PROPOSAL TITLE: Breast Surgery: ERAS for Same-Day Discharge for Mastectomies and Reduction Mammoplasties
PROJECT LEADS: Sarah Goldin, Annie Tang MD, Stephanie Chu, Aldea Meary-Miller
EXECUTIVE SPONSORS: Laurel Bray-Hanin, Laura Esserman MD MBA, Merisa Piper MD
ABSTRACT: Breast cancer is one of the leading cancer diagnoses in the US with an average lifetime risk of breast cancer of 12%.In 2019, the cost of breast cancer care comprised$21 billion with patient outof pocket costs amounting to$16.2 billion.1Same day discharge for mastectomies and reduction mammoplastiesprovides an opportunity to reduce health care costs for patients and mitigate unnecessary costs and resource usage in a healthcare system. Multiple studies confirm that same-day discharge following mastectomy improves patient satisfaction and conserves hospital resources with similar post-operative outcomes.2-8 Our proposal aims to implement a same-day mastectomy protocol that allowsappropriate patients to be discharged directly from the PACU, avoiding an overnight stay in the hospital.
TEAM: Annie Tang, MD- Breast Surgery Fellow;Sarah Goldin, BSN, BA, RN- Breast Surgery Practice Nurse;Aldea Meary-Miller, MBA, MPH, Breast Care Service Line Director; Stephanie Chu, MPA, BSN, RN, CCRN, NE-BC, Associate Director of Clinical Operations- Breast Care Center; Merisa Piper, MD, Assistant Professor, Plastic Surgery & Medical Director, Breast Plastic Surgery; Laura Esserman, MD, MBA, Alfred A. de Lorimier Endowed Chair in General Surgery, Director UCSF Breast Care Center
PROBLEM: Breast cancer is the leading cancer diagnosis in women and comprises a significant cost for both the patient and healthcare system. Our current practice is totransfer patients after mastectomy or reduction mammoplasty from the PACU to the acute care surgery floor for a 23-hour hold/overnight hospital stay. The proposed intervention would allow medically stable patients to be discharged directly home. It would also potentially reduce the risk of financial toxicity for patients by reducing out of pockets costs incurred by the inpatient hospital stay. This initiative is also critical to the successful launch of the three new UCSF ambulatory surgery centers opening in FY 2025.
Same-day discharge following mastectomy optimizes hospital resource allocation while maintaining patient safety and satisfaction. This shift in post-mastectomy care has been proven across multiple academic centers and offers UCSF the opportunity to improve our patient experience while maintaining patient satisfaction and psychological recovery.5, 9By replacing overnight stays with extended PACU observation and a focused shift in patient education, we anticipate that the number of hours spent in the hospital would significantly decrease, leading to an estimated cost reduction of 65%.5 Same-day discharge for mastectomies and reduction mammoplasty would reduce excess inpatient bed days, improve outpatient, inpatient, and perioperative clinical access, and reduce hospital acquired infections.
TARGET:Breast cancer comprisesa third of all invasive cancers for patients diagnosed in the Greater Bay Area and in California.12UCSF is a tertiary breast cancer center serving the Greater Bay Area, including additionalpatients in remote settings.The project's main target population is patients at high-risk or with breast cancer who undergo mastectomies and reduction mammoplasty and meet the eligibility criteria. In addition, this project would provide more equitablecare. Patients with Medicare and Medical are less likely to receive outpatient mastectomies and plastic reconstruction.13-14 UCSF provides care to patients with commercial, Medicaid, and Medicare. This would allow an opportunity to decrease the health disparities gap between various insurance types.(Table 1)
Beyond the primary audience, this project will benefit additional individuals at healthcare systems outside of UCSF. The lessons learned from this quality improvement initiative can provide a framework for other institutions to adapt same-day mastectomy discharge.As we initiate the same-day discharge protocol, we plan to evaluate the outcomes listed below. Appropriate patients would be identified in advance by their surgeons with the plan for same-day discharge included in their initial surgery planning consultation.
