1/ I haven’t written a #periopmedicine #tweetorial in a while, but last night @etsshow tapped me on the shoulder w a request for a #Medthread re preop evals via #telehealth

The specific❓was re assuaging surgeon (& I’ll add anesthesiologist) concerns re the lack of an exam

🧵
2/ Background 1️⃣–telehealth across the board has rapidly expanded given the challenges of providing care while keeping safe distances due to #covid19

We’ve had an incredible amount of institution level support for this at @OHSUnews @OHSUSOM! https://news.ohsu.edu/2020/04/13/ohsu-telehealth-rockets-into-new-era-of-medicine
OHSU telehealth rockets into ‘new era of medicine’

Global pandemic instigates exponential expansion of OHSU telemedicine program.

https://news.ohsu.edu/2020/04/13/ohsu-telehealth-rockets-into-new-era-of-medicine
3/ Background 2️⃣–telehealth for PREOP has been a goal for years w go-live in June.

Why?

To meet the care needs in a large, rural state—many of our sicker/older patients lived very far away & w limited socioeconomic means to get to preop clinic before surgery
4/ Background 3️⃣—there’s precedence for telehealth for preop visits, esp the work @DrNVKamdar at UCLA

Although there are concerns for rural/socioeconomic disparities with telehealth, the data I’ve seen for preop is encouraging

https://bit.ly/2VTLfSp 

https://pdfs.semanticscholar.org/74c1/d0e22df97dd114f92c7f02bd9451169ace24.pdf
5/ Background 4️⃣–we jumped into PHONE visits in mid-March as soon as OHSU started very proactively rising to the challenge of #covid19—video visits have slowly but ultimately followed

Huge HT to our lead NP @KristenAshNP who has spearheaded this workflow for our clinic
6/ background 5️⃣–this thread won’t focus on regulatory/billing issues, though that’s another conversation (HT the active Down Under convos about this! @GongGasGirl)

It’s a discussion-generating thread re how this type of eval doesn’t substract value from preop care
7/ so remember, a preoperative visit is not for “clearance”

It’s to perform a patient-centered ASSESSMENT by learning about the patient in ways that EMPOWER their intraop & postop care—including RISK STRATIFICATION and PREDICTION
8/ most periop experts say that the most important step of a preop evaluation is the HISTORY & PHYSICAL

the 2007 ACC/AHA periop guidelines also emphasize HISTORY....and physical

What is the relative weight we put on history v physical?
8/ most periop experts say that the most important step of a preop evaluation is the HISTORY & PHYSICALthe 2007 ACC/AHA periop guidelines also emphasize HISTORY....and physicalWhat is the relative weight we put on history v physical?
8/ most periop experts say that the most important step of a preop evaluation is the HISTORY & PHYSICALthe 2007 ACC/AHA periop guidelines also emphasize HISTORY....and physicalWhat is the relative weight we put on history v physical?
9/ let’s take a step back!

Which of the risk calculators pull in elements of the exam??

✳️MICA (Gupta) Cardiac doesn’t
✳️RCRI maybe does? But that’s also history...
✳️NSQIP barely does—you can learn about ascites from history, and BMI can be calculated from prior data
9/ let’s take a step back!Which of the risk calculators pull in elements of the exam??MICA (Gupta) Cardiac doesn’tRCRI maybe does? But that’s also history...NSQIP barely does—you can learn about ascites from history, and BMI can be calculated from prior data
9/ let’s take a step back!Which of the risk calculators pull in elements of the exam??MICA (Gupta) Cardiac doesn’tRCRI maybe does? But that’s also history...NSQIP barely does—you can learn about ascites from history, and BMI can be calculated from prior data
9/ let’s take a step back!Which of the risk calculators pull in elements of the exam??MICA (Gupta) Cardiac doesn’tRCRI maybe does? But that’s also history...NSQIP barely does—you can learn about ascites from history, and BMI can be calculated from prior data
10/ the pulmonary calculators don’t include components you can only get from a in-person exam (you can get O2 sat from available prior vitals or patients’ home monitors)

HT @KurtPfeifer for these screen grabs from his prior lecture slides @PeriopSummit
10/ the pulmonary calculators don’t include components you can only get from a in-person exam (you can get O2 sat from available prior vitals or patients’ home monitors)HT @KurtPfeifer for these screen grabs from his prior lecture slides @PeriopSummit
10/ the pulmonary calculators don’t include components you can only get from a in-person exam (you can get O2 sat from available prior vitals or patients’ home monitors)HT @KurtPfeifer for these screen grabs from his prior lecture slides @PeriopSummit
10/ the pulmonary calculators don’t include components you can only get from a in-person exam (you can get O2 sat from available prior vitals or patients’ home monitors)HT @KurtPfeifer for these screen grabs from his prior lecture slides @PeriopSummit
11/ let’s say history >> exam

( @AndreMansoor don’t throw your book at me...)

