Download Quality-Based Procedures Clinical Handbook for Cancer Surgery

Quality-Based
Procedures Clinical
Handbook for Cancer
Surgery
Ministry of Health and Long-Term Care
January 2016
Version: January 12, 2015
Table of Contents
1.0
Purpose .......................................................................................................................... 3
2.0
Introduction ..................................................................................................................... 3
3.0
Cancer Surgery QBP .....................................................................................................10
4.0
Prostate Cancer Surgery ...............................................................................................15
5.0
Colorectal Cancer Surgery .............................................................................................22
6.0
Thyroid Cancer Surgery………………………………………………………………………..30
7.0
Breast Cancer Surgery ................................................................................ ………… 38
8.0
Implementation of best practices ...................................................................................... 57
9.0
What does it mean for multi-disciplinary teams? .............................................................. 58
10.0 Service capacity planning.................................................................................................. 59
11.0 Performance evaluation and feedback ............................................................................. 60
12.0 Cancer Surgery Quality Indicators .................................................................................... 64
13.0 Support for Change ........................................................................................................... 66
14.0 Frequently Asked Questions ............................................................................................. 67
15.0 Membership ....................................................................................................................... 68
Appendices ................................................................................................................................... 72
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Quality-Based Procedures Clinical Handbook:
Cancer Surgery
1.0 Purpose
This clinical handbook has been created to serve as a compendium of the evidencebased rationale and clinical consensus driving the development of the policy framework
and implementation approach for Cancer Surgery.
This document has been prepared for informational purposes only. This document
does not mandate health care providers to provide services in accordance with the
recommendations included herein. The recommendations included in this document
are not intended to take the place of the professional skill and judgment of health care
providers.
2.0 Introduction
Historically, a large portion of health service providers’ funding has been grounded on a
base annualized funding (global allocation), which is used to maintain day-to-day
operations, such as: staff wages & benefits; overheard costs and service/maintenance
contracts and new incremental funding, based on a funding formula, which takes into
account demographics and acuity: growth funding targeted at fastest growing
communities, hospital type (i.e. small/rural to cover service gaps, academic hospital
sites to cover higher cost and acuity).
There needs to be a move to better integrate and align funding mechanisms across
sectors to respond to volume and mix of services that meet population need through the
pathway of care for patients. By focusing on an enhanced alignment between high
quality patient care and funding, reductions in variation in practice across the province
can be achieved. The results of such reduction in practice variation facilitate the
adoption of best clinical evidence-informed practices, ensuring our patients receive the
right care, at the right place and at the right time.
In response to these fiscal challenges, as of April 1, 2012, the Ministry of Health and
Long-Term Care (ministry) has implemented Health System Funding Reform (HSFR).
3
Over the fiscal years 2012/13 to 2014/15, HSFR will shift much of Ontario’s health care
system funding for hospitals and Community Care Access Centres (CCACs) away from
the current global funding allocation towards paying for activity and patient outcomes, to
further support quality, efficiency and effectiveness in the health care system.
HSFR is predicated on the tenets of Ontario’s Action Plan for Health Care and is
aligned with the four core principles of the Excellent Care for All Act (ECFAA):
•
•
•
•
Care is organized around the person to support their health;
Quality and its continuous improvement is a critical goal across the health
system;
Quality of care is supported by the best evidence and standards of care; and
Payment, policy and planning support quality and efficient use of resources.
HSFR is comprised of three key components:
1. Organizational-Level funding, which will be allocated as base funding using the
Health Based Allocation Model (HBAM);
2. Quality-Based Procedure (QBP) funding, which will be allocated for targeted
clinical areas based on a “price x volume” approach premised on evidence-based
practices and clinical and administrative data; and
3. Global funding approach.
2.1 What are we moving towards?
Prior to the introduction of HSFR, a significant proportion of hospital funding was
allocated through a global funding approach, with specific funding for select provincial
programs, wait times services and other targeted activities. A global funding approach
may not account for complexity of patients, service levels and costs and may reduce
incentives to adopt best practices that result in improved patient outcomes in a costeffective manner.
Under HSFR, provider funding is based on: the types and quantities of patients
providers treat, the services they deliver, the quality of care delivered and patient
experience/ outcomes. Specifically, QBPs provide incentives to health care providers to
become more efficient and effective in their patient management by accepting and
adopting best practices that ensure Ontarians get the right care, at the right time and in
the right place.
The variations in patient care evident in the global funding approach warrant the move
towards a system where ‘money follows the patient” (Figure 1).
4
Internationally, similar models have been implemented since 1983. While Ontario is one
of the last leading jurisdictions to move down this path, this puts the province in a
unique position to learn from international best practices and pitfalls and create a
funding model that is best suited for the province.
Figure 1: The Ontario government is committed to moving towards patient-centred, evidenceinformed funding that reflects local population needs and incents delivery of high quality care
Current
Based on a lump sum, historical
funding
Fragmented system planning
Funding not linked to outcomes
Does not recognize efficiency,
standardization and adoption of best
practi ces
Maintains sector specific silos
Transition Phase
Future
Transpare nt, evidence-based to better
reflect population needs
Strong Clinical
Engagement
Current Agency
Infrastructure
System Capacity
Building for Change
and Improvement
Knowledge to Action
Toolkits
Supports system service capacity
planning
Supports quality improvement
Encourages provider adoption of best
practice through linking funding to
activity and patient outcomes
Ontarians will get the right care, at the
right place and at the right time
Meaningful
Performance
Evaluation Feedback
2.2 How will we get there?
The ministry has adopted a multi-year implementation strategy to phase in the HSFR
strategy and will make modest funding shifts beginning April 2012. A three-year outlook
has been provided to the field to support planning for upcoming funding policy changes.
The ministry has released a set of tools and guiding documents to further support the
field in adopting the funding model changes. For example, a Quality-Based Procedure
(QBP) interim list has been published for stakeholder consultation and to promote
transparency and sector readiness. The list is intended to encourage providers across
the continuum to analyze their service provision and infrastructure in order to improve
clinical processes and where necessary, build local capacity. However, as
implementation evolves, the interim List will continue to undergo further refinements
pending stakeholder feedback and advice from the QBP Clinical Expert Advisory
Groups.
The successful transition from the current, ‘provider-centred’ funding model towards a
‘patient-centred model’ will be catalyzed by a number of key enablers and field
supports. These enablers translate to actual principles that guide the development of
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the funding reform implementation strategy related to QBPs. These principles further
translate into operational goals and tactical implementation, as presented in Figure 2.
Figure 2: Principles guiding the implementation of funding reform related to Quality-Based
Procedures
Principles for developing QBP
implementation strategy
 Cross-Sectoral Pathways
 Evidence-Based
 Balanced Evaluation
Operationalization of principles to
tactical implementation (examples)
 Development of best practice patient
clinical pathways through clinical expert
advisors and evidence-based analyses
 Integrated Quality Based Procedures
Scorecard
 Alignment with Quality Improvement Plans
 Transparency
 Publish practice standards and evidence
underlying prices for QBPs
 Routine communication and consultation
with the field
 Sector Engagement
 Clinical Expert Advisory Groups
 Overall HSFR Governance structure in
place that includes key stakeholders
 Technical and clinical engagement
sessions
 Knowledge Transfer
 Applied Learning Strategy/ IDEAS
 Tools and guidance documents
 HSFR Helpline; HSIMI website (repository
of HSFR resources)
2.3 What are Quality-Based Procedures?
QBPs are clusters of patients with clinically related diagnoses or treatments that have
been identified using an evidence-based framework as providing opportunity for process
improvements, clinical re-design, improved patient outcomes, and enhanced patient
experience and potential cost savings.
The evidence-based framework uses data from the Discharge Abstract Database (DAD)
and National Ambulatory Care Reporting System (NACRS) adapted by the ministry for
its HBAM repository. The HBAM Inpatient Grouper (HIG) groups inpatients based on
the diagnosis or treatment responsible for the majority of their patient stay. Additional
data was used from the Ontario Case Costing Initiative (OCCI), and Ontario Cost
Distribution Methodology (OCDM). Evidence such as publications from Canada and
other jurisdictions and World Health Organization reports were also used to assist with
the patient clusters and the assessment of potential opportunities.
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The evidence-based framework assessed patients using five perspectives, as
presented in Figure 3. This evidence-based framework has identified QBPs that have
the potential to improve quality of care, standardize care delivery across the province
and show increased cost efficiency.
Figure 3: Evidence-Based Framework
1. Practice Variation
The DAD has every Canadian patient discharge (except Quebec), coded and
abstracted for over 50 years. This information is used to identify patient transition
through the acute care sector, including discharge locations, expected lengths of stay
and readmissions for each and every patient, based on their diagnosis and treatment,
age, gender, co-morbidities and complexities and other condition specific data. A
demonstrated large practice or outcome variance may represent a significant
opportunity to improve patient outcomes by reducing this practice variation and focusing
on evidence-informed practice. A large number of ‘Beyond Expected Length of Stay’
and a large standard deviation for length of stay and costs were flags to such variation.
Ontario has detailed case costing data from many hospitals, as far back as 1991 for all
patients discharged from some case costing hospitals, as well as daily utilization and
cost data by department, by day and by admission.
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2. Availability of Evidence
A significant amount of research has been completed both in Canada and across the
world to develop and guide clinical practice. Working with the clinical experts, best
practice guidelines and clinical pathways can be developed for these QBPs and
appropriate evidence-informed indicators can be established to measure the quality of
QBP care and help identify areas for improvement at the provider level and to monitor
and evaluate the impact of QBP implementation.
3. Feasibility/ Infrastructure for Change
Clinical leaders play an integral role in this process. Their knowledge of the patients and
the care provided or required represents an invaluable component of assessing where
improvements can and should be made. Many groups of clinicians have already formed
and provided evidence and the rationale for care pathways and evidence-informed
practice.
4. Cost Impact
The selected QBP should have as a guide no less than 1,000 cases per year in Ontario
and represent at least one per cent of the provincial direct cost budget. While cases that
fall below these thresholds may in fact represent improvement opportunity, the resource
requirements to implement a QBP may inhibit the effectiveness for such a small patient
cluster, even if there are some cost efficiencies to be found. Clinicians may still work on
implementing best practices for these patient sub-groups, especially if it aligns with the
change in similar groups. However, at this time, there will be no funding implications.
The introduction of evidence into agreed-upon practice for a set of patient clusters that
demonstrate opportunity as identified by the framework can directly link quality with
funding.
5. Impact of Transformation
The selected QBPs must align with the government’s transformational priorities
including alignment with the tenets of Ontario’s Action Plan for Health Care. In
addition, a natural progression and trajectory to assess a QBP’s impact on
transformation would be to begin to look at other patient cohorts (e.g. paediatric patient
populations), impact on the transition of care from acute-inpatient to community care
setting, significant changes from historical funding models/ approaches, integrated care
models etc. QBPs with a lesser cost impact but a large impact on the transformation
agenda may still be a high priority for creation and implementation.
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2.4 How will QBPs encourage innovation in health care
delivery?
QBP strategy is driven by clinical evidence and best practice recommendations from the
Clinical Expert Advisory Groups. The Clinical Expert Advisory Groups are comprised of
cross-sectoral, multi-geographic and multi-disciplinary membership with representation
from patients as well. The panel members leverage their clinical experience and
knowledge to define the patient populations and recommend best practices.
Once recommended best practices are defined, these practices are used to understand
required resource utilization for the QBPs and further assist in the development of
evidence-informed prices. The development of evidence-informed pricing for the QBPs
is intended to incent health care providers to adopt best practices in their care delivery
models, maximize their efficiency and effectiveness, and engage in process
improvements and / or clinical redesign to improve patient outcomes.
Best practice development for the QBPs is intended to promote standardization of care
by reducing unexplained variation and ensure the patient gets the right care, at the right
place and at the right time. Best practices standards will encourage health service
providers to ensure the appropriate resources are focused on the most clinically and
cost effective approaches.
QBPs create opportunities for health system change where evidence-informed prices
can be used as a financial lever to incent providers to:
•
Adopt best practice standards;
•
Re-engineer their clinical processes to improve patient outcomes;
•
Improve coding and costing practices; and
•
Develop innovative care delivery models to enhance the experience of patients.
An integral part of the enhanced focus on quality patient care will be in the development
of indicators to allow for the evaluation and monitoring of actual practice and support
on-going quality improvement.
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3.0 Cancer Surgery QBP
Cancer surgery and surgeons play a key role in many aspects of the patient’s journey:
Diagnosis: Biopsy of a tumour and other investigations including radiological
investigations to determine whether the growth is cancerous (malignant) or
noncancerous (benign).
Staging: Endoscopic evaluations such as panendoscopy, mediastinoscopy, needle
biopsies, colonoscopies, etc. that allow evaluation of the extent and size of the tumour.
Curative: Removal of the entire cancerous tumour or growth from the body.
Palliative: Surgery used to treat cancer when incurable with the intent being to relieve
discomfort, manage symptoms or increase effectiveness of other cancer treatments.
Reconstruction and Rehabilitation: Following curative surgery a patient’s appearance
or body function may be altered. Restorative surgery restores appearance or function
some examples include, head and neck microvascular surgery, breast, bladder or rectal
reconstruction surgery.
Cancer Surgery procedures are carried out by a wide variety of surgeons, those who
may specialize in cancer patients exclusively but more commonly cancer surgery is
performed by surgeons who do not exclusively treat cancer patient.
In Ontario, over 80 hospitals provide some type of cancer surgery services.
3.1 Overview of Cancer Surgery Agreements (CSA)
Cancer Care Ontario (CCO) has been advising the Ministry of Health and Long Term
Care (MOHLTC) on the allocation of cancer surgery funding through the CSA program
since 2004. The intent of the CSA is to increase the volume of high quality cancer
surgeries performed in Ontario to reduce wait times while continually improving the
quality of cancer surgery across Ontario.
The CSA program funds approximately 20% of all cancer surgeries in Ontario across 35
hospitals. As a condition of receiving funding, hospitals are required to sign the Cancer
Surgery Agreements (CSA). This agreement links incremental funding with quality
improvement initiatives, clear accountabilities for performance, and the development of
regional cancer programs.
On an annual basis, CCO distributes funding to participating hospitals and monitors the
conditions set out in each agreement in association with funding and meeting the
annual targets. The Regional Vice-Presidents (RVP) of Cancer Services actively works
with hospitals in their regions to identify difficulties completing cases and develop
solutions to meet the agreed-upon targets. Each participating hospital has four main
requirements to achieve in order to attain the targets set out in the CSA. These include:
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



Volume requirements to ensure the hospital performs the allocated number of
surgeries and work with hospitals within the region to ensure volumes are
completed and patients have appropriate access;
Quality requirements which involves developing and implementing quality
guidelines and standards and implementing best practices;
Reporting requirements which involves reporting performance data on all cancer
surgery volumes, cancer surgery waiting times for each surgical specialty, and
other key quality indicators, and
Working with the RVP to develop a Regional cancer Program as described in the
Ontario Cancer Plan.
With the implementation of QBP for cancer surgery the goal is to:
a) Use lessons learned from the CSA process and apply them to QBP
b) Eventually merge the portions of the CSA program into QBP funding
c) Allow the funding to follow the patient providing equitable access and distribution
of funds
Also with the transition, QBP will run in conjunction with Cancer Surgery Agreements
(CSA), as disease sites are implemented into QBP they will be removed from CSA
incremental funding. For example, in FY15/16 all funding for prostate and colorectal
cancer surgery will be accounted for through QBP and prostate and colorectal cancer
will not be a part of the CSA. Slowly disease sites will transition from CSA to QBP.
3.2 Overview of Cancer Surgery QBP Implementation
Strategy
There are over 50,000 curative cancer surgeries every year which are compiled of
several hundred types of procedures across 100 hospitals in Ontario. A phased
approach will be taken in order to accomplish the significant task of implementing QBP
based funding for all of cancer surgery.
The phased approach will be based on the patient journey and disease site.
Patient Journey Scope:
The patient journey scope refers to the patients experience before, during and after
treatment. These are described as:
•
Consult / Pre-Treatment Assessment: Before a treatment plan is decided upon
the surgeon will conduct an assessment to understand the extent of the disease
and if the patient is a surgical candidate. This assessment may include
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diagnostic imaging and biopsy including pathology assessment, a
multidisciplinary consult or multidisciplinary cancer conference. These activities
may occur within a hospital or physician office.
•
Treatment: This phase refers to the surgical procedure performed within an
operating room. By definition, it occurs within the hospital setting. It begins at the
pre-admission visit (approximately 1 week before the surgical procedure) and
ends when the patient is discharged from the hospital.
•
Follow up: Once the surgical procedure is completed, a patient will require
follow up to monitor recurrence of the disease. The frequency of visits and tests
required are dependent upon the disease. This activity may occur in or out of the
hospital setting.
NOTE: The initial phase for Cancer Surgery QBP implementation will focus
on the Treatment phase.
Figure 4: Patient Journey Scope
3.3 Disease Site Selection
The Cancer Surgery QBP portfolio will consists of numerous disease sites. The disease
sites include:

Gastrointestinal: Colon, Rectal, Stomach,

Hepatobiliary: liver, biliary, pancreas

Thoracic: Lung, esophagus

Breast

Thyroid

Genitourinary: kidney, bladder, testis, adrenal gland

Prostate
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
Gynecology: Endometrium, Cervical, Ovarian, Vulvar

Ophthalmic

Head & Neck

Sarcoma: Bone, Soft Tissue

Neurology: brain, spinal

Skin (including melanoma)
Cancer surgery has been identified as a QBP using the evidence based selection
framework. These criteria are described in Figure 5.
Figure 5: Evidence and Quality-Based Framework- Cancer Surgery
Feasibility &
Infrastructure for
Change
Availability of
Evidence
Cancer
Surgery
Significant number of
guidelines and pathways
that describe appropriate
treatment paths for
various disease sites
Regional leadership in place
for a number of disease
sites
Indicators in place for
various disease sites that
are currently measured and
planned to be measured in
the future
Cost
Estimate
Demonstrated
successes with
identifying quality
issues the
improvement of
specific indicators
It is estimated
that cancer
surgery
accounts for
approximately
$450M in
funding, over
50,000
surgeries
annually taking
place at over 80
hospitals
Impacts
patient care
and journey
though the
cancer care
trajectory
Positive Margins
for pT2
• Ontario: 22%
• LHIN Range:
16%-36%
Cost Estimate
GU/Prostate MCC
Concordance to
minimum
standards
• Q1 FY13/14:
66%
• Q1 FY14/15:
76%
2788 x $5015 =
$1.4M
Potentially
with transfer
from
hospital to
community
care
Through Organizational
Guidelines some disease
sites have been centralized
to designated centres.
Prostate
Cancer
Surgery
Significant number of
guidelines and pathways
that describe appropriate
treatment paths
 Prostate Clinical
Pathway (DPM)
 Margins and lymph
nodes guidelines
(Surgery and
Pathology)
 Active Surveillance for
the management of
localized prostate
cancer
Leadership

Prostate Champions
(Surgery and
Pathology)
Data/Reporting

Positive Margins;
radiation oncology
consults before surgery
that are currently in
place
Transformation
Impact
Practice
Variation
# prostate
cases x CSA
case cost
(merged rate) =
Hospitals
~ 51 hospitals
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Colon
and
Rectal
Cancer
Surgery
Significant number of
guidelines and pathways
that describe appropriate
treatment paths
 CRC Clinical Pathway
(DPM)
 Margins and lymph
nodes guidelines
(Surgery and
Pathology)
 Appropriate
assessment of rectal
cancer
 Laparoscopic surgery
for colon cancer
 Radiology and
Pathology
tools/templates
Leadership
CRC Champions
(Surgery and Pathology)

Data/Reporting

Positive Margins;
lymph node
examination,

Development of
indicator for
appropriate
assessment (eg. MRI)
before surgery
GI MCC
Concordance to
minimum
standards
• Q1 FY13/14:
76%
• Q1 FY14/15:
86%
Cost Estimate
The provincial
positive
circumferential
margin rate is less
than 10% with
some regional
variation.
Hospitals
Potentially
with transfer
from
hospital to
community
care
# CRC cases x
CSA case cost
(merged rate) =
7000 x $10615
= $74M
 ~ 90
hospitals
The lymph node
retrieval rate after
colon resection
has been above
90% consistently.
Preliminary
Ontario data
indicates variation
in pre-op MRI
assessment of
rectal cancer
Cancer Surgery QBP implementation will take a phased implementation approach
by disease site:
o FY15/16: Implementation of prostate (radical prostatectomy) and
colon/rectal cancer surgery
o FY16/17: Implementation of breast and thyroid cancer surgery
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4.0 Prostate Cancer Surgery
Prostate cancer is the most commonly diagnosed malignancy among Canadian men
and is the second largest cause of male cancer deaths in Canada. Nearly 23 600 cases
of prostate cancer are diagnosed in Canada and close to 4000 Canadian men die from
prostate cancer every year (Prostate Cancer Canada, 2013).
Prostate cancer occurs when cells of the prostate reproduce at a faster rate than in a
normal prostate, causing a tumour. There are numerous treatment options available for
men with prostate cancer based on the risk and grade of the cancer and patient
preference. Active surveillance, which consists of regular monitoring for signs of
disease progression, is a common treatment for prostate cancers that are slow growing
and may not require a surgical procedure. Additional treatments include radiation
therapy as well as hormone therapy, which stops testosterone from being released to
the prostate gland to aid in the fight against cancer. Surgery for the removal of the
prostate gland and surrounding tissue, known as a radical prostatectomy, is another
available treatment for patients with prostate cancer.
Prostate cancer surgery is performed by urologists. Urologists performing prostate
cancer surgery can either be general urologists, treating a number of diseases, or
urologic oncologists, focusing specifically on the treatment of urologic cancers
A radical prostatectomy is the surgical removal of the prostate gland and surrounding
tissue. The prostate is surrounded by important nerves that in most cases are avoided
though some patients may experience urinary incontinence (stress and total) and
erectile dysfunction (ED) as some of the side effects.
There are four surgical approaches used for a Radical Prostatectomy.