Table 1
Patient Type | COMMERCIAL | MEDI-CAL | MEDICARE | OTHER |
Inpatient | 64% | 26% | 9% | 0% |
Outpatient | 63% | 21% | 15% | 1% |
Grand Total | 63% | 22% | 14% | 1% |
Process Metrics:
Number of eligible patients following new pathway: Goal is 75% of eligible patients following the pathway by Q4 of FY25
Outcome Metrics:
Median patient length of stay (in hours)
Patient Satisfaction: survey
Unplanned 30-day readmissions
Post-operative 30-day complications
Contribution Margin Increase
Hospital Acquired Infection Rates
Eligibility Criteria for Same-Day Discharge:
Procedures: simple, unilateral, or bilateral mastectomies with tissue expander or direct-to-implant, unilateral, or bilateral reduction mammoplasties
Age < 75 years
ASA < 3
Lives within 2 hours of UCSF and 30 minutes from a local hospital
Strong home support, defined as a physically capable and willing support person
BMI < 35
No history of Obstructive Sleep Apnea
GAPS:Breast cancer was initially treated with a radical mastectomy with limited anesthesia and pain management. Improvements in anesthesia have led to reduced staysof 1-2 days.15 The opiate crisis has led to overtreating pain for patients, especially in the post-operative setting. After data emerged on the over prescribing of opiates and improved control of pain management with other opiate sparing agents, post-operative management of surgical patients has led to decreased inpatient stays and conversion of inpatient hospital admissions to outpatient surgeries. Barriers to same-day discharge for mastectomies and breast reconstruction include limited established protocols, hospital support, and limited data on outcomes comparing inpatient versus outpatient mastectomies and breast reconstruction. Provider fear of increased complications, including hematomas, and decreased patient satisfaction may also be barriers. Same day mastectomy is still not widely practiced within the US.Over the last few years, partially catalyzed by improvement in pain management and the COVID pandemic, some institutionshave initiated ERAS (enhanced recovery after surgery) with same-day discharge for mastectomies and breast reconstruction.Liposomalbupivacaine (Exparel) has been introducedin the perioperative setting as a long-acting non-opiate pain medication.16 Studies have shown that Exparelmay be given as a nerve block in patients who undergo breast reconstruction for improved pain control and to decrease opiate use and may be used as an adjunct for same day discharges.7, 17 It is currently unavailable at UCSF.Current studies comparing patients who complete same-day discharge to those with standard discharge (1-2 days) have shown no change in post-operative complications, patient satisfaction, or readmissions.2-8 More data and protocols can be further provided such that more institutions may adopt same-day mastectomy and breast reconstruction discharge.
INTERVENTION:Our Primary Goal is to direct discharge from PACU for appropriate patientsafter mastectomy or reduction mammoplasty. Changes in our current practice would also include shifts in pre- and post-op education (specifically for drain care), advanced prescription of post-op medications, and a post-op Day 1 Zoom appointment with one of the Breast Care Center nurses.
Potential Barriers
We anticipate that we will need to refine post op pain management; thus, we will add a Zoom appointment post-op day 1 to assess the patient’s pain
Patient preference- we will reframe how we communicate post op expectations, set up expectations in the initial surgery consultation, and establisha plan for safe discharge with the patient. We will also provide emotional and psychological support in the Zoom Appointment post-op day 1.
Resistance to culture change- We will educate all involved stakeholders on the expected benefits to the patient and the hospital system.
PACU staffing/bandwidth to educate more patients on JP drain care- We will collaborate with PACU leadership and supplant with more pre-op education up front. We will also provide patients with a teaching video for JP drain care.
We will ensure that all patients will have pectoralis blocks during the day of the procedure and that prescription pain meds will be given to patients in advance. We will conduct a trial of Exparel (IRB will be submitted) to assess if pain will be better controlled with less use of opiates.
Possible Adverse Outcomes:
Objective 1: Preoperative Preparation
Patient Selection: The surgeon will select patients based upon the procedure and patient criteria stated above.
The surgeon will introduce and discuss same-day discharge with the patient alongside preoperative discussion of risks, benefits, and expectations.
Patient Education
Pain education: post-operative medications will be reviewed with the patient, including multimodal pain medications with acetaminophen, gabapentin, ibuprofen, narcotics, and intraop nerve block.
Pain medications will be ordered prior to surgery for patients to pick up preoperatively
Drain education: we will create a video and new smartphrases that teach patients about drain care
Nurse Education: Drain management will be reviewed by the Breast Cancer Care Center nurses with the patient, alongside standard preoperativeeducationand confirmation of receipt of medications.
