A Quality Improvement Project to Improve the Pathway and Outcomes for Patients with Necrotising Fasciitis

Necrotising fasciitis (NF) is a life-threatening illness that requires a multidisciplinary approach between surgeons in multiple specialties, intensivists, and microbiologists. Serial debridements and change of dressings are required prior to reconstruction. The aim of this study was to review the workload and streamline services in a tertiary centre for regional and internal referrals by formalizing an NF pathway agreed upon by all multidisciplinary team stakeholders and securing adequate resources for these complex patients.

Retrospective data was collected on all patients with NF referred to the plastic surgery department between January 2017 and September 2018. Referrals were categorized as either regional (debridement had already taken place at another hospital) or internal (conducted on patients admitted through the emergency department).

A total of 41 patients (17 regional and 24 internal referrals) with a median age of 63 years (range, 28 to 85 years) were included in the study. Overall mortality rate was found to be 27%, median length of stay (LOS) amongst internal referrals was 25 days (range, 11 to 94 days), and median intensive care unit LOS was 8 days (range, 0 to 64 days). A total of 121 operations were conducted by 4 surgical specialties with a median time per procedure of 145 minutes (range, 50 to 605). 11 patients underwent reconstruction with split thickness graft and the median number of days between initial debridement to grafting was 13 (range, 2 to 38 days).

Patients with NF require complex care and treatment. By characterizing and defining the workload involved in treating these patients, it may be possible to improve advanced planning and allocate resources accordingly to ensure that the centre runs as smoothly as possible without interruption to the acute trauma service.