Thread by @aoglasser, 1/ I haven’t written a #periopmedicine #tweetorial in a while, but last [...]

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

https://abs.twimg.com/emoji/v2/... draggable="false" alt="❓" title="Red question mark ornament" aria-label="Emoji: Red question mark ornament">was re assuaging surgeon (& I’ll add anesthesiologist) concerns re the lack of an exam

https://abs.twimg.com/emoji/v2/... draggable="false" alt="🧵" title="Thread" aria-label="Emoji: Thread">

2/ Background

https://abs.twimg.com/emoji/v2/... draggable="false" alt="1️⃣" title="Keycap digit one" aria-label="Emoji: Keycap digit one">–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">https://news.ohsu.edu/2020/04/1...

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

https://abs.twimg.com/emoji/v2/... draggable="false" alt="2️⃣" title="Keycap digit two" aria-label="Emoji: Keycap digit two">–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

https://abs.twimg.com/emoji/v2/... draggable="false" alt="3️⃣" title="Keycap digit three" aria-label="Emoji: Keycap digit three">—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://bit.ly/2VTLfSp&q... href=" https://pdfs.semanticscholar.org/74c1/d0e22df97dd114f92c7f02bd9451169ace24.pdf">https://pdfs.semanticscholar.org/74c1/d0e2...

4/ Background https://abs.twimg.com/emoji/v2/... draggable=

—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&q... href=" https://pdfs.semanticscholar.org/74c1/d0e22df97dd114f92c7f02bd9451169ace24.pdf">https://pdfs.semanticscholar.org/74c1/d0e2..." title="4/ Background https://abs.twimg.com/emoji/v2/... draggable="false" alt="3️⃣" title="Keycap digit three" aria-label="Emoji: Keycap digit three">—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&q... href=" https://pdfs.semanticscholar.org/74c1/d0e22df97dd114f92c7f02bd9451169ace24.pdf">https://pdfs.semanticscholar.org/74c1/d0e2..." class="img-responsive" style="max-width:100%;"/>

5/ Background

https://abs.twimg.com/emoji/v2/... draggable="false" alt="4️⃣" title="Keycap digit four" aria-label="Emoji: Keycap digit four">–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

https://abs.twimg.com/emoji/v2/... draggable="false" alt="5️⃣" title="Keycap digit five" aria-label="Emoji: Keycap digit five">–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?

9/ let’s take a step back!

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

https://abs.twimg.com/emoji/v2/... draggable="false" alt="✳️" title="Eight spoked asterisk" aria-label="Emoji: Eight spoked asterisk">MICA (Gupta) Cardiac doesn’t

https://abs.twimg.com/emoji/v2/... draggable="false" alt="✳️" title="Eight spoked asterisk" aria-label="Emoji: Eight spoked asterisk">RCRI maybe does? But that’s also history...

https://abs.twimg.com/emoji/v2/... draggable="false" alt="✳️" title="Eight spoked asterisk" aria-label="Emoji: Eight spoked asterisk">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??https://abs.twimg.com/emoji/v2/... draggable=

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:

https://abs.twimg.com/emoji/v2/... draggable="false" alt="💠" title="Diamond shape with a dot inside" aria-label="Emoji: Diamond shape with a dot inside">HPI

https://abs.twimg.com/emoji/v2/... draggable="false" alt="💠" title="Diamond shape with a dot inside" aria-label="Emoji: Diamond shape with a dot inside">PMHx

https://abs.twimg.com/emoji/v2/... draggable="false" alt="💠" title="Diamond shape with a dot inside" aria-label="Emoji: Diamond shape with a dot inside">med rec

https://abs.twimg.com/emoji/v2/... draggable="false" alt="💠" title="Diamond shape with a dot inside" aria-label="Emoji: Diamond shape with a dot inside">ROS

https://abs.twimg.com/emoji/v2/... draggable="false" alt="💠" title="Diamond shape with a dot inside" aria-label="Emoji: Diamond shape with a dot inside">Social history—habits AND living situation, esp for older/frailer patients

12/ from the above, I can learn about

https://abs.twimg.com/emoji/v2/... draggable="false" alt="🌀" title="Cyclone" aria-label="Emoji: Cyclone">Chest pain

https://abs.twimg.com/emoji/v2/... draggable="false" alt="🌀" title="Cyclone" aria-label="Emoji: Cyclone">Dyspnea

https://abs.twimg.com/emoji/v2/... draggable="false" alt="🌀" title="Cyclone" aria-label="Emoji: Cyclone">Orthpnea/PND

https://abs.twimg.com/emoji/v2/... draggable="false" alt="🌀" title="Cyclone" aria-label="Emoji: Cyclone">Edema

https://abs.twimg.com/emoji/v2/... draggable="false" alt="🌀" title="Cyclone" aria-label="Emoji: Cyclone">Palpitations

https://abs.twimg.com/emoji/v2/... draggable="false" alt="🌀" title="Cyclone" aria-label="Emoji: Cyclone">Exercise capacity

https://abs.twimg.com/emoji/v2/... draggable="false" alt="🌀" title="Cyclone" aria-label="Emoji: Cyclone">Use of EtOH/marijuana/tobacco/illegal drugs

https://abs.twimg.com/emoji/v2/... draggable="false" alt="🌀" title="Cyclone" aria-label="Emoji: Cyclone">ADLs, IADLs

https://abs.twimg.com/emoji/v2/... draggable="false" alt="🌀" title="Cyclone" aria-label="Emoji: Cyclone">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

https://abs.twimg.com/emoji/v2/... draggable="false" alt="🌀" title="Cyclone" aria-label="Emoji: Cyclone">Self-measured vitals (BP cuff, HR monitor, scale)

