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One of the few positive things to come out of the COVID-19 pandemic (yes, there are some positives!) is that telemedicine has flourished. As shutdowns and restrictions and fear led to significant drop-offs in office/clinic visits, telehealth and “virtual” visits began to fill the gaps and both patients and clinicians have begun to see the benefits of such visits. Since CMS (Centers for Medicare & Medicaid Services) issued emergency waivers in April 2020 to allow payment for telehealth services and many other insurers followed suit, such visits have skyrocketed. A report from McKinsey & Co. in June concluded that 46% of consumers in the U.S. were using telemedicine, up from 11% a year earlier, and estimated that with changes such as replacing 20% of emergency room visits and 25% of health-care office visits, telemedicine eventually could account for a fifth of all Medicare, Medicaid and commercial insurance spending on outpatient, office and home health care (Cortez 2020).
But not all patients are ready for or able to participate in telehealth visits. And for many, clinicians must be aware of barriers they will encounter during such visits. Lam 2020
Nieman and Oh (Nieman 2020) have very practical recommendations for connecting with older adults via telemedicine:
Practical recommendations for telehealth visits have also been made by the AMA AMA 2020, Canadian Patient Safety Institute and Canadian Medical Association CPSI 2020, and the British Medical Journal Car 2020. TRC 2020
The Joint Commission (Joint Commission 2020) acknowledged some additional benefits of telehealth during the COVID-19 pandemic:
It stressed that your telehealth visits, of course, must be done on secure systems and are subject to HIPAA and all other security and confidentiality concerns.
It’s also critical to recognize that not all conditions can be appropriately or safely managed via telehealth. Patients must be informed that certain symptoms (like chest pain, or even “indigestion” which might be a sign of an MI) merit immediate attention and should not be attempted via telemedicine.
Joint Commission stresses that organizations should develop protocols for virtual care and standards for which symptoms and conditions can be managed virtually They should also pay attention to regulations on scope of practice, noting that limitations regarding different health care disciplines can vary by state. It also has recommendations regarding training, supervision, workflow, and feedback.
Some types of interaction are ideal for telehealth visits. The annual “wellness visit”, where the focus is on managing risk factors, can often be fully accomplished using telemedicine. And the annual “brown bag” medication review that is so important in geriatrics is actually easier to do via telemedicine. The patient doesn’t have to bring in their “brown bag” of medications but can simply show everything in their medicine cabinet to you via these communication links. It saves all time and still allows for face-to-face interaction. For years we have recommended that clinicians provide a phone call to most patients 24-48 hours after discharge from hospitals. Better yet, do that via a telemedicine visit!
One of the drawbacks of the telehealth visit is lack of a physical exam. But that is not always the case. Back in the early 1990’s we developed one of the first telemedicine systems at the Erie County Medical Center, SUNY Buffalo’s major teaching facility. We had contracts to deliver medical care for inmates at Attica Prison and other New York State prisons. It was very costly for the prison system to send inmates for clinic visits (they had to send at least 2 guards with each prisoner and this led to substantial overtime costs). So, we began using telemedicine visits. A nurse practitioner or physician assistant at the prison would be able to place a stethoscope so we could audibly appreciate heart sounds, lung sounds, bowel sounds, etc. The views of the tympanic membrane we’d see from their otoscope made us all envious. We even had a special glove lined with sensors that allowed us to examine the abdomen as the on-site clinician palpated the patient’s abdomen. Of course, your typical patient does not have access to all these items in his/her home. But, someday, patients with certain conditions will be supplied with stethoscopes or otoscopes or other tools that will allow parts of the physical exam to become part of the telehealth visit. Some smartphones already allow transmission of reasonable fundoscopic views. Much of the neurological exam can be appreciated by watching the patient walk and talk (it’s difficult for some patients to set up their webcam to allow viewing of their gait but it’s easy to transmit video of their gait by their spouse or other using a smartphone).
Telemedicine has had a substantial impact on stroke care, particularly in rural areas. Physicians in rural ED’s who were previously reluctant to diagnose strokes and begin thrombolytic therapy can now interact with a neurologist via telemedicine and be better positioned to make such decisions.