An open perineal approach is an approach for a radical prostatectomy whereby
the surgeon makes a primary incision through the perineum and carries out the
operation through the incision. The procedure includes the removal of the entire
prostate along with the seminal vesicles.
An open retropubic approach is an approach for radical prostatectomy whereby
the surgeon makes a primary incision through the pubic area and carries out the
operation through the incision. This process includes the removal of the entire
prostate as well as the seminal vesicles.
A laparoscopic approach for a radical prostatectomy is a “minimal access
approach” by which small incisions are made in the abdomen and a video
camera is inserted to the view the prostate while the surgeon operates surgical
instruments to remove the prostate gland and seminal vesicles.
A robotic-assisted radical prostatectomy is similar to the laparoscopic
approach. Similar to the laparoscopic approach small incisions are made in the
abdomen to allow for insertion of the robotic arms and video camera. The
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surgeon manipulates surgical tools robotically allowing removal of the prostate
gland.
4.1 Prostate Cancer Surgery Scope (Radical Prostatectomy)
Factor
Diagnosis &
Procedure
Codes
Data Source
Visit Type/
Activity
Additional
Patient
Factors
Included
A radical prostatectomy will be identified as a
case that has:
 Main diagnosis code: C61 (malignant
neoplasm of the prostate)
AND
Primary intervention field:
one of the following CCI procedure codes
 1QT91PB - Radical excision prostate
(open perineal)
 1QT91PK - Radical excision prostate
(open retropubic)
 1QT91DA – Radical excision prostate
(laparoscopic)
Note: Robotic procedures are captured with
the CCI procedure code 1QT91DA AND the
subcode 7.SF.14.ZX Robotic assisted
telemanipulation of tools, service, using
system NEC, mandatory (robotic)
DAD
In-patient
• Elective cases
• Urgent cases
• Emergent cases
•
•
Government insured patients only
(i.e. OHIP)
Patients 18 years of age and over
Excluded
Records where main
intervention is missing
NACRS
• Day Surgery
• Interventions flagged as
‘Out of Hospital’
• Interventions flagged as
‘Abandoned’
• Interventions flagged as
‘Cancelled
• Out-of-province records
(i.e., Province not equal
“ON”)
• Records where
responsibility for Payment
is not equal to ‘01’
• Records where calculated
age is less than 18 years.
Age is calculated as the
difference between admit
date and birth date
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4.2 Best practices guiding the implementation of Prostate
Cancer Surgery
Radical Prostatectomy Length of Stay
Analysis
Length of stay analysis was conducted for the in-scope patient cohort over the most
recent timeframe available.
FY12/13
Diagnosis
Code
CCI Procedure
Code
1QT91DA
(Laparoscopic)
Malignant
neoplasm
of Prostate
(C61)
1QT91DA
(Robotic)
1QT91PB
(Open
Perineal)
1QT91PK
(Open
Retropubic)
Description
Ontario
Mean
Ontario
Mean
Volume
Ontario
Mean
1.95
90
1.87
1.76
1.92
1.71
376
1.73
1.57
98
2.8
2.42
43
2.58
1.61
2057
2.97
2.63
893
3.03
2.64
Volume
Ontario
Mean
505
2.27
209
Excision radical,
prostate using open
perineal approach
Excision radical,
prostate using open
retropubic
approach
Excision radical,
prostate, using
endoscopic
(laproscopic)
approach
Excision radical,
prostate, using
endoscopic
(laproscopic)
approach WITH
LINK TO Robotics
FY13/14 (Q1 +Q2)
(excl. > 90th
percentile)
Recommendation:
The following recommendations are based on analysis and expert consensus:
Radical Prostatectomy Procedure Type
Best Practice Length of Stay
Open Perineal
3 days
Open Retropubic
3 days
Robotic
2 days
Laparoscopic
2 days
17
(excl. > 90th
percentile)
Radical Prostatectomy Best Practice Definition
Relevant Cancer Care Ontario Guidelines:
•
Guideline for Optimization of Surgical and Pathological Quality
Performance in Radical Prostatectomy in Prostate Cancer Management. 173 EBS: September 2008
•
Special Report: Multidisciplinary Cancer Conferences (MCC) June 2006
Pathway Development Process
To develop the best practice pathway of care for radical prostatectomy, the following
process was followed:
•
A literature scan was completed
•
Existing care paths were collected from the hospitals of QBP members
•
Common practices and collaborative guidelines were then consolidated to create
the best practice care path recommended for the patient population
•
Expert consensus was obtained
The best practice focused on identifying and implementing evidence-informed practice
driven by clinical consensus. The pathway reflects current available evidence, however
it is recognized that changes to the evidence may occur between review cycles.
Best practice has been categorized into the following stages:
1. Pre-Surgical Assessment (prior to surgery)
2. Day before Surgery (1 day prior)
3. Day of Surgery (Day 0): Pre-Operative Care Unit (POCU)
4. Day of Surgery (Day 0): Operating Room
5. Day of Surgery (Day 0): Post-Anesthetic Care Unit (PACU)
6. Post-operative Surgery: Day 1 onward (day after OR)
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Final Recommendations
1. Pre-Surgical Assessment (prior to surgery)
Tests:
 CBC to determine risk of transfusion
- ~ 6% of patients require blood transfusions
 Na, K, CL, Creatinine, Glucose, Electrolytes
If applicable:
 ECG if patient has heart disease, diabetes or other risk factors for cardiac condition
 PT/PTT/INR if patient has liver disease
 Urine and culture if patient at risk of or showing symptoms of urinary tract infection
Assessments:
 Pre-admission assessment (Vital signs, HT, WT etc.)
 MRSA/CPE screening
 Assessment by transfusion nurse/nurse
Consults:
 Anesthesiology/pain management consult- as required
 Internal Medicine (Cardiology)- as required
Medications:
 Review all current medications by Pharmacist or Nurse
 Note allergies and intolerances
 Provide information about discontinuation of NSAIDS/antiplatelet/anticoagulants if necessary
Patient/Family Teaching:
 Educate patient on the surgical procedure
 Review pre-operation and post- operative events and expectations
 Review plan for pain management
 Inform patient about blood transfusion should it become necessary
 Review self-care measures to prevent post-op complications
 Review patient education booklets, pamphlets, etc.
 Educate patient on breathing and recovery exercises
 Obtain consent for possible transfusion- completed by surgeon
Discharge Planning:
 Review discharge plan with the patient including, expected length of stay, discharge time, and
issues or complications that could delay discharge
 Involve Social worker or CCAC if necessary
2. Day Before Surgery
Assessments:
 +/- Bowel preparation- if required
Nutrition:
 DAT
 Clear liquids up to 2-3 hours prior to surgery
 No solids after midnight the day prior to surgery
19
3. Day of Surgery- POCU
Tests:
 Cross match blood for patients at high risk for bleeding- if necessary
Assessments:
 Pre-operative assessment by nurse, surgeon and anesthesiologist
 Blood work as required (e.g. glucose)
-Type 2 diabetes impacts 15% of patients
 +/- Enema- if required
Medications:
 IV antibiotics:1st/2nd gen. Cephalosporin, Aminoglycoside + Metronidazole or Clindamycin
Alternative:
 Ampicillin/Sulbactam, Fluoroquinolone- if patient allergic
 Colloid fluid
 Tranexamic Acid, as required
 VTE prophylaxis (e.g. heparin, SCD as per institutional protocol) administered in the POCU or
Operating Room
Nutrition:
 NPO – no solid food after midnight the day prior to surgery
 Sips of water with meds
 Encourage 8oz. of clear carbohydrate drink (e.g.: apple juice, cranberry juice, Gatorade) 3 hours
prior to the surgery- optional
4. Day of Surgery- Operating Room
Assessments:
 Complete surgical checklist
Treatments:
 Radical prostatectomy and pelvic lymph node dissection (if necessary) performed
 Ensure all equipment is available
- Special equipment: arterial line, cardiac output monitors, etc.)
 Ensure all resources are present (OR nurse, surgeon, anesthesiologist)
 CCO pathology requisition completed by surgeon
 Ensure specimen is appropriately labelled and sent to pathology for processing/assessment
Medications:
 Local anesthetic block- as needed
5. Day of Surgery- PACU (Day 0)
Tests:
 CBC
 Electrolytes, creatinine, etc.
 Diabetic patient (glucose ordering and monitoring)
- Type 2 diabetes impacts 15% of patient population
(Tests may be performed once or as needed based on patient condition)
Assessment:
 Post-operative assessment by nurse, surgeon and anesthesiologist (system & pain)
Consults:
 Acute Pain Services
Treatment:
 Monitor patient recovery (e.g. urine output, catheter drainage, wound dressing, JP drain, IV, etc.)
Medication:
20
Patient specific medication
Oral pain medication
VTE prophylaxis
Medication for bladder spasms
- 100% patients get preventative medication
 PCA (for a duration of 24 hours), as required
Activity:
 Breathing and recovery exercises
Nutrition
 Clear liquids




6. Day after Surgery- Post Operative Day 1+ onwards
Tests:
 CBC
 Electrolytes, creatinine, etc.
 Diabetic patient (glucose ordering and monitoring)
- Type 2 diabetes impacts 15% of patient population
(Tests may be performed once or as needed based on patient condition)
Assessment:
 Discharge assessment by nurse and/or surgeon (system, pain, recovery)
Consults:
 Physiotherapy (pelvic floor rehabilitation)
Treatment:
 Removal of IV
 Remove JP drain once drainage is less than 50 ml for 24 hours
- Less than 2% of patients are discharged with a JP drain in place
 Wound dressing
Medication:
 Patient specific medication
 Oral pain medication
 VTE prophylaxis
Activity:
 Walking independently
Nutrition
 Regular Diet
Patient/Family Teaching:
 Review home management of catheter
 Review home management of wound
 Review signs and symptoms of wound infection, urine infection and bladder distention
Discharge Planning:
 Discuss discharge preparation
 Ensure patient meets clinical indicators to be discharged
 Review discharge plan with patient and family
 Inform patients of follow-up appointments
 CCAC consult
21
5.0 Colorectal Cancer Surgery
Colorectal cancer, cancer of the colon or rectum, is a disease in which malignant
(cancer) cells form in the tissues of the colon. The colon is part of the body’s digestive
system which helps pass waste material out of the body. The first part of the large
intestine is called the colon. The last part is the rectum and the anal canal. The anal
canal ends at the anus.
Depending on the size, location and spread of the cancer, different modalities of therapy
may be employed to treat the disease. The main treatment for colorectal cancer is
surgery, but often multiple treatments are given including systemic therapy, therapies in
interventional radiology, and radiation therapy. Some patients may access one or more
of these therapies in the management of their disease. Surgical resection is often the
main treatment for earlier stage colon and rectal cancer.
Colorectal cancer surgery is performed by general surgeons, treating a number of
diseases, or colorectal surgical oncologists, focusing specifically on the treatment of
colorectal cancers
The goals of colorectal cancer surgery are to a) remove cancer completely, b) remove
adjacent lymph nodes and c) re-join the bowel to provide normal or near normal
function. Achieving these goals is dependent on a number of factors such as location of
tumour, tumour size, timing of surgery, stage and patient status and preferences. There
are different types of surgical procedures including the following:
1. Bowel resection with anastomosis: A part of the bowel with the cancer is
removed and then the bowel is joined back together (anastomosis) either with staples or
sutures.
2. Bowel resection with an anastomosis and a (temporary) stoma: Whenever the
bowel is joined together, there is always a chance it might not heal. Where this risk is
high, sometimes a temporary stoma (ileostomy or colostomy) is constructed so
digestive waste collects in the bag to allow the bowel to heal. In the future the temporary
stoma can be closed once the surgeon is certain that the join (anastomosis) is healed.
Hartmann’s resection: Part of the bowel is removed which includes the
diseased area but instead of joining the bowel back together, a stoma is
performed. The remaining colon or rectum is usually closed off with staples or
sutures and left inside the abdomen. This is often done in emergency situations
and the bowel can often be joined together at a later date.
3. Bowel resection with abdominoperineal resection (APR): Complete removal of
the rectum, and anus resulting in a permanent colostomy. APRs are primarily used for
the treatment of a rectal carcinoma situated in the distal (lower) part of the rectum.
22
5.1 Colorectal Cancer Surgery Scope
Factor
Included
Excluded
Diagnosis &
Procedure
Codes
A colorectal cancer surgery will be identified
as a case that has:
• Main diagnosis code: all malignant
neoplasm codes specifically C00 to
C97 within ICD-10- CA or organrelated benign neoplasm, as outlined
in Table 1 of Appendix A,
AND
Records where main
intervention is missing
•
Primary Intervention (CCI procedure
code): as listed in Table 2 of
Appendix A
Data Source
DAD
Visit Type/
Activity
Inpatient
• Elective cases
• Urgent cases
• Emergent cases
NACRS
•
•
•
•
Additional
Patient
Factors
•
•
Government insured patients only (i.e.
OHIP)
Patients 18 years of age and over
•
•
•
Day Surgery
Interventions flagged as
‘Out of Hospital’
Interventions flagged as
‘Abandoned’
Interventions flagged as
‘Cancelled
Out-of-province records
(i.e., Province not equal
“ON”)
Records where
responsibility for Payment
is not equal to ‘01’
Records where calculated
age is less than 18 years.
Age is calculated as the
difference between admit
date and birth date
23
5.2 Best practices guiding the implementation of Colorectal
Cancer Surgery
Colorectal Cancer Surgery Length of Stay
Analysis
Length of stay analysis was conducted for the in-scope patient cohort over the most recent
timeframe available.
Elective
Colon
Emergency
Laparoscopic
1909
6.1
5.0
2057
5.9
4.0
-2%
-20%
Open
1743
9.4
7.0
1565
8.7
6.0
-8%
-14%
Laparoscopic
179
14.7
10.0
241
12.6
9.0
-14%
-10%
Open
792
17.8
13.0
739
16.6
12.0
-7%
-8%
4623
9.7
6.0
4602
8.9
6.0
·8%
0%
525
1474
27
111
6.7
9.7
15.4
19.8
5.0
7.0
8.0
13.0
507
1320
30
112
6.1
9.3
12.3
16.3
4.0
7.0
6.0
11 .0
-10%
-4%
-20%
-18%
-20%
0%
-25%
-15%
2137
9.6
7.0
1969
8.9
7.0
-7%
0%
Total Colon
Elective
Rectum
Emergency
Laparoscopic
Open
Laparoscopic
Open
Total Rectum
Recommendation:
The following recommendations are based on analysis of empirical data and expert
consensus:
Procedure Group
Admission Category
Procedure Type
Best Practice
24
Length of Stay
Elective
Colon
Emergency
Elective
Rectum
Emergency
Laparoscopic
4 days
Open
6 days
Laparoscopic
9 days
Open
12 days
Laparoscopic
4 days
Open
7 days
Laparoscopic
6 days
Open
11 days
Colorectal Cancer Surgery Best Practice Definition
Relevant Cancer Care Ontario Guidelines:
•
Optimization of Preoperative Assessment in Patients Diagnosed with Rectal
Cancer 17-8 EBS: January 20, 2014
•
Optimization of Surgical and Pathological Quality Performance in Radical
Surgery for Colon and Rectal Cancer: Margins and Lymph Nodes
17-4 EBS: April 2008
•
Special Report: Multidisciplinary Cancer Conferences (MCC) June 2006
Pathway Development Process
To develop the best practice pathway of care for colorectal cancer surgery, the following
process was followed:
•
A literature scan was completed
•
Existing care paths were collected from the hospitals of QBP members. It was
apparent that the majority of hospitals are implementing the Enhanced Recovery after
Surgery pathway for colon and rectal surgery developed by Best Practice in General
Surgery1. With working group consensus this pathway was used as the basis for the
QBP best practice.
•
Common practices and collaborative guidelines were then consolidated to create the
best practice care path recommended for the patient population
•
Expert consensus was obtained with the working group
Aarts MA, Okrainec A, McCluskey S, Siddiqui N, Wood T, Pearsall E, & McLeod RS on behalf of the Best Practice in
General Surgery. Enhanced Recovery after Surgery Guideline. www.bpigs.ca.
1
25
The best practice focused on identifying and implementing evidence-informed practice
driven by clinical consensus. The pathway reflects current available evidence, however it is
recognized that changes to the evidence may occur between review cycles.
Best practice for colon and rectal resections has been categorized into the following stages:
1. Pre-Surgical Assessment (prior to surgery)
2. Day before Surgery (1 day prior)
3. Day of Surgery (Day 0): Pre-Operative Care Unit (POCU)
4. Day of Surgery (Day 0): Operating Room
5. Day of Surgery (Day 0): Post-Anesthetic Care Unit (PACU)
6. Post-operative Surgery: Day 1 onward (day after OR)
Final Recommendations
1. Pre-Surgical Assessment (prior to surgery)
Tests:
 CBC to determine risk of transfusion
 Na, K, Cl, creatinine, glucose, electrolytes
 CEA for all patients if one has not been ordered previously
 Group and screen for all patients having a colon operation
 If applicable:
 ECG if patient has heart disease, diabetes or other risk factors for cardiac condition
 PT/PTT/INR if patient has liver disease
Assessments:
 Pre-admission assessment (vital signs, HT, WT etc.)
 Assessment by transfusion nurse/nurse
Consults:
 Anesthesiology/pain management consult- as required
 Enterostomal Therapy Nurse (ET Nurse) for patients planning to have a stoma
Medications:
 Review all current medications by pharmacist or nurse
 Note allergies and intolerances
 Penicillin allergies should be reviewed
 Provide information about discontinuation of NSAIDS/antiplatelet agents/anticoagulants if
applicable
 Prescribe iron to patient or arrange iron transfusion pre-operatively to decrease transfusion rates
Patient/Family Teaching:
 Educate patient on the surgical procedure
 Review pre-operation and post- operative events and expectations
 Review length of stay expectations with patient
 Review plan for pain management and anesthetics
 Inform patient about blood transfusion should it become necessary
 Review self-care measures to prevent post-op complications
 Review patient education booklets, pamphlets, etc.
 Educate patient on breathing and recovery exercises
 Provide patient with instructions for bowel prep- as required
 Educate the patient on the type of stoma, postoperative goals of care and life with an ostomy
26
 Educate patient on Enhanced recovery after surgery
Discharge Planning:
 Review discharge plan with the patient including, expected length of stay, discharge time, and
issues or complications that could delay discharge
 Involve Social worker or CCAC if necessary
- All patients having a stoma require CCAC on discharge
2. Day Before Surgery
Assessments:
 Recommended bowel preparation for patients with anastomosis below the peritoneal reflection
Nutrition:
 Encourage 8oz. of clear carbohydrate drink (e.g.: apple juice, cranberry juice, Gatorade®) the night
before surgery and 2 hours prior to the surgery
 NPO – no solid food after midnight the day prior to surgery
3. Day of Surgery- POCU
Tests:
 Cross match blood for patients at high risk for bleeding- if necessary
Assessments:
 Pre-operative assessment by nurse, surgeon and anesthesiologist
 Blood work as required (e.g. glucose)
Medications:
 Unfractionated or low molecular weight heparin injection (Administered in the POCU or Operating
Room unless patient is scheduled for an epidural)
 NSAIDS for patients not having anastomosis
 Gabapentin- to decrease pain post-operatively
 Acetaminophen
4. Day of Surgery- Operating Room
Assessments:
 Complete surgical checklist.
Treatments:
 Colon/rectal resection performed, with appropriate lymph node removal
 Ensure all equipment is available
- This includes laparoscopic equipment if the procedure is being performed
 Ensure all human resources are present (OR nurse, surgeon, anesthesiologist)
 CCO pathology requisition completed by surgeon
 Ensure specimen is appropriately labelled and sent to pathology for processing/assessment
 Perioperative normothermia
- Warming blanket
- Fluid warming
 Skin prep with chlorhexidine alcohol solution
 Intraoperative fluid management
 Avoidance of prophylactic drains and tubes
Medications:
 SSI prophylaxis (SSI guideline)
 VTE prophylaxis (VTE guideline)
 Thoracic epidural or intravenous Lidocaine for pain management (intra-operatively)
27
5. Day of Surgery- PACU (Day 0)
Assessments:
 Post-operative assessment by nurse, surgeon and anesthesiologist (system & pain)
 Patient recovery (e.g. bleeding, etc.)
Consults:
 Acute Pain Services
Medication:
 Patient specific medication
 NSAIDS for patients not having anastomosis
 PCA narcotics
 Acetaminophen
 Lidocaine for pain management
Activity:
 Breathing and recovery exercises
 Sit up with assistance and dangle legs for at least 10-15 minutes at side of bed every 2-4 hours
Nutrition
 Clear fluids
6. Day after Surgery- Post Operative Day 1+ onwards
Assessment:
 Discharge assessment by nurse and/or surgeon (system, pain, recovery)
Care of Patient:
 Surgeon, nurse, pain service care and physiotherapy, dietician and pharmacist care and consults
as necessary
 Special care for ostomy patients. E.g.:
- Pouch emptying
- Pouch changes
- Ordering of supplies
Treatment:
 Removal of foley catheter within 24 hours for colon surgery so that the patient can urinate on their
own
 Removal of foley catheter within 72 hours for rectal surgery so that the patient can urinate on their
own
Medication:
 Patient specific medication
 Oral pain medication
 Multimodal pain management (PCA or epidural, acetaminophen, NSAIDs for patients not having
anastomosis) and oral pain medication for discharge
Activity:
 Deep breathing and coughing exercises 10 times every hour while awake
 Sit in chair for all meals
 Get up and walk every 4-6 hours (with assistance if necessary)
 Use the bathroom to urinate- patient will not use bedpan or urinal
Nutrition
 Begin eating solids and continue drinking fluids
 Chew gum for 5 minutes 3 times a day to get the digestive system working
Discharge Planning:
 Discuss discharge preparation
 Ensure patient meets clinical indicators to be discharged (bowel movement, regular diet, no
nausea, etc.)
 Review discharge plan with patient and family
28




