DEVELOPMENT AND IMPLEMENTATION OF AN ADVANCED PRACTICE NURSE DRIVEN TELEMEDICINE PROJECT FOR PREOPERATIVE EVALUATION

CHAPTER ONE INTRODUCTION Problem Description The pre-surgical testing practice at Memorial Sloan Kettering Cancer Center (MSKCC) includes eight New York and New Jersey clinic locations that serve its patient population. With the increasing need for surgical options in cancer care management and the expansion of clinical sites, the practice at the time of the study faced serious challenges with the available appointment dates and timelines needed to accommodate the patients thorough evaluation and optimization before their surgery date. In 2021, data collected for quarters one through four revealed a 7.15% surgery cancellation rate for patients who were seen at the pre-surgical testing clinic proceeding for surgery. Among this percentage, about 4.5% of cancellations were due to patients not being medically cleared for surgery due to insufficient time between Preoperative evaluation and the day of surgery. For quarters one through three in 2022, the cancellation rate was 7.06%. To expand services, MSKCC needed to adjust to the current trend of digital healthcare delivery (Cooling et al., 2021). MSKCC needed to incorporate telehealth forms of healthcare delivery to promote patient-centered outcomes (Manatt, 2019). The telemedicine platform considered accommodated the evaluation of patients proceeding with low-risk surgeries. Based on MSKCC’s indicated testing grids, most low-risk surgery patients did not need diagnostic tests before surgery. This allowed workflow to schedule patients proceeding for intermediate and high-risk surgeries for Preoperative evaluation at least 2 weeks before their surgery date to allow time for workup if warranted. Research studies have shown the effectiveness of telemedicine for Preoperative evaluation in decreasing surgery cancellations (Mullen-Fortino et al., 2019). Surgery cancellation 2 is an ongoing benchmark that helps measure the performance and efficiency of the operating room in terms of revenue growth per patient, profit margin, and patient satisfaction. Practice Prior to Implementation Traditionally, pre-surgical testing entails an in-person medical evaluation of the patient to ensure the patient is optimized for surgery to ensure an optimal peri and postoperative outcome. The evaluation was completed in a Preoperative testing clinical setting where the clinician received a thorough medical, surgical, and anesthesia history taking, a review of the system, a physical examination, and diagnostic tests to evaluate their surgical risk. If identified, a referral was made to specialists who ensured patient optimization for surgery. The core assessment in a pre-surgical testing clinic is an anesthesia evaluation which entails an airway examination to identify potential needs in the operating room. The assessment was completed in person by an anesthesiologist or a trained advanced practice registered nurse (APRN). Nursing Practice in Telemedicine The healthcare system continues to adopt healthcare delivery through telephone and video conferencing as forms of telehealth or telemedicine visits between patients and their providers. The roles of APRNs in pre-surgical healthcare settings range from the design to the implementation of telehealth programs to help bridge healthcare gaps, particularly as seen during the COVID-19 pandemic. These platforms for Preoperative evaluation have shown to be as successful as in-person visits in different healthcare settings (Cooling et al., 2021). Patients who meet the telemedicine inclusion/exclusion criteria are identified as low-risk and may need no preoperative diagnostic testing based on the indicated testing grids according to MSKCC guidelines. Typically, these patients will get a detailed provider-led examination via