https://abs.twimg.com/emoji/v2/... draggable="false" alt="🌀" title="Cyclone" aria-label="Emoji: Cyclone">Work of breathing

https://abs.twimg.com/emoji/v2/... draggable="false" alt="🌀" title="Cyclone" aria-label="Emoji: Cyclone">Hearing

https://abs.twimg.com/emoji/v2/... draggable="false" alt="🌀" title="Cyclone" aria-label="Emoji: Cyclone">Head/neck/airway assessment

https://abs.twimg.com/emoji/v2/... draggable="false" alt="🌀" title="Cyclone" aria-label="Emoji: Cyclone">cognitive status

https://abs.twimg.com/emoji/v2/... draggable="false" alt="🌀" title="Cyclone" aria-label="Emoji: Cyclone">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/londyloo/... href=" https://twitter.com/adamcifu/status/1253674868165525504?s=20">https://twitter.com/adamcifu/... https://twitter.com/adamcifu/status/1253674868165525504">https://twitter.com/adamcifu/...

https://twitter.com/londyloo/status/1248237970613841921?s=20

15/ speaking of which, there’s a lot of attention right now on preop frailty and geriatric assessments

https://abs.twimg.com/emoji/v2/... draggable="false" alt="✳️" title="Eight spoked asterisk" aria-label="Emoji: Eight spoked asterisk">the Edmonton Fraity includes timed get up and go—can you do that with patient in their home??

https://abs.twimg.com/emoji/v2/... draggable="false" alt="✳️" title="Eight spoked asterisk" aria-label="Emoji: Eight spoked asterisk">NSQIP has geriatric questions you can answer w/o exam

https://abs.twimg.com/emoji/v2/... draggable="false" alt="✳️" title="Eight spoked asterisk" aria-label="Emoji: Eight spoked asterisk">DASI can get asked

15/ speaking of which, there’s a lot of attention right now on preop frailty and geriatric assessmentshttps://abs.twimg.com/emoji/v2/... draggable=

the Edmonton Fraity includes timed get up and go—can you do that with patient in their home?? https://abs.twimg.com/emoji/v2/... draggable="false" alt="✳️" title="Eight spoked asterisk" aria-label="Emoji: Eight spoked asterisk">NSQIP has geriatric questions you can answer w/o examhttps://abs.twimg.com/emoji/v2/... draggable="false" alt="✳️" title="Eight spoked asterisk" aria-label="Emoji: Eight spoked asterisk">DASI can get asked" title="15/ speaking of which, there’s a lot of attention right now on preop frailty and geriatric assessmentshttps://abs.twimg.com/emoji/v2/... draggable="false" alt="✳️" title="Eight spoked asterisk" aria-label="Emoji: Eight spoked asterisk">the Edmonton Fraity includes timed get up and go—can you do that with patient in their home?? https://abs.twimg.com/emoji/v2/... draggable="false" alt="✳️" title="Eight spoked asterisk" aria-label="Emoji: Eight spoked asterisk">NSQIP has geriatric questions you can answer w/o examhttps://abs.twimg.com/emoji/v2/... draggable="false" alt="✳️" title="Eight spoked asterisk" aria-label="Emoji: Eight spoked asterisk">DASI 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.ncbi.nlm.nih.gov/pmc/artic... href=" https://www.mocatest.org/wp-content/uploads/2015/tests-instructions/MoCA-Test-BLIND.pdf">https://www.mocatest.org/wp-conten...

https://www.mocatest.org/wp-conten..." title="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 MoCAOur clinic team is also using the 5 minute/mini MOCA https://www.ncbi.nlm.nih.gov/pmc/artic... href=" https://www.mocatest.org/wp-content/uploads/2015/tests-instructions/MoCA-Test-BLIND.pdf">https://www.mocatest.org/wp-conten..." class="img-responsive" style="max-width:100%;"/>

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.cdc.gov/steadi/pd... href=" https://www.alz.org/media/Documents/ad8-dementia-screening.pdf">https://www.alz.org/media/Doc...

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?

https://abs.twimg.com/emoji/v2/... draggable="false" alt="1️⃣" title="Keycap digit one" aria-label="Emoji: Keycap digit one">we obtain too many preop EKGs that don’t change management

https://abs.twimg.com/emoji/v2/... draggable="false" alt="2️⃣" title="Keycap digit two" aria-label="Emoji: Keycap digit two">better EHR interoperability may provide access to prior

https://abs.twimg.com/emoji/v2/... draggable="false" alt="3️⃣" title="Keycap digit three" aria-label="Emoji: Keycap digit three">obtain on surgery day

https://abs.twimg.com/emoji/v2/... draggable="false" alt="4️⃣" title="Keycap digit four" aria-label="Emoji: Keycap digit four">banter 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... https://twitter.com/nickkotch/status/1251201342070312960">https://twitter.com/nickkotch...

https://twitter.com/nickkotch/status/1251201342070312960?s=20

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... https://twitter.com/erictopol/status/1199088326633914368">https://twitter.com/erictopol...

https://twitter.com/EricTopol/status/1199088326633914368?s=20

21/ what about Labs?

https://abs.twimg.com/emoji/v2/... draggable="false" alt="1️⃣" title="Keycap digit one" aria-label="Emoji: Keycap digit one">we probably obtain too many preop labs that don’t change management

https://abs.twimg.com/emoji/v2/... draggable="false" alt="2️⃣" title="Keycap digit two" aria-label="Emoji: Keycap digit two">better EHR interoperability may provide access to prior & recent one

https://abs.twimg.com/emoji/v2/... draggable="false" alt="3️⃣" title="Keycap digit three" aria-label="Emoji: Keycap digit three">work 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

https://abs.twimg.com/emoji/v2/... draggable="false" alt="🧶" title="Yarn" aria-label="Emoji: Yarn">

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