title: Processes of care in autogenous breast reconstruction with pedicled TRAM flaps: expediting postoperative discharge in an ambulatory setting.
abstract: BACKGROUND
  A multidisciplinary patient care plan was developed to facilitate early discharge following autogenous breast reconstruction and included (1) preadmission patient education, (2) perioperative multimodal pain management, (3) intraoperative nerve blocks, and (4) postdischarge telephone advice. This study evaluated the success of this care plan in the first 18 months after its implementation.
  
  
  METHODS
  A retrospective cohort study of all consecutive women undergoing pedicled transverse rectus abdominis myocutaneous (TRAM) flap breast reconstruction (November of 2009 to May of 2011) was performed. The primary outcome was time to discharge; secondary outcomes included complications, readmission, and self-report pain at discharge. Predictors of discharge time were analyzed using stepwise multivariable regression modeling.
  
  
  RESULTS
  Ninety-one women (mean age, 50.0 ± 8.5 years) underwent pedicled TRAM flap reconstruction (76 percent unilateral and 81 percent delayed), with 77 percent receiving the intended multimodal analgesia protocol. Mean time to discharge was 38.7 ± 27.6 hours. Overall, 40 percent of patients were discharged within 24 hours, but successful early discharge increased significantly over the study period. Key predictors of shorter time to discharge were use of multimodal analgesia, lower American Society of Anesthesiologists class, and surgery more than 6 months after implementation of the care plan.
  
  
  CONCLUSIONS
  The authors' initial experience has supported the safety and feasibility of expedited discharge following pedicled TRAM flap breast reconstruction, with adherence to the authors' care plan improving steadily over the study period. Multimodal pain management proved a key modifiable factor in facilitating early discharge. A prospective study is currently underway to evaluate patient-reported quality of recovery following ambulatory surgery in this population.
authors.affiliation: Toronto, Ontario, Canada From the Division of Plastic and Reconstructive Surgery and the Department of Anesthesia, University of Toronto; and Women's College Hospital.
authors.forename: Kristen M
authors.initials: KM
authors.lastname: Davidge
authors.forename: Mitch
authors.initials: M
authors.lastname: Brown
authors.forename: Pamela
authors.initials: P
authors.lastname: Morgan
authors.forename: John L
authors.initials: JL
authors.lastname: Semple
mesh_terms: D000328:Adult; D000556:Ambulatory Surgical Procedures / Q000379:methods / Q000706:statistics & numerical data; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D007902:Length of Stay / Q000706:statistics & numerical data; D016462:Mammaplasty / Q000379:methods / Q000706:statistics & numerical data; D008875:Middle Aged; D015999:Multivariate Analysis; D010043:Outcome and Process Assessment, Health Care; D059408:Pain Management / Q000379:methods*; D010149:Postoperative Pain / Q000517:prevention & control*; D010351:Patient Discharge / Q000706:statistics & numerical data; D019990:Perioperative Care / Q000379:methods*; D012044:Regression Analysis; D012189:Retrospective Studies; D013524:Surgical Flaps