Inform patients of follow-up appointments
Provide patient with pain medication prescription- if necessary
CCAC Consult
Patient education including wound care
29
6.0 Thyroid Cancer Surgery
Thyroid Cancer is characterized by abnormal growth of thyroid gland cells that have become
cancerous. The thyroid gland is an endocrine organ located in the front of the neck, just
below the larynx. The thyroid gland is composed of two halves, called lobes, which sit on
either side of the trachea and are connected by a thin bridge of tissue called the isthmus.
The main function of the thyroid gland is to regulate metabolism. Key thyroid hormones T3
and T4 regulate key bodily functions such as heart rate, blood pressure, body temperature
and weight.
There are four major types of thyroid cancer:
•
•
•
•
Papillary thyroid cancer is the most common type of thyroid cancer. It is a
differentiated form of thyroid cancer that typically grows slowly. Papillary thyroid
cancer may spread to the surrounding lymph nodes in the neck, however spread to
distant organs is uncommon.
Follicular thyroid cancer is the second most common type of thyroid cancer and is
also a differentiated thyroid cancer. Unlike papillary cancers, follicular cancers do not
typically spread to lymph nodes but follicular cancers can spread to other parts of the
body, such as the bones or lungs.
Medullary thyroid cancer differs from the differentiated thyroid cancers (papillary and
follicular) because it develops from the C cells of the thyroid gland as opposed to the
follicular cells. The C cells produce calcitonin, a hormone which helps regulate the
amount of calcium within blood.
Anaplastic carcinoma is a rare form of thyroid cancer that is characterized by rapid
growth into the neck and other parts of the body.
Thyroid cancer is a common cancer and with appropriate treatment, the long-term survival
rates are generally excellent. Surgery is the main treatment for thyroid cancer, except for
certain anaplastic thyroid cancers. In some circumstances, additional treatments including
radioactive iodine ablation, thyroid hormone replacement, external beam radiation,
chemotherapy and targeted therapy may be recommended. Thyroid surgery is performed by
surgeons who possess special training.
The primary goal of thyroid cancer surgery is to remove the tumour and if required, some
surrounding healthy tissue. The main types of thyroid cancer surgery are:
1. Partial Thyroidectomy: Partial thyroidectomy procedures can include removal of a
single lobe of the thyroid gland called a ‘hemithyroidectomy’ or ‘lobectomy’. Other
partial thyroidectomy procedures can include a ‘subtotal thyroidectomy’ which
includes a lobe and thyroid isthmus and the medial portion of the contralateral lobe.
Partial thyroidectomy procedures are sometimes necessary as diagnostic procedures
where a needle biopsy is not diagnostic or equivocal.
2. Total Thyroidectomy: The removal of the entire thyroid gland.
30
In conjunction with the thyroidectomy procedure, removal of adjacent lymph nodes, a
lymphadenectomy (neck dissection) may be performed if there is the possibility that cancer
has spread to the lymph nodes in the neck. There are two types of neck dissections to
remove the lymph nodes:
•
•
Central Compartment Neck Dissection: The removal of lymph nodes located
around the thyroid gland. This procedure is usually performed if the lymph
nodes are known to contain cancer, or there is a high suspicion that they
contain cancer.
Lateral Neck Dissection: The removal of lymph nodes located in the lateral
neck. This procedure is performed if the lymph nodes are known to contain
cancer.
6.1 Thyroid Cancer Surgery Scope
Factor
Included
Excluded
Diagnosis &
Procedure
Codes
A thyroid cancer surgery will be identified as a
case that has:
Main diagnosis code:
• C73 – Malignant neoplasm of thyroid
gland
• D093 – Carcinoma in situ of thyroid
and other endocrine glands
• D34 – Benign neoplasm of thyroid
gland
• D440 – Neoplasm of uncertain or
unknown behavior of thyroid gland
• E041 – Nontoxic single thyroid nodule
AND
Records where main intervention
is missing
Primary Intervention (CCI procedure code):
• one of 14 thyroidectomy CCI
procedure codes as listed in Table 3
Appendix A
Data Source
Note: Due to the behavior of the disease and
final pathological diagnosis may not be known
at time of resection more than malignant
neoplasm diagnosis codes were included.
DAD
NACRS
Visit Type/
Activity
Inpatient
• Elective cases
• Urgent cases
• Emergent cases
Day surgery
•
•
•
Interventions flagged as ‘Out
of Hospital’
Interventions flagged as
‘Abandoned’
Interventions flagged as
‘Cancelled
31
Additional
Patient
Factors
•
•
Government insured patients only (i.e.
OHIP)
Patients 18 years of age and over
•
•
•
Out-of-province records (i.e.,
Province not equal “ON”)
Records where responsibility
for Payment is not equal to
‘01’
Records where calculated
age is less than 18 years.
Age is calculated as the
difference between admit
date and birth date
6.2 Best practices guiding the implementation of Thyroid
Cancer Surgery
Thyroid Cancer Surgery Length of Stay
Analysis
Length of stay analysis was conducted for the in-scope patient cohort over the most recent
timeframe available.
Length of Stay (In-patient)
1213
1314
1415
Thyroid Group Interventions(s) Volume Mean Median Volume Mean Median Volume Mean Median
Thyroidectomy
1246
1.2
1
1207
1.2
1
1196
1.2
1
Partial
Thyroidectomy Partial
Thyroidectomy
with HNK*
46
1.9
1
69
1.7
1
68
1.5
1
All Partial
1292
1.2
1
1276
1.4
1
1264
1.2
1
Thyroidectomy
2080
1.8
1
2072
1.7
1
2021
1.6
1
Total
Thyroidectomy
Thyroidectomy
338
2.6
2
394
3.1
2
443
2.5
2
with HNK*
All Total
2418
1.9
2
2466
2
1
2464
2.0
1
3710
1.7
1
3742
1.7
1
3728
1.7
1
Total Inpatient
32
*HNK procedure refers to any procedure classified as a HNK procedure in CSA (HNK-R or HNK-NR) that
appears in the secondary intervention field. In the majority of these cases the HNK procedure is a neck
dissection.
Recommendation:
The following recommendations are based on analysis of empirical data and expert
consensus:
Thyroid Surgery In-patient Procedure Type
Best Practice Length of Stay
Partial Thyroidectomy
1 days
Total Thyroidectomy
2 days
Total Thyroidectomy + HNK procedure*
3 days
*HNK procedure refers to any procedure classified as a HNK procedure in CSA (HNK-R or HNK-NR)
that appears in the secondary intervention field. In the majority of these cases the HNK procedure is a
neck dissection.
Please note: Analysis shows that the average LOS in hours for day surgery patients fits
within the CIHI day surgery definition. The proportion of thyroid surgery patients treated as
day surgery versus in-patient will be monitored to assess for practice change as a result of
QBP implementation.
Thyroid Cancer Surgery Best Practice Definition
Relevant Documents
Cancer Care Ontario Guidelines:
• Special Report: Multidisciplinary Cancer Conferences (MCC) June 2006
Additional Guidelines:
•
•
•
•
•
Guidelines to the Practice of Anesthesia, Revised Edition 2015
Venous Thromboembolism Prophylaxis and Treatment in Patients with Cancer:
American Society of Clinical Oncology Clinical Practice Guideline Update 2014
Prevention of VTE in Non-orthopedic Surgical Patients, 9th Edition: American College
of Chest Physicians Evidence-Based Clinical Practice Guidelines
2015 American Thyroid Association Management Guidelines for Adult Patients with
Thyroid Nodules and Differentiated Thyroid Cancer
American Head and Neck Society Consensus Statement on Laryngeal Examination
in Thyroid and Parathyroid Surgery (publication pending)
33
Pathway Development Process
To develop the best practice pathway of care for thyroid cancer surgery, the following
process was followed:
•
A literature search and environmental scan was completed
•
Existing care paths were collected from the hospitals of QBP members.
•
Common practices and collaborative guidelines were then consolidated to create the
best practice care path recommended for the patient population
•
Expert consensus was obtained with the working group
The best practice focused on identifying and implementing evidence-informed practice
driven by clinical consensus. The pathway reflects current available evidence, however it is
recognized that changes to the evidence may occur between review cycles.
Best practice for partial and total thyroidectomies has been categorized into the following
stages:
1. Pre-Surgical Assessment (~ 4 weeks prior to 1 day prior to surgery)
2. Day of Surgery (Day 0): Pre-Operative Care Unit (POCU)
3. Day of Surgery (Day 0): Operating Room
4. Day of Surgery (Day 0): Post-Anesthetic Care Unit (PACU)
5. Post-operative Surgery: Day 1+ onward (day after OR)
Final Recommendations
This pathway is intended to represent care for patients receiving either a partial or total
thyroidectomy for either day surgery or in-patient surgery.
•
•
Day Surgery includes the Pre-Surgical Assessment phase to the Day of Surgery –
PACU phase
In-Patient includes the entire pathway from the Pre-Surgical Assessment phase to
the Post-operative Day 1+ Onwards phase.
1. Pre-Surgical Assessment (~4 weeks prior to 1 day prior to surgery)
Tests:
All thyroid cancer patients:
 Serum ionized or non-ionized corrected for albumin calcium, as required
 Ultrasound of thyroid and neck nodes
 FNA of thyroid mass and any suspicious lymph nodes
 Pre-operative laryngeal exam should be performed on all patients undergoing thyroid surgery who
are at high risk for nerve injury (e.g. pre-operative voice abnormalities, history of cervical or upper
34
chest surgery, thyroid cancer with known posterior extension or extensive cervical node metastases)
Recommended if clinically indicated:
 ECG if patient has heart disease, diabetes or other risk factors for cardiac condition
 Chest X-ray
 CT with contrast for patients with suspicion of advanced disease (local and/or regional)
 Na, K, Cl, creatinine, glucose, electrolytes
 Urinalysis if signs of urinary tract infection
 Pregnancy test if pregnancy possible
 PT/PTT/INR for patient on Warfarin
Medullary thyroid cancer patients:
 Blood and urinary tests (calcitonin, CEA, corrected calcium, 24-hour urine collections for fractionated
metanephrines)
 CT neck, chest abdomen and pelvis with dual phase contract liver scan +/- bone scan, in patients
with symptoms of advanced disease (local and/or regional) and patients with elevated serum
calcitonin above 500 pg/mL
 Arrange genetic testing (RET gene) pre- or post-op
Assessments:
 Pre-admission assessment (vital signs, HT, WT, O2 saturation, etc.)
 Pre-operative questionnaire (patient history and physical examination)
 Vitamin D level testing can be considered for patients at risk of deficiency
Consults:
 Nursing
 CCAC - as required
 Anesthesiology/Pain management consult -as required
 Internal Medicine (Cardiology, Endocrinology, etc.)- as required
Medications:
 Review all current medication (by Pharmacist)
 Note allergies and intolerances
 Provide information about discontinuation of NSAIDS/ antiplatelet/ anticoagulants if necessary
 Prophylactic calcium and vitamin D supplementation can be considered
 Complete medication reconciliation form
Patient/Family Teaching:
 Educate patient on the surgical procedure
 Review pre-operation events and expectations
 Review post-operative events and expectations
 Review plan for pain management
 Review self-care measures to prevent post-op complications
 Review patient education booklets, pamphlets, etc.
 Discuss risk of nerve and parathyroid injury
 Clarify any patient questions
Discharge Planning:
 Review discharge plan with the patient including, expected length of stay, discharge time, and issues
or complications that could delay discharge
 Involve Social worker or CCAC if necessary
2. Day of Surgery- POCU
Tests:
 Ensure tests completed as ordered
 Glucose, as required (if patient is diabetic and blood sugars are not within normal limits)
Assessments:
 Pre-operative assessment by nurse and/or surgeon
 Ensure medications have been taken as directed
 Vital signs, O2 saturation
 Verify NPO status
35
 Mark correct side for surgery in partial thyroidectomy patients
Medications:
 Surgical site infection (SSI) prophylaxis (cefazolin) should be considered, when appropriate
- Alternative: Vancomycin – if patient allergic
 VTE prophylaxis administered in the POCU or operating room should be considered for at risk
patients (i.e. high Caprini score or other risk factors)
- Particular consideration should be given to patients receiving a neck dissection or patients
with comorbidities
Nutrition:
 No solids after midnight the day prior to surgery
 Clear liquids until 2-3 hours prior to surgery
 NPO 2-3 hours prior to surgery
3. Day of Surgery- Operating Room
Assessments:
 Complete surgical checklist
Treatments:
 Thyroidectomy (partial or total) and neck dissection (if necessary) performed
 Assess for parathyroid damage and recurrent laryngeal injury
 Ensure all equipment is available
 Ensure all human resources are present (OR nurse, surgeon, anesthesiologist)
 CCO pathology requisition completed by surgeon
 Use CCO requirements for sending specimen to pathology
 Ensure specimen is appropriately labeled and sent to pathology
Medications:
 Patient specific medication
 Antiemetic prophylaxis
 Pain medication- recommendations from anesthesiologist
 Superficial cervical plexus block - as needed
4. Day of Surgery- PACU (Day 0)
NOTE: End point for day surgery
Tests:
For total thyroidectomy patients:
 Post-op calcium profile either via calcium monitoring or PTH (with results available in a timely manner)
Assessment:
 Assess vital signs upon admittance
 Assess for haematoma, respiratory distress, bleeding, stridor
 Ensure trach tray and suture/staple remover kit is readily available
For Day surgery patients:
 Discharge assessment by nurse and/or surgeon (system, pain, recovery)
Consults:
For Total thyroidectomy patients:
 Endocrinology – as required
Treatment:
 Monitor patient recovery (e.g. intake and output, pain, nausea)
 Monitor wound dressings
 Empty drain, if drain present
Medication:
 Patient specific medication
 Pain medication
 IV therapy
36
 Antiemetic
 Levothyroxine
For total thyroidectomy patients, as clinically indicated:
 Calcium supplementation
 Vitamin D3 supplementation
 Thyroid replacement
Activity:
 Ambulation as tolerated
 No active neck exercises
Nutrition
 Diet as tolerated
Patient/Family Teaching
For Day Surgery Patients:
 Ensure patient has pamphlets
 Review home management of wound
 Review prescription and medication protocol
 Review signs and symptoms of wound infection
Discharge Planning
For Day Surgery patients:
 Discuss discharge preparation
 Ensure patient meets clinical indicators to be discharged
 Review discharge plan with patient and family
 Inform patients of follow-up appointments
5. Day after Surgery- Post Operative Day 1+ onwards
NOTE: Only applicable to in-patient
Tests:
For total thyroidectomy patients:
 Post-op calcium profile either via calcium monitoring or PTH (with results available in a timely manner)
Assessment:
 Discharge assessment by nurse and/or surgeon (system, pain, recovery)
Consults:
 CCAC consult, if necessary
Treatment:
 Monitor patient recovery (e.g. intake and output, pain, nausea)
 Removal of drain, if drain present
 Wound dressing
Medication:
 Patient specific medication
 Pain medication
 IV therapy
 Antiemetic
 Levothyroxine
For total thyroidectomy patients:
 Calcium supplementation
 Vitamin D3 supplementation
 Thyroid replacement
Activity:
 Activity as tolerated
 No active neck exercises
Nutrition
 Diet as tolerated
Patient/Family Teaching:
 Ensure patient has pamphlets
 Review home management of wound
37
 Review prescription and medication protocol
 Review signs and symptoms of wound infection
Discharge Planning:
 Discuss discharge preparation
 Ensure patient meets clinical indicators to be discharged
 Review discharge plan with patient and family
 Inform patients of follow-up appointments
38
7.0 Breast Cancer Surgery
Breast cancer is the most commonly diagnosed cancer among women in Ontario,
accounting for approximately 26%1 of all women’s cancers. Breast cancer has one of the
highest survival rates, when compared to other cancers, with a five-year relative survival
rate of approximately 88%2.
Breast cancer treatments include surgery, radiotherapy, chemotherapy, hormone
therapy, and targeted (biological) therapy. The type of treatment that an individual
receives depends on factors that include the type and stage of the cancer, as well as the
size and location of the tumour. Most women diagnosed with non-metastatic breast
cancer are candidates for local treatment options, such as surgery.
Breast cancer surgery
Breast cancer surgery is performed by general surgeons while plastic surgeons
complete breast reconstruction procedures. There are several surgical treatment options
for the removal of breast cancer are, including:
• A lumpectomy (also known as breast-conserving surgery) is the removal of the
cancer and a margin of breast tissue surrounding the affected area. The additional
tissue removal acts as a safety perimeter to try to remove all of the cancer. This
procedure is less invasive than a mastectomy and is usually combined with
radiation therapy.
• A mastectomy (complete removal of breast) is used for more advanced types of
breast cancer, when a woman has small breasts, or extensive ductal carcinoma in
situ. A mastectomy procedure removes the entire breast and nipple.
In addition, patients may require the surgical biopsy and/or removal of the breastassociated lymph nodes. Options for biopsy/removal of these lymph nodes include:
• An axillary lymph node dissection (ALND) is the removal of fatty tissue and a
number of lymph nodes from the underarm area. This procedure can occur at the
same time as a lumpectomy or mastectomy, or at a separate encounter. This
procedure is usually performed if the lymph nodes are known to contain cancer, or
there is a high suspicion that they contain cancer. The tissue is reviewed by a
pathologist to determine the number of lymph nodes that are positive for cancer
cells – this helps to establish the stage of breast cancer.
• A sentinel lymph node biopsy (SLNB) is the removal of the sentinel lymph node
to help determine if breast cancer has spread to lymph node(s) in the axilla. The
sentinel lymph nodes are the first lymph nodes that the cancer spreads to. If the
2
Canadian Cancer Society
39
biopsy of the sentinel node is cancer free it indicates the remaining axillary lymph
nodes are unlikely to contain cancer.
Breast Cancer Reconstruction Surgery:
Breast reconstruction surgery rebuilds the breast for women who have had a breast
removed (mastectomy) due to breast cancer. Women who have had breast conserving
surgery (such as a lumpectomy) may not need reconstruction. Breast reconstruction is
done by a plastic surgeon and may be performed at the time of mastectomy or at a later
date. Reconstruction performed at the same time as the mastectomy is referred to as
Immediate (or primary) Reconstruction while reconstruction performed after the initial
mastectomy is referred to as Delayed (or secondary) Reconstruction.
There is some variability in the indications and best practices for immediate and delayed
breast reconstruction in Ontario. To address this variation in care, Cancer Care Ontario
in partnership with the Program in Evidence Based Care have published the Breast
cancer reconstruction surgery (immediate and delayed) across Ontario: Patient
indications and appropriate surgical options guideline which address recommendations
for the optimal delivery of breast cancer reconstruction services.
There are many factors that may contribute to performing immediate versus delayed
reconstruction which include (but are not limited to):
• Patient choice – patients may choose to wait to have their surgery performed for a
variety of reasons (e.g. indecision about treatment options, personal factors such
as ability to be off from work, child care arrangements, etc.). Also, some patients
may choose not to have breast reconstruction performed.
• Patient medical condition - immediate breast reconstruction after a therapeutic
mastectomy may be postponed due to radiation and chemotherapy treatments
(which can affect the body's wound-healing ability), lymph node status, condition of
tissue post-surgery, patient’s overall medical status (ability to endure another
procedure), and urgency of the patient’s condition
• Resource availability – hospitals around the province have variation in surgical wait
times depending on the number of surgeons, support staff availability, operating
room funding, population density of the region, degree of specialty of the
procedure, etc.
Types of Reconstruction:
There are basically 3 types of breast cancer reconstruction surgery. The appropriate
surgical operation for an individual patient depends on several factors including breast
size, the adequacy of skin flaps and whether radiotherapy is planned or has been
previously used, and reconstruction of the nipple/areola.
Breast reconstruction surgery has been categorized into the following areas:
a) Implant only
40
b) Microvascular tissue with or without implants
c) Non-Microvascular tissue with or without implants
Patient education and awareness about their options for reconstruction is an important
consideration to be able to make informed decisions. All women undergoing breast
cancer surgery should have access to a patient education program and be aware of their
choices regarding breast cancer surgical treatment and reconstruction.
Prophylactic Breast Surgery
The advent of identification of inherited genes in cancer has improved the ability to
identify patients that may be at increased risk of developing breast cancer during their
lifetime. This has enabled prophylactic surgery to be performed on individuals who may
be at very high risk of developing breast cancer in their lifetime. In most cases, this is
elective surgery as the patient must weigh their risk against the side effects of the
proposed treatment. Removal of the organ usually does not detect any cancer as the
organ is removed before the cancer develops. The World Journal of Surgery has
identified the following criteria as important in prophylactic cancer surgery:
1. The genetic mutation causing the hereditary malignancy must have a very high
penetrance and be expressed regardless of environmental factors;
2. There must be a highly reliable test to identify patients who have inherited the
mutated gene;
3. The organ must be removed with minimal morbidity and virtually no mortality;
4. There must be a suitable replacement for the function of the removed organ; and
5. There must be a reliable method of determining over time that the patient has
been cured by "prophylactic surgery."
Women who decide to have prophylactic mastectomy may choose to have breast
reconstruction surgery at the same time as prophylactic mastectomy.
Patients at high risk, according to the recommendations of the Cancer Care Ontario
Breast Cancer Disease Pathway Management Group, may be appropriate candidates
for prophylactic mastectomy. Confirmation of high risk breast cancer status must be
established prior to surgery in order to ensure eligibility for QBP based funding. A preapproval process must be completed to ensure in-scope status.
41
7.1 Breast Cancer Surgery Scope
Factor
Included
Excluded
Diagnosis Lumpectomy,
Mastectomy
&
Procedure
Codes
A lumpectomy or mastectomy surgery will be
identified as a case that has:
• Main diagnosis code: all malignant
neoplasm codes specifically C00 to C97
within ICD-10- CA or organ-related benign
neoplasm, as outlined in Table 4 of
Appendix A
Records where main intervention is
missing
AND
Primary Intervention (CCI procedure
code):
o Lumpectomy as listed in Table 5
Appendix A
o Mastectomy as listed in Table 6
Appendix
An ALND will be identified as a case that has:
• Main diagnosis code: breast-specific
malignant and benign neoplasm diagnosis
codes, as outlined in Table 7 of Appendix A
•
ALND
AND
Primary Intervention (CCI procedure code):
as listed in Table 8 of Appendix A
A SLNB will be identified as a case that has:
• Main diagnosis code: breast-specific
malignant and benign neoplasm diagnosis
codes or observation, follow-up and
screening Z codes, as outlined in Table 9
of Appendix A
•
SLNB
AND
Primary Intervention (CCI procedure code):
o 2MD71LA - Biopsy, axillary lymph
nodes using open approach
A mastectomy + immediate reconstruction
surgery will be identified as a case that has:
• Main diagnosis code: all malignant
neoplasm codes specifically C00 to C97
within ICD-10- CA or organ-related benign
neoplasm, as outlined in Table 4 of
Appendix A
•
Mastectomy +
immediate
reconstruction
AND
Primary Intervention (CCI procedure
code): as listed in Table 10 Appendix A
A delayed breast reconstruction surgery will be
identified as a case that has:
• Main diagnosis code: breast-specific
malignant and benign neoplasm diagnosis
codes or personal history of breast
neoplasm diagnosis codes, as outlined in
•
Delayed
breast
reconstruction
42
Table 11 of Appendix A
AND
Primary Intervention (CCI procedure code):
as listed in Table 12 Appendix A
A prophylactic mastectomy will be identified as a
case that has:
 Main diagnosis code: Z4000 (prophylactic
removal of breast)
•
Prophylactic
Mastectomy
AND
•
Data Source
Primary Intervention (CCI procedure code):
as listed in Tables 6 & 10 of Appendix A
Note: A patient must be pre-approved as highrisk for developing breast cancer to be in-scope
for this QBP
DAD
NACRS
Visit Type/ Activity
Inpatient
• Elective cases
• Urgent cases
• Emergent cases
Day surgery
Additional Patient
Factors
•
•
•
Government insured patients only (i.e.
OHIP)
Patients 18 years of age and over
For prophylactic surgery: Only patients
identified as high-risk within the Ontario
Breast Screening Program (OBSP).
•
•
•
•
•
•
Interventions flagged as ‘Out of
Hospital’
Interventions flagged as
‘Abandoned’
Interventions flagged as
‘Cancelled
Out-of-province records (i.e.,
Province not equal “ON”)
Records where responsibility for
Payment is not equal to ‘01’
Records where calculated age is
less than 18 years. Age is
calculated as the difference
between admit date and birth
date
43
7.2 Best practices guiding the implementation of Breast
Cancer Surgery
Breast Cancer Surgery Length of Stay
Analysis
Length of stay analysis was conducted for the in-scope patient cohort over the most recent
timeframe available.
Length of Stay (In-patient)
Category
Breast Surgery
(without
immediate
reconstruction)
Breast Surgery
(with
immediate
recon)
Delayed
Reconstruction
Prophylactic
Interventions(s)
Lumpectomy
Mastectomy
ALND
SLNB
Implants only
Microvascular Tissue
(+/-implants)
Non-microsurgical
Tissue (+/-implants)
Implants Only
Microvascular Tissue
(+/-implants)
Non-microsurgical
Tissue (+/-implants)
Prophylactic
Mastectomy
Mastectomy with
immediate
reconstruction
1213
1314
1415
LOS
LOS
LOS
LOS
LOS
LOS
Volume Mean Median Volume Mean Median Volume Mean Median
613
1852
159
12
224
1.6
1.6
1.2
4.0
1.3
1
1
1
1
1
575
1875
116
5
228
1.6
1.5
1.2
1.5
1.3
1
1
1
1.5
1
560
1783
116
7
232
1.4
1.6
1.2
1.1
1.4
1
1
1
1
1
101
4.4
4
117
4.5
4
125
4.6
4
41
42
2.7
1.3
2
1
49
65
3.3
1.3
3
1
47
77
3.0
1.4
3
1
139
4.2
4
137
4.3
4
146
4.2
4
132
3.0
2.5
121
2.4
2
133
2.6
2
63
1.4
1
85
1.2
1
93
1.3
1
110
2.3
2
132
2.3
1
164
2.3
1
44
Recommendation:
The following recommendations are based on analysis of empirical data and expert
consensus:
In-patient Procedure Type
Breast
Cancer
Surgery
Prophylactic
Mastectomy
Best
Practice
Length of
Stay
Breast surgery without reconstruction (mastectomy, lumpectomy, ALND, SLNB)
1 day
Reconstruction (immediate and delayed) – Implants only
1 day
Reconstruction (immediate and delayed) – Non-microsurgical tissue (+/- implants)
3 days
Reconstruction (immediate and delayed) –Microsurgical tissue (+/- implants)
4 days
Mastectomy without reconstruction
1 day
Mastectomy with immediate reconstruction – Implants only
1 day
Mastectomy with immediate reconstruction - Non-microsurgical tissue (+/- implants)
3 days
Mastectomy with immediate reconstruction – Microsurgical tissue (+/- implants)
4 days
Please note: Analysis shows that the average LOS in hours for day surgery patients fits
within the CIHI day surgery definition. The proportion of breast surgery patients treated as
day surgery versus in-patient will be monitored to assess for practice change as a result of
QBP implementation.
Breast Cancer Surgery Best Practice Definition
Relevant Documents
Cancer Care Ontario Guidelines:
•
Sentinel Lymph Node Biopsy in Early-Stage Breast Cancer July 2009
• Special Report: Multidisciplinary Cancer Conferences (MCC) June 2006
•
Breast cancer reconstruction surgery (immediate and delayed) across Ontario:
Patient indications and appropriate surgical options (publication pending)
•
Breast Cancer Pathway Map (2015)
Additional Guidelines:
•
•
•
Guidelines to the Practice of Anesthesia, Revised Edition 2015
Venous Thromboembolism Prophylaxis and Treatment in Patients with Cancer:
American Society of Clinical Oncology Clinical Practice Guideline Update 2014
Prevention of VTE in Non-orthopedic Surgical Patients, 9th Edition: American College
of Chest Physicians Evidence-Based Clinical Practice Guidelines
45
•
Best Practice in General Surgery Guideline #1: Strategies to Prevent Surgical Site
Infections, Updated June 2012
Pathway Development Process
To develop the best practice pathways of care for breast cancer surgery procedures the
following process was followed:
•
A literature search and environmental scan was completed
•
Existing care paths were collected from the hospitals of QBP members.
•
Common practices and collaborative guidelines were then consolidated to create the
best practice care path recommended for the patient population
•
Expert consensus was obtained with the working group
The best practice focused on identifying and implementing evidence-informed practice
driven by clinical consensus. The pathway reflects current available evidence and it is
recognized that changes to the evidence may occur between review cycles.
Best practice for the various types of breast cancer surgery has been categorized into the
following stages:
1. Pre-Surgical Assessment (~ 4 weeks prior to check-in)
2. Day of Surgery (Day 0): Pre-Operative Care Unit (POCU)
3. Day of Surgery (Day 0): Operating Room
4. Day of Surgery (Day 0): Post-Anesthetic Care Unit (PACU)
5. Post-operative Surgery: Day 1+ onward (day after OR)
Final Recommendations
These pathways are intended to represent care for patients receiving a breast cancer
surgery procedure for either day surgery or in-patient surgery.
•
•
Day Surgery includes the Pre-Surgical Assessment phase to the Day of Surgery –
PACU phase
In-Patient includes the entire pathway from the Pre-Surgical Assessment phase to
the Post-operative Day 1+ Onwards phase.
46
As a number of breast procedures are included in the QBP, a summary of the best practice
for each clinical pathways is provided.
Surgical Treatment
1. Breast surgery without
reconstruction (mastectomy,
lumpectomy, ALND, SLNB)
2. Mastectomy + Immediate
Reconstruction
3. Delayed Breast Reconstruction
Day Surgery
Pre-Surgical
Assessment phase to
the Day of Surgery –
PACU phase
In-Patient
Entire pathway from
the Pre-Surgical
Assessment phase
to the Postoperative Day 1+
Onwards phase
4. Prophylactic Surgery
47
Breast Surgery Best Practice Clinical Pathway Recommendations:
a) Breast surgery without reconstruction (mastectomy, lumpectomy, ALND, SLNB)
1. Pre-Surgical Assessment (~4 weeks prior to check-in)
Tests:
 Appropriate breast imaging
Recommended if clinically indicated:
 CBC
 ECG if patient has heart disease, diabetes or other risk factors for cardiac condition
 Na, K, Cl, creatinine, glucose, electrolytes
 Urinalysis if signs of urinary tract infection
 Pregnancy test if pregnancy possible
 PT/PTT/INR for patient on anticoagulant therapy or has liver disease
Assessments:
 Physical assessment (vital signs, HT, WT, O2 saturation)
 Pre-operative questionnaire (patient history and physical form)
Treatments:
 Sentinel lymph node injection – on day prior to surgery only if this service is unavailable on day of
surgery
 Localization – as required - on day prior to surgery only if this service is unavailable on day of
surgery
Consults:
 Nursing
 CCAC - as required
 Anesthesiology/Pain management consult - as required
 Internal Medicine (Cardiology, etc.) - as required
 Plastic surgery - as required
 Medical Oncology - as required
 Radiation Oncology - as required
 Physiotherapy – as required
 Psychosocial referral – as required
Medications:
 Review all current medication (by Pharmacist)
 Note allergies and intolerances
 Provide information about discontinuation of NSAIDS/ antiplatelet/ anticoagulants if necessary
 Complete medication reconciliation form
Patient/Family Teaching:
 Educate patient on the surgical procedure
 Review pre-operation events and expectations
 Review post-operative events and expectations
 Inform patient about blood transfusion should it become necessary – as required
 Review plan for pain management
 Review self-care measures and wound management to prevent post-op complications
 Teach arm exercises
Particularly important for patients receiving ALND
 Review patient education booklets, pamphlets, etc.
 Provide prosthesis information – as required
 Clarify any patient questions
Discharge Planning:
 Review discharge plan with the patient including, expected length of stay, discharge time, and
issues or complications that could delay discharge
 Discuss available supports on discharge
48

