[Analysis and options for optimization of preoperative assessment for anesthesia at a university hospital]

Virtual Reality-Assisted Informed Consent for Anesthesia: A Prospective and Randomized Proof-of-Concept Study

Background/Objectives: Informed consent for anesthesia poses both legal challenges and problems of understandable communication. Fulfilling all the requirements through anesthesiologists directly interacting with patients is a time- and staff-consuming strategy. Given today's smart technologies, notably including virtual reality (VR), we explored in a prospective randomized study whether 'VR-assisted informed consent' could improve this situation. Methods: Fifty patients scheduled for orthopedic surgery were randomized. In the control group, informed consent was obtained via patient-specialist dialogs only. The patients in the study group, wearing a head-mounted display, watched an 8 min immersive 3D movie with the standard explanations of general anesthesia, followed by a patient-specialist dialog to address open questions. The time spent on the dialogs in both groups was evaluated as the primary outcome variable. As secondary variables, we analyzed both a three-item Likert scale on patient satisfaction with the VR experience and cost differences between both groups. Results: Patient-specialist dialogs were carried on for median (IQR) durations of 93 (20-182) seconds in the study group versus 665 (261-829) seconds in the control group (p < 0.001). All the patients exposed to VR rated this experience as favorable (87.5%) or neutral (12.5%). Based on anesthesiologists' incomes in the US and UK, our approach would reduce the staff expenditure for each patient-specialist dialog by median amounts of USD ≈40 or ≈11, respectively (2 × p < 0.001). Conclusions: 'VR-assisted informed consent' for anesthesia is well accepted by patients and reduces the time requirements for patient-specialist dialogs, thus pointing out a potential avenue towards increasing the work-time efficiency of anesthesiologists.

Teleconsultation for Preoperative Anesthesia Evaluation: Identifying Environmental Potentials by Life Cycle Assessment

Introduction: Teleconsultations for preoperative evaluation in anesthesiology proved to be feasible during the COVID-19 pandemic. However, widespread implementation of teleconsultations has not yet occurred. Besides time savings and economic benefits, teleconsultations in anesthesia may have the potential to reduce CO2 emissions. Methods: We conducted a life cycle assessment based on prospective surveys to assess the potential environmental benefits of preoperative anesthesia teleconsultations in comparison to the status-quo in-person consultations. Within 1 month, all patients presenting at the preoperative anesthesia clinic at RWTH Aachen University Hospital were asked about the distance traveled and mode of transportation to the hospital. The main outcome measure was the potential environmental benefit resulting from the implementation of teleconsultations. Results: In total, 821 out of 981 patients presenting at the anesthesia clinic participated in the survey. Most patients visited on an outpatient basis (62.9%) and traveled by car (81.7%). The median travel distance was 25 km [interquartile range 12-40]. If patients who came to the hospital solely for the anesthesia appointment had scheduled virtual appointments, the emissions of 3.03-ton CO2 equivalents (CO2-eq) could be avoided in the first month after implementation. The environmental impact associated with the production of teleconsultation equipment is outweighed by the reduction in patient travel. If all outpatient appointments were performed virtually, these savings would triple. Within 10 years, more than 1,300 tons CO2-eq could be avoided. Conclusion: Teleconsultations can mitigate the environmental impact of in-person anesthesia consultations. Further research is essential to leverage teleconsultations for preoperative evaluation also across other medical specialties.

[Telemedical anesthesia consent - Are the patients ready for it? : A comparative requirement analysis before and during the pandemic]

BACKGROUND

Comprehensive anesthesia preparation by means of the anamnesis and physical examination is considered an essential part of the quality criteria for anesthesia. Especially due to the shortage of specialists, there are usually long waiting times in anesthesia outpatient departments and patients must frequently return in cases of missing or pending findings. Telemedicine already offers alternatives in the context of video communication. These alternatives are now particularly prominent due to the currently existing COVID-19 pandemic and the resulting recommendations for digitalization.

OBJECTIVES

This comparative cross-sectional study was carried out to show via a patient survey which patient groups are suitable for a telemedical anesthesia preparation and whether the patients are already technically sufficiently equipped.

MATERIAL AND METHODS

For this purpose, a total of 2080 patients (1030 before and 1050 during the pandemic) were interviewed using a questionnaire. For matched paired analyses, 630 pairs were formed according to their age and gender.