Telehealth can be a godsend for certain populations. Those with significant physical disabilities that limit their ability to travel to an office or clinic are likely to benefit. Patients in rural areas may avoid long trips to get access to specialists. There is a nationwide shortage of psychiatrists, particularly child and adolescent psychiatrists, and telehealth can improve access to these. Telehealth could also reduce the long wait times patients have to see another specialist in short supply, the dermatologist (though not all dermatological problems can be diagnosed in telemedicine visits). Followups from surgery may be facilitated by telemedicine by allowing visualization of healing wounds. Our April 7, 2020 Patient Safety Tip of the Week “From Preoperative Assessment to Preoperative Optimization” discussed how prehabilitation may help reduce complications prior to surgery. That included an opinion piece (Silver 2020) in the British Medical Journal that suggested we should use prehabilitation to prepare patients for COVID-19 infections and that these interventions can be delivered while patients are practicing social distancing or are sheltering in place and can be easily delivered via telemedicine.
There is also a “good news, bad news” feature of telehealth – death of the waiting room. The good news is that patients won’t be exposed to transmissible diseases in a waiting room. The bad news is that many patients actually like the social interactions that occur in a waiting room. But there is also an important point we make over and over regarding practice management – some of the most important people in your practice are your front line staff. Patients will often confide to them things they are reluctant to reveal to the clinicians (such as that they are not taking their medications because they cannot afford them).
One nuance of telemedicine that we consider extremely important is that it forces the clinician to actually look at his/her patient! All too often in today’s more typical “face-to-face” office visits, the clinician is looking at a computer screen rather than at the patient. Body language and facial expression often convey much more meaning than the spoken word. By carefully observing those in your patient, you may recognize when they are having difficulty comprehending something. Those of you who give talks or chair meetings have probably begun to appreciate that same nuance as we’ve moved from the “old” webcast format to the new zoom format. If we see our audience fidgeting, we know it’s time for a break. Similarly, if we see some of the yawning, we know it’s time to move on to something else or deliver whatever ploys you use to wake up your audience.
Telehealth and “virtual” visits are clearly here to stay. But every hospital, office, clinic, or other healthcare organization must ensure that they deliver such services securely and safely as well as conveniently.
Cortez M. Telemedicine, Washington Post 2020; September 14, 2020
Nieman CL, Oh ES. Connecting With Older Adults via Telemedicine. Annals of Internal Medicine 2020; Epub ahead of print 11 August 2020
The Joint Commission. The optimal use of telehealth to deliver safe patient care. Quick Alert 2020; Issue55:| October 7,2020
Silver JK. Prehabilitation could save lives in a pandemic BMJ 2020; 369 :m1386
Most of our columns on PIM’s (Potentially Inappropriate Medications) in the elderly have focused on the safety issues. But there is also a fiscal downside of such prescribing. Two recent articles in the Journal of the American Geriatrics Society have highlighted those costs.
Clark et al. (Clark 2020) used data from the 2011–2015 Medical Expenditure Panel Survey (MEPS) to estimate the prevalence of PIM prescribing in community‐dwelling U.S. adults aged 65 and older. According to the press release for this study (UB 2020), “among the 218 million-plus older adults surveyed, more than 34% were prescribed at least one potentially inappropriate medication. Those patients were, on average, prescribed twice as many drugs, were nearly twice as likely to be hospitalized or visit the emergency department, and were more likely to visit a primary care physician compared to older adults who were not prescribed potentially inappropriate medication.
Patients who received these medications also spent an additional $458 on health care, including an extra $128 on prescription drugs.”
In that study the crude rate of hospitalizations was higher in those prescribed PIM’s at 35.6 per 100 persons versus 19.3 per 100 persons in the non-PIM group. The rate of ED visits was 41.1 per 100 persons in the PIM group compared with 23.6 per 100 persons in the non-PIM group. In the crude data, the difference in average total expenditures was higher for those on PIM’s within the inpatient ($1,767), ED ($141), and outpatient ($1,568) settings. Prescription drug expenditures were also higher in those prescribed PIM’s ($2,263). Totaling expenditures across all types resulted in a difference of $5,168 for those exposed to PIM’s as compared with the non-PIM group.
