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. Author manuscript; available in PMC: 2023 Aug 29.
Published in final edited form as: J Healthc Qual. 2022 Aug 29;44(6):354. doi: 10.1097/JHQ.0000000000000358

Optimizing Unilateral Deep Inferior Epigastric Perforator Flap Breast Reconstruction: A Quality Improvement Study

Carrie S Stern 1, Ethan L Plotsker 1, Jonas A Nelson 1, Evan Matros 1, Eleni Kalandranis 1, Dana Fatterusso 1, Colette Mooney 1, Yigu Chen 1, Jeena Velzen 1, Babak J Mehrara 1
PMCID: PMC9633393  NIHMSID: NIHMS1825830  PMID: 36036719

Abstract

Deep inferior epigastric perforator (DIEP) flap surgery commonly involves multiday hospitalization, although data suggest 95% of complications following unilateral DIEP flap breast reconstruction occur within the first 24 hours. The aim of this study was to decrease hospitalization time and optimize care of patients undergoing unilateral DIEP flap breast reconstruction. Our study followed Six Sigma’s DMAIC (define, measure, analyze, improve, control) framework. First, we delineated the stakeholders involved in the process and defined workgroups based on temporal relation to the operation. We measured performance according to project SMART (specific, measurable, achievable, relevant, timebound) goals and subsequently conducted an analysis of inefficiencies. We then created new interventions for quality improvement. Control will entail ongoing monitoring to ensure progress is sustained after study completion. Our interventions lasted 6 months and included 70 patients. By actively striving to advance patients through postoperative milestones during their inpatient stay and creating an outpatient nursing roadmap including aspects of inpatient care, we decreased median length of stay from 67.8 to 44.8 hours (p<0.001). After receiving nursing instruction, 77% of patients agreed they felt ready to be discharged. Our study suggests the DMAIC framework can decrease hospitalization time following DIEP surgery and spare resources for additional patients.

Keywords: DIEP, DMAIC, hospitalization time, quality improvement

INTRODUCTION

Following deep inferior epigastric perforator flap (DIEP) breast reconstruction, enhanced recovery after surgery (ERAS) interventions have been shown to significantly improve management of postoperative pain.1–7 ERAS standardized protocols are important because they decrease length of stay (LOS), thus reducing hospital costs and increasing patient access to complex procedures, including DIEP breast reconstruction.3,8,9 However, despite ERAS efforts to optimize care, there is still no consensus on the length of time that is required to monitor patients after microsurgical breast reconstruction. Historically, these patients were monitored as in-patients for 3–7 days to ensure timely return to the operating room (OR) in the event of a vascular complication.5,10 This timing was based on the observation that nearly all microsurgical thromboses occurred within 5 days of surgery. However, more recent unpublished data from our institution have shown that 95% of complications necessitating a return to the OR following unilateral DIEP flap breast reconstruction occur within 24 hours of surgery. Similarly, other centers have noted that for patients who do require return to the OR for vascular compromise, complications usually occur within the first 24 hours.11–13 The aim of this pilot study was to determine the feasibility of decreasing the LOS of this patient population to 48 hours, with a future goal of performing these procedures in an ambulatory setting with monitoring limited to 23 hours.

To achieve this aim, we used Six Sigma’s DMAIC (define, measure, analyze, improve, control) framework to cut inefficiencies and further optimize the processes that are currently effective.14,15 Using the DMAIC framework to look at performance measures is especially effective for evaluating quality improvement initiatives. Defined as standardized sets of observational methods to collect uniform data to track outcomes, performance measures can be used to identify which aspects of an intervention have the largest impact on hospital operations.16,17 DMAIC relies on stakeholders closest to the work so they can identify and solve the most pressing problems they encounter.18,19 By incorporating input from individuals across the care continuum, the intervention is more likely to succeed. We aimed for this enhanced communication across the care continuum and focus on improvement to yield shorter overall hospitalization times.

In this study, we recruited an array of hospital stakeholders to delineate inefficiencies in the unilateral DIEP flap breast reconstruction process. By following the individual steps outlined in the DMAIC model, we aimed to standardize and optimize the operative experience. Based on prior studies,11–13 we hypothesized that decreasing OR time and total LOS to 2 days would not adversely affect patient quality of care while concomitantly sparing resources for additional unilateral DIEP flap breast reconstructions. Overall, our quality improvement initiative to trim inefficiencies in the surgical process adheres to the tenets of quality improvement: increasing standardization, optimizing efficiency, and eliminating waste through key stakeholder involvement.

METHODS

SETTINGS & PARTICIPANTS

All patients consented for unilateral DIEP surgery were included in the study, which began in December of 2020. No formal IRB exemption was issued as this study classified as quality improvement rather than human subject research.