Involve Social worker or CCAC if necessary
2. Day of Surgery- POCU
Assessments:
 Pre-operative assessment by nurse, surgeon and anesthesiologist
 Ensure medications have been taken as directed
 Vital signs, O2 saturation
 Pre-operative marking to verify laterality
 Blood work - as required (e.g. glucose)
Treatments:
 Sentinel lymph node injection – as required
 Localization – as required
Medications:
 VTE prophylaxis administered in the POCU or operating room should be considered for at risk
patients (i.e. high Caprini score or other risk factors)
 Multimodal analgesic regimen should be considered
Nutrition:



No solid food after midnight the day prior to surgery
Clear liquids until 2-3 hours prior to surgery
NPO 2-3 hours prior to surgery
3. Day of Surgery- Operating Room
Assessments:
 Complete surgical checklist
 Imaging of localization – as required
 Intraoperative frozen section – as required
 Essential intra-operative imaging available – as required
 When lesion localization techniques are used, specimen imaging to confirm complete excision
Treatments:
 Lumpectomy, Mastectomy (+/- SLND or ALND) , ALND or SLNB performed
 Ensure all equipment is available
 Ensure all human resources are present (OR nurse, surgeon, anesthesiologist, radiology as
needed)
 Pathology requisition completed by surgeon
 Use CCO requirements for sending specimen to pathology
 Ensure specimen is appropriately labelled and oriented to send to pathology for
processing/assessment
 Ensure the specimen is sent to pathology in the recommended timeframe for molecular and
receptor analysis
 Time to specimen fixation should be within 1 hour
Medications:
 Patient specific medication
 Pain medication
 Local anesthetic block – as required
4. Day of Surgery- PACU (Day 0)
NOTE: End point for day surgery
Assessment:
 Post-operative assessment by nurse and/or surgeon (system & pain)
 Patient recovery (assess for haematoma or frank bleeding at all sites)
49
Consults:
 Acute Pain Services - as required
 CCAC consult – as required
o CCAC consult is required if drain is present
Treatment:
 Monitor patient recovery (e.g. intake and output, wound dressing, pain, nausea)
 Monitor closed drainage system, if drain present
Medication:
 Patient specific medication
 Pain medication
 Antiemetic
Activity:
 Breathing and recovery exercises; other activity as tolerated
 Early ambulation is recommended, as tolerated
Nutrition:
 Clear fluids and progress to DAT
Patient/Family Teaching
 Deep breathing and coughing
For Day Surgery Patients:
 Ensure patient has education materials
 Review prescription and medication protocol
 Review signs and symptoms of wound infection
 Sponge bath until drain and/or initial dressing removed
 Exercise program
 Review pre-operative teachings (home management of wound, pain management, arm exercises,
etc.)
Discharge Planning
For Day Surgery patients:
 Discuss discharge preparation
 Ensure patient meets clinical indicators to be discharged
 Review discharge plan with patient and family
 Inform patients of follow-up appointments
5. Day after Surgery- Post Operative Day 1+ onwards
NOTE: Only applicable to in-patient
Assessment:
 Discharge assessment by nurse and/or surgeon (system, pain, recovery)
Consults:
 CCAC consult – as required
• CCAC consult is required if drain is present
Treatment:
 Monitor patient recovery (e.g. intake and output, wound dressing, pain, nausea)
 Monitor closed drainage system, if drain present
Medication:
 Patient specific medication
 Pain medication
 Antiemetic
Activity:
 Activity as tolerated
Nutrition
 Diet as tolerated
Patient/Family Teaching:
 Ensure patient has education materials
50
Review prescription and medication protocol
Review signs and symptoms of wound infection
Sponge bath until drain and/or initial dressing removed
Exercise program
Review pre-operative teachings (home management of wound, pain management, arm exercises,
etc.)
Discharge Planning:
 Discuss discharge preparation
 Ensure patient meets clinical indicators to be discharged
 Review discharge plan with patient and family
 Inform patients of follow-up appointments





b) Mastectomy + Immediate Reconstruction
1. Pre-Surgical Assessment (~4 weeks prior to check-in)
Tests:
 Appropriate breast imaging
Recommended if clinically indicated:
• CBC
• ECG if patient has heart disease, diabetes or other risk factors for cardiac condition
• Na, K, Cl, creatinine, glucose, electrolytes
• Urinalysis if signs of urinary tract infection
• Pregnancy test if pregnancy possible
• PT/PTT/INR for patient on anticoagulant therapy or has liver disease
Assessments:
 Physical assessment (vital signs, HT, WT, O2 saturation)
 Pre-operative questionnaire (patient history and physical form)
 Review of the Surgical Consent and confirm all planned procedures
Treatments:
 Sentinel lymph node injection – on day prior to surgery only if this service is unavailable on day of
surgery
 Localization – on day prior to surgery only if this service is unavailable on day of surgery
Consults:
 Nursing
 CCAC - as required
 Anesthesiology/Pain management consult - as required
 Internal Medicine (Cardiology, etc.) - as required
 Plastic surgery - as required
 Medical Oncology - as required
 Radiation Oncology - as required
 Physiotherapy – as required
 Psychosocial referral – as required
Medications:
 Review all current medication (by Pharmacist)
 Note allergies and intolerances
 Provide information about discontinuation of NSAIDS/ antiplatelet/ anticoagulants if necessary
 Complete medication reconciliation form
 Provide information about discontinuation of endocrine and/or hormonal therapy for patients
receiving a microsurgical reconstruction
Patient/Family Teaching:
 Educate patient on the surgical procedure
 Review pre-operation events and expectations
51
Review post-operative events and expectations
Inform patient about blood transfusion should it become necessary – as required
Review plan for pain management
Review self-care measures and wound management to prevent post-op complications
Teach arm exercises
Particularly important for patients receiving ALND and/or immediate breast reconstruction
 Review patient education booklets, pamphlets, etc.
 Provide prosthesis information – as required
 Clarify any patient questions
Discharge Planning:
 Review discharge plan with the patient including, expected length of stay, discharge time, and
issues or complications that could delay discharge
 Discuss available supports on discharge
 Involve Social worker or CCAC if necessary





