant difference in length of stay between the two cohorts. When the two groups were broken into upper and lower quartiles for length of stay, the upper quartile mean length of stay was 10 days verses the post-intervention group at 6 days (Table 3).
Conclusions: In the patients undergoing our novel geriatric protocol, we observed less 30-day readmissions and a higher percentage of patients discharging to home as opposed to a skilled nursing facility. This project highlights the value of careful preoperative planning in this venerable patient population and the importance of optimization of inpatient variables that can improve hospital stay and diminish the risk of delayed recovery from major head and neck surgery.