ERAS Protocols for Outpatient Operations in Otolaryngology: Review of Literature
Kevin Chorath (Presenter); Sara Hobday; Beatrice C. Go; Alvaro G. Moreira, MD; Karthik Rajasekaran, MD
Introduction: Enhanced recovery after surgery (ERAS) protocols are patient-centered, evidence-based pathways designed to reduce complications, promote recovery, and improve outcomes following surgery; these protocols have been successfully applied for the management of head and neck cancer, but relatively few studies have investigated the applicability of these pathways for other outpatient procedures in otolaryngology. Our goal was to perform a systematic review of available evidence reporting the utility of ERAS protocols for the management of patients undergoing outpatient otolaryngology operations.
Method: A systematic literature review was conducted using MEDLINE via PubMed, EMBASE, SCOPUS and gray literature to identify studies that evaluated ERAS protocols among patients undergoing otologic, laryngeal, nasal/sinus, pediatric, and general otolaryngology operations. We assessed the outcomes and ERAS components across protocols as well as the study design and limitations.
Results: A total of 8 studies met the inclusion criteria and were included in the analysis. Types of procedures evaluated with ERAS protocols included tonsillectomy and adenoidectomy, functional endoscopic sinus surgery, mastoidectomy, and septoplasty. A reduction in postoperative length of stay and hospital costs was reported in 2 and 3 studies, respectively. Comparative studies between ERAS and control groups also showed persistent improvement in pre- and postoperative anxiety and pain levels, without an increase in postoperative complications and readmissions rates.
Conclusion: A limited number of studies discuss implementation of ERAS protocols for outpatient operations in otolaryngology. These clinical pathways appear promising for these procedures as they may reduce length of stay, decrease costs, and improve pain and anxiety postoperatively.
Hearing Loss and Risk of Falls in Elderly
Natalia Baraky (Presenter); Paula Rodrigues; Leticia Baraky
Introduction: Hearing loss is a condition of great impact for elderly individuals, being the most common sensory deficit in this population. It is known that falling from one’s own height is also an important disabling event and that it may be related to several contributing factors. Several studies indicate that hearing problems are strictly related to the increased risk of falls.
Method: This is a descriptive cross-sectional study, carried out on a population sample of 117 individuals aged between 60 and 90 years and who were being followed up at the Health Department for the Elderly, in the city of Juiz de Fora, between 2017 and 2018. Data were collected from questionnaire, otoscopic examination and audiometric evaluation at frequencies of 500 Hz and 4 KHz. Chi-square test was applied, and a P value less than .05 for univariate analysis between hearing loss and falls and associated factors.
Results: Hearing impairment was observed in 23 individuals (19.6%), and at least 1 episode of falling by 42 (35.9%) was described, 7 of which were identified with hearing loss. The association between hearing loss and falls in the sample showed a P value of .84. As for the association between sex and falls, in the female population (n = 95), falls were reported by 36.8%. In the male population (n = 22), 31.8% reported falls. The P value for gender and falls was .84. In the population that lived unaccompanied (n = 31), the presence of falls was 41.9%, with a P value of .55.
Conclusion: There was no statistically significant association between falls and factors such as hearing loss, sex, and living together.
Impact of Standardization in M&M Reporting Within an Otolaryngology Department
Maximilian C. Stahl (Presenter); Sydney Jiang, MD; Diana Zarowin; Christina J. Yang, MD; Vikas Mehta, MD, MPH
Introduction: The morbidity and mortality (M&M) conference identifies areas for improvement in patient care and safety. To more effectively capture potential cases, especially “near-misses,” we attempted to standardize reporting and presentation of cases by developing a rubric for identifying potential cases and streamlining electronic reporting of possible cases so they could be done in real-time.
Method: This is a retrospective chart review of adverse events reported from November 2016 and December 2019. Adverse events were categorized as pre- or postimplementation of a standardized reporting and conference format, which occurred on July 1, 2018. Patient demographic data, inpatient vs outpatient setting, adverse event verus near-miss event, and attending physician subspecialty were collected.