I believe in the power of the exam—BUT, I also believe in the power of the HISTORY, esp:
💠HPI
💠PMHx
💠med rec
💠ROS
💠Social history—habits AND living situation, esp for older/frailer patients
12/ from the above, I can learn about

🌀Chest pain
🌀Dyspnea
🌀Orthpnea/PND
🌀Edema
🌀Palpitations
🌀Exercise capacity
🌀Use of EtOH/marijuana/tobacco/illegal drugs
🌀ADLs, IADLs
🌀STOP-BANG score (gestimate neck circ from video, or ask collar size!)
13/ stay curious
Utilize the power of observation
get exam info via video

🌀Self-measured vitals (BP cuff, HR monitor, scale)
🌀Work of breathing
🌀Hearing
🌀Head/neck/airway assessment
🌀cognitive status
🌀edema

Bonus points to @AndreMansoor if he can see JVP via telehealth!
14/ how else can you get creative?
is this potentially a WIN?
I woke up to THIS tweet by @adamcifu

Yes—helping med recs
Yes—see people at home

PS— @londyloo tweet re rug assessment in geriatric telehealth visit!
https://twitter.com/londyloo/status/1248237970613841921?s=20

https://twitter.com/adamcifu/status/1253674868165525504?s=20 https://twitter.com/adamcifu/status/1253674868165525504
15/ speaking of which, there’s a lot of attention right now on preop frailty and geriatric assessments

✳️the Edmonton Fraity includes timed get up and go—can you do that with patient in their home??
✳️NSQIP has geriatric questions you can answer w/o exam
✳️DASI can get asked
15/ speaking of which, there’s a lot of attention right now on preop frailty and geriatric assessmentsthe Edmonton Fraity includes timed get up and go—can you do that with patient in their home?? NSQIP has geriatric questions you can answer w/o examDASI can get asked
15/ speaking of which, there’s a lot of attention right now on preop frailty and geriatric assessmentsthe Edmonton Fraity includes timed get up and go—can you do that with patient in their home?? NSQIP has geriatric questions you can answer w/o examDASI can get asked
15/ speaking of which, there’s a lot of attention right now on preop frailty and geriatric assessmentsthe Edmonton Fraity includes timed get up and go—can you do that with patient in their home?? NSQIP has geriatric questions you can answer w/o examDASI can get asked
16/ the Minicog has a clock draw which you can do that with patients via video (the Edmonton also includes a clock draw)

HT @Jeanna_BlitzMD for recommending the Blind MoCA

Our clinic team is also using the 5 minute/mini MOCA

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4373962/

https://www.mocatest.org/wp-content/uploads/2015/tests-instructions/MoCA-Test-BLIND.pdf
17/ @Jeanna_BlitzMD @Duke_Anesthesia & I have also chatted
about using the AD8, # of animals you can name in a minute, and
30 second chair sit stands (with that, I would watch/listen for dyspnea, too!)

https://www.cdc.gov/steadi/pdf/STEADI-Assessment-30Sec-508.pdf

https://www.alz.org/media/Documents/ad8-dementia-screening.pdf
18/ typically, if I’m leaning towards preop cardiac testing, I’m nearly at that decision before I start my exam

When does the exam really surprise me?

Murmurs—could they have incidental moderate or asymptomatic severe valve disease?

Even the LV assessment recs go by symptoms
18/ typically, if I’m leaning towards preop cardiac testing, I’m nearly at that decision before I start my exam When does the exam really surprise me?Murmurs—could they have incidental moderate or asymptomatic severe valve disease?Even the LV assessment recs go by symptoms
18/ typically, if I’m leaning towards preop cardiac testing, I’m nearly at that decision before I start my exam When does the exam really surprise me?Murmurs—could they have incidental moderate or asymptomatic severe valve disease?Even the LV assessment recs go by symptoms
19/ but what about EKG?

1️⃣we obtain too many preop EKGs that don’t change management
2️⃣better EHR interoperability may provide access to prior
3️⃣obtain on surgery day
4️⃣banter already happening re the role of apple watches and other wearables w telehealth
https://twitter.com/nickkotch/status/1251201342070312960?s=20 https://twitter.com/nickkotch/status/1251201342070312960
20/ btw, this is a really cool share by @EricTopol about how to obtain a 12 lead via Apple Watch (note the date—pre covid)

https://twitter.com/EricTopol/status/1199088326633914368?s=20 https://twitter.com/erictopol/status/1199088326633914368
21/ what about Labs?

1️⃣we probably obtain too many preop labs that don’t change management
2️⃣better EHR interoperability may provide access to prior & recent one
3️⃣work with your team to create a pathway for labs on the morning of surgery esp ones with restrictions on age (T&S)
22/ but does all this still risk day-of-surgery cancellation?

Yes...but...resource utilization is dramatically different now & the risk of COVID19 spread is real

The risk/benefit equation regarding DOS cancellations seems to have shifted if patients (& clinicians) stayed home
23/ remember also, the surgeries that are proceeding right now are likely the ones that are least elective such that delay/postponement for cardiac testing or other optimization may not additionally change management
24/ create a triage system to escalate to an occasional inperson visit based on the through HISTORY and assessment/observations during televisit...

Create processes to check in frequently with local stakeholders—how’s it going? Have there been surgery cancellations in the PACU?
FIN
this is a rapidly expanding practice area...
is it the same? No
Is it worth the innovative? Yes

Turn to #medtwitter to share experiences—And I anticipate a lot of discussion & reflections re this in the next year as we move into the new “normal” state of covid

🧶
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