An innovative flap monitoring booklet and concerns escalation protocol: Converting flap observations into flap monitoring decisions.

Dear Sir,

The administrative burden of patient-care paperwork in the United Kingdom's National Health Service (NHS-UK) is ever increasing., It seems imperative that the various charts, forms and booklets are effective at what they are designed for, yet there is a dearth of evidence to suggest such evaluations have been performed. An example of this in Plastic Surgery is the flap observations sheet, which has a familiar appearance worldwide. Unfortunately, in our department we found that, on occasion, potentially salvageable flaps were simply observed to their detriment and even demise.

We investigated the potential reasons behind these failures to escalate flap concerns by asking Theatre Recovery, Intensive Care Unit and Plastic Surgery Ward nurses involved in flap monitoring to complete an evaluation questionnaire for the original flap observation sheet (OFOS). Thirty-four nurses completed the OFOS questionnaire. Concerns raised regarding the OFOS included lack of: empowerment to raise concerns; an escalation protocol; guidelines regarding duration to wait for an escalation response; ease of chart use; handover documentation between nursing shifts; overall satisfaction in the flap monitoring task. These were addressed through the development of a new and innovative flap monitoring booklet (FMB) and adjoined flap escalation protocol (FEP).

The new FMB-FEP comprises a front summary page that requests the patient's details, primary operation title, date of surgery, responsible consultant(s) name(s) and provides guidelines for frequency of monitoring, acceptable physiological parameters and expected length of stay in a temperature-controllable room. The second page (Figure 1) describes the FEP using an algorithmic flowchart and a Red-Amber-Green color scheme that is referred to if any flap problems or potential problems are diagnosed. The rest of the FMB is divided into seven postoperative days.

Figure 1

Top Left to Right: Flap escalation protocol (FEP) page (located on the inside front cover of the new flap monitoring booklet highlighting the system of raising concerns by nursing staff to the surgeon(s) responsible for the care of the patient, with associated acceptable time limits); Ward round benchmarking page – with completed clinical example (It is completed each morning by the doctor in charge of the ward round and communicates clearly what are considered acceptable perfusion characteristics for the flap, as “normal” or “acceptable” perfusion can change with postoperative flap acclimatisation). Bottom Left to Right: Dynamic flap monitoring page (an example, demonstrating recognition of a compromised flap, action taken, flap salvage and continuation of monitoring); Flap benchmarking/handover page – with completed clinical example (the final page of each 24 hour period and is utilised for when two responsible clinical staff handover a flap. This process brings into the open and documents those interpretational differences and encourages clear discussion of the perfusion status of a flap between members of the team at all levels, including nurses, training doctors and responsible consultants).

Each postoperative day comprises four pages. The first page requests the responsible doctor to document: 1) their opinion of the current status of the four flap clinical parameters, with the benchmark comparator being the flap donor site; 2) the clinical parameters that should be monitored through the course of the next 24 h; 3) the monitoring frequency; and 4) instructions for positioning of the flap and patient (Figure 1).

The second and third pages represent a 24-hour period of flap monitoring. These are divided, in the far-left column, into the following (Figure 1):

“Observe”: requesting observations of selectable and de-selectable parameters: recipient site, capillary refill, colour, turgor, temperature, handheld Doppler signal, implantable Doppler signal and dermal scratch bleeding;

“Decide”: requesting that a flap diagnosis be concluded from these observations, utilising a Red-Amber-Green color system: “acceptable perfusion”, “becoming congested (?)”, “worsening/definite venous congestion”, “inflow reducing (?)”, and “worsening/definite arterial problem”;

“Action”: requesting various possible interventions to be selected, and;

“Sign”: requesting the user's identifying initials.

Two time periods are identified per day mandating a patient-flap review that is either Senior-Trainee-led or Consultant-led along with the nurse in charge of the patient's care for that nursing shift.

The fourth page requests staff (nurses and/or doctors) to benchmark flap colour, capillary refill and turgor interpretations between the outgoing and incoming staff member at handovers and decide their individual clinical interpretation of whether the flap has concerning or acceptable clinical perfusion features (Figure 1).

The same evaluation questionnaire was used two years following the FMB-FEP introduction (completed by 26 nurses from the same three clinical areas), demonstrating significant improvements in satisfaction (p < 0.0001 in all domains) (Figure 2).

Figure 2

Results bar chart. Analysis of the Likert outcome scores against the individual questions asked of the nurses.

Nursing empowerment to raise their concerns is imperative. As the front-line staff in flap care, they are entrusted to alert the surgical team early enough to rescue a compromised flap. This point is compounded by the frequent off-site location of the senior plastic surgical team out-of-hours, resulting in a travel time delay.

Johnston et al. performed a systematic review looking at factors affecting failure to escalate care and rescue in surgery. They identified the key areas to address were recognition that there is a problem and communicating this effectively to the team. Furthermore, they recognized that hierarchical communication issues were a major cause of failure to escalate. This was corroborated as a major factor for delays in concerns escalation from the root cause investigations in our department.

The Royal College of Nursing guidelines for accountability and delegation also highlight the importance of the individual nurse not being pressured into making a standalone clinical judgment and the person should feel empowered to raise a clinical concern to the team. The FEP manages this hierarchical issue by introducing a mandatory and documented direct line to senior surgical staff when a concern has been raised. This provides an increased sense of responsibility for nurses to communicate their concern directly to the surgeon.

The FMB-FEP has been a welcomed, positive change in departmental practice that has improved morale and confidence amongst staff involved in flap monitoring. Furthermore, it has developed a new rapport between surgical and nursing staff, owing to the formalisation and documentation of flap handover as well as a clear protocol for front line flap monitoring nursing staff to escalate their concerns. Qualitative validation of it as a monitoring tool has been achieved through this study.

The FMB-FEP has enhanced the standard flap observation protocol into one of active monitoring, allowing early intervention through its innovations and improving communications between staff responsible for the care of these patients.