Objective 2: Intra-op Preparation
Anesthesia: we will work collaboratively with the Anesthesia Chief and team to devise appropriate intraoperative pain and nausea regimen
Pectoralis nerve blocks for all included patients
Trial of Exparel
Multimodal pain control with limit of opiates
Multiple antiemetic regimen
Objective 3: PACU Post-op Preparation
PACU: We will meet with the PACU Nurse manager to discussworkflow changes and drain teaching
Observation: 4-hour observation to ensure medical stability. We will reassess this timeframe periodically.
Drain teaching: PACU RN to review drain management with patient and caregiver.
Objective 4: Outpatient Post-op Preparation
Add Post-op Day 1 Follow-up: Breast Cancer Care Center RN Zoom appointment with patient
Continue Standard post-op follow-up with the breast surgical oncology and breast plastics team.
PROPOSED EHR MODIFICATIONS
Objective 1: Preoperative Preparation
Include post-operative medications in the EPIC preop smartset for mastectomies and reduction mammoplasty
Include note to start surgery prior to 11:00 am in preop smartsets for mastectomies and reduction mammoplasty
Change preoperative smartphrase to include drain education and pain education
ROIWe estimate this project to increase our contribution margin related to these surgeries by$281,710 in FY25 and by $375,612in FY26.Table twoshows the average contribution margin for inpatient vs outpatient breast reduction mammoplasty in FY23 covering all financials related to all activities for FY23 between inpatient and outpatientobtained from the EPSi database. The absolute contribution margin difference is $3,603. Currently, we do not have average contribution margin differences between inpatient and outpatient mastectomies. We anticipate that it would be similar to and, in fact, a likely more significant difference than reduction mammoplasties given greater resources and inpatient stays associated with mastectomies. From our database, we obtained the annual number of patients who would qualify for same day discharge given the criteria of procedure type, age, and BMI and reachedan estimate of 139 patients a year. We anticipate that the number of eligible patients will increase in FY25 as we are hiring an additional breast surgeon and an additional microvascular surgeon in FY25.Therefore, the number of eligible patients is likely andunderestimate. Table three illustrates the predicted increase in contribution margin of our proposal. For FY25, weanticipate a gradual accrual of patients participating in the program until a peak of 75%. We will have a goal of putting 75% of eligible patients on the new pathway.
Table 2
Patient Type | Cases | Average Contribution Margin |
Inpatient | 41 | -$781 |
Outpatient | 213 | $2,822 |
Table 3
| Q1 FY25 | Q2 FY25 | Q3 FY25 | Q4 FY25 | Q1 FY26 | Q2 FY26 | Q3 FY26 | Q4 FY26 |
Eligible Patients | 34.75 | 34.75 | 34.75 | 34.75 | 34.75 | 34.75 | 34.75 | 34.75 |
% Eligible Patients on Pathway | 30% | 50% | 70% | 75% | 75% | 75% | 75% | 75% |
Increase Contribution Margin from Pathway | $37,561 | $62,602 | $87,643 | $93,903 | $93,903 | $93,903 | $93,903 | $93,903 |
Total Eligible Patient Population (based on surgeries performed in calendar year 2023) | 139 |
Contribution Margin Difference for Inpatient vs Outpatient | $3,603 |
Contribution Margin Increase for FY25 | $281,710 |
Contribution Margin Increase for FY26 | $375,613 |
SUSTAINABILITY
The breast cancer group collaborative will hold meetings with the appropriate department lead managers prior to implementation to deliver proposed plans and adjust for any suggestions. After implementation of the ERAS protocol, we will begina rapid cycle-process improvement. We will have a designated team member to assess bimonthly progress and barriers and provide solutions in real-time.The breast cancer group collaborative will conduct monthly progress review meetings to discuss improvements or barriers and adjust as necessary. We will also conduct an annual assessment of outcome metrics. Once real-time patient level outcomes are available, we will review the data to identify and inform barriers on the macro and micro level. The Breast Care Center nurse manager will help coordinate patient navigation services. The surgery team will adjust patient and surgery criteria as appropriate in addition to prescribed post-operative pain medications. We will start conservatively and then periodically reassess the amount of time the patients need to stay for observation in the PACU, decreasing it if appropriate. This data will be reviewed with the surgery, perioperative nursing, and anesthesia staff to adjust any systemic barriers.As the protocol is refined, we will continue to educate oncoming staff including clinic nurses, surgeons, residents, fellows, perioperative nurses, and anesthesiologists.
BUDGET
