Newsletter December 2022: Anaesthesia and telemedicine-is there any conflict?

Gabriel M. Gurman, MD
Chief editor

There is no doubt that anaesthesia cannot be provided from a distance. However, the continuous presence of the anaesthesiologist near their patient is an obligation which must be respected; otherwise, there would be an invitation for catastrophe.

But what about using telemedicine for the pre-anaesthetic examination?

Here is a subject which deserves a severe glance and a deep thought.

Pre-anaesthesia examination and evaluation is the first rule of a correct approach in preparing the patient before surgery. This concept is right, even in emergency surgery, in which the anaesthesiologist will use every single minute before bringing the patient to the operating room (OR) to gather data about his/her condition.

But this task is much easier to fulfil when we deal with elective surgery. This is because the preoperative contact between the patient and their anaesthesiologist offers, besides essential data regarding their medical condition, a unique opportunity for helping the patient to achieve confidence in the person who will soon be responsible for his/her life during surgical intervention.

Once upon a time, when I started my residency in anaesthesia, patients used to be admitted to the hospital a couple of days before the day of surgery, lab tests were done, various specialists examined the patient, and finally, the anaesthesiologist paid a visit, performed a complete examination and drew the conclusions regarding the patient readiness for surgery and the technique of anaesthesia.

But today, the percentage of elective surgeries done on the same day in the USA and UK (like in many other countries) reached 70% (1). This new reality obliged the system to change its habits, which explains the appearance of the pre-anaesthesia outpatient clinics (PAC). Interestingly enough, the first publication on PAC is almost 85 years old (2). However, the opening of such a clinic in nearly every single hospital started only by the end of the previous century.

PAC solves almost all the problems related to patient evaluation and preparation for elective surgery since the patient is seen by anaesthesiologist days or weeks before the planned intervention. In some cases, they were already seen by other specialists, and if necessary more consultations and tests are prescribed and performed.

But PAC also has some drawbacks. First of all, it needs space and a workforce. Then, many unpleasant and unexpected things can appear between the patient’s visit to PAC and the day of planned surgery. Last but not least, much too often, the anaesthesiologist who examines the patient at PAC is not the same one who will anaesthetize him/her. This fact will reduce, to a minimum, the impact of the degree of confidence the patient gained with his/her anaesthesiologist.

In the last years, a new development has taken place in our daily activity.

The impact of telemedicine on the routine activity of a hospital has an influence on the preoperative period and the way the patient is prepared for elective surgery and anaesthesia.

The use of telemedicine for pre-anaesthesia visits was described for the first time by Wong et al. in 2004 (3). They included ten patients in the pilot study. They found that nine out of the ten patients and all the anaesthesiologists involved in the study expressed high satisfaction with the system.

The last year’s literature deals in detail with this new way of evaluating and preparing the patient for an elective surgical procedure.

It was shown that remote examination systems offer a complete and relevant history, reduce cost and are accompanied by a higher level of availability (4). Furthermore, when they compared the classical evaluation with telemedicine before anaesthesia, Applegate et al. (5) reported some advantages of the tele-examination: less missing documentation and no decrease in the percentage of predicting difficult intubation.

Zhang et al. (6), in a meta-analysis of 15 studies, found that virtual examination (in comparison with in-person evaluation) was accompanied by a similar percentage of surgery cancellations and a significant percentage of saving time and money.

Zetterman et al. (7) reported that the tele-system for evaluating the elective surgical patient before anaesthesia saved money and time and that 70% of the patients expressed their preference for this method rather than the in-person examination.

By the way, the COVID pandemic emphasized the place of telemedicine in times of restricted travelling. MacDonald and Berv (8) reported this year that telemedicine allowed patients to reach the comfort of their homes, reduced the cost, eased the travel burden and enabled family members to participate in visits more easily.

Only some of the studies presented encouraging reports. For example, Gordon et al. (9) selected the following title for their paper: “I’m Not Feeling Like I’m Part of the Conversation”. Patients’ Perspectives on Communicating in Clinical Video Telehealth Visits”. They interviewed 27 diabetic patients who passed a telehealth visit. Despite some positive results (better access, shorter travel, no waiting time), several patients complained about needing to be more evaluated, getting less attention, and missing the relationship with the physician.

They reproduced some of the patients’ impressions, like this: “when I see the doctor, I feel good when I talk to him…when I talk to doctors on telehealth, I do not feel the same way….”.

So, what could be the impact of telemedicine in the pre-anaesthesia stage?

Our clinical experience taught us that the preoperative period is emotionally stressful for many patients who may fear surgery and anaesthesia. Talking to and with the patient by conducting an unhurried, organized interview could alleviate these feelings, and reassuring them that you will meet again in the OR creates a strong sentiment of confidence.

But, as one can see from the quoted papers, tele-preoperative contact with the patient has some clear advantages.

And what is the best way?

The famous Greek philosopher Plato wrote: “In everything, the middle road is the best. All things in excess bring trouble to man”.

How can this famous quote be interpreted in our case?

I believe mixing both systems can offer real advantages.

For instance, the computerized tele-system can save time by collecting, through a well-built-up questionnaire, all the data regarding the patient’s history, medication, previous surgery and possible complications. Then, an in-person examination and discussion can come later, in the premises of PAC, offering the patient the necessary confidence in his/her anaesthesiologist and creating effective patient-clinician communication.

One system cannot completely replace the other one. However, when the logistic reality creates difficulties for an in-person interview and examination, the tele-system can be the answer.

But this method is questionable in case we have faced a patient with severe comorbidity. In this case, the in-person is preferable.

One cannot but agree with what Scott (10) wrote more than 40 years ago: “The preoperative visit, from the patient’s point of view, is the most important act of the anaesthetist”.

It would be interesting to get our readers’ opinions about this topic and how they think the so-called conflict could be solved.

References:

1. Lemos P, Jarrett P, Philip B. Day Surgery Development and Practice, 2006, pp.22
2. Lee A Anaesthesia 1949;4:169
3. Wong DT et al. Anesthesiology 2004;100:1605
4. Burton BN et al.  JMIR Form Res 2022;25:e38054
5. Applegate RL et al. Telemed JE Health 2013;19:211
6. Zhang K et al. J Clin Anesth 2021;75:110540
7. Zetterman CV et al. Stud Health Technol Inform 2011;163:737
8. MacDonald SM, Berv J. New Engl J Med 2022;387:775
9. Gordon HS et al. J Gen Int Med 2020;35:1751
10. Scott W. Anaesthesia 1980;35:584

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