2. Day of Surgery- POCU
Assessments:
 Pre-operative assessment by nurse, surgeon and anesthesiologist
 Ensure medications have been taken as directed
 Vital signs, O2 saturation
 Pre-operative marking to verify laterality and flap donor site (if using flap reconstruction)
 Blood work - as required (e.g. glucose)
Treatments:
 Sentinel lymph node injection – as required
 Localization – as required
Medications:
 VTE prophylaxis administered in the POCU or operating room should be considered for at risk
patients (i.e. high Caprini score or other risk factors)
- VTE prophylaxis is recommended for all patients receiving a flap reconstruction (micro and
non-microsurgical) and should be administered as per institution protocol
 Multimodal analgesic regimen should be considered
Nutrition:



No solid food after midnight the day prior to surgery
Clear liquids until 2-3 hours prior to surgery
NPO 2-3 hours prior to surgery
3. Day of Surgery- Operating Room
Assessments:
 Complete surgical checklist
 Imaging of localization – as required
 Intraoperative frozen section – as required
 Essential intra-operative imaging available – as required
Treatments:
 Mastectomy (+/- SLND or ALND if necessary) performed, plus immediate breast reconstruction
 Implants only
 Non-microsurgical (+/- implants)
 Microsurgical (+/- implants)
 Ensure all equipment is available
 Ensure implants or tissue expanders are available in the OR, as required
 Ensure microscope is available for microsurgical procedure
 Ensure all human resources are present (OR nurse, general surgeon + plastic surgeon,
anesthesiologist)
52
Pathology requisition completed by surgeon
Use CCO requirements for sending specimen to pathology
Ensure specimen is appropriately labelled and oriented to send to pathology for
processing/assessment
 Ensure the specimen is sent to pathology in the recommended timeframe for molecular and
receptor analysis
 Time to completed specimen fixation should be within 1 hour
Medications:
 Patient specific medication
 Pain medication
 Consider use of PCA and multimodal pain medications if patient is receiving immediate
reconstruction with any type of flap
 Local anesthetic block – as required



4. Day of Surgery- PACU (Day 0)
NOTE: End point for day surgery
Tests:
For patients that received a flap reconstruction:
• CBC
Assessment:
 Post-operative assessment by nurse and/or surgeon (system & pain)
 Patient recovery (assess for haematoma or frank bleeding at all sites)
Consults:
 Acute Pain Services - as required
 CCAC consult – as required
CCAC consult is required if drain is present
Treatment:
 Monitor patient recovery (e.g. intake and output, wound dressing, pain, nausea)
 Monitor closed drainage system, if drain present
 Monitor flap viability, if flap reconstruction performed
For non-microsurgical flap reconstructions, assess flap viability q 4-8 hours
For microsurgical flap reconstructions, assess flap every hour for the first 24 hours
Medication:
 Patient specific medication
 Pain medication
Consider use of PCA and multimodal pain medications if patient received immediate
reconstruction with any type of flap
 Antiemetic
 Antibiotic prophylaxis should be considered for patients that received an implant to prevent
infection
 VTE prophylaxis is recommended for all patients receiving a flap (micro and non-microsurgical)
reconstruction and should be administered as per institution protocol.
Activity:
 Breathing and recovery exercises; other activity as tolerated
 Early ambulation is recommended, as tolerated
 No heavy lifting greater than 10 lbs with arms for the first 3 weeks
Nutrition:
 Clear fluids and progress to DAT
For patients that received a microsurgical flap reconstruction:
 NPO for the first 24 hours and thereafter progression clear fluids and DAT
Patient/Family Teaching
 Deep breathing and coughing
For Day Surgery Patients:
 Ensure patient has education materials
 Review prescription and medication protocol
53
Review signs and symptoms of wound infection
Review signs and symptoms of implant infection, as required
Sponge bath until drain and/or initial dressing removed
Exercise program
Review pre-operative teachings (home management of wound, pain management, arm exercises,
etc.)
Discharge Planning
For Day Surgery patients:
 Discuss discharge preparation
 Ensure patient meets clinical indicators to be discharged
 Review discharge plan with patient and family
 Inform patients of follow-up appointments
 Discuss the surveillance plan for recurrence, in alignment with the regular breast cancer follow-up
regimen





5. Day after Surgery- Post Operative Day 1+ onwards
NOTE: Only applicable to in-patient
Assessment:
 Discharge assessment by nurse and/or surgeon (system, pain, recovery)
Consults:
 CCAC consult – as required
• CCAC consult is required if drain is present
Treatment:
 Monitor patient recovery (e.g. intake and output, wound dressing, pain, nausea)
 Monitor closed drainage system, if drain present
 Monitor flap viability, if flap reconstruction performed
• Assess flap viability q 4-8 hours
• For microsurgical flap reconstructions, assess flap every hour for the first 24 hours
Medication:
 Patient specific medication
 Pain medication
 Antiemetic
 Antibiotic prophylaxis should be considered for patients that received an implant to prevent
infection
 VTE prophylaxis is recommended for all patients receiving a flap reconstruction (micro and nonmicrosurgical) and should be administered as per institution protocol.
Activity:
 Activity as tolerated
 Early ambulation is recommended, as tolerated
 No heavy lifting greater than 10 lbs with arms for the first 3 weeks
Nutrition
 Diet as tolerated
For patients that received a microsurgical flap reconstruction:
 NPO for the first 24 hours and thereafter progression to clear fluids and DAT
Patient/Family Teaching:
 Ensure patient has education materials
 Review prescription and medication protocol
 Review signs and symptoms of wound infection
 Review signs and symptoms of implant infection, as required
 Sponge bath until drain and/or initial dressing removed
 Exercise program
 Review pre-operative teachings (home management of wound, pain management, arm exercises,
etc.)
54
Discharge Planning:
 Discuss discharge preparation
 Ensure patient meets clinical indicators to be discharged
 Review discharge plan with patient and family
 Inform patients of follow-up appointments
 Discuss the surveillance plan for recurrence, in alignment with the regular breast cancer follow-up
regimen
c) Delayed Breast Reconstruction
1. Pre-Surgical Assessment (~4 weeks prior to check-in)
Tests:
Recommended if clinically indicated:
 CBC
 ECG if patient has heart disease, diabetes or other risk factors for cardiac condition
 Na, K, Cl, creatinine, glucose, electrolytes
 Urinalysis if signs of urinary tract infection
 Pregnancy test if pregnancy possible
 PT/PTT/INR for patient on anticoagulant therapy or has liver disease
Assessments:
 Physical assessment (vital signs, HT, WT, O2 saturation)
 Pre-operative questionnaire (patient history and physical form)
 Review of the Surgical Consent and confirm all planned procedure(s)
Consults:
 Plastic surgery
 Nursing
 General surgery – as required, based on planned procedure(s)
 Anesthesiology/Pain management consult - as required
 Internal Medicine (Cardiology, etc.) - as required
 Physiotherapy – as required
 Psychosocial referral – as required
Medications:
 Review all current medication (by Pharmacist)
 Note allergies and intolerances
 Provide information about discontinuation of NSAIDS/ antiplatelet/ anticoagulants if necessary
 Provide information about discontinuation of endocrine and/or hormonal therapy for patients
receiving a microsurgical reconstruction
 Complete medication reconciliation form
Patient/Family Teaching:
 Educate patient on the surgical procedure
 Review pre-operation events and expectations
 Review post-operative events and expectations
 Inform patient about blood transfusion should it become necessary – as required
 Review plan for pain management
 Review self-care measures and wound management to prevent post-op complications
 Teach arm exercises
 Review patient education booklets, pamphlets, etc.
 Clarify any patient questions
Discharge Planning:
 Review discharge plan with the patient including, expected length of stay, discharge time, and
issues or complications that could delay discharge
 Discuss available supports on discharge
55

Involve Social worker or CCAC if necessary
2. Day of Surgery- POCU
Assessments:
 Pre-operative assessment by nurse, surgeon(s) and anesthesiologist
 Ensure medications have been taken as directed
 Vital signs, O2 saturation
 Pre-operative marking of breast to verify laterality and flap donor site (if using flap reconstruction)
 Blood work - as required (e.g. glucose)
Medications:
 VTE prophylaxis administered in the POCU or operating room should be considered for at risk
patients (i.e. high Caprini score or other risk factors)
- VTE prophylaxis is recommended for all patients receiving a flap reconstruction (micro and
non-microsurgical) and should be administered as per institution protocol
 Multimodal analgesic regimen should be considered
Nutrition:
 No solid food after midnight the day prior to surgery
 Clear liquids until 2-3 hours prior to surgery
 NPO 2-3 hours prior to surgery
3. Day of Surgery- Operating Room
Assessments:
 Complete surgical checklist
Treatments:
 Breast reconstruction (unilateral or bilateral)
 Implants only
 Non-microsurgical (+/- implants)
 Microsurgical (+/- implants)
 Ensure all equipment is available
 Ensure implants or tissue expanders are available in the OR, as required
 Ensure microscope is available for microsurgical procedures
 Ensure all human resources are present (OR nurse, plastic surgeon +/- general surgeon,
anesthesiologist)
Medications:
 Patient specific medication
 Pain medication
 Consider use of PCA and multimodal pain medications if patient is receiving reconstruction
with any type of flap
 Local anesthetic block – as required
4. Day of Surgery- PACU (Day 0)
NOTE: End point for day surgery
Tests:
For patients that received a flap reconstruction:
 CBC
Assessment:
 Post-operative assessment by nurse and/or surgeon (system & pain)
 Patient recovery (assess for haematoma or frank bleeding at all sites)
Consults:
 Acute Pain Services - as required
56
CCAC consult – as required
o CCAC consult is required if drain is present
Treatment:
 Monitor patient recovery (e.g. intake and output, wound dressing, pain, nausea)
 Monitor closed drainage system, if drain present
 Monitor flap viability, if flap reconstruction performed
o For non-microsurgical flap reconstructions, assess flap viability q 4-8 hours
o For microsurgical flap reconstructions, assess flap every hour for the first 24 hours
Medication:
 Patient specific medication
 Pain medication
o Consider use of PCA and multimodal pain medications if patient received reconstruction
with any type of flap
 Antiemetic
 Antibiotic prophylaxis should be considered for patients that received an implant to prevent
infection
 VTE prophylaxis is recommended for all patients receiving a flap reconstruction (micro and nonmicrosurgical) and should be administered as per institution protocol.
Activity:
 Breathing and recovery exercises; other activity as tolerated
 Early ambulation is recommended, as tolerated
 No heavy lifting greater than 10 lbs with arms for the first 3 weeks
Nutrition:
 Clear fluids and progress to DAT
For patients that received a microsurgical flap reconstruction:
 NPO for the first 24 hours and thereafter progression clear fluids and DAT
Patient/Family Teaching
 Deep breathing and coughing
For Day Surgery Patients:
 Ensure patient has education materials
 Review prescription and medication protocol
 Review signs and symptoms of wound infection
 Review signs and symptoms of implant infection, as required
 Sponge bath until drain and/or initial dressing removed
 Exercise program
 Review pre-operative teachings (home management of wound, pain management, arm exercises,
etc.)
Discharge Planning
For Day Surgery patients:
 Discuss discharge preparation
 Ensure patient meets clinical indicators to be discharged
 Review discharge plan with patient and family
 Inform patients of follow-up appointments
 Discuss the surveillance plan for recurrence, in alignment with the regular breast cancer follow-up
regimen