The authors did note a small but significant decrease over the period studied in the use of specific inappropriate medications including antispasmodics, antidepressants, digoxin, non-benzodiazepine hypnotics, androgens, estrogens, and metoclopramide. But, notably, some of the agents most commonly targeted for deprescribing in older adults (eg, first generation antihistamines, antipsychotics, benzodiazepines, nonsteroidal anti-inflammatory drugs, PPI’s, and long-acting sulfonylureas) did not change over this time period.
They conclude that PIM’s continue to be prescribed at high rates among older adults and are associated with increased healthcare utilization and costs across the healthcare continuum. They note that deprescribing is “currently in its infancy” in the United States, and that further interventions are needed to target unnecessary and inappropriate medications in older adults and reduce unnecessary healthcare utilization.
In the other study, Fralick et al. (Fralick 2020) analyzed data from the Medicare Part D Prescription Drug Program data set (2014–2018). They found that, from 2014 to 2018, 43 billion doses of potentially inappropriate medications were dispensed, with a reported spending of $25.2 billion. In 2018, 7.3 billion doses of potentially inappropriate medications were dispensed. The most common medications by number of doses dispensed were proton pump inhibitors, benzodiazepines, and tricyclic antidepressants, and the top five unique medications by reported spending were dexlansoprazole, esomeprazole, omeprazole, dronedarone, and conjugated estrogens.
Speaking of proton pump inhibitors, another recent study (Patel 2020) confirmed a point we have made over and over – PPI’s (and other acid suppressing medications) are often inappropriately continued after patients are discharged from or transferred from the ICU. The researchers analyzed data on patients admitted to ICU’s from 13 hospitals within a health system over a 6-month period. The highest incidence of inappropriate medication continuation after ICU transfer or discharge occurred in patients receiving a PPI (26.78%), followed by H2 blockers (8.39%) They also found frequent inappropriate continuation of bronchodilators (5.9%). They conclude that inappropriate discharge of patients on these medications not only poses risk for long term effects on a patient’s body but also costs the patients money for a medication they may not require.
Those authors note that studies have shown no benefits of adding PPI/H2RA medications in decreasing morbidity and mortality in the ICU and that many studies on long-term PPI usage have shown adverse effects. That is in keeping with a just-released scientific statement from the American Heart Association “Prevention of Complications in the Cardiac Intensive Care Unit” (Fordyce 2020) noted in our November 2020 What's New in the Patient Safety World column “Prevention of Complications in the Cardiac Intensive Care Unit”. That statement says “Newer evidence suggests that stress ulcer prophylaxis may be associated with reduced gastrointestinal bleeding in high-risk patients but overall has no demonstrated mortality benefit, and the number needed to treat is high.” It goes on to say “Routine use of stress ulcer prophylaxis is not necessary for low-risk patients in the CICU (cardiac ICU), including all patients receiving MV (mechanical ventilation). Stress ulcer prophylaxis is reasonable for patients in the CICU with multiple risk factors for gastrointestinal bleeding (including patients with shock, acute kidney injury requiring renal replacement therapy, MV, liver disease, use of anticoagulants, and ongoing coagulopathy as defined by platelet count <50 000/m3, an international normalized ratio >1.5, or a partial thromboplastin time >2 times the control value or on dual antiplatelet therapy), although the data supporting this approach are weak.”
Based on their findings of inappropriate continuation of these categories of drugs, Patel et al. believe that a multidisciplinary approach to medication reconciliation during ICU downgrade would prove beneficial in preventing such occurrences.
Bottom line: Far too many patients continue to take medications that are likely to be inappropriate. This leads not only to adverse effects on the patients but also increases healthcare utilization and costs. Careful medication reconciliation is needed at all transitions of care and, for most older adults, the annual “brown bag” medication review is important. Evidence-based deprescribing is critical in reducing hazards to patients and costs to the healthcare system. It’s also worth noting our previous warnings that sometimes the drug you thought you discontinued is still being taken by your patients.
