Preadmission Anesthesia Consultation Using Telemedicine Technology: A Pilot Study

TELEMEDICINE has been defined as the delivery of healthcare and sharing of medical knowledge over a distance using telecommunications systems. 1It uses modern high-speed telecommunication systems that allow interactive video-mediated clinical consultations. Telemedicine enables the delivery of healthcare irrespective of geographic location or ability to travel to tertiary healthcare centers. 2In Canada, a significant population lives in remote regions away from tertiary care centers. At Toronto Western Hospital, 15% of patients are referred from remote regions. Telemedicine can potentially reduce travel costs and improve accessibility to health care.Although telemedicine has been used by other medical and surgical specialties, there have been no reports in the literature evaluating telemedicine technology for anesthesia consultations. 3–5We report the technical aspects and implementation of telemedicine anesthesia consultation, the first 10 patients interviewed, and their satisfaction regarding telemedicine consultations.The University Health Network in Toronto recently developed a partnership with the Northern Ontario Remote Telecommunication Health (NORTH) Network to provide telemedicine clinical consultations to residents of central and northern Ontario in Canada. The NORTH Network started in 1998 and now connects more than 65 distant sites throughout Ontario and Manitoba.Both sites are equipped with videoconference television monitors and cameras that allow live two-way communication.A light source is connected to two analog cameras (AMD-2500s; AMD Telemedicine Inc., Lowell, MA). The first camera functions as the room camera, and the second serves as the airway camera for intraoral views. A digital electronic stethoscope (AMD-3550; AMD Telemedicine Inc.) permits the transmission of heart and lung sounds.The NORTH network uses the existing communications network Smart Systems for Health, provided by Bell Canada (Montreal, Quebec, Canada), operating with a bandwidth of 384 kbps.The Tandberg 880 portable videoconference unit (Tandberg, New York, NY) (fig. 1) is mounted on a mobile stand and is located in the anesthesia preadmission clinic. The setup incorporates a monitor, a camera, a desktop computer, and a digital stethoscope. When connected to the remote site, the anesthesiologist can visualize, hear, and auscultate the patient using the digital stethoscope system (AMD-3550). The anesthesiologist inserts the digital stethoscope earpieces in exactly the same manner as a conventional stethoscope. The audible frequency range can be varied manually, depending on whether high-pitched or low-pitched sounds are being auscultated.Institutional research ethics board approval was obtained for the study. Patient referrals were made by the surgeon’s office. Potential candidates were identified by the preadmission booking clerk if their address was located outside of the Greater Toronto Area and if a telemedicine center was located near their home. The patient was then contacted by telephone and asked whether he or she wished to participate. An anesthesiologist with a special interest in telemedicine was then contacted regarding the suitability for telemedicine consultation. Patients who were mentally challenged, those who did not reside near a telemedicine facility, and those with complex medical issues that required additional preoperative investigations that were unavailable at the distant telemedicine site were excluded.For agreeable candidates, medical information was then requested from the patient using the institutional preoperative patient questionnaire and from their family physician using the institutional preoperative history and physical examination form.An anesthesiologist was present at the consultant site while a nurse accompanied the patient at the remote site during anesthesia consultation. The anesthesiologist took a history from the patient as in a conventional consultation. Examination of the airway and respiratory and cardiovascular systems was performed. Mouth opening and the Mallampati score were assessed using the airway camera. The patient was then turned, and a side-view visual assessment of the airway profile, thyromental distance, and neck movement was made using the room camera. The digital stethoscope was used to auscultate the heart and lung sounds. The nurse at the remote center was instructed on the positioning of the stethoscope on the patient’s chest and precordium. The rest of the consultation was conducted as per a conventional consultation.Data were collected by an anesthesia research fellow. Degree of satisfaction by the patient and consulting and attending anesthesiologist were graded on five-point Likert response scales. 