5. Day after Surgery- Post Operative Day 1+ onwards
NOTE: Only applicable to in-patient
Assessment:
 Discharge assessment by nurse and/or surgeon (system, pain, recovery)
Consults:
 CCAC consult – as required
• CCAC consult is required if drain is present
57
Treatment:
 Monitor patient recovery (e.g. intake and output, wound dressing, pain, nausea)
 Monitor closed drainage system, if drain present
 Monitor flap viability, if flap reconstruction performed
• For non-microsurgical flap reconstructions, assess flap viability q 4-8 hours until discharge
• For microsurgical flap reconstructions, assess flap viability q 4-8 hours until discharge
Medication:
 Patient specific medication
 Pain medication
 Antiemetic
 Antibiotic prophylaxis should be considered for patients that received an implant to prevent
infection
 VTE prophylaxis is recommended for all patients receiving a flap reconstruction (micro and nonmicrosurgical) and should be administered as per institution protocol.
Activity:
 Activity as tolerated
 Early ambulation is recommended, as tolerated
 No heavy lifting greater than 10 lbs with arms for the first 3 weeks
Nutrition
 Diet as tolerated
For patients that received a microsurgical flap reconstruction:
 NPO for the first 24 hours and thereafter progression to clear fluids and DAT
Patient/Family Teaching:
 Ensure patient has education materials
 Review prescription and medication protocol
 Review signs and symptoms of wound infection
 Review signs and symptoms of implant infection, as required
 Sponge bath until drain and/or initial dressing removed
 Exercise program
 Review pre-operative teachings (home management of wound, pain management, arm exercises,
etc.)
Discharge Planning:
 Discuss discharge preparation
 Ensure patient meets clinical indicators to be discharged
 Review discharge plan with patient and family
 Inform patients of follow-up appointments
 Discuss the surveillance plan for recurrence, in alignment with the regular breast cancer follow-up
regimen
d) Prophylactic Mastectomy (+/- immediate reconstruction)
1.
Pre-Surgical Assessment (~4 weeks prior to check-in)
Tests:
• Confirmation that patient is at high-risk for developing breast cancer
Recommended if clinically indicated:
 CBC
 ECG if patient has heart disease, diabetes or other risk factors for cardiac condition
 Na, K, Cl, creatinine, glucose, electrolytes
 Urinalysis if signs of urinary tract infection
 Pregnancy test if pregnancy possible
 PT/PTT/INR for patient on anticoagulant therapy or has liver disease
58
Assessments:
 Physical assessment (vital signs, HT, WT, O2 saturation)
 Pre-operative questionnaire (patient history and physical form)
Consults:
 Nursing
 CCAC – as required
 Anesthesiology/Pain management consult - as required
 Internal Medicine (Cardiology, etc.) - as required
 Plastic surgery – as required
 Physiotherapy – as required
 Psychosocial referral – as required
Medications:
 Review all current medication (by Pharmacist)
 Note allergies and intolerances
 Provide information about discontinuation of NSAIDS/ antiplatelet/ anticoagulants if necessary
 Complete medication reconciliation form
Patient/Family Teaching:
 Educate patient on the surgical procedure
 Review pre-operation events and expectations
 Review post-operative events and expectations
 Inform patient about blood transfusion should it become necessary – as required
 Review plan for pain management
 Review self-care measures and wound management to prevent post-op complications
 Teach arm exercises
Particularly important for patients receiving ALND and/or immediate breast reconstruction
 Review patient education booklets, pamphlets, etc.
 Provide prosthesis information – as required
 Clarify any patient questions
Discharge Planning:
 Review discharge plan with the patient including, expected length of stay, discharge time, and
issues or complications that could delay discharge
 Discuss available supports on discharge
 Involve Social worker or CCAC if necessary
2. Day of Surgery- POCU
Assessments:
 Pre-operative assessment by nurse, surgeon(s) and anesthesiologist
 Ensure medications have been taken as directed
 Vital signs, O2 saturation
 Pre-operative marking of breast to verify laterality and flap donor site (if using flap reconstruction)
 Blood work - as required (e.g. glucose)
Medications:
 VTE prophylaxis administered in the POCU or operating room should be considered for at risk
patients (i.e. high Caprini score or other risk factors)
- VTE prophylaxis is recommended for all patients receiving a flap reconstruction (micro and
non-microsurgical) and should be administered as per institution protocol
 Multimodal analgesic regimen should be considered
Nutrition:
 No solid food after midnight the day prior to surgery
 Clear liquids until 2-3 hours prior to surgery
 NPO 2-3 hours prior to surgery
59
3. Day of Surgery- Operating Room
Assessments:
 Complete surgical checklist
Treatments:
 Mastectomy performed, plus immediate breast reconstruction
 Ensure all equipment is available
 Ensure implants or tissue expanders are available in the OR, as required
 Ensure microscope is available for microsurgical procedures
 Ensure all human resources are present (OR nurse, general surgeon + plastic surgeon,
anesthesiologist)
 Pathology requisition completed by surgeon
 Use CCO requirements for sending specimen to pathology
 Ensure specimen is appropriately labelled and oriented to send to pathology for
processing/assessment
 Ensure the specimen is sent to pathology in the recommended timeframe for molecular and
receptor analysis
 Time to completed specimen fixation should be within 1 hour
Medications:
 Patient specific medication
 Pain medication
 Consider use of PCA and multimodal pain medications if patient is receiving reconstruction
with any type of flap
 Local anesthetic block – as required
4. Day of Surgery- PACU (Day 0)
NOTE: End point for day surgery
Tests:
For patients that received a flap reconstruction:
 CBC
Assessment:
 Post-operative assessment by nurse and/or surgeon (system & pain)
 Patient recovery (assess for haematoma or frank bleeding at all sites)
Consults:
 Acute Pain Services - as required
 CCAC consult – as required
o CCAC consult is required if drain is present
Treatment:
 Monitor patient recovery (e.g. intake and output, wound dressing, pain, nausea)
 Monitor closed drainage system, if drain present
 Monitor flap viability, if flap reconstruction performed
o For non-microsurgical flap reconstructions, assess flap viability q 4-8 hours
o For microsurgical flap reconstructions, assess flap every hour for the first 24 hours
Medication:
 Patient specific medication
 Pain medication
o Consider use of PCA and multimodal pain medications if patient received reconstruction
with any type of flap
 Antiemetic
 Antibiotic prophylaxis should be considered for patients that received an implant to prevent
infection
For patients that received a flap reconstruction (micro and non-microsurgical):
 VTE prophylaxis is recommended for all patients receiving a flap reconstruction and should be
administered as per institution protocol.
60
Activity:
 Breathing and recovery exercises; other activity as tolerated
 No heavy lifting greater than 10 lbs with arms for the first 3 weeks
Nutrition:
 Clear fluids and progress to DAT
For patients that received a microsurgical flap reconstruction:
 NPO for the first 24 hours and thereafter progression clear fluids and DAT
Patient/Family Teaching
 Deep breathing and coughing
For Day Surgery Patients:
 Ensure patient has education materials
 Review prescription and medication protocol
 Review signs and symptoms of wound infection
 Review signs and symptoms of implant infection, as required
 Sponge bath until drain and/or initial dressing removed
 Exercise program
 Review pre-operative teachings (home management of wound, pain management, arm exercises,
etc.)
Discharge Planning
For Day Surgery patients:
 Discuss discharge preparation
 Ensure patient meets clinical indicators to be discharged
 Review discharge plan with patient and family
 Inform patients of follow-up appointments
5. Day after Surgery- Post Operative Day 1+ onwards
NOTE: Only applicable to in-patient
Assessment:
 Discharge assessment by nurse and/or surgeon (system, pain, recovery)
Consults:
 CCAC consult – as required
• CCAC consult is required if drain is present
Treatment:
 Monitor patient recovery (e.g. intake and output, wound dressing, pain, nausea)
 Monitor closed drainage system, if drain present
 Monitor flap viability, if flap reconstruction performed
• Assess flap viability q 4-8 hours
Medication:
 Patient specific medication
 Pain medication
 Antiemetic
 Antibiotic prophylaxis should be considered for patients that received an implant to prevent
infection
For patients that received a flap reconstruction (micro and non-microsurgical):
 VTE prophylaxis is recommended for all patients receiving a flap reconstruction and should be
administered as per institution protocol.
Activity:
 Activity as tolerated
 No heavy lifting greater than 10 lbs with arms for the first 3 weeks
Nutrition
 Diet as tolerated
For patients that received a microsurgical flap reconstruction:
 NPO for the first 24 hours and thereafter progression to clear fluids and DAT
61
Patient/Family Teaching:
 Ensure patient has education materials
 Review prescription and medication protocol
 Review signs and symptoms of wound infection
 Sponge bath until drain and/or initial dressing removed
 Exercise program
 Review pre-operative teachings (home management of wound, pain management, arm exercises,
etc.)
Discharge Planning:
 Discuss discharge preparation
 Ensure patient meets clinical indicators to be discharged
 Review discharge plan with patient and family
 Inform patients of follow-up appointments
62
8.0 Implementation of best practices
The Cancer Surgery QBP funding model is based on the following principles, ensuring the
implementation of best practices:
•
Align funding framework development with Ontario’s Excellent Care for All Act &
Patient-Based Payment policy
•
Address in-hospital care phase initially with expansion to the pre-treatment and follow
up care phases
•
Transition on a disease site basis.
•
Use lessons learned from the Cancer Surgery Agreement (CSA) process (allocation,
re-allocation and reconciliation) and apply them to QBP
•
Ensure clinical best practices remain current with existing evidence
•
Continue to maintain linking the implementation of clinical guidelines and organization
guidelines similar to the Schedule B requirements within the Cancer Surgery
Agreement.
•
Ensure model development process is transparent, multi-disciplinary and
collaborative
•
Promote high quality care close to home as appropriate
•
Promote timely access to care
•
Support decreased practice variation
•
Promote value for money and improve efficiency (i.e., track and evaluate money
spent by outcomes achieved)
•
Improve outcome measurement and accountability for reported outcomes
•
Balance implementation of funding framework with financial risk to organizations
•
Ensure that ongoing governance structure (including clinical oversight) is supported
by transparent dispute resolution processes for Cancer Surgery QBP
•
Establish ongoing monitoring, reporting and evaluation of processes/quality
indicators/outcomes
•
Establish recognized and transparent performance management cycle and funding
agreements
•
Respond to and incorporate new evidence and support new models of care
63
8.1 Knowledge Transfer and Exchange of Best Practice Care
Communicating the defined best practice for cancer surgery procedures (in-hospital care) is
critical to the implementation of Cancer Surgery QBP. CCO will work closely not only the
working groups but also hospital administrators and clinicians for successful implementation
within each disease site.
9.0 What does it mean for multi-disciplinary teams?
Successful implementation of the new funding model for cancer surgery requires the
collaboration on the part of all those involved in the patients care delivery. Surgeons,
pathologists, radiation oncologists, radiologist, medical oncologists, anaethesiologists,
nursing and physiotherapists should be aware of and contribute to the best practice. Clerical
staff ensure accurate data entry and coding for reimbursement and quality indicator
measurement. Administrative staff need to be aware of best practice in regards of
performance management and quality indicator reporting.
As the initial implementation of the prostate surgery QBP only addresses the surgical
procedure, the impact on some of the members of the multi-disciplinary team will be
minimal. In future with further expansion of the cancer surgery QBP to include the
Consult/Pre-Treatment Assessment or Follow-up phases will have a greater impact on the
multidisciplinary team.
9.1 How does Cancer Surgery as a QBP align with clinical
practice?
The implementation of previous QBPs, and evidence informed practices have resulted in
improved patient experiences, better outcomes and a streamlined length of stay for patients.
QBPs align with clinical practice by encouraging the adoption of best practices in order to
maximize system capacity and use of available resources. This process will result in
improvements in patient satisfaction and improved quality of care.
9.2 What are the implications for clinicians?
64
The changes associated with the QBPs focus on identifying and implementing evidenceinformed practice driven by clinical consensus. Clinicians will be tasked with identifying
within their own expertise best practice protocols and identifying where there are variances
from such practice. Collaboration with hospital administration will assist the clinicians in
identifying the challenges within the service, as well as opportunities and the feasibility for
changes to the best practice.
Clinicians will continue to play an essential role in guiding hospitals to meet the needs of
their patient population and ensuring that the highest quality care is provided for all their
patients.
At this time, physician payment models and OHIP fee schedules, as they relate to
QBPs will remain unchanged. Physicians currently working under fee-for-service will
continue to submit claims to OHIP for consultations, treatment and follow-up
9.3 Will this change current practice?
The cancer surgery procedure-based funding framework may create change in current
practice for some clinicians and hospitals in Ontario.
10.0 Service capacity planning
The service capacity planning for Cancer Surgery QBP will build on existing processes that
are in place with the Cancer Surgery Agreements (CSA). Hospitals will be required to
maintain their volumes; therefore, resulting in minimal impact or change in service capacity.
65
11.0 Performance evaluation and feedback
In introducing the QBPs the ministry has a strong interest in:
•
Supporting monitoring and evaluation of the impact (intended and unintended) of the
introduction of QBPs
•
Providing benchmark information for clinicians and administrators that will enable
mutual learning and promote on-going quality improvement
•
Providing performance-based information back to Expert Panels to evaluate the
impact of their work and update as required in real time
There was recognition that reporting on a few system-level indicators alone would not be
sufficient to meet the ministry’s aim of informing and enabling quality improvement initiatives
at the provider-level. Therefore measures meaningful to hospitals and clinicians that are
interpretable and have demonstrable value in improving the quality of care provided to
patients are also of utmost importance.
To guide the selection and development of relevant indicators for each QBP, the ministry, in
consultation with experts in evaluation and performance measurement, developed an
approach based on the policy objectives of the QBPs and a set of guiding principles. This
resulted in the creation of an integrated scorecard with the following six quality domains:
•
Effectiveness (including safety)
•
Appropriateness
•
Integration
•
Efficiency
•
Access
•
Patient-centeredness
The scorecard is based on the following guiding principles:
•
Relevance – the scorecard should accurately measure the response of the system to
introducing QBPs
•
Importance – to facilitate improvement, the indicators should be meaningful for all
potential stakeholders (patients, clinicians, administrators, LHINs and the ministry)
•
Alignment – the scorecard should align with other indicator-related initiatives where
appropriate
•
Evidence – the indicators in the integrated scorecard need to be scientifically sound
or at least measure what is intended and accepted by the respective community
(clinicians, administrators and/or policy-decision makers)
66
A set of evaluation questions was identified for each of the QBP policy objectives outlining
what the ministry would need to know in order to understand the intended and unintended
impact of the introduction of QBPs. These questions were translated into key provincial
indicators resulting in a QBP scorecard (see table below).
Quality Domain
What is being measured?
Effectiveness
What are the results of care
received by patients and do
the results vary across
providers that cannot be
explained by population
characteristics as well as is
care provided without
harm?
Is patient care being
provided according to
scientific knowledge and in
a way that avoids overuse,
underuse or misuse?
Appropriateness
Key provincial indicators
1. Proportion of QBPs that improved outcomes
2. Proportion of QBPs that reduced variation in outcome
3. Proportion of (relevant) QBPs that reduced rates of
adverse events and infections
4. Proportion of QBPs that reduced variation in utilization
5. Proportion of (relevant) QBPs that saw a substitution
from inpatient to outpatient/day surgery
6. Proportion of (relevant) QBPs that saw a substitution
to less invasive procedures
7. Increased rate of patients being involved in treatment
decision
8. Proportion of (relevant) QBPs that saw an increase in
discharge dispositions into the community
Integration
Are all parts of the health
system organized,
connected and work with
another to provide high
quality care?
9. Reduction in 30-day readmissions rate (if relevant)
10. Improved access to appropriate primary and
community care including for example psychosocial
support (e.g. personal, family, financial, employment
and/or social needs)
11. Coordination of care (TBD)
12. Involvement of family (TBD)
Efficiency
Access
Does the system make best
use of available resources
to yield maximum benefit
ensuring that the system is
sustainable for the long
term?
Are those in need of care
able to access services
when needed?
13. Actual costs vs. QBP price
14. Increase in wait times for QBPs / for specific
populations for QBP
15. Increase in wait times for other procedures
16. Increase in distance patients have to travel to receive
the appropriate care related to the QBP
17. Proportion of providers with a significant change in
resource intensity weights (RIW)
67
Quality Domain
What is being measured?
PatientCenteredness
(to be further
developed)
Is the patient/user at the
center of the care delivery
and is there respect for and
involvement of patients’
values, preferences and
expressed needs in the
care they receive? (TBC)
Key provincial indicators
18. Increased rate of patients being involved in treatment
decision
19. Coordination of care (TBD)
20. Involvement of family (TBD)
It should be noted that although not explicitly mentioned as a separate domain, the equity
component of quality of care is reflected across the six domains of the scorecard and will be
assessed by stratifying indicator results by key demographic variables and assessing
comparability of findings across sub-groups. Where appropriate, the indicators will be riskadjusted for important markers of patient complexity so that they will provide an accurate
representation of the quality of care being provided to patients.
The ministry and experts recognized that to be meaningful for clinicians and administrators,
it is important to tie indicators to clinical guidelines and care standards. Hence, advisory
groups that developed the best practices were asked to translate the provincial-level
indicators into QBP-specific indicators. In consulting the advisory groups for this purpose,
the ministry was interested in identifying indicators both for which provincial data is readily
available to calculate and those for which new information would be required. Measures in
the latter category are intended to guide future discussion with ministry partners regarding
how identified data gaps might be addressed.
In developing the integrated scorecard approach, the ministry recognized the different users
of the indicators and envisioned each distinct set of measures as an inter-related cascade of
information. That is, the sets of indicators each contain a number of system or provincial
level measures that are impacted by other indicators or driving factors that are most relevant
at the Local Health Integration Networks (LHINs), hospital or individual clinician level. The
indicators will enable the province and its partners to monitor and evaluate the quality of
care and allow for benchmarking across organizations and clinicians. This will in turn
support quality improvement and enable target setting for each QBP to ensure that the focus
is on providing high quality care, as opposed to solely reducing costs.
It is important to note that process-related indicators selected by the expert panels will be
most relevant at the provider level. The full list of these measures is intended to function as
a ‘menu’ of information that can assist administrators and clinicians in identifying areas for
quality improvement. For example, individual providers can review patient-level results in
conjunction with supplementary demographic, financial and other statistical information to
help target care processes that might be re-engineered to help ensure that high-quality care
is provided to patients.
68
Baseline reports and regular updates on QBP specific indicators will be included as
appendices to each QBP Clinical Handbook. Reports will be supplemented with technical
information outlining how results were calculated along with LHIN and provincial-level
results that contextualize relative performance. Baseline reports will also be accompanied
by facility-level information that will facilitate sharing of best practices and target setting at
the provider-level.
The ministry recognizes that the evaluation process will be on-going and will require
extensive collaboration with researchers, clinicians, administrators and other relevant
stakeholders to develop, measure, report, evaluate and, if required, revise and/or include
additional indicators to ensure that the information needs of its users are met.
69
12.0 Cancer Surgery Quality Indicators
Measuring the quality of care provided to Ontarians is a significant aspect of the QBP funding initiative. Many indicators
on the provincial scorecard apply to cancer surgery and have been highlighted. In addition, more indicators for cancer
surgeries have been selected that either relate to: a) all cancer surgeries or b) are disease site specific.
Quality Domain
Description
Effectiveness
What are the
results of care
received by
patients and do
the results vary
across
providers that
cannot be
explained by
population
characteristics
as well as is
care provided
without harm?
Is patient care
being provided
according to
scientific
knowledge and