Some of our past columns on Beers’ List and Inappropriate Prescribing in the Elderly:
Some of our past columns on deprescribing:
Some of our previous columns on medication reconciliation:
October 23, 2007 “Medication Reconciliation Tools”
December 30, 2008 “Unintended Consequences: Is Medication Reconciliation Next?”
September 8, 2009 “Barriers to Medication Reconciliation”
August 2011 “The Amazon.com Approach to Medication Reconciliation”
January 2012 “AHRQ’s New Medication Reconciliation Tool Kit”
September 2012 “Good News on Medication Reconciliation”
October 1, 2019 “Electronic Medication Reconciliation: Glass Half Full or Half Empty?”
Some of our other columns on failed discontinuation of medications:
May 27, 2014 “A Gap in ePrescribing: Stopping Medications”
March 2017 “Yes! Another Voice for Medication e-Discontinuation!”
February 2018 “10 Years on the Wrong Medication”
August 28, 2018 “Thought You Discontinued That Medication? Think Again”
December 18, 2018 “Great Recommendations for e-Prescribing”
August 2019 “Including Indications for Medications: We Are Failing”
August 6, 2019 “Repeat Adverse Drug Events”
Clark CM, Shaver AL, Aurelio LA, et al. Potentially Inappropriate Medications Are Associated with Increased Healthcare Utilization and Costs. J Am Geriatr Soc 2020; Published online 05 August 2020
UB (University at Buffalo). Study: 34% of older adults in the U.S. are prescribed potentially inappropriate drugs, raising health care costs by hundreds. (Press Release). Newswise 2020; October 21, 2020
Fralick, M., Bartsch, E., Ritchie, C.S. and Sacks, C.A. (2020), Estimating the Use of Potentially Inappropriate Medications Among Older Adults in the United States. J Am Geriatr Soc 2020; Early View
Fordyce CB, Katz JN, Alviar CL, et al. Prevention of Complications in the Cardiac Intensive Care Unit: A Scientific Statement From the American Heart Association. Circulation 2020; Published online 29 October 2020
The American Heart Association has just released a scientific statement “Prevention of Complications in the Cardiac Intensive Care Unit” (Fordyce 2020). The suggested practices for cardiac intensive care units (CICU’s) are based primarily on evidence generated from patients admitted to general medical or surgical ICU’s but take into account the special circumstances and underlying conditions that CICU patients have. They recognize there has been “substantial heterogeneity in care of critically ill cardiac patients” and note that this document aims to provide standardized approaches to preventive care using the best available evidence. It suggests the use of a bedside checklist to inform best practices in the prevention of complications in this unique population.
Details of the topics in this comprehensive 28-page document are beyond the scope of today’s column. The topics are arranged under the following categories:
PREVENTION OF CICU-ACQUIRED INFECTIONS
APPROACH TO ANALGESIA AND SEDATION AND THE DIAGNOSIS AND PREVENTION OF DELIRIUM
PREVENTION OF VENTILATOR COMPLICATIONS
BENEFITS OF EARLY MOBILIZATION
PREVENTION OF GASTROINTESTINAL COMPLICATIONS
PREVENTION AND RECOGNITION OF MEDICATION COMPLICATIONS AND ERRORS
COMPLICATIONS OF INVASIVE CARDIAC PROCEDURES AND DEVICES
TRANSITIONS OF CARE BEST PRACTICES
The document also provides a sample “Daily Bedside Checklist” to encourage best practices and to prevent complications for patients admitted to the cardiac intensive care unit (CICU). It has reminders sorted into the major categories noted above.
This is a very useful and timely document and comes with 150 references. We hope you’ll read the details of each topic and implement their suggested best practices.
Fordyce CB, Katz JN, Alviar CL, et al. Prevention of Complications in the Cardiac Intensive Care Unit: A Scientific Statement From the American Heart Association. Circulation 2020; Published online 29 October 2020
The fact that most gastrointestinal endoscopy procedures require some level of sedation raises patient safety concerns. Most sedation for such procedures involves use of benzodiazepines with or without an opioid. Propofol has also been used in some circumstances. Propofol has the advantage of rapid onset of action and predictable depth of sedation but it has a relatively narrow therapeutic window. Moreover, it lacks a reversal agent. Therefore, use of propofol usually requires administration by an anesthetist or anesthesiologist.