Results: A total of 280 cases were reported between November 2016 and December 2019 (109 preimplementation, 171 postimplementation). There were 209 adult cases (81 pre-, 128 postintervention) and 71 pediatric cases (28 pre-, 43 postimplementation). The average age of all reported cases was 42.2 (95% CI, 16.8–67.6). There was a 56.9% increase in total cases reported postintervention. The average number of cases reported per month was 6.1 (±4.6) preimplementation and 10.1 (±8.6) postimplementation (P = .025). The rate of near-miss event reporting increased by 78.5% in the postimplementation period. In addition, the rate of cases reported in the outpatient setting increased by 12.6% in the postintervention period. Subspecialties with an increased rate of event reporting postimplementation were pediatrics (8.6% increase), rhinology (27.5% increase), sleep (43.4% increase), and neurotology (186.8% increase).
Conclusion: The implementation of a standardized reporting and conference format significantly increased the total number of cases reported per month and the incidence of near-miss event reporting. These qualitative and quantitative changes led to the development of several quality improvement initiatives within our department that have the potential to improve patient care throughout our system.
Is Giving Patients Your Personal Phone Number Good Clinical Practice?
Matthew D. Adams (Presenter); Jeff Wong, MD; Aileen Wertz, MD; Thorsen W. Haugen, MD
Introduction: Communication between patients and Medical providers is a major barrier to care, with some providers giving their personal phone number (PPN) to patients to increase accessibility. We investigated the following (1) extent to which patients utilize their provider’s PPN, (2) effect of this practice on patient satisfaction, (3) provider’s ability to predict abuse of this practice, and (4) evolving provider perceptions.
Method: A prospective, randomized study from August to December 2020 wherein 9 otolaryngology providers enrolled subjects during a 2-week period. Subjects were randomized to either receive their PPN or not. Providers predicted the likelihood of abuse after each encounter. Subjects were allotted 4 weeks to use their provider’s PPN, and all calls/texts were documented. At the conclusion of the study, subjects were surveyed using Press Ganey provider satisfaction metrics. Providers were also surveyed before and after the study to assess their likelihood in providing patients with their PPN and the impact of this practice on work demands.
Results: Of the 507 subjects enrolled, 266 (52.5%) were randomized to the PPN group. A total of 42 calls/texts from 24 subjects occurred, with 7 considered inappropriate. Of the 10 subjects predicted to abuse the PPN, only 1 was accurately identified. Subjects in the PPN group had a greater mean composite satisfaction score than those in the control group (4.8 vs 4.3; Welch’s t test, P < .0011). Providers indicated they were more likely to give patients their PPN at the end of the study (Wilcoxon signed-rank test, P < .0313), and the provider’s perceived impact of this practice on workload was lower at the conclusion of the study (Wilcoxon signed-rank test, P < .0469).
Conclusion: Our study demonstrates a low rate of patient utilization of provider PPNs and poor predictive ability of providers to assess which patients will abuse it. Giving patients their provider’s PPN was associated with improved patient satisfaction. We recommend contextualizing appropriate communication with patients when employing this practice to minimize patient misuse.
Patient and Provider Satisfaction With Telemedicine in Otolaryngology
Phoebe E. Riley, MD (Presenter); Jakob Fischer; Anthony Tolisano; Edward D. McCoul, MD, MPH; Ryan Nagy; Charles Riley
Introduction: The year 2020 has been marked by the COVID-19 pandemic, creating a worldwide public health emergency, resulting in otolaryngologists adopting telemedicine to facilitate access to care. The objective of this study is to evaluate patient and provider satisfaction with telemedicine encounters across 3 otolaryngology practices.
Method: A telephone-based, cross-sectional survey of patients undergoing telemedicine encounters for routine otolaryngology appointments was performed between April and July 2020. Patients were asked about their satisfaction, the factors affecting care, and demographic information. A provider survey was emailed to staff otolaryngologists. The survey asked about