Safety of Surgical Telehealth in the Outpatient and Inpatient Setting

Adoption of Telemedicine for Postoperative Follow-Up After Inpatient Cancer-Related Surgery

PURPOSE

The COVID-19 pandemic has resulted in significant changes in health care delivery, including the rapid adoption of telemedicine across multiple specialties and practice environments. This includes postoperative visits (POV), despite limited data on outcomes following these telemedicine POV. We sought to determine whether these types of visits successfully identify and address postoperative complications when compared with in-person POV.

METHODS

This was a retrospective cohort study of patients undergoing elective inpatient cancer-related surgery from March 2020 through December 2020. The exposure variable was type of POV (telemedicine v in-person). The primary outcome was unplanned hospital readmission within 90 days, and secondary outcomes included 30-day readmission, length of stay of first readmission, and mortality.

RESULTS

Five-hundred thirty-five patients underwent elective inpatient operations and met our inclusion criteria. Of these, 98 (18.5%) had an initial telemedicine POV. There was no difference in 90-day readmission on the basis of POV type (16.3% telemedicine v 16.5% in-person, P = .99). Reasons for readmission did not differ between patients who underwent a telemedicine POV compared with in-person POV (all P > .05). After adjustment for patients' demographic and clinical factors, telemedicine POV was not associated with 90-day readmission (odds ratio, 0.89; 95% CI, 0.43 to 1.70; P = .77).

CONCLUSION

Telemedicine POV use adopted during the COVID-19 pandemic did not increase risk of readmission when compared with in-person visits following inpatient oncologic surgery. These data can help inform policy on the continued use and application of telemedicine after the pandemic.

Telemedicine Implementation Trends in Surgical Specialties Before and After COVID-19 Shelter in Place: Adjusting to a Changing Landscape

Background

The COVID-19 pandemic caused a shift from in-person care to telemedicine, providing a unique opportunity to evaluate trends and efficiency of telemedicine usage within surgical subspecialties in a large, integrated health care system before and after shelter in place mandates.

Methods

This retrospective cohort study included all of the Kaiser Permanente Northern California members referred to surgical services from January 1, 2019 to June 13, 2020 and receiving a surgical procedure. We compared the patient referrals (categorized as benign, urgent, or cancer) before and after shelter in place mandates, and we examined rates of telemedicine (video or telephone) usage for preoperative consultations, postoperative visits, time from referral to first surgical encounter, and to surgery or procedure. In multivariate analyses, we assessed the patient and provider characteristics associated with telemedicine usage.

Results

There was a total of 34,875 surgical referrals resulting in a procedure, with a significant decline in referral after shelter in place mandates. Preoperative encounter types shifted from 89.8% in-person before shelter in place mandates to 70.2% telemedicine after shelter in place mandates (P < .0001). The median time from referral to first encounter decreased after shelter in place mandates, as did median time to procedure. After shelter in place mandates, postoperative encounters were mainly telemedicine (65.8%) compared with before shelter in place mandates (41.7%) (P < .0001). Overall, there was a comparable uptake of telemedicine usage in almost all evaluated categories of patient characteristics after shelter in place mandates.

Conclusion

Within a health care system with prior telemedicine capability, surgical specialties were able to shift to telemedicine rapidly, equitably, and efficiently in the preoperative and postoperative encounters of benign, urgent, and cancer diagnosis during mandated COVID-19 restrictions.

The Perioperative Patient Experience During COVID-19

Background

Access to elective surgical procedures has been impacted by the COVID-19 pandemic.

Methods

We sought to understand the patient experience by developing and distributing an anonymous online survey to those who underwent non-emergency surgery at a large academic tertiary medical center between March and October 2020.

Results

The survey was completed by 184 patients; the majority were white (84%), female (74.6%), and ranged from 18 to 88 years old. Patients were likely unaware of case delay as only 23.6% reported a delay, 82% of which agreed with that decision. Conversely, 44% felt that the delay negatively impacted their quality of life. Overall, 82.7% of patients indicated high satisfaction with their care. African American patients more often indicated a “neutral” vs “satisfactory” hospital experience (P < .05) and considered postponing their surgery (P < .01). Interestingly, younger patients (<60) were more likely than older (≥60) patients to note anxiety associated with having surgery during the pandemic (P < .01), feeling unprepared for discharge (P < .02), not being allowed visitors (P < .02), and learning about the spread of COVID-19 from health care providers (P < .02).

Discussion

These results suggest that patients are resilient and accepting of changes to health care delivery during the current pandemic; however, certain patient populations may have higher levels of anxiety which could be addressed by their care provider. These findings can help inform and guide ongoing and future health care delivery adaptations in response to care disruptions.

Telemedicine for preanesthesia evaluation: review of current literature and recommendations for future implementation

PURPOSE OF REVIEW

The in-person preanesthesia visit serves multiple purposes including identification and optimization of comorbid conditions as well as patient education. However, it imposes a significant burden on patients and healthcare providers. In this review, we define the scope of telemedicine and present the most up-to-date literature supporting its role for the preanesthesia evaluation. The opportunities and challenges are discussed and approaches to implementation of telemedicine in preanesthesia care are offered. Finally, the future of telemedicine as it pertains to preanesthesia care is examined.