The emergence of propofol target-controlled infusion (TCI) systems is felt by some to provide a potential alternative to anesthetist-managed sedation. Propofol TCI systems are pre-programmed with pharmacokinetic models and some adjust for patient weight and age.
A recent study from a tertiary medical center in Argentina analyzed the experience of patients who had undergone elective gastrointestinal endoscopy under propofol target-controlled infusion sedation (García Guzzo 2020). 823 outpatients, age 18 and older with ASA scores I–III (85% were actually score I-II) who underwent diagnostic and therapeutic EGD, colonoscopy, or both were included in the analysis. 48% had colonoscopy alone and 37% had combined EGD and colonoscopy. Patients who had endoscopic retrograde cholangiopancreatography, enteroscopy, and procedures performed under planned tracheal intubation were excluded from the study. The propofol target-controlled infusions (TCI’s) were administered and monitored by anesthetists. Conventional monitoring included blood pressure, EKG, and oxygen saturation by pulse oximetry. Capnography apparently was not used.
The following adverse events were noted during the procedure: oxygen desaturation < 95% (rate 22.35%), vasoactive drug administration (19.2%), hypotension (12.64%), and oxygen desaturation < 90% (9.92%). Only 0.5% of patients required advanced airway management. No patients required ACLS or died. In the post-anesthetic period, hypotension occurred in 4.6% and oxygen desaturation (SaO2 < 95%) in 0.12%. No patients had SaO2 < 90%. The incidence of nausea/vomiting episodes was 0.6%. No patients required advanced airway management or ACLS during the post-anesthetic period. Colonoscopy and higher doses of propofol were associated with hypotensive episodes. All patients were discharged on the day of the procedure.
A strong dose-effect relationship was found between hypoxia and obesity; patients with body mass index ≥40 were nine times (odds ratio 10.22) more likely to experience oxygen desaturation < 90% events.
The authors conclude that propofol sedation using target-controlled infusion appears to be a safe and effective anesthetic technique for gastrointestinal endoscopic procedures with acceptable rates of adverse events and could be more widely adopted in clinical practice.
Overall, this was a low-risk population and the procedures were relatively low-risk, So the results cannot be extrapolated to patients with higher ASA scores. These results are comparable or better than most results reported for use of other sedation regimens for such gastrointestinal endoscopic procedures.
Though the overall safety profile looks very good, we are concerned about use of propofol in patients with obesity. In fact, the researchers found a strong dose–effect relationship between obesity and episodes of oxygen desaturation to SaO2 < 90%. Compared to patients with a normal BMI, the risk of those with BMI 30–35 was almost double (OR 1,68), for those with BMI 35–40 three times (OR 2.85) and for those with BMI ≥40 nine times (OR 10.22) more likely to experience episodes of oxygen desaturation to SaO2 < 90%.
Of course, we would not be surprised if those same rates of desaturation are seen in obese patients undergoing these procedures using alternative sedation protocols. Obese patients have a high incidence of obstructive sleep apnea (OSA) and apneic episodes are probably as likely triggered by sedation with benzodiazepines, opioids, or propofol. Also keep in mind that 87% of the patients in this study received not only propofol but also received the opioid fentanyl.
The authors note that use of a high-flow nasal cannula or continuous positive airway pressure via nasal mask (SuperN2va) have been proposed to reduce oxygen desaturation events for spontaneously breathing obese patients.
We remain cautious about the use of propofol with or without an opioid for GI endoscopic procedures in obese patients (or others who are at risk for obstructive sleep apnea). We’d probably like to see use of capnographic monitoring for that population. But the jury is still out on the value of capnography in the GI suite. Our March 2018 What's New in the Patient Safety World column “Capnography in the GI Suite” discussed that issue. The ASGE guidelines for sedation and anesthesia in GI endoscopy (Early 2018) state “capnography has been demonstrated to detect depressed respiratory activity before transient hypoxemia, but a clear link between transient hypoxemia and serious cardiopulmonary unplanned events during sedated endoscopy has not been established. Integrating capnography into patient monitoring protocols for endoscopic procedures with moderate sedation has not been shown to improve patient safety; however, there is evidence supporting its use in procedures targeting deep sedation.” However, under its recommendations for propofol use during endoscopy, it does state “Capnography should be considered because it may decrease the risks during deep sedation.” And under their summary recommendations they “suggest that capnography monitoring be considered for patients undergoing endoscopy targeting deep sedation.”