RESULTS

Before and after the pandemic, there was an increase in the percentage of patients already using video communication in their daily lives (30.4% vs. 41.8%). Before the pandemic, 31.7% of patients indicated that they considered this concept of communication to be a practical and appropriate method for an educational conversation and after the pandemic this number increased to 46.6%. For the majority of patients personal contact with a local anesthesiologist was important (80.7% before vs. 67.4% during the pandemic). The number of patients who had the necessary technical equipment for video communication also increased as a result of the COVID-19 pandemic (50.4% vs. 58.2%).

DISCUSSION

Almost half of the patients already seem to be open to a telemedical preoperative evaluation. As digitalization progresses, older generations are more likely to recognize the benefits and be able to own and use the necessary technology in the near future. User acceptance should be the central goal of concept development. This must be followed by a randomized controlled study to evaluate the potentials but also the problems in the perioperative process.

A comparison of face-to-face, brochure- and video-assisted anesthesia interviews: a qualitative randomized survey study

BACKGROUND

Previous studies showed mixed results for patient satisfaction by supplementing the pre-anesthetic assessment with written or audio-visual materials. We hypothesize that an audio-visual aid or a brochure in addition to face-to-face interview, leads to improved patient satisfaction and shortens the pre-anesthetic assessment duration.

METHODS

We randomly assigned 1051 patients scheduled for pre-anesthetic assessment to three different groups: face-to-face pre-anesthetic interview alone (Group 1), videos before the interview (Group 2), and brochure before the interview (Group 3). All patients were asked to complete a post-interview questionnaire assessing patient satisfaction, knowledge gain, prior experience with anesthesia, and quality of supplementary media.

RESULTS

The use of additional materials immediately before the pre-anesthetic interview did increase the overall patient satisfaction (F(2, 1003) = 3.10, p <0 .05, ƞ² = 0.006) but not the interview satisfaction (F(2, 1011) = 0.756, p >0 .05) nor information gain (procedure explanations F(2, 987) = 0.400, p > 0.05) or quality of answered questions (F(2, 1029) = 0.769, p > 0.05). A statistically significant effect on interview satisfaction (F(13,996) = 5.15, p < 0.01., ƞ² = 0.063), overall satisfaction (F(13,988) = 4.25, p < 0.01., ƞ² = 0.053) and given explanations (F(13, 972) = 3.132, p < 0.001, ƞ² = 0.04) was associated with the explanation of different anesthetic techniques by the provider. No differences of response quality between the anesthesiologists was found (F(13, 1014) = 1.494, p > 0.05).

CONCLUSIONS

Additional information imparted in the form of an educational brochure or videos immediately before the pre-anesthetic assessment and interview does not lead to higher patient satisfaction.

Teleconsultation for preoperative evaluation during the coronavirus disease 2019 pandemic: A technical and medical feasibility study

BACKGROUND

During the surge in coronavirus disease 2019 (COVID-19) infections in early 2020, many medical organisations began developing strategies for implementing teleconsultation to maintain medical services during lockdown and to limit physical contact. Therefore, we developed a teleconsultation preoperative evaluation platform to replace on-site preoperative meetings.

OBJECTIVE

This study assessed the feasibility of a teleconsultation for preoperative evaluation and procedure-associated adverse events.

DESIGN

Implementation study.

SETTING

A tertiary care university hospital in Germany from April 2020 to October 2020.

PATIENTS

One hundred and eleven patients scheduled for elective surgery.

INTERVENTION

Patients were assigned to receive teleconsultation for preoperative evaluation and to complete a subsequent survey.

MAIN OUTCOME MEASURES

Primary endpoints were medical and technical feasibility, user satisfaction and time savings.

RESULTS

For 100 out of 111 patients, telepreoperative consultations allowed for adequate perioperative risk assessment, patient education and also for effective collection of legal signatures. For six patients (5.4%), consultations could not be started because of technical issues, whereas for five patients (4.8%), clearance for surgery could not be granted because of medical reasons. A clear majority of anaesthetists (93.7%) rated the telepreoperative evaluations as equivalent to on-site meetings. The majority of the patients considered teleconsultation for preoperative evaluation as convenient as an on-site meeting (98.2%) and would choose a teleconsultation again (97.9%). Median travel time saved by patients was 60 min (Q1 40, Q3 80). We registered one adverse event: we detected atrial fibrillation in one patient only immediately prior to surgery.