in a way that
avoids overuse,
underuse or
misuse?
Appropriateness
Prostate Cancer
1.
2.
3.
4.
5.
6.
Thyroid Cancer*
Colorectal Cancer
Breast Cancer**
Proportion of patients reoperated on within 30
days after radical
prostatectomy
Proportion of patients
that died within 30 days
after radical
prostatectomy
Proportion of patients
that experience a
complication (e.g. rectal
injury, transfusion rate,
SSI)
1. Proportion of patients reoperated on within 30 days
after a colorectal resection
2. Proportion of patients that
died within 30 days after a
colorectal resection
3. Proportion of patients that
experience a complication
(e.g. anastomotic leak, SSI)
1. Proportion of patients re1. Proportion of patients reoperated on within 30 days
operated on (for a nonafter thyroidectomy
breast ablative procedure)
2. Proportion of patients that
within 30 days after breast
died within 30 days after a
surgery
2. Proportion of patients that
thyroidectomy
died within 30 days after a
3. Proportion of patients that
breast surgery
experience a complication
(e.g. recurrent laryngeal nerve
injury, hypoparathyroidism)
Discipline participation in
a high-quality
Multidisciplinary Cancer
Conference (MCC)
Proportion of patients
that receive a radiation
oncologist consult or
discussion at a MCC
prior to surgery
Proportion of patients
with positive pT2 margins
after radical
prostatectomy
3. Discipline participation in a
high-quality Multidisciplinary
Cancer Conference (MCC)
4. Proportion of patients with
positive circumferential
margins after rectal
resection
5. Proportion of colon resection
patients with 12 or more
lymph node retrieved
6. Proportion of patients that
receive a MRI and CT
before rectal cancer surgery
3. Discipline participation in a
4. Discipline participation in a
high-quality
high-quality Multidisciplinary
Cancer Conference (MCC)
Multidisciplinary Cancer
5. Proportion of patients that
Conference (MCC)
received a partial
4. Proportion of patients that
receive appropriate prethyroidectomy for low risk
operative imaging of the
disease
breast (mammogram
6. Proportion of patients found to
and/or ultrasound and/or
have benign disease following
MRI)
thyroidectomy
5. Proportion of patients
7. Proportion of patients with
staged with fine needle
adequate lymph node
retrieval following central neck
aspiration or core biopsy
dissection
prior to resection
6. Proportion of patients with
positive margins after
70
Quality Domain
Description
Prostate Cancer
Thyroid Cancer*
Colorectal Cancer
Breast Cancer**
breast cancer surgery
(lumpectomy and
mastectomy)
Integration
Efficiency
Access
Are all parts of
the health
system
organized,
connected and
work with
another to
provide high
quality care?
Does the
system make
best use of
available
resources to
yield maximum
benefit ensuring
that the system
is sustainable
for the long
term?
Are those in
need of care
able to access
services when
needed?
7.
8.
9.
Proportion of patient
readmissions within 30
days of discharge
Proportion of patients
with positive margins that
had a radiation oncology
consult post-surgery
8. Proportion of patient
8. Proportion of patient
readmissions within 30 days
readmissions within 30 days
of discharge
of discharge
7. Proportion of patient
readmissions within 30
days of discharge
Average length of stay for
a radical prostatectomy
patient
9. Average length of stay for a
colorectal resection patient
8. Average length of stay for
breast surgery patients
10. Proportion of prostate
cancer surgery patients
that received surgery
(Wait 2) within the priority
target
11. Proportion of patients
with a discharge
disposition into the
community
9. Average length of stay for
thyroidectomy patients
10. Proportion of thyroid cancer
10. Proportion of colorectal
surgery patients that
cancer surgery patients
received surgery (Wait 2)
that received surgery
within the priority target
(Wait 2) within the priority
target
71
9. Proportion of breast cancer
surgery (+/- immediate
reconstruction) patients
that received surgery (Wait
2) within the priority target
10. Proportion of mastectomy
patients that receive
reconstruction within 2
years post mastectomy
Quality Domain
Description
PatientCenteredness
(to be further
developed)
Is the
patient/user at
the center of the
care delivery
and is there
respect for and
involvement of
patients’ values,
preferences and
expressed
needs in the
care they
receive? (TBC)
Prostate Cancer
Thyroid Cancer*
Colorectal Cancer
NOTES:
Breast Cancer**
*Although medullary thyroid cancer patients are included in the Thyroid Cancer Surgery QBP, the Working Group felt that measurement of an indicator specific
to medullary cancer would be of limited value due to the small number of patients
**An indicator specific to prophylactic mastectomy may be determined at a later date
72
13.0 Support for Change
Cancer Care Ontario (CCO) will continue to work with various stakeholders across the
province to educate all multidisciplinary teams impacted by the new Cancer Surgery
Funding Model. Currently, CCO works with numerous clinical specialists that will
provide the necessary support for clinical knowledge transfer and exchange (KTE).
The ministry, in collaboration with its partners, will deploy a number of field supports to
support adoption of the funding policy. These supports include:
•
Committed clinical engagement with representation from cross-sectoral health
sector leadership and clinicians to champion change through the development of
standards of care and the development of evidence-informed patient clinical
pathways for the QBPs.
•
Dedicated multidisciplinary clinical expert group that seek clearly defined purposes,
structures, processes and tools which are fundamental for helping to navigate the
course of change.
•
Strengthened relationships with ministry partners and supporting agencies to seek
input on the development and implementation of QBP policy, disseminate quality
improvement tools, and support service capacity planning.
•
Alignment with quality levers such as the Quality Improvement Plans (QIPs). QIPs
strengthen the linkage between quality and funding and facilitate communication
between the hospital board, administration, providers and public on the hospitals’
plans for quality improvement and enhancement of patient-centered care.
•
Deployment of a Provincial Scale Applied Learning Strategy known as IDEAS
(Improving the Delivery of Excellence across Sectors). IDEAS is Ontario’s
investment in field-driven capacity building for improvement. Its mission is to help
build a high-performing health system by training a cadre of health system change
agents that can support an approach to improvement of quality and value in
Ontario.
We hope that these supports, including this Clinical Handbook, will help facilitate a
sustainable dialogue between hospital administration, clinicians, and staff on the
underlying evidence guiding QBP implementation. The field supports are intended to
complement the quality improvement processes currently underway in your
organization.
73
14.0 Frequently Asked Questions
There have been no frequently asked questions identified to date.
74
15.0 Membership
The following table outlines the members of the Cancer Surgery QBP Advisory
Committee:
* Cancer Care Ontario representative
CANCER SURGERY QBP ADVISORY COMMITTEE (2015)
NAME
TITLE & ORGANIZATION
NAME
Dr Jonathan Irish*
Provincial Health, Surgical Oncology
Program
Faith Forbes
Dr Alice Wei*
Surgical Lead, Quality Improvement &
Knowledge Transfer
Dr. Stan Feinburg
Garth Matheson*
Vice- President, Planning & Regional
Program
Leslie Motz
Irene Blais*
Director, Funding Unit,
Dr. John Dickie
Elaine Meertens*
Director, Regional Programs
Brenda Carter
Saul Melamed*
Director, Clinical Programs & Quality
Initiative,
Nathalie Cadieux
Amber Hunter*
Manager, Surgical Oncology Program,
Leigh McKnight*
Sukaina Sheraly*
Project Lead, Surgical Oncology
Program
Project Lead, Surgical Oncology
Program
Dr. Sudir
Sundaresan
Dr. Mike Anderson
Tiz Silveri
Julia Monakova*
Manager, Funding Unit
Dr. Jeff Kolbasnik
Dr. Aaron Pollet*
Provincial Head, Pathology &
Laboratory Medicine
Anubhu Prashad
Jeff Booth
Director, Windsor Regional Cancer
Centre
Thomas Smith
Silvie Crawford
Vice-President, Patient Centred Care,
London Health Sciences
Marnie Escaf
Dr. Stephen Pautler
Judy Burns
Dr. Ved Tandan
Regional Surgical Lead, St. Joseph’s
Hospital- London
Regional Vice-President, Grand River
Regional Cancer Center
Regional Surgical Lead, St. Joseph’s
Hospital- Hamilton
Dr. Andy Smith
Filomena Travossos
Kim Alvardo
TITLE & ORGANIZATION
Finance & Manager of Redevelopment,
HBAM & QBP, Humber River Hospital
Medical Director of Cancer Care &
Ambulatory Care, North York General
Hospital
Senior Director, Surgery, Pharmacy,
Ambulatory Clinics, OTN, Lakeridge
Health
Head, Section of Thoracic Surgery &
Chief, Department of Surgery,
Lakeridge Health
Regional Vice President, South East
LHIN, Kingston General Hospital
Corporate Financial Controller, The
Ottawa Hospital
Chief, Division of Thoracic Surgery, The
Ottawa Hospital
Regional Surgical Lead, Simcoe
Muskoka Regional Cancer Centre
Vice President of Clinical Services,
North Bay Regional Health Centre
Chief, Department of Surgery, Halton
Healthcare Services and Chair, General
Surgery Section, Ontario Medical
Association
Senior Policy Consultant, MOHLTC
Program Manager, Negotiations &
Accountability Management Division,
Provincial Programs Branch, MOHLTC
Senior Vice- President & Executive
Lead, PM Cancer Program, University
Health Network
Executive Vice President & Chief
Medical Officer, Odette Cancer Centre
Manager, Decision Support, Trillium
Health Partners
Director, Surgical Oncology,
Orthopedics & Critical Care, Juravinski
Cancer Centre
75
The following table outlines the members of the Prostate Cancer Surgery Working
Group
PROSTATE CANCER SURGERY WORKING GROUP
NAME
TITLE & ORGANIZATION
Dr. Rag Goel
Urologist, Windsor Regional Cancer Centre
Dr. Paul Martin
Urologist, Bluewater Health
Dr. Joe Chin
Urologist, London Health Sciences Centre
Dr. Demo Divaris
Regional Pathology Lead, Grand River Hospital & St. Mary’s General Hospital
Dr. Bobby Shayegan
Urologist, St. Joseph’s Healthcare- Hamilton
Dr. Chris Morash
Urologist, The Ottawa Hospital
Dr. Munir Jamal
Head, Division of Urology, Trillium Health Partners
Dr. Thomas McGowan
Physician Director, Radiation Oncology, Trillium Health Partners
Dr. Rajiv Singal
Urologist, Toronto East General Hospital
Dr. Tony Finelli
Urologist, University Health Network
Dr. Neil Fleshner
Urologist, University Health Network
Dr. Stephen Pautler
Regional Surgical Lead, St. Joseph’s Hospital- London
The following table outlines the members of the Colorectal Cancer Surgery Working
Group
COLORECTAL CANCER SURGERY WORKING GROUP
NAME
TITLE & ORGANIZATION
Dr. Patrick Colquoin
Registered Nurse & Clinical Manager, Diagnostic Assessment Programs & Integrated
Screening, Grand River Cancer Centre
General Surgeon, London Health Sciences Centre
Dr. Chala Eskicioglu
General Surgeon, St. Joseph’s Healthcare
Dr. Jeff Kolbasnik
General Surgeon, Halton Healthcare Services
Dr. William Chu
Radiation Oncologist, Sunnybrook Health Sciences Centre
Dr. Erin Kennedy
General Surgeon, Mount Sinai Hospital
Dr. Stan Feinburg
General Surgeon, North York General Hospital
Pamela Richards
Nurse, Mackenzie Health
Dr. Lynn Mikula
General Surgeon, Peterborough Regional Health Centre
Dr. Janet Van Vlymen
Anesthesiologist, Kingston General Hospital
Dr. Mike Anderson
Regional Surgical Lead, North Simcoe Muskoka
Maureen McGrath
Nurse, The Ottawa Hospital
Dr. Blair MacDonald
Radiologist, The Ottawa Hospital
Dr. Kevin Gagne
Anesthesiologist, North Bay Regional Health Centre
Dr. Bill Harris
General Surgeon, Thunder Bay Regional Health Sciences Centre
Barbara-Anne Maier
76
The following table outlines the members of the Thyroid Cancer Surgery Working Group
THYROID CANCER SURGERY WORKING GROUP
NAME
TITLE & ORGANIZATION
Dr. Linda Tietze
Otolaryngology, Windsor Regional Hospital
Dr. Deric Morrison
Endocrinology, London Health Sciences Centre
Dr. John Yoo
Otolaryngology – Head & Neck Surgery, London Health Sciences Centre
Dr. Patrick Whelan
General Surgery, Markham Stouffville Hospital
Dr. Julia Jones
General Surgery, Lakeridge Health
Dr. Ozgur Mete
Pathology, Lakeridge Health
Laurie Thomas
Nursing, Kingston General Hospital
Dr. Stephanie Thomas
ENT, The Ottawa Hospital
Dr. Rob Hekkenberg
General Surgery, Royal Victoria Hospital
Dr. Pankaj Bhatia
General Surgery, Health Sciences North
Dr. Tom Carr
Nuclear Medicine, Health Sciences North
Dr. Marc Freeman
Nuclear Medicine, Trillium Health Partners
Dr. Kevin Higgins
Otolaryngology – Head & Neck Surgery, Sunnybrook Health Sciences Centre
Dr. Jim Brierley
Radiation Oncology, University Health Network
Dr. Ralph Gilbert
Otolaryngology – Head & Neck Surgery, University Health Network
Dr. Richard Brull
Anesthesiology, University Health Network
Salin Kim
Nursing, University Health Network
Dr. Eric Monteiro
Otolaryngology – Head & Neck Surgery, Mount Sinai Hospital
The following table outlines the members of the Breast Cancer Surgery Working Group
BREAST CANCER SURGERY WORKING GROUP
NAME
TITLE & ORGANIZATION
Dr. David Shum
Pathology, Windsor Regional Hospital
Dr. Swati Kulkarni
Medical Oncology, Windsor Regional Hospital
Dr. Muriel Brackstone
General Surgery, London Health Sciences Centre
Dr. Mike Maurice
General Surgery, Grand River Hospital/St. Mary’s General Hospital
Dr. Peter Lovrics
General Surgery, St. Joseph’s Healthcare
Dr. Anna Kobylecky
General Surgery, Niagara Health System
Dr. Jeff Kolbasnik
General Surgery, Halton Healthcare Services
Dr. Anita Bane
Pathology, Hamilton Health Sciences Centre
Dr. Nancy Down
General Surgery, North York General Hospital
Dr. Elizabeth Hartley
Anesthesiology, Rouge Valley Hospital
Dr. Dragana Pilavdzic
Pathology, Lakeridge Health
77
Kristina Cruess
Nursing, Quinte Health Care
Dr. Kaes Al-Ali
General Surgery, Northumberland Hills Hospital
Dr. Laurie Wherrett
General Surgery, Lakeridge Health
Dr. Angel Arnaout
General Surgery, The Ottawa Hospital
Dr. Jennifer Macmillan
General Surgery, Muskoka Algonquin Healthcare
Dr. Rachelle Paradis
General Surgery, Health Sciences North
Dr. Ted McAlister
General Surgery, Brampton Civic Hospital
Dr. Laura Snell
Plastic Surgery, Sunnybrook Health Sciences Centre
Fatima San Pedro
Nursing, Sunnybrook Health Sciences Centre
Dr. Andrea Eisen
Medical Oncology, Sunnybrook Health Sciences Centre
Dr. Ralph George
General Surgery, St. Michael’s Hospital
Dr. David McCready
General Surgery, University Health Network
Dr. Derek Muradali
Radiology, University Health Network
Janet Papadakos
Nursing, University Health Network
Dr. Toni Zhong
Plastic Surgery, University Health Network
78
Appendix A – In-scope Diagnosis & Procedure Codes
Table 1: Colon and Rectal resection diagnosis codes for Cancer Surgery QBP
ICD10-CA
(Diagnosis)
Description
From C00 to C97
All malignant neoplasm diagnosis codes
ICD10-CA
(Diagnosis)
Description
D010
Carcinoma in situ of colon
D011
Carcinoma in situ of rectosigmoid junction
D012
Carcinoma in situ of rectum
D014
Carcinoma in situ of other and unspecified parts of intestine
D017
Carcinoma in situ of other specified digestive organs
D019
Carcinoma in situ of digestive organ, unspecified
D097
Carcinoma in situ of other specified sites
D099
Carcinoma in situ, unspecified
D120
Benign neoplasm of caecum
D121
Benign neoplasm of appendix
D122
Benign neoplasm of ascending colon
D123
Benign neoplasm of transverse colon
D124
Benign neoplasm of descending colon
D125
Benign neoplasm of sigmoid colon
D126
Benign neoplasm of colon, unspecified
D127
Benign neoplasm of rectosigmoid junction
D128
Benign neoplasm of rectum
D139
Benign neoplasm of ill-defined sites within the digestive system
D175
Benign lipomatous neoplasm of intra-abdominal organs
D1803
Haemangioma of digestive system
D1809
Haemangioma, unspecified site
D367
Benign neoplasm of other specified sites
D369
Benign neoplasm of unspecified site
D373
Neoplasm of uncertain or unknown behaviour of appendix
D374
Neoplasm of uncertain or unknown behaviour of the colon
D375
Neoplasm of uncertain or unknown behaviour of the rectum
D377
Neoplasm of uncertain or unknown behaviour of other digestive organs
D379
Neoplasm of uncertain or unknown behaviour of digestive organ, unspecified
D489
Neoplasm of uncertain or unknown behaviour, unspecified
79
Table 2: Colon and Rectal resection procedure codes for Cancer Surgery QBP
CCI CODE
(Procedure)
CCI LONG DESCRIPTION
1NQ89SFXXG
Excision total, rectum abdominal [anterior] approach pouch formation
1NQ90LAXXG
Excision total with reconstruction, rectum using open approach with ileum [for construction of pouch]
1NQ89KZXXG
Excision total, rectum abdominoperineal approach pouch formation
1NK87DN
Excision partial, small intestine endoscopic [laparoscopic] approach Enterocolostomy anastomosis technique
1NK87RE
Excision partial, small intestine open approach Enterocolostomy anastomosis technique
1NM87DA
Excision partial, large intestine endoscopic [laparoscopic] approach Simple excisional technique
1NM87DE
Excision partial, large intestine endoscopic [laparoscopic] approach Colorectal anastomosis technique
1NM87DF
Excision partial, large intestine endoscopic [laparoscopic] approach Colocolostomy anastomosis technique
1NM87DN
Excision partial, large intestine endoscopic [laparoscopic] approach Enterocolostomy anastomosis technique
1NM87LA
Excision partial, large intestine open approach Simple excisional technique
1NM87PN
Excision partial, large intestine endoscopic [laparoscopic, laparoscopic-assisted, hand-assisted] approach robotic assisted
telemanipulation of tools [telesurgery]
1NM87RD
Excision partial, large intestine open approach Colorectal anastomosis technique
1NM87RE
Excision partial, large intestine open approach Enterocolostomy anastomosis technique
1NM87RN
Excision partial, large intestine open approach Colocolostomy anastomosis technique
1NM89DF
Excision total, large intestine endoscopic [laparoscopic] approach Ileorectal [endorectal, ileoproctostomy] anastomosis technique
1NM89RN
Excision total, large intestine open approach using Ileorectal [endorectal, ileoproctostomy] anastomosis technique
1NM91DF
Excision radical, large intestine endoscopic [laparoscopic] approach Colocolostomy anastomosis technique
1NM91DN
Excision radical, large intestine endoscopic [laparoscopic] approach Enterocolostomy anastomosis technique
1NM91RD
Excision radical, large intestine open approach Colorectal anastomosis technique
1NM91RE
Excision radical, large intestine open approach Enterocolostomy anastomosis technique
1NM91RN
Excision radical, large intestine open approach Colocolostomy anastomosis technique
1NQ87CA
Excision partial, rectum perineal [e.g. pull through, transanal, sacral or sphincteric] approach closure by apposition technique [e.g.
1NQ87DA
Excision partial, rectum endoscopic [laparoscopic] approach closure by apposition technique [e.g. suturing, stapling] or no closure
re
1NQ87DE
Excision partial, rectum endoscopic [laparoscopic, laparoscopic-assisted, hand-assisted] approach colorectal anastomosis
technique
1NQ87DF
Excision partial, rectum endoscopic [laparoscopic] approach colorectal anastomosis technique
1NQ87LA
Excision partial, rectum open abdominal [e.g. anterior] approach closure by apposition technique [e.g. suturing, stapling] or no
closu
1NQ87PB
Excision partial, rectum perineal (e.g. pull through, transanal, sacral or sphincteric) approach colorectal anastomosis technique
1NQ87PF
Excision partial, rectum posterior [e.g. entering through incision between coccyx and anal verge with proctotomy] approach
closure by
1NQ87RD
Excision partial, rectum open abdominal [e.g. anterior] approach colorectal anastomosis technique
1NQ89GV
Excision total, rectum combined endoscopic [abdominal] with perineal approach Coloanal [or ileoanal] anastomosis technique
80
1NQ89KZ
Excision total, rectum abdominoperineal approach Coloanal [or ileoanal] anastomosis technique
1NQ89SF
Excision total, rectum abdominal [anterior] approach Coloanal [or ileoanal] anastomosis technique
1NQ89AB
Excision total, rectum, stoma formation with distal closure, combined endoscopic [laparoscopic] abdominoperinea
1NQ89LH
Excision total, rectum abdominoperineal approach Stoma formation with distal closure
1NQ89LHXXG
Excision total, rectum abdominoperineal approach Continent ileostomy formation
1NQ89RSXXG
Excision total, rectum abdominal [anterior] approach Continent ileostomy formation
1NM91DE
Excision radical, large intestine endoscopic [laparoscopic] approach Colorectal anastomosis technique
1NM87DX
Excision partial, large intestine endoscopic [laparoscopic] approach Stoma formation and distal closure
1NM87TF
Excision partial, large intestine open approach Stoma formation with distal closure
1NM89DX
Excision total, large intestine endoscopic [laparoscopic] approach Stoma formation with distal closure
1NM91DX
Excision radical, large intestine endoscopic [laparoscopic] approach Stoma formation with distal closure
1NM91TF
Excision radical, large intestine open approach Stoma formation with distal closure
1NM87DY
Excision partial, large intestine endoscopic [laparoscopic] approach Stoma formation with creation of mucous fistula
1NM89TF
Excision total, large intestine open approach Stoma formation with distal closure
1NM91TG
Excision radical, large intestine open approach Stoma formation with creation of mucous fistula
1NM87TG
Excision partial, large intestine open approach Stoma formation with creation of mucous fistula
1NQ87TF
Excision partial, rectum open abdominal approach [e.g. anterior] stoma formation with distal closure
1NQ89RS
Excision total, rectum abdominal [anterior] approach Stoma formation with distal closure
1NM91DY
Excision radical, large intestine endoscopic [laparoscopic, laparoscopic-assisted, hand-assisted] approach stoma formation with
creation of mucous fistula
1NQ87DX
Excision partial, rectum endoscopic [laparoscopic, laparoscopic-assisted, hand-assisted] approach stoma formation with distal
closure
1NQ87PN
Excision partial, rectum endoscopic [laparoscopic, laparoscopic-assisted, hand-assisted] approach robotic assisted
telemanipulation of tools [telesurgery]
1NM87GB
Excision partial, large intestine endoscopic [laparoscopic, laparoscopic-assisted, hand-assisted] approach special excisional
technique (without anastomosis)
1NM87WJ
Excision partial, large intestine open approach special excisional technique (without anastomosis)
Table 3: Thyroidectomy procedure codes for Cancer Surgery QBP
CCI CODE
(Procedure)
CCI LONG DESCRIPTION
1FU87DA
Excision partial, thyroid gland endoscopic (video assisted) approach using device NEC
1FU87DAAG
Excision partial, thyroid gland endoscopic (video assisted) approach using laser
1FU87NZ
Excision partial, thyroid gland open approach [e.g. neck incision] using device NEC
1FU87NZAG
Excision partial, thyroid gland open approach [e.g. neck incision] using laser
1FU87PZ
Excision partial, thyroid gland open substernal approach using device NEC
1FU87PZAG
Excision partial, thyroid gland open substernal approach using laser
1FU87QT
Excision partial, thyroid gland open trans-oral approach [e.g. lingual, submental] using device NEC
1FU89DA
Excision total, thyroid gland endoscopic (video assisted) approach using device NEC
81
1FU89DAAG
Excision total, thyroid gland endoscopic (video assisted) approach using laser
1FU89NZ
Excision total, thyroid gland open approach [e.g. neck incision] using device NEC
1FU89NZAG
Excision total, thyroid gland open approach [e.g. neck incision] using laser
1FU89PZ