Most of the studies looking at the added value of capnography in GI procedures have concluded that, while capnography may reduce the number of hypoxic events, it has not changed the overall risk of serious events (Kim 2018, Veazie 2020, Saunders 2017).
A recent study at a high-volume university hospital GI department (Bisschops 2019) found that the relative risks of experiencing both adverse events and interventions during recovery were reduced significantly in patients monitored by capnography compared to a control group. There were 1,044 patients in the capnography arm and 1,092 patients in the control arm. The primary endpoint (change in total incidence of mild oxygen desaturation, severe oxygen desaturation, bradycardia, and tachycardia) occurred on average 11.45 times per 100 procedures in the control group, compared to 5.08 times per 100 procedures in the group monitored by capnography, a 55.69% reduction. There were nine escalations of care in the control group and none in the capnography group.
Jopling and Qiu (Jopling 2017) performed a retrospective analysis of a huge number of inpatients and outpatients undergoing gastrointestinal endoscopic procedures with sedation. They found the use of capnography was associated with and a 61% estimated reduction in the odds of a pharmacological rescue event compared to the matched outpatient population. (And note that, for the inpatient population, use of capnography was associated with a reduction in both mortality and pharmacologic rescue rates.)
But most studies have not stratified the patients by obesity or OSA risk. One study (Prathanvanich 2015) used capnography during upper endoscopy in morbidly obese patients and found it very useful in detecting early respiratory depression and no clinically significant cardiorespiratory complications occurred. However, there was no control group for comparison.
While the Argentina study suggests that propofol sedation using target-controlled infusion appears to be a safe and effective anesthetic technique for gastrointestinal endoscopic procedures with acceptable rates of adverse events, we would still recommend that capnography be used to monitor high risk patients (those with obesity or other risk factors for OSA) and those in whom a deeper level of sedation is considered likely.
García Guzzo ME, Fernandez MS, Sanchez Novas D, et al. Deep sedation using propofol target-controlled infusion for gastrointestinal endoscopic procedures: a retrospective cohort study. BMC Anesthesiology2020; 20(1): 195
Early DS, Lightdale JR,Vargo JJ, et al for the ASGE Standards Of Practice Committee. Guidelines for sedation and anesthesia in GI endoscopy. Gastrointestinal Endoscopy 2018; 87(2): 327-337
Kim SH, Park M, Lee J, Kim E, Choi YS. The addition of capnography to standard monitoring reduces hypoxemic events during gastrointestinal endoscopic sedation: a systematic review and meta-analysis. Ther Clin Risk Manag 2018;14: 1605-1614. Published 2018 Sep 6
Veazie S, Vela K, Mackey K. Evidence Brief: Capnography for Moderate Sedation in Non-Anesthesia Settings. US Department of Veterans Affairs Evidence Synthesis Program; June 2020
Saunders R, Struys MMRF, Pollock RF, et al Patient safety during procedural sedation using capnography monitoring: a systematic review and meta-analysis. BMJ Open 2017; 7: e013402
Bisschops R, Demedts I, Roelandt P. et al. Capnography During Endoscopy – A Value-Based Healthcare Pilot In A High-Volume Gastroenterology Practice. Endoscopy 2019; 51(04): S165
Jopling MW, Qiu J. Capnography Sensor Use Is Associated With Reduction of Adverse Outcomes During Gastrointestinal Endoscopic Procedures With Sedation Administration
BMC Anesthesiol 2017; 17(157): Published 28 November 2017
Prathanvanich P, Chand B. The role of capnography during upper endoscopy in morbidly obese patients: a prospective study. Surgery for Obesity and Related Diseases 2015; 11(1): 193-198
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