Neurosurgical spine care during COVID-19 pandemic: The Department of Neurological Surgery Houston Methodist experience





Introduction


Telemedicine has traditionally been utilized for remote consultations in areas of medicine such as trauma, neurology, and psychiatry. However, with the 2020 COVID-19 pandemic, multiple disciplines of medicine quickly learned the utility of this modality of providing health care to our patients. This became necessary in order to deliver health care during this pandemic while reducing staff exposure to ill persons, reducing the burden of cases, as well as preserving personal protective equipment. Although this presented some challenges, namely changing some of our traditional ways of assessing patients, we saw this as a great opportunity not only to learn, but also to continue to provide neurosurgical spine care to our existing patients as well as to offer health care to new patients.


Our approach


The approach began with communicating to our established patients that continuity of care was available through telemedicine. The referring physicians were made aware of our capacity to offer telemedicine evaluation to new patients. Prior to the pandemic, a physician had to be licensed in the state where the patient was located; however, waivers were put in place to allow physicians to serve some patients out of state. We did not face this situation, as most of our patients remained in the state of Texas. The process also was easier to implement immediately as non-Health Insurance Portability and Accountability Act (HIPPA)-compliant modes of communication, such as FaceTime, became permissible. Hence, the option was given to the patient to communicate via video teleconferencing, including FaceTime, telephone only, or electronic communication such as email. Almost unanimously, our patient population elected for video teleconferencing, and we used HIPPA-compliant teleconferencing means of communication, using electronic privacy information center (EPIC) electronic medical record (Verona, Wisconsin). Only on the rare occasion of being unable to connect, after multiple attempts, did we conduct the evaluation via telephone. We did not find it necessary ever to employ electronic communication by way of email or medical record messaging, except for sending out and receiving new patient packet information. Once the patient was scheduled for a visit, the workflow essentially followed the same pattern as for our face-to-face inpatient visits.


The visit


Most of our follow-ups, including postoperative, scheduled, and new patients, agreed to telemedicine follow-up/consultation. The typical patient packet information was emailed to new patients. The latter was then reviewed within 30 min prior to their appointment by our medical assistant, especially the patient’s mode of identification, chief complaint, onset, location, duration, and previous treatment of symptoms, medication allergies, and current medications. Once this was completed, the medical assistant instructed the patient to log onto the mode of communication chosen—EPIC EMR in our case—no less than 15 min prior to their scheduled appointment.


Evaluation/examination


For the appointment, patients were instructed to be in a quiet room and wearing comfortable clothing. At this point the visit was no different than in-person visits, beginning with a detailed history taking, addressing each pertinent symptom. Our examination was conducted in as detailed a manner as the mode of communication permitted (see Table 13.1 ). It was helpful during the examination to ask the patient to step away from the device so as to be able to see the entire body or ask somebody, such as a family member, to hold the device during the examination. In this fashion we were typically able to complete a mental status evaluation, cranial nerves assessment, limited motor exam, range of motion, cerebellar examination, gait, overall spinal balance, and wound assessment, on postoperative patients ( Table 13.1 ).



Table 13.1

Basic evaluation/examination.












































Face-to-face visit Telemedicine
General appearance Whether patient is well kept or not. Note any degree of distress. Same
HEENT (head, eyes, ears, nose, and throat) Look for any gross head trauma. Cervical range of movement. Pupillary function and funduscopic examination. Look for any gross head trauma. Cervical range of movement.
Range of movement Lumbar spine flexion extension, rotation, and lateral flexion Same
Gait Check whether gait unstable, antalgic or not Same
Neurological Orientation to self, place, and time Same
Cranial nerves II–XII: the usual manner II (ask patient to read newspaper at arm’s-length)
VII (ask if patient is wearing hearing aids)
IX (ask if patient has any difficulty with swallowing and note their phonation)
Other CNs: the usual manner.
Motor function Perform Barre. Motor strength graded 0–5 upper and lower extremity major muscle groups. Perform Barre. Observe patient move all extremities against gravity and lift different weight objects. Ask patient to walk on heels and toes.
Cerebellar function Note any nystagmus. Check finger-nose-finger testing and rapid alternating movements as well as heel-to-shin. Same
Wound Inspect for discharge, induration, and erythema Same

Only gold members can continue reading. Log In or Register to continue

Oct 30, 2021 | Posted by in NEUROLOGY | Comments Off on Neurosurgical spine care during COVID-19 pandemic: The Department of Neurological Surgery Houston Methodist experience
Premium Wordpress Themes by UFO Themes