5Postoperatively, the patient was visited by the anesthesia research fellow and asked whether he or she was satisfied with the telemedicine consultation. The consulting anesthesiologist was asked to rate his satisfaction with the telemedicine format after completion of the consultation. The attending anesthesiologist was asked on the day of the operation to rate his satisfaction with the telemedicine anesthesia consultation.Results from the first 10 consecutively completed tele-medicine preadmission anesthetic consultations performed in 2003 were shown. Two patients were male, and eight were female. Four were had an American Society of Anesthesiologists (ASA) physical status classification of II, and six had an ASA physical status classification of III. The age of the patients was 58 ± 14 yr. The time to complete the telemedicine anesthetic consultation was 31 ± 7 min.Nine of 10 patients stated that they were highly satisfied, and 1 of 10 were satisfied with telemedicine anesthesia consultation. Four anesthesiologists performed the telemedicine anesthesia consultation. Telemedicine consultation was satisfactory to both the consulting anesthesiologist and to the attending anesthesiologist. Eight of 10 consulting anesthesiologists were highly satisfied, and 2 of 10 were satisfied with the telemedicine consultation format. Ten of 10 attending anesthesiologists were highly satisfied with the preoperative anesthesia consultation. There were no reports of missing information from the attending anesthesiologists.During preoperative screening, one patient was deemed inappropriate for telemedicine anesthesia consultation because he had obesity and inadequately investigated sleep apnea. The patient was assessed in person, and additional investigations were performed. One patient had her operation postponed as a result of the anesthesiologist noting documented results of an abnormal cardiac perfusion scan during the telemedicine consultation. After a coronary angiogram was obtained, the patient proceeded to surgery.The results of this pilot study indicate that preadmission anesthesia consultations using telemedicine technology can be successfully performed. Patients and consulting and attending anesthesiologists are very satisfied with telemedicine consultation.Nine of 10 patients in this study were highly satisfied with anesthesia consultation by telemedicine. There are no reports in the literature evaluating telemedicine technology for preoperative consultations by anesthesiologists. In patients who underwent conventional preadmission anesthesia consultations, 92% thought that there was improved perioperative care, and 84% thought that they were less anxious as a result of the consultation. 6Eighty-eight percent of patients surveyed by Murchison 7indicated that the anesthesia consultation was beneficial to them. Ninety-three percent thought that the preadmission anesthetic consultation before cardiothoracic surgery was valuable. 8The incidence of patient satisfaction in this study is in keeping with what is reported in the literature for conventional anesthesia consultation 6–8and with telemedicine studies in other disciplines. 2,4,5,9In 140 telemedicine pediatric consultations, 90% preferred the telemedicine format over the conventional consultation, and 71% were completely satisfied with the consultation. 9All attending anesthesiologists found that the quality of anesthesia consultation using telemedicine was satisfactory, and there was no missing information. A retrospective study of 43 patients booked for dentoalveolar surgery during general anesthesia found that 95% of the patients undergoing preadmission telemedicine consultations were judged to have been adequately assessed by oral and maxillofacial surgical residents for general anesthesia and nasotracheal intubation. 10A junior surgical trainee, not an anesthesiologist, evaluated the airway using an airway camera.The majority of the consulting anesthesiologists were satisfied with the telemedicine format for consultation. Because the physical examination by the anesthesiologist consists primarily of airway examination and heart and lung auscultation, the telemedicine format lends itself well to anesthesia consultations. The airway camera enables the anesthesiologist to assess the airway in a manner similar to that of a conventional consultation, but with better visualization of the posterior pharynx because of illumination. The digital stethoscope allows adequate examination of the cardiovascular and respiratory systems.There are several limitations to the telemedicine consultation process. First, there are privacy concerns for the patient because they are being asked to provide personal details and exposure of the chest for auscultation. Second, telemedicine consultation does not permit any physical contact between the physician and the patient. Third, the patient and the anesthesiologist cannot speak at the same time.This pilot study indicates that telemedicine preadmission anesthesia consultation can be successfully completed for patients residing in remote areas. Patients and anesthesiologists are satisfied with telemedicine consultations. However, a formal cost-effectiveness study must be performed before adopting this technology over conventional consultations on a wider scale. A randomized controlled trial with one group randomized to telemedicine consultation and the other to conventional consultation is needed. The aspects of cost, patient satisfaction, missing data, and necessary in-person visitation can then be compared between the groups to fully evaluate the cost effectiveness of this promising novel approach to preadmission anesthesia consultation.The authors thank Barb Thompson, R.N., Donna Williams, R.N. (Clinical Educator, Preadmission Program), and Arlene Falcon (Telehealth Program Secretary) for their valuable assistance in the telehealth program operation at Toronto Western Hospital, Toronto, Ontario, Canada.

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