CONCLUSION

Telepreoperative evaluations are medically and technically feasible, yielding high satisfaction rates on both sides. However, regarding patient safety, not every patient is equally well suited. Overall, implementation of teleconsultation for preoperative evaluation into clinical routine could help maintain medical care during the COVID-19 pandemic.

TRIAL REGISTRATION

NCT04518514, ClinicalTrials.gov.

Development and internal validation of an algorithm to predict intraoperative risk of inadvertent hypothermia based on preoperative data

Intraoperative hypothermia increases perioperative morbidity and identifying patients at risk preoperatively is challenging. The aim of this study was to develop and internally validate prediction models for intraoperative hypothermia occurring despite active warming and to implement the algorithm in an online risk estimation tool. The final dataset included 36,371 surgery cases between September 2013 and May 2019 at the Vienna General Hospital. The primary outcome was minimum temperature measured during surgery. Preoperative data, initial vital signs measured before induction of anesthesia, and known comorbidities recorded in the preanesthetic clinic (PAC) were available, and the final predictors were selected by forward selection and backward elimination. Three models with different levels of information were developed and their predictive performance for minimum temperature below 36 °C and 35.5 °C was assessed using discrimination and calibration. Moderate hypothermia (below 35.5 °C) was observed in 18.2% of cases. The algorithm to predict inadvertent intraoperative hypothermia performed well with concordance statistics of 0.71 (36 °C) and 0.70 (35.5 °C) for the model including data from the preanesthetic clinic. All models were well-calibrated for 36 °C and 35.5 °C. Finally, a web-based implementation of the algorithm was programmed to facilitate the calculation of the probabilistic prediction of a patient's core temperature to fall below 35.5 °C during surgery. The results indicate that inadvertent intraoperative hypothermia still occurs frequently despite active warming. Additional thermoregulatory measures may be needed to increase the rate of perioperative normothermia. The developed prediction models can support clinical decision-makers in identifying the patients at risk for intraoperative hypothermia and help optimize allocation of additional thermoregulatory interventions.

Improvement in pre-operative risk assessment in adults undergoing noncardiac surgery by a process-oriented score: A prospective single-centre study

BACKGROUND

Pre-operative risk assessment is important to quantify the patient's risks of morbidity and mortality, but its quality differs. We created a process-oriented score (PRO-score) for risk evaluation of adults as a three-stage warning score checklist with concrete guidance. It contains the contents of current guidelines and the assessment of vital signs.

OBJECTIVES

We investigated whether the PRO-score is suitable to detect 'red flag' warning signs not only in American Society of Anesthesiologists (ASA) physical status (PS) 3 or 4 patients but also in ASA-PS 1 or 2 patients. Resulting medical, therapeutic or structural consequences were recorded.

DESIGN

Prospective single-centre study.

SETTING

The study was performed in a German university hospital between November 2015 and December 2018.

PATIENTS

We included 54 455 adult patients undergoing a pre-operative risk assessment for general or regional anaesthesia and elective noncardiac surgery.

RESULTS

In all, 388 patients presented 'red flag' warning signs in the PRO-score during risk assessment; 85 (21.9%) were labelled ASA-PS 1 or 2, 244 (62.9%) ASA-PS 3 and 59 (15.2%) ASA-PS 4. Additional examinations were performed in 179 patients and technical tests in 175 patients (ASA-PS 1 or 2: 53 and 63 patients, respectively). After re-evaluation of the peri-operative risk in an interdisciplinary conference, surgery was cancelled in 44 patients (ASA-PS 1 and 2, 17 patients) or performed under local anaesthesia in 15 patients (ASA-PS 1 and 2, 2 patients). A downgrading to PRO-score 2 was reached in 168 patients after therapeutic interventions (ASA-PS 1 and 2, 54 patients). Undergoing surgery despite 'red flag' events resulted in major complications in 34 patients, and 16 patients died (ASA-PS 1 or 2: 7 and 3 patients, respectively).

CONCLUSION

The PRO-score detected warning signs in 'healthy' ASA-PS 1 or 2 and in ASA-PS 3 or 4 patients. Furthermore, it influenced the management of these patients, and thus improved the process quality of risk assessment. The physical examination should include the assessment of vital signs.