Patients can safely recover from mastectomy at home, according to two studies reported at the 2019 American Society of Breast Surgeons Annual Meeting.1,2 The studies examined outcomes after implementation of comprehensive postmastectomy surgical home recovery programs, showing that they significantly increased same-day discharge rates without compromising quality of life for patients.
[The increased rate of outpatient mastectomies as a result of a surgical home recovery program] reflects the tremendous satisfaction of all stakeholders in the program.— Brooke Vuong, MD, MHA
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Implementation of a surgical home recovery program after mastectomy—including bilateral procedures and implant-based reconstruction—increased the rate of outpatient mastectomies from 26% to 65% (P < .001) across 21 California hospitals, in an evaluation of 1,248 patients. Currently, more than 85% of women at these institutions undergo these procedures as outpatients, researchers from The Permanente Medical Group reported.1
“This increase reflects the tremendous satisfaction of all stakeholders in the program,” said Brooke Vuong, MD, MHA, of Kaiser Permanente South Sacramento Medical Center, who presented the study findings.
In 2017, The Permanente Medical Group initiated a mastectomy home recovery program with the goal of increasing home care and patient satisfaction. The key concepts involved consultation (patient selection, management of expectations, patient education), the operation of the program (enhanced recovery after surgery, anesthesia, discharge care plans), and recovery (drain care, pain management, follow-up calls and e-mails). The surgical home recovery programs involved the entire surgical team—from breast care coordinators to postanesthesia care unit recovery nurses, explained Dr. Vuong.
How the Program Works
Dr. Vuong described how the program works. “After their initial surgical consultation, patients have a visit with the breast care coordinator to discuss drain care (with links to videos) and the need for durable medical equipment. Their support system is evaluated, and most important, patients receive information for points of contact should they have any questions,” she said. “This teaching is done well before the day of surgery, so patients feel prepared, and the expectation that they will be going home is understood.”
Despite the increase in outpatient mastectomies and home recoveries, the study found no significant differences in emergency visits, reoperations, or readmissions. Patients who are considered to be at high risk or who lack adequate support at home are not considered to be candidates for home recovery, she added. “The consistent messaging, reassurance, and education by nurses in the postanesthesia care unit are also key elements,” she said.
Home Recovery Rate Jumps From 1% to 46%
In the second study, surgeons from the University of Calgary reported the results of a province-wide, 13-hospital quality improvement initiative supporting same-day surgery and home recovery as the standard of care for all patients undergoing mastectomy.2 The same-day surgery pathway was developed by the Cancer Strategic Clinical Network (CSCN) in response to a national performance review showing that just 1% of approximately 1,000 mastectomies per year in Alberta were performed as same-day surgery.
May Lynn Quan, MD, MSc, FRCSC
As described by May Lynn Quan, MD, MSc, FRCSC, of the University of Calgary and medical lead of the CSCN, a multitiered perioperative pathway was conceived. It encompassed targeted educational interventions for three main groups: surgeons/nurse navigators, perioperative nurses, and patients/caregivers across a variety of hospital and regional settings. The program was implemented to support patients throughout the surgical process, from the initial consultation to 30 days postoperatively. The educational program provided order set templates for surgeons, in-service teaching for clinic and perioperative nurses, and standard operating procedures for handling postoperative issues outside of emergency services. A patient education booklet, group teaching classes, and online resources were developed for patients and families.
Same-day discharge after mastectomy increased from 1% to 46% after implementation of the pathway. Patient-reported experiences were found to be favorable, with more than 90% saying they felt “excellent or good” with the plan to go home, with how to care for themselves at home, and with whom to contact should issues arise. A standardized questionnaire designed to measure the quality of recovery 1 week after surgery yielded an average score of 7.9 out of 10, said Dr. Quan.
“We found patients really wanted to go home following surgery…. Wound pain, shoulder movement, and some psychological healing have demonstrated superiority in a home environment. With proper education and support, many patients can recover [at home] and return to normal activities more quickly,” she commented. ■
DISCLOSURE: Drs. Vuong and Quan reported no conflicts of interest.
Jeffrey S. Falk, MD
Jeffrey S. Falk, MD, a surgical oncologist at the Ascension Saint John Hospital in Grosse Pointe Woods, Michigan, commented on these studies of same-day mastectomy and home recovery programs: “The impetus behind these two significant quality-improvement studies was to...!-->!-->