RECENT FINDINGS

Although telemedicine for preanesthesia practice was proposed almost two decades ago, the COVID-19 pandemic has accelerated its implementation. The potential benefits of telemedicine include improved patient satisfaction as well as the ability to provide cost-effective specialty services while reducing the burden on healthcare providers. Limitations to telemedicine include lack of technology, training, regulatory barriers, and an inability to perform a physical exam.

SUMMARY

Telemedicine will continue to expand and its application to the preanesthesia evaluation is a clear example of how technology will revolutionize anesthesia practice. In order for telemedicine to continue to expand in the postpandemic period, steps must be taken to ensure that healthcare facilities and providers keep up with the times.

Inpatient Telemedicine and New Models of Care during COVID-19: Hospital Design Strategies to Enhance Patient and Staff Safety

The challenges of the COVID-19 pandemic have led to the development of new hospital design strategies and models of care. To enhance staff safety while preserving patient safety and quality of care, hospitals have created a new model of remote inpatient care using telemedicine technologies. The design of the COVID-19 units divided the space into contaminated and clean zones and integrated a control room with audio-visual technologies to remotely supervise, communicate, and support the care being provided in the contaminated zone. The research is based on semi-structured interviews and observations of care processes that implemented a new model of inpatient telemedicine at Sheba Medical Center in Israel in different COVID-19 units, including an intensive care unit (ICU) and internal medicine unit (IMU). The study examines the impact of the diverse design layouts of the different units associated with the implementation of digital technologies for remote care on patient and staff safety. The results demonstrate the challenges and opportunities of integrating inpatient telemedicine for critical and intermediate care to enhance patient and staff safety. We contribute insights into the design of hospital units to support new models of remote care and suggest implications for Evidence-based Design (EBD), which will guide much needed future research.

Assessing the immediate impact of COVID-19 on surgical oncology practice: Experience from an NCI-designated Comprehensive Cancer Center in the Northeastern United States

Background

The effects of the coronavirus disease 2019 (COVID‐19) pandemic on surgical oncology practice are not yet quantified. The aim of this study was to measure the immediate impact of COVID‐19 on surgical oncology practice volume.

Methods

A retrospective study of patients treated at an NCI‐Comprehensive Cancer Center was performed. “Pre‐COVID” era was defined as January–February 2020 and “COVID” as March–April 2020. Primary outcomes were clinic visits and operative volume by surgical oncology subspecialty.

Results

Abouyt 907 new patient visits, 3897 follow‐up visits, and 644 operations occurred during the study period. All subspecialties experienced significant decreases in new patient visits during COVID, though soft tissue oncology (Mel/Sarc), gynecologic oncology (Gyn/Onc), and endocrine were disproportionately affected. Telehealth visits increased to 11.4% of all visits by April. Mel/Sarc, Gyn/Onc, and Breast experienced significant operative volume decreases during COVID (25.8%, p = 0.012, 43.6% p < 0.001, and 41.9%, p < 0.001, respectively), while endocrine had no change and gastrointestinal oncology had a slight increase (p = 0.823) in the number of cases performed.

Conclusions

The effects of the COVID‐19 pandemic are wide‐ranging within surgical oncology subspecialties. The addition of telehealth is a viable avenue for cancer patient care and should be considered in surgical oncology practice.

E-consensus on telemedicine in proctology: A RAND/UCLA-modified study

BACKGROUND

Coronavirus disease 2019 is revolutionizing healthcare delivery. The aim of this study was to reach a consensus among experts as to the possible applications of telemedicine in the proctologic field.

METHODS

A group of 55 clinical practice recommendations was developed by a clinical guidance group based on coalescence of evidence and expert opinion. The Telemedicine in Proctology Italian Working Group included 47 Italian Society of Colorectal Surgery nominated experts evaluating the appropriateness of each clinical practice recommendations based on published RAND/UCLA methodology in 2 rounds.

RESULTS

Stakeholder median age was 53 years (interquartile range limits 40-60), and 38 (81%) were men. Nine (19%) panelists reported no experience with telemedicine before the pandemic. Agreement was obtained on a minimum of 3 to 5 years of practice in the proctologic field before starting teleconsultations, which should be regularly paid, with advice and prescriptions incorporated into a formal report sent to the patient by e-mail along with a receipt. Of the panelists, 35 of 47 (74%) agreed that teleconsultation carries the risk of misdiagnosis of cancer, thus recommending an in-person assessment before scheduling any surgery. Fifteen additional clinical practice recommendations were re-elaborated in the second round and assessed by 44 of 47 (93.6%) panelists. The application of telemedicine for the diagnosis of common proctologic conditions (eg, hemorrhoidal disease, anal abscess and fistula, anal condylomas, and anal fissure) and functional pelvic floor disorders was generally considered inappropriate. Teleconsultation was instead deemed appropriate for the diagnosis and management of pilonidal disease.

CONCLUSION

This e-consensus revealed the boundaries of telemedicine in Italy. Standardization of infrastructures, logistics, and legality remain to be better elucidated.