STEP 1: DEFINE

To deliver effective quality of care for patients undergoing unilateral DIEP flap breast reconstruction, it is imperative to understand structure dictates process, and process dictates outcome. Thus, in our study, we began by defining the structures at play in the hospital. This included defining the system-level steps involved in a unilateral DIEP flap reconstruction: the initial surgery clinic visit, time spent in the pre-surgical center (PSC), the intraoperative period, the post-anesthesia care unit (PACU), and subsequent inpatient stay.

Next, we defined the stakeholders whose input would be central to refining our quality improvement initiative. Key stakeholder groups were plastic surgeons, perioperative support services, OR nursing, PSC and PACU nursing, anesthesia services, hospital operations, inpatient nursing, outpatient nursing, rehabilitation services, case management, and pharmacy. These stakeholders would implement performance measures to assess whether our intervention was successful.

Two workgroups were defined to identify problems and were constructed based on the timeline of the reconstructive process: the intraoperative workgroup, which would streamline OR setup and procedure time, and the LOS reduction workgroup, which had a more perioperative focus and assisted with postoperative recovery.

STEP 2: MEASURE

The intraoperative workgroup measured various time segments -- namely toes-in to toes-out time, as well as time to anesthesia induction -- during the reconstructive process using several methods. These included observational studies, interviews with stakeholders, and process mapping around the surgical preparation process. Procedure variation and delays were analyzed with further observational studies, REDCap surveys capturing intraoperative timing, and a retrospective data query. Lastly, efficacy of surgical requirements was assessed via reviews of picklists and preference cards, which are tools surgeons can use to request certain pieces of surgical equipment.

We measured the success of our interventions according to clearly defined performance measures called SMART (specific, measurable, achievable, relevant, timebound) goals. These included improving OR access by decreasing total average breast free-flap setup and procedure time by 25%, as well as developing and implementing a pathway that reduces hospital stay from 3–4 days to 2 days for unilateral DIEP flap patients.

Lastly, to measure patient satisfaction, participants were given a patient satisfaction survey to rate whether they agreed or disagreed with the following sentiments on a 5-point Likert scale: 1) I feel ready to leave the hospital to continue my recovery, 2) the healthcare providers I saw before and after my surgery told me I’d be in the hospital for the same number of days, and 3) I am satisfied with the care I received before my surgery, the day of my surgery, and after my surgery.

ANALYZE, IMPROVE, CONTROL

Workgroups used data collected during the measurement process to analyze the root cause of inefficiencies throughout the surgical process.

Following analysis, new interventions were set into motion for quality improvement. A series of run charts were constructed to assess the efficacy of our efforts over time. Our SMART goals were used to quantify our success as well.

The control stage of our study entails ongoing monitoring to ensure that progress is sustained. We are actively monitoring order compliance, education delivery, patient experience, and our performance measures (such as LOS) over time following our interventions. We will continue to provide key stakeholders with feedback to ensure that new standards were met.

OTHER METRICS

In order to ensure the safety of our intervention, we captured the rate of complications after our intervention. We analyzed rates of cellulitis, wound dehiscence, and seroma pre-intervention and post-intervention.

RESULTS

70 patients were included in our new intervention to decrease hospitalization times, which lasted for a total of 6 months. Through measurement, stakeholders in the intraoperative workgroup collaborated to identify three key problems contributing to excess time spent in surgery. The first inefficiency discovered was a high variability of instruments picked for unilateral DIEP flap cases, adding to the complexity of procedure setup. Overall, analysis revealed that this variability was a direct result of outdated, customized picklists and fear of damaged microsurgical instruments. To address this, our steps toward improvement included eliminating the outdated picklists. We also instituted a standardized microsurgical tray for all free flaps, increased tray availability, and a service standard for picklist items. This standardized tray was designed to streamline surgery by incorporating surgeons’ consensus, thus reducing the number of instruments on the tray by removing rarely used instruments, avoiding opening of multiple trays, and having peel-packs available for commonly broken instruments, which previously would necessitate opening an entire new tray. Feedback reporting from OR nursing demonstrated that standardized tray decreased the learning curve for OR nurses to understand the DIEP procedure, helping them more effectively assist the surgeons in the OR.

Measurement through stakeholder interviews revealed a second problem: Surgeons, anesthesiologists, and other OR staff often thought of unilateral DIEP surgical cases as all-day cases. Analysis of their comments revealed that this was due to their prior experience with the surgery. This expectation of a long case was associated with extended surgical time, as medical staff would allot additional time for DIEP cases (later start time, longer to set up the room and prepare the patient) and consequently spend more time in the OR. Our improvement involved installing a poster in each plastic surgery OR to prompt a time goal for the end of the case.

The third problem was that data analysis showed anesthesia-related delays during clearance and during induction related to variability in anesthesia approach. To address this variability, we established an ERAS pathway with standardized anesthesia protocols that would be conducive to early mobility and pain control.

Our improvement protocol interventions did not help us achieve our SMART goal of decreasing average free flap setup and procedure time by 25%. Following standardization of tray instruments, operative time remained at its baseline of 7 hours and 48 minutes. Goal setting posters were associated with a mean decrease of 5 minutes spent in the OR. Overall, through stakeholder interviews, we noted a more collaborative, standardized and streamlined workflow conducive to enabling completion of more unilateral DIEP flap cases.

Stakeholders in the LOS workgroup, meanwhile, used measurement to identify several key problems contributing to increased stay: Clinical Information System (CIS) orders that were incongruent with our new protocols, outdated patient education protocols, and lack of caregiver engagement at preoperative visits. Analysis revealed that these issues were all remnants of perioperative processes that existed before our interventions and were likely amenable to optimization. Further analysis involved using nursing flowsheets to capture milestone completion (such as flap health checks, vital signs, and drain output) and identify which factors contributed to prolonged LOS. These flowsheets revealed several barriers to patient discharge after 2 days. The most common reason was not meeting adequate milestones for postoperative vital signs, followed by low activity status, inappropriate Jackson-Pratt drain output, and patient pain.

Our first improvement efforts to update the perioperative workflow and create a new ERAS protocol involved modification of CIS orders. These modifications included creating new orders for Foley discontinuation in the PACU, updated flap check cadence, and ambulation at postoperative day 0. While order compliance for early Foley removal in the PACU had fluctuated upon initiation of the new order set, we eventually achieved 100% compliance (Figure 1). Regarding total time spent in the PACU, a combination of early ambulation on postoperative day 0 and prompt Foley removal was associated with a slight decrease in PACU duration by 0.6 hours, or about 13%. Our second improvement effort involved aligning patient education with new LOS expectations. To do this, we identified protocols that were traditionally done in the inpatient process and incorporated them into a new outpatient nursing roadmap. Third, we expedited patient and caregiver engagement by inviting caregivers to the preoperative visit and educating them about proper outpatient care (Figure 2). Lastly, nursing flowsheets for milestone tracking documented specific barriers to discharging unilateral DIEP flap patients on postoperative day 2.

Figure 1:

Figure 1:

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New CIS order compliance results by week, shown in relation to foley catheter removal on postoperative day 0.

Figure 2:

Figure 2:

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An outpatient checklist for patients to track progress with their perioperative education and responsibilities.

Following the initiation of the revision of our nursing roadmaps protocol, marked effects were seen in overall measurements of LOS. Prior to ERAS initiation, the median and mean total LOS following unilateral DIEP flap reconstruction were 3 days and 2.9 days (SD = 0.41 days), respectively. Collaboration between PACU and inpatient nursing to expedite the care provided, as well as tracking key milestones in care, brought median and mean LOS down to 2 days and 2.1 days (SD = 0.36 days), respectively. Total LOS had decreased by 28% to 2 days (p<0.001) (Figure 3). Our final improvement metric was patient-reported outcomes (Figure 4). 77% of patients strongly agreed that they felt ready to continue their recovery at home by 48 hours. 62% of patients strongly agreed that the healthcare providers they saw before and after surgery told them they would be admitted in the hospital for the same number of days. 38% of patients strongly agreed that they were highly satisfied with their care following implementation.

Figure 3:

Figure 3:

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Median and mean total LOS times spent in the hospital following institution of an interdisciplinary ERAS protocol in December 2020. LOS decreased by 28% after ERAS institution. To the left of the black line indicates the pre-intervention period, and to the right of the black line indicates the post-intervention period.

Figure 4:

Figure 4:

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Patient satisfaction following interdisciplinary ERAS protocol initiation as measured by three questions using 5-point Likert scale.

Through our interventions we achieved our SMART goal of reducing postoperative LOS from 3–4 days to 2 days, with 85% of total patients being discharged on postoperative day 2. Safety achievements included zero adverse outcomes after discharge, such as readmission or return to the OR, as well as increased communication between outpatient, inpatient, and perioperative teams.

No patient experienced major adverse events when we decreased the hospital LOS from 3–4 days to 2 days. One patient experienced a hematoma requiring return to OR, but this was on postoperative day 0, and would not have been impacted by our earlier discharge. In terms of minor complication rates, the pre-intervention rate of cellulitis was 9.1%, compared to the post-intervention rate of 6.5%. The pre-intervention rate of wound dehiscence was 0.6% compared to the post-intervention rate of 2.17%. Additionally, the pre-intervention rate of seroma was 8.6% compared to the post-intervention rate of 0%. Given that we would be underpowered, we did not conduct statistical analyses on these complication rates. The patients who were kept after 2 days postoperatively all failed to meet their specific postoperative milestones, or experienced milestone regression.

LIMITATIONS

Study limitations include a relatively small sample size. Still, a strength of this study is that it identifies the most helpful aspects contributing to quality improvement after DIEP surgery, which can be challenging when outcomes are integrative and result from the combined effort of many different parties.

DISCUSSION

We found that an interdisciplinary ERAS protocol incorporating all stakeholders involved in unilateral DIEP flap reconstruction safely reduced LOS to 2 days after surgery. The most helpful interventions occurred postoperatively and included significant collaboration between PACU and inpatient nursing teams to advance patients along their care. Intraoperative interventions, while helpful in streamlining the operative process through uniform instruments, did not contribute to meeting our performance measure goal of decreasing total free flap setup and procedure time by 25%. After review, we concluded that operative time likely did not decrease because of the number of surgeons, fellows, and residents involved in each surgery, with multiple steps performed by different individuals.

Our results raise the question of why intraoperative measures did not result in meeting our SMART goal. We hypothesize that we did not meet our performance measures due to the variability innate to the OR, surgeons moving between multiple ORs, involvement of fellows and physician assistants, and surgeons’ dedication to teaching. Still, feedback from stakeholders about intraoperative interventions showed these efforts were useful for decreasing the learning curve for nurses to understand the procedure and decreasing OR burden for preparing for DIEP flap reconstruction cases, thus making it possible for us to do multiple cases in a single day, if required, and decreasing surgeon frustration due to lack of proper instruments or broken instruments.

In comparison with other studies that have aimed to decrease LOS following DIEP flap reconstruction, our study reduces LOS to a significantly greater degree, as we were successfully able to discharge patients at 48 hours rather than 72 hours or beyond.1,2,6 Further, our intervention specifically focused on collecting perspectives from stakeholders in DIEP breast reconstruction. Historically, after new quality improvement interventions, patients undergoing DIEP flap reconstruction were monitored as inpatients for 3–7 days to ensure timely return to the OR in the event of a vascular complication. 5,10 Here, we were able to reduce total LOS to 2 days without experiencing any additional adverse complications that might be secondary to the streamlined hospitalization experience.

To date, we have covered the define, measure, analysis, and improvement steps of the Six Sigma model. In the control stage, we will attempt to achieve continuous improvement. This will be done via six key areas of focus: 1) including bilateral free flaps in the pathway for reduced LOS, 2) further refining order sets and roadmaps for expansion, as needed, 3) automating nursing flowsheet milestone collections, 4) monitoring LOS to study possible reduction to under 23 hours, 5) integrating all free flaps patients into this quality improvement program, and 6) refining the ERAS anesthesia pathway. Other studies in plastic and reconstructive surgery have similarly utilized DMAIC, performance measures, and collaboration across stakeholders to enact change by leveraging unique observations from individuals involved in different aspects of care.20–24 Golshan et al.23 applied multidisciplinary thinking and DMAIC to breast reconstruction and found that they were able to achieve goals according to specific performance measures, showing how DMAIC is an effective tool to enact change in the timeline of breast reconstruction. Challenges to accomplishing this model include a need for strong organization of many moving parts that collaborate throughout the spectrum of a patient’s care.

Our work fits into the body of literature studying length of stay following DIEP reconstruction. A 2022 paper25 examining the effects of patient expectations found that patients who expected to have a shorter postoperative stay following microvascular reconstruction indeed had a shorter length of stay. These results are interesting in that they underscore the role of patient desires and thoughts on a post-surgical outcome. Even if patient expectations of a shorter stay were to contribute to the decreased LOS we observed in our study, our discussion of unchanged complication rates corroborates the objective safety and feasibility of our intervention. Given the data about the influence of patient expectations, it would be reasonable to predict that following a discharge in patients who expected a shorter LOS, most patients would be satisfied with their care. This aligns with the patient-reported outcomes discussed in this study, particularly question 3. In terms of the other patient-reported outcomes discussed, the 2022 study helps us rationalize why most patients might have felt ready for an early discharge: they expected the decreased stay and worked with their healthcare providers to advance along discharge milestones. Additionally, our data corroborating the safety of an early discharge following DIEP reconstruction aligns with research from a 2017 study with 14 patients, which suggested that a microfascial incision could be used when aiming for earlier discharge.26 Our results, meanwhile, involve unchanged surgical methodology, a higher sample size, and a focus on perioperative collaboration.

As our study and others have shown, DMAIC yields significant dividends. Our protocol adds to the reconstructive literature by describing a quality improvement system particular to DIEP flap reconstruction that promotes flap health by coordinating changes to outpatient and inpatient care.

CONCLUSIONS

We found DMAIC to be an effective quality improvement framework at our institution. Calling together all relevant stakeholders to identify inefficiencies in the system made our quality improvement process more powerful. This collaboration between plastic surgeons, nurses, and operative support services is conducive to identifying trends, which in turn are conducive to a data-focused approach to improving care. Overall, our study shows that DMAIC methodology and performance measures, combined with interdisciplinary collaboration, can be used to target systemic problems and inefficiencies in DIEP flap reconstruction, resulting in shorter LOS and resource sparing.

IMPLICATIONS

Our results fit into an ongoing discussion about healthcare resource utilization. Recent cost analyses of the different types of breast reconstruction concluded that autologous tissue usage incurred the highest cost to the healthcare system in the early stages after reconstruction.27,28 If we can successfully reduce LOS to 2 days for patients undergoing unilateral DIEP flap reconstruction, as demonstrated in this pilot study, we can avoid potentially unnecessary spending. Resources, such as beds and nursing staff, could then be spared for other patients undergoing unilateral DIEP flap reconstruction. Future research, as an extension of our “control” step within DMAIC, should aim to characterize whether our interdisciplinary program could be safely applied patients receiving bilateral DIEP flaps, which would similarly spare resources for additional patients. Additionally, future work should clarify why certain patients have longer LOS following DIEP flap reconstruction than others. Expansion and utilization of our pilot study framework could thus result in substantially greater patient capacity and a higher overall quality of care.

Conflicts of Interest and Source of Funding:

This research was funded in part through the NIH/NCI Cancer Center Support Grant P30 CA008748.

Biographies

Biographical Sketches

Carrie Stern, MD, is an Assistant Attending in the Plastic and Reconstructive Surgery Service At Memorial Sloan Kettering Cancer Center in New York, NY. She also serves as an Assistant Professor of Surgery at Weill Cornell Medical College. Her primary areas of research focus are clinical outcomes following breast reconstruction, the role of 3D imaging in plastic surgery, and quality improvement.

Ethan L. Plotsker, BA, is a clinical research fellow in the Plastic and Reconstructive Surgery Service at Memorial Sloan Kettering Cancer Center in New York, NY. His research interests include clinical outcomes following breast reconstruction.

Jonas A. Nelson, MD, MPH, is an Assistant Attending in the Plastic and Reconstructive Surgery Service At Memorial Sloan Kettering Cancer Center in New York, NY. He also serves as an Assistant Professor of Surgery at Weill Cornell Medical College. His primary areas of research focus are clinical outcomes following breast reconstruction, microsurgery, in plastic surgery, and quality improvement.

Evan Matros, MD, MPH, MMSc, is an Assistant Attending in the Plastic and Reconstructive Surgery Service At Memorial Sloan Kettering Cancer Center in New York, NY. His primary areas of research focus are healthcare disparities in reconstructive surgery and quality improvement.

Eleni Kalandranis, MSN, is a nurse leader at Memorial Sloan Kettering Cancer Center in New York, NY. She helped put many of the quality improvement initiatives described in this study into clinical practice.

Dana Fatterusso, BSN, is a nurse at Memorial Sloan Kettering Cancer Center in New York, NY. She helped put many of the quality improvement initiatives described in this study into clinical practice.

Colette Mooney, BSN, is a nurse at Memorial Sloan Kettering Cancer Center in New York, NY. She helped put many of the quality improvement initiatives described in this study into clinical practice.

Yigu Chen, MPH, is a senior process manager at Memorial Sloan Kettering Cancer Center in New York, NY. He helped put many of the quality improvement initiatives described in this study into clinical practice.

Jeena Velzen, PhD, is the group lead for Inpatient Care & Perioperative Services at Memorial Sloan Kettering Cancer Center in New York, NY. She also serves on the operational excellence branch of the hospital administration and clinical operations offices.

Babak J. Mehrara, is the chief of the Plastic and Reconstructive Surgery Service at Memorial Sloan Kettering Cancer Center in New York, NY. He maintains numerous leadership positions with groups including the American Society of Plastic Surgeons and The American College of Surgeons. His research interests include breast reconstruction, lymphedema, and quality improvement.

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