Excision total, thyroid gland open substernal approach using device NEC
1FU89PZAG
Excision total, thyroid gland open substernal approach using laser
1FU91NZ
Excision radical, thyroid gland using open approach [e.g. neck incision]
Table 4: Lumpectomy, Mastectomy (+/- immediate reconstruction) diagnosis codes for
Cancer Surgery QBP
ICD10-CA
(Diagnosis)
Description
From C00 to C97
All malignant neoplasm diagnosis codes
ICD10-CA
(Diagnosis)
Description
D24
Benign neoplasm of breast
D051
Intraductal carcinoma in situ
D059
Carcinoma in situ of breast, unspecified
D486
Neoplasm of uncertain or unknown behaviour of breast
D050
Lobular carcinoma in situ
D057
Other carcinoma in situ of breast
D0500
Lobular carcinoma in situ of right breast
D0501
Lobular carcinoma in situ of left breast
D0509
Lobular carcinoma in situ of breast, unspecified side
D0510
Intraductal carcinoma in situ of right breast
D0511
Intraductal carcinoma in situ of left breast
D0519
Intraductal carcinoma in situ of breast, unspecified side
D0570
Other carcinoma in situ of right breast
D0571
Other carcinoma in situ of left breast
D0579
Other carcinoma in situ of breast, unspecified side
D0590
Carcinoma in situ of right breast, unspecified
D0591
Carcinoma in situ of left breast, unspecified
D0599
Carcinoma in situ of breast, unspecified, unspecified side
82
Table 5: Lumpectomy procedure codes for Cancer Surgery QBP
CCI CODE
(Procedure)
CCI LONG DESCRIPTION
1YM87DA
Excision partial, breast using endoscopic approach with simple apposition
1YM87GB
Excision partial, breast using endoscopic guide wire (or needle hook) excision technique with simple apposition of tissue
1YM87LA
Excision partial, breast using open approach with simple apposition of tissue (e.g. suturing)
1YM87LAXXA
Excision partial, breast using open approach and full thickness autograft to close defect
1YM87LAXXE
Excision partial, breast using open approach and local flap (to close defect)
1YM87UT
Excision partial, breast using open guide wire (or needle hook) excision technique and simple apposition of tissue
1YM87UTXXA
Excision partial, breast using open guide wire (or needle hook) excision technique with autograft (to close defect)
1YM87UTXXE
Excision partial, breast using open guide wire (or needle hook) excision technique with local flap (to close defect)
Table 6: Mastectomy procedure codes for Cancer Surgery QBP
CCI CODE
(Procedure)
CCI LONG DESCRIPTION
1YM91LAXXQ
Excision radical, breast using combined sources of tissue [e.g. local flap and tissue expander] modified or NOS
1YM89LA
Excision total, breast without tissue repair
1YM89LAXXA
Excision total, breast with full thickness autograft
1YM89LAXXE
Excision total, breast using open approach and local flap
1YM91LA
Excision (modified) radical, breast without tissue
1YM91LAPM
Excision radical, breast with implantation of breast prosthesis modified or NOS
1YM91LATP
Excision (modified) radical, breast with implantation of tissue expander
1YM91LAXXA
Excision radical (modified), breast using full thickness autograft
1YM91LAXXE
Excision (modified) radical, breast using local flap
1YM91TR
Excision extended radical, breast without tissue
1YM91TRXXA
Excision extended radical, breast using full thickness autograft
1YM91TRXXE
Excision extended radical, breast using local flap
1YM91WP
Excision super radical, breast without tissue
1YM91WPXXA
Excision radical, breast using autograft super [Wangensteen}
1YM91WPXXE
Excision super radical, breast using local flap
Table 7: Axillary Lymph Node Dissection diagnosis codes for Cancer Surgery QBP
83
ICD10-CA
(Diagnosis)
Description
C5000
Malignant neoplasm of right nipple and areola
C5001
Malignant neoplasm of left nipple and areola
C5009
Malignant neoplasm of nipple and areola, unspecified side
C5010
Malignant neoplasm of central portion of right breast
C5011
Malignant neoplasm of central portion of left breast
C5019
Malignant neoplasm of central portion of breast, unspecified side
C5020
Malignant neoplasm of upper-inner quadrant of right breast
C5021
Malignant neoplasm of upper-inner quadrant of left breast
C5029
Malignant neoplasm of upper-inner quadrant of breast, unspecified side
C5030
Malignant neoplasm of lower-inner quadrant of right breast
C5031
Malignant neoplasm of lower-inner quadrant of left breast
C5039
Malignant neoplasm of lower-inner quadrant of breast, unspecified side
C5040
Malignant neoplasm of upper-outer quadrant of right breast
C5041
Malignant neoplasm of upper-outer quadrant of left breast
C5049
Malignant neoplasm of upper-outer quadrant of breast, unspecified side
C5050
Malignant neoplasm of lower-outer quadrant of right breast
C5051
Malignant neoplasm of lower-outer quadrant of left breast
C5059
Malignant neoplasm of lower-outer quadrant of breast, unspecified side
C5060
Malignant neoplasm of axillary tail of right breast
C5061
Malignant neoplasm of axillary tail of left breast
C5069
Malignant neoplasm of axillary tail of breast, unspecified side
C5080
Overlapping malignant lesion of right breast
C5081
Overlapping malignant lesion of left breast
C5089
Overlapping malignant lesion of breast, unspecified side
C5090
Malignant neoplasm of right breast, part unspecified
C5091
Malignant neoplasm of left breast, part unspecified
C5099
Malignant neoplasm of breast, part unspecified, unspecified side
C773
Secondary malignant neoplasm of axillary and upper limb lymph nodes
C7980
Secondary malignant neoplasm of breast
D24
Benign neoplasm of breast
D051
Intraductal carcinoma in situ
D059
Carcinoma in situ of breast, unspecified
D486
Neoplasm of uncertain or unknown behaviour of breast
D050
Lobular carcinoma in situ
D057
Other carcinoma in situ of breast
D0500
Lobular carcinoma in situ of right breast
D0501
Lobular carcinoma in situ of left breast
D0509
Lobular carcinoma in situ of breast, unspecified side
84
D0510
Intraductal carcinoma in situ of right breast
D0511
Intraductal carcinoma in situ of left breast
D0519
Intraductal carcinoma in situ of breast, unspecified side
D0570
Other carcinoma in situ of right breast
D0571
Other carcinoma in situ of left breast
D0579
Other carcinoma in situ of breast, unspecified side
D0590
Carcinoma in situ of right breast, unspecified
D0591
Carcinoma in situ of left breast, unspecified
D0599
Carcinoma in situ of breast, unspecified, unspecified side
Table 8: Axillary Lymph Node Dissection procedure codes for Cancer Surgery QBP
CCI CODE
(Procedure)
CCI LONG DESCRIPTION
1MD87LA
Excision partial, lymph node(s), axillary using open approach
1MD89LA
Excision total, lymph node(s), axillary using open approach
1MD89LAXXA
Excision total, lymph node(s), axillary using open approach with full thickness graft
1MD89LAXXE
Excision total, lymph node(s), axillary using open approach with local flap
1MD89LAXXF
Excision total, lymph node(s), axillary using open approach with free distant flap
1MD89LAXXG
Excision total, lymph node(s), axillary using open approach with pedicled distant flap
1MD89LAXXN
Excision total, lymph node(s), axillary using open approach with synthetic tissue
Table 9: Sentinel Lymph Node Biopsy diagnosis codes for Cancer Surgery QBP
ICD10-CA
(Diagnosis)
Description
C5000
Malignant neoplasm of right nipple and areola
C5001
Malignant neoplasm of left nipple and areola
C5009
Malignant neoplasm of nipple and areola, unspecified side
C5010
Malignant neoplasm of central portion of right breast
C5011
Malignant neoplasm of central portion of left breast
C5019
Malignant neoplasm of central portion of breast, unspecified side
C5020
Malignant neoplasm of upper-inner quadrant of right breast
C5021
Malignant neoplasm of upper-inner quadrant of left breast
C5029
Malignant neoplasm of upper-inner quadrant of breast, unspecified side
C5030
Malignant neoplasm of lower-inner quadrant of right breast
C5031
Malignant neoplasm of lower-inner quadrant of left breast
C5039
Malignant neoplasm of lower-inner quadrant of breast, unspecified side
C5040
Malignant neoplasm of upper-outer quadrant of right breast
85
C5041
Malignant neoplasm of upper-outer quadrant of left breast
C5049
Malignant neoplasm of upper-outer quadrant of breast, unspecified side
C5050
Malignant neoplasm of lower-outer quadrant of right breast
C5051
Malignant neoplasm of lower-outer quadrant of left breast
C5059
Malignant neoplasm of lower-outer quadrant of breast, unspecified side
C5060
Malignant neoplasm of axillary tail of right breast
C5061
Malignant neoplasm of axillary tail of left breast
C5069
Malignant neoplasm of axillary tail of breast, unspecified side
C5080
Overlapping malignant lesion of right breast
C5081
Overlapping malignant lesion of left breast
C5089
Overlapping malignant lesion of breast, unspecified side
C5090
Malignant neoplasm of right breast, part unspecified
C5091
Malignant neoplasm of left breast, part unspecified
C5099
Malignant neoplasm of breast, part unspecified, unspecified side
C773
Secondary malignant neoplasm of axillary and upper limb lymph nodes
C7980
Secondary malignant neoplasm of breast
D24
Benign neoplasm of breast
D051
Intraductal carcinoma in situ
D059
Carcinoma in situ of breast, unspecified
D486
Neoplasm of uncertain or unknown behaviour of breast
D050
Lobular carcinoma in situ
D057
Other carcinoma in situ of breast
D0500
Lobular carcinoma in situ of right breast
D0501
Lobular carcinoma in situ of left breast
D0509
Lobular carcinoma in situ of breast, unspecified side
D0510
Intraductal carcinoma in situ of right breast
D0511
Intraductal carcinoma in situ of left breast
D0519
Intraductal carcinoma in situ of breast, unspecified side
D0570
Other carcinoma in situ of right breast
D0571
Other carcinoma in situ of left breast
D0579
Other carcinoma in situ of breast, unspecified side
D0590
Carcinoma in situ of right breast, unspecified
D0591
Carcinoma in situ of left breast, unspecified
D0599
Carcinoma in situ of breast, unspecified, unspecified side
Z031
Observation for suspected malignant neoplasm
Z080
Follow-up examination after surgery for malignant neoplasm
Z123
Special screening examination for neoplasm of breast
86
Table 10: Mastectomy + Immediate Reconstruction procedure codes for Cancer
Surgery QBP
CCI CODE
(Procedure)
CCI LONG DESCRIPTION
1YM88LAPM
Excision partial with reconstruction, breast without tissue with implantation of prosthesis
1YM88LAPME
Excision partial with reconstruction, breast with local flap with implantation of prosthesis
1YM88LAPMF
Excision partial with reconstruction, breast using free flap with implantation of prosthesis
1YM88LAPMG
Excision partial with reconstruction, breast using distant pedicled flap with implantation of prosthesis
1YM88LAPMK
Excision partial with reconstruction, breast using homograft with implantation of prosthesis
1YM88LAQF
Excision partial with reconstruction, breast without tissue with implantation of prosthesis and expander
1YM88LAQFE
Excision partial with reconstruction, breast with local flap with implantation of prosthesis and expander
1YM88LAQFF
Excision partial with reconstruction, breast using free flap with implantation of prosthesis and expander
1YM88LAQFG
Excision partial with reconstruction, breast using distant pedicled flap with implantation of prosthesis and ex
1YM88LATP
Excision partial with reconstruction, breast without tissue with implantation of tissue expander
1YM88LATPE
Excision partial with reconstruction, breast with local flap with tissue expander
1YM88LATPF
Excision partial with reconstruction, breast using free flap with implantation of tissue expander
1YM88LATPG
Exc prt breast w tiss expand ped flp reconstr
1YM88LATPK
Excision partial with reconstruction, breast using homograft with implantation of tissue expander
1YM88LAXXE
Excision partial with reconstruction, breast using local flap with no implanted device
1YM88LAXXF
Excision partial with reconstruction, breast using free flap with no implanted device
1YM88LAXXG
Excision partial with reconstruction, breast using distant pedicled flap with no implanted device
1YM90LAPM
Excision total with reconstruction, breast simple mastectomy with no node dissection without tissue with implantation of breast
prosth
1YM90LAPME
Excision total with reconstruction, breast simple mastectomy with no node dissection using local flap with implantation of breast
pros
1YM90LAPMF
Excision total with reconstruction, breast simple mastectomy with no node dissection using free flap (2) with implantation of
breast p
1YM90LAPMG
Excision total with reconstruction, breast simple mastectomy with no node dissection using distant pedicled flap(1) with
implantation
1YM90LAPMK
Excision total with reconstruction, breast using homograft with implantation of breast prosthesis
1YM90LAQF
Excision total with reconstruction, breast simple mastectomy with no node dissection without tissue with implantation of
prosthesis an
1YM90LAQFE
Excision total with reconstruction, breast simple mastectomy with no node dissection using local flap with implantation of
prosthesis
1YM90LAQFF
Excision total with reconstruction, breast simple mastectomy with no node dissection using free flap (2) with implantation of
prosthes
1YM90LAQFG
Excision total with reconstruction, breast simple mastectomy with no node dissection using distant pedicled flap(1) with
implantation
1YM90LATP
Excision total with reconstruction, breast simple mastectomy with no node dissection without tissue with implantation of tissue
expand
87
1YM90LATPE
Excision total with reconstruction, breast using local flap with implantation of tissue expander
1YM90LATPF
Excision total with reconstruction, breast simple mastectomy with no node dissection using free flap (2) with implantation of tissue
e
1YM90LATPG
Excision total with reconstruction, breast simple mastectomy with no node dissection using distant pedicled flap(1) with
implantation
1YM90LATPK
Excision total with reconstruction, breast using homograft with implantation of tissue expander
1YM90LAXXE
Excision total with reconstruction, breast simple mastectomy with no node dissection using local flap with no implanted device
1YM90LAXXF
Excision total with reconstruction, breast simple mastectomy with no node dissection using free flap (2) with no implanted device
1YM90LAXXG
Excision total with reconstruction, breast simple mastectomy with no node dissection using distant pedicled flap(1) with no
implanted
1YM90LAXXQ
Excision total with reconstruction, breast with no implanted device using combined sources of tissue (e.g. free
1YM92LAPME
Excision (modified) radical with reconstruction, breast using local flap with implantation of breast prosthesis
1YM92LAPMF
Excision (modified) radical with reconstruction, breast using free flap with implantation of breast prosthesis
1YM92LAPMG
Excision (modified) radical with reconstruction, breast using distant pedicled flap with implantation of breast prosthesis
1YM92LAPMK
Excision radical with reconstruction, breast modified or NOS using homograft with implantation of breast prosthesis
1YM92LAQFE
Excision (modified) radical with reconstruction, breast using local flap with implantation of prosthesis and expander
1YM92LAQFG
Excision (modified) radical with reconstruction, breast using distant pedicled flap with implantation of prosthesis and expander
1YM92LATPE
Excision (modified) radical with reconstruction, breast using local flap with implantation of tissue expander
1YM92LATPF
Excision (modified) radical with reconstruction, breast using free flap with implantation of tissue expander
1YM92LATPG
Excision (modified) radical with reconstruction, breast using distant pedicled flap with implantation of tissue expander
1YM92LATPK
Excision radical with reconstruction, breast modified or NOS using homograft with implantation of tissue expander
1YM92LAXXE
Excision (modified) radical with reconstruction, breast using local flap with no implanted device
1YM92LAXXF
Excision (modified) radical with reconstruction, breast using free flap with no implanted device
1YM92LAXXG
Excision (modified) radical with reconstruction, breast using distant pedicled flap with no implanted device
1YM92LAXXQ
Excision radical with reconstruction, breast modified or NOS with no implanted device using combined sources of
1YM92TRPME
Excision radical with reconstruction, breast extended [Urban] using local flap with implantation of breast prosthesis
1YM92TRPMF
Excision radical with reconstruction, breast extended [Urban] using free flap with implantation of breast prosthesis
1YM92TRPMG
Excision radical with reconstruction, breast extended [Urban] using distant pedicled flap with implantation of breast prosthesis
1YM92TRPMK
Excision radical with reconstruction, breast extended [Urban] using homograft with implantation of breast prosthesis
1YM92TRTPE
Excision radical with reconstruction, breast extended [Urban] using local flap with implantation of tissue expander
1YM92TRTPF
Excision radical with reconstruction, breast extended [Urban] using free flap with implantation of tissue expander
1YM92TRTPG
Excision radical with reconstruction, breast extended [Urban] using distant pedicled flap with implantation of tissue expander
1YM92TRTPK
Excision radical with reconstruction, breast extended [Urban] using homograft with implantation of tissue expander
1YM92TRXXE
Excision extended radical with reconstruction, breast using local flap with no implanted device
1YM92TRXXF
Excision extended radical with reconstruction, breast using free flap with no implanted device
1YM92TRXXG
Excision radical with reconstruction, breast extended [Urban] using distant pedicled flap with no implanted device
88
1YM92TRXXQ
Exc rad w reconstr breast OA w ext rad excisn combo tis
1YM92WPPME
Excision radical with reconstruction, breast super [Wangensteen] using local flap with implantation of breast prosthesis
1YM92WPPMF
Excision radical with reconstruction, breast super [Wangensteen] using free flap with implantation of breast prosthesis
1YM92WPPMG
Excision radical with reconstruction, breast super [Wangensteen] using distant pedicled flap with implantation of breast prosthesis
1YM92WPPMK
Excision radical with reconstruction, breast super [Wangensteen] using homograft with implantation of breast prosthesis
1YM92WPTPE
Excision radical with reconstruction, breast super [Wangensteen] using local flap with implantation of tissue expander
1YM92WPTPF
Excision radical with reconstruction, breast super [Wangensteen] using free flap with implantation of tissue expander
1YM92WPTPG
Excision radical with reconstruction, breast super [Wangensteen] using distant pedicled flap with implantation of tissue expander
1YM92WPTPK
Excision radical with reconstruction, breast super [Wangensteen] using homograft with implantation of tissue expander
Table 11: Delayed Breast Reconstruction diagnosis codes for Cancer Surgery QBP
ICD10-CA
(Diagnosis)
Description
C5000
Malignant neoplasm of right nipple and areola
C5001
Malignant neoplasm of left nipple and areola
C5009
Malignant neoplasm of nipple and areola, unspecified side
C5010
Malignant neoplasm of central portion of right breast
C5011
Malignant neoplasm of central portion of left breast
C5019
Malignant neoplasm of central portion of breast, unspecified side
C5020
Malignant neoplasm of upper-inner quadrant of right breast
C5021
Malignant neoplasm of upper-inner quadrant of left breast
C5029
Malignant neoplasm of upper-inner quadrant of breast, unspecified side
C5030
Malignant neoplasm of lower-inner quadrant of right breast
C5031
Malignant neoplasm of lower-inner quadrant of left breast
C5039
Malignant neoplasm of lower-inner quadrant of breast, unspecified side
C5040
Malignant neoplasm of upper-outer quadrant of right breast
C5041
Malignant neoplasm of upper-outer quadrant of left breast
C5049
Malignant neoplasm of upper-outer quadrant of breast, unspecified side
C5050
Malignant neoplasm of lower-outer quadrant of right breast
C5051
Malignant neoplasm of lower-outer quadrant of left breast
C5059
Malignant neoplasm of lower-outer quadrant of breast, unspecified side
C5060
Malignant neoplasm of axillary tail of right breast
C5061
Malignant neoplasm of axillary tail of left breast
C5069
Malignant neoplasm of axillary tail of breast, unspecified side
89
C5080
Overlapping malignant lesion of right breast
C5081
Overlapping malignant lesion of left breast
C5089
Overlapping malignant lesion of breast, unspecified side
C5090
Malignant neoplasm of right breast, part unspecified
C5091
Malignant neoplasm of left breast, part unspecified
C5099
Malignant neoplasm of breast, part unspecified, unspecified side
Z421
Follow-up care involving plastic surgery of breast
Z853
Personal history of malignant neoplasm of breast
Z8530
Personal history of malignant neoplasm of right breast
Z8531
Personal history of malignant neoplasm of left breast
Z8539
Personal history of malignant neoplasm of breast, unspecified side
D24
Benign neoplasm of breast
D051
Intraductal carcinoma in situ
D059
Carcinoma in situ of breast, unspecified
D486
Neoplasm of uncertain or unknown behaviour of breast
D050
Lobular carcinoma in situ
D057
Other carcinoma in situ of breast
D0500
Lobular carcinoma in situ of right breast
D0501
Lobular carcinoma in situ of left breast
D0509
Lobular carcinoma in situ of breast, unspecified side
D0510
Intraductal carcinoma in situ of right breast
D0511
Intraductal carcinoma in situ of left breast
D0519
Intraductal carcinoma in situ of breast, unspecified side
D0570
Other carcinoma in situ of right breast
D0571
Other carcinoma in situ of left breast
D0579
Other carcinoma in situ of breast, unspecified side
D0590
Carcinoma in situ of right breast, unspecified
D0591
Carcinoma in situ of left breast, unspecified
D0599
Carcinoma in situ of breast, unspecified, unspecified side
Table 12: Delayed Breast Reconstruction procedure codes for Cancer Surgery QBP
Grouping
Microvascular
Tissue
Nonmicrosurgical
Tissue
Type of Recon
Microsurgical Flap
Pedicled Flap
Mixed flap and
Procedure Code
Description
1YM80LAPMF
Repair, breast using free flap (2) with implantation of breast prosthesis
1YM80LAQFF
Repair, breast using free flap (2) with implantation of prosthesis and expander
1YM80LATPF
Repair, breast using free flap (2) with implantation of tissue expander
1YM80LAXXF
Repair, breast using free flap with no implantation of device
1YM80LAXXG
Repair, breast using distant pedicled flap with no implantation of device
1YM80LAPMG
Repair, breast using distant pedicled flap (1) with implantation of breast prosthesis
90
implant
Implants Only
Tissue Expander
or Prosthesis
1YM80LAQFG
1YM80LATPG
Repair, breast using distant pedicled flap (1) with implantation of prosthesis and
expander
Repair, breast using distant pedicled flap (1) with implantation of tissue expander
1YM80LAPM
Repair, breast without tissue with implantation of breast prosthesis
1YM80LAPMA
Repair, breast using autograft with implantation of breast prosthesis
1YM80LAPME
Repair, breast using local flap with implantation of breast prosthesis
1YM80LAQF
Repair, breast without tissue with implantation of prosthesis and expander
1YM80LATP
Repair, breast without tissue with implantation of tissue expander
1YM80LATPA
Repair, breast using autograft with implantation of tissue expander
1YM80LATPE
Repair, breast using local flap with implantation of tissue expander
1YM80LAQFA
Repair, breast using autograft with implantation of prosthesis and expander
1YM80LAQFE
Repair, breast using local flap with implantation of prosthesis and expander
1YM80LAPMK
Repair, breast open approach using homograft with implantation of breast
prosthesis
Repair, breast open approach using homograft with implantation of tissue expander
1YM80LATPK
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