Preop anesthetic evaluation: Live or Zoom?
Myron Yaster MD, Ivor Berkowitz MB BS, Melissa Brooks Peterson MD, and Allison Kinder Ross MD
Occasionally, I read an article in preparation for writing the PAAD and I wonder, “How come this study was never done before? It so obviously needed to be done!” And then I remember the immortal words of Sherlock Holmes: “The world is full of obvious things which nobody by any chance ever observes”.
I’ve got to admit that preop anesthesia evaluations were never my strong suit and I always wondered how and when they should be done. In my early career, if you can believe it, many (most?) pediatric patients were routinely admitted to the hospital the night before surgery for these evaluations! How times have changed (and for the better)! Today’s PAAD looks to answer the question: Is the preoperative assessment done virtually the same, better, or worse than a live assessment in terms of safety, effectiveness and patient/parent satisfaction? Because as I’ve said this is not really an area of my expertise, I’ve asked Drs. Ivor Berkowitz (Johns Hopkins), Melissa Brooks Peterson (Children’s Hospital Colorado) and Allison Kinder Ross (Duke) to help. Myron Yaster MD
Original article
Strassberger-Nerschbach N, Magyaros F, Maria W, Ehrentraut H, Ghamari S, Schenk A, Neumann C, Schindler E. Quality comparison of remote anesthetic consultation versus on-site consultation in children with sedation for a magnetic resonance imaging examination-A randomized controlled trial. Paediatr Anaesth. 2023 Aug;33(8):647-656. doi: 10.1111/pan.14679. Epub 2023 Apr 17. PMID: 37069740.
“The pre-anesthesia consultation (PrAC) has different aims. These include: (A) gaining information about the patients' health status, optimally by means of a physical examination, to assess the perioperative risk, (B) information of the patient about the planned anesthesia and possible adverse events, (C) decision on the choice of anesthesia, if possible, (D) getting legally informed consent and (E) giving advice to the patient, how to improve his behavior to have a better outcome.”1 Typically this is done via a live parental interview, usually within a week or 2 of the scheduled surgery or procedure. Although virtual interviews and consultations were becoming common, the COVID 19 epidemic and the desire to reduce our carbon footprint by eliminating unnecessary travel to the hospital or outpatient center accelerated the trend. Strassberger-Nerschbach et al.1 wondered if a virtual (telephone plus video) consultation was as good, better, or worse than a live one?
In a randomized, controlled prospective study of children scheduled for neuro and cardiac MRI evaluations “under sedation”, the patients who were < 14 year of age were divided into 2 groups, virtual vs live pre-anesthesia evaluation. OK, what did they find? “Both groups showed high levels of satisfaction. Some anesthesiologists and parents were less satisfied with the quality of on-site pre-anesthesia consultation than with the remote consultation. There was no evidence for higher risk of complications when information was provided by telephone. Further, parents as well as anesthesiologists clearly favored the combined form of telephone information and online video. Overall, 61.2% of parents and 64% of anesthesiologists would choose this form of pre-anesthesia consultation for repeat anesthesia.”1
Would the results be the same for patients undergoing general anesthesia for more complex surgery or with more complex medical histories? We don’t know but suspect that it would be (a study for one of you!). I (Melissa), do think that one of the largest benefits of a virtual preoperative assessment is lead time to obtain studies from outside hospitals, communicate with surgical teams about their plan, assimilate data from multiple specialists and make an assessment of the patient from there. Especially in regional catchment centers. One of the places I see this most effectively used is in the multidisciplinary clinic space – essentially seeing the most complex patients (e.g. Aerodigestive patients) for the most complex surgeries (e.g. High Risk Spine Fusion in an Aerodigestive patient!). The dedicated time for thorough data capture and assimilation is where I suspect the value in any high-risk patient, high risk procedure, or even high-risk patient having a low- or moderate-risk procedure lies. And there is another common theme we see of ways that “Anesthesiologists providing value” in non-operating room ways: the provision of dedicated time! We need to figure out how and for whom the provision of dedicated time for assessment makes a difference. I agree with these authors that can be done virtually or in-person
If the virtual assessment is safe and effective, the authors point out the many benefits to the family, including reducing long waiting times and avoiding travel to the facility which in this study improved the family’s satisfaction, decreased the risk of infection by contact and interactions with other patients and health care providers, and reduced their carbon footprint. There may be cost efficiencies to the health care system as well. The combination of time to assimilate complex or hard-to-locate data plus time/economic ease on the family and physician providing the preoperative consultation is a compelling reason for doing comprehensive preoperative evaluation, and doing it remotely whenever possible!
There are additional considerations. First, the process in this article compared a preoperative assessment with an anesthesiologist in person versus an anesthesiologist remotely. The practice in most centers in the United States, for example, instead uses either nurse practitioners, physician assistants or registered nurses for preoperative assessments under the guidance of an anesthesiologist. The anesthesiologist who will be doing the case sees the patient the day of surgery for outpatient procedures. What has been questioned through the Pediatric Anesthesia Leadership Council (PALC) is whether or not practices have a preoperative assessment clinic or team, who staffs it, and how do you bill for it? There are many different models, each with pros and cons. Certainly, a remote process would alleviate much of the expense of a physical space and provide that convenience that was found to be a satisfier in the referenced article.
Another consideration is the expectation of the preoperative clinic. The above listed 5 aims of the preoperative assessment include the best evaluation and instruction for safety and efficiency, with an additional goal of not having last minute cancellations. The American College of Surgeons Children’s Surgery Verification (CSV) program specifically addresses the “Perioperative Anesthesia Risk Assessment Program” and states that the CSV “endorses the development of perioperative anesthesia risk assessment programs to optimize the evaluation and perioperative management of children with complex medical conditions or who are undergoing extensive or complex surgeries”. The ability to track cancellations as a result of a failure of preoperative assessment is also encouraged. As stated in the referenced article, specific guidelines should be developed that will help guide the process of which patients are considered complex, which procedures are considered extensive and to triage the preoperative assessment process based on these criteria. Surprisingly, 46% of the patients in the referenced article were ASA 3 and 8% were ASA 4, but this apparently did not affect the complication rate.
Thus, should we eliminate the live assessment all together, particularly for these patients who are undergoing simple procedures? After all we eliminated the admission to the hospital on the night before surgery as well as routine laboratory testing? With the right infrastructure [provision of dedicated time!], the future of remote preop assessments may be one of the silver linings of the Covid pandemic. What are your thoughts? Send to Myron who will post in a Friday Reader Response.
References
1. Strassberger-Nerschbach N, Magyaros F, Maria W, et al. Quality comparison of remote anesthetic consultation versus on-site consultation in children with sedation for a magnetic resonance imaging examination-A randomized controlled trial. Paediatric anaesthesia. Aug 2023;33(8):647-656. doi:10.1111/pan.14679