ORIGINAL RESEARCH–FACIAL PLASTIC AND RECONSTRUCTIVE SURGERY Postoperative monitoring in free tissue transfer patients: Effective use of nursing and resident staff Ryan S. Jackson, MD, Ronald J. Walker, MD, Mark A. Varvares, MD, and Michael J. Odell, MD, Saint Louis, MO No sponsorships or competing interests have been disclosed for this article. ABSTRACT OBJECTIVES: To compare the outcomes of two different free flap monitoring protocols and determine whether nursing staff can safely and effectively monitor free flaps. STUDY DESIGN: Historical cohort study on all head and neck free tissue transfer patients from August 2003 to August 2007. SETTING: Tertiary care teaching institution. SUBJECTS AND METHODS: The patients were divided into two groups according to monitoring protocol. Group A (n = 49) had free flaps monitored primarily by resident physicians, while Group B patients (n = 45) were evaluated primarily by nursing staff. Demographic and outcomes data, including complications, reoperations, length of hospital stay, and flap viability, were then compared. RESULTS: Overall, 28 (57%) patients in Group A and 16 (37%) in Group B had at least one complication (P = 0.05). Only eight patients in each group had major complications. There were 25 (27%) patients who required further intervention in the operating room: 18 (37%) in Group A and seven (16%) in Group B (P = 0.03). Only 12 (13%) patients returned to the operating room for concerns of flap viability: seven from Group A and five from Group B. The median length of hospital stay was 11 days for both groups (P = 0.76). The flap success rate was 95 percent, with three failures in Group A and two in Group B (P = 0.72). CONCLUSIONS: A monitoring protocol utilizing trained nurs- ing staff has no detrimental effect on free tissue transfer outcomes. This may be used to optimize resident time within the current duty-hour restrictions. © 2009 American Academy of Otolaryngology–Head and Neck Surgery Foundation. All rights reserved. F ree tissue transfer (FTT) has become the standard of care for reconstruction of major defects in the head and neck. Surgeons with microvascular training are becoming commonplace in many tertiary otolaryngology departments. With increasing numbers of flap donor sites and improved microsurgical techniques, success rates are reported to be 95 percent or higher. 1,2 This impressive flap survival rate is due, in part, to the ability of current flap monitoring proto- cols, which allow for early intervention should the flap show signs of compromise. 3 Most complications are secondary to vessel thrombosis, and early detection has been proven to be of utmost impor- tance in restoring flap viability. 4 Therefore, it is essential to have an effective monitoring protocol in place to ensure early detection of flap compromise and allow appropriate and timely intervention. Determining flap viability is im- portant, and monitoring protocols vary widely. Despite this, success rates are not necessarily dependent on the specific- ity of monitoring protocols. 5 With the increased number of FTT operations comes an increased demand for monitoring of these patients. Resident physicians in academic settings often carry out this time- consuming task in whole or in part. In 2003, the Accredi- tation Council for Graduate Medical Education (ACGME) passed a mandate that limits residents’ duty hours to 80 hours per week, averaged over the course of four weeks. Changes in residency training programs have strategically included tracking resident work hours, the use of “home call,” and hiring new employees to share responsibilities. 6 Therefore, their time at the hospital has become even more valuable, thus making efficiency and the ability to prioritize a necessity such that the time actually spent at the hospital is high yield both clinically and educationally. In an effort to reduce low yield resident responsibilities, we sought to alter our flap monitoring protocol such that the intensive care unit (ICU) nursing staff performed the majority of routine monitoring procedures. The purpose of our study was to determine whether the change in monitoring protocol had an effect on overall flap outcomes and whether nursing staff can safely and effectively monitor free flaps. MATERIALS AND METHODS After appropriate approval by the Saint Louis University Biomedical Institutional Review Board Group #1, a histor- ical cohort study at a tertiary care residency training pro- gram was performed on all patients who underwent FTT for Received March 9, 2009; revised July 5, 2009; accepted July 22, 2009. Otolaryngology–Head and Neck Surgery (2009) 141, 621-625 0194-5998/$36.00 © 2009 American Academy of Otolaryngology–Head and Neck Surgery Foundation. All rights reserved. doi:10.1016/j.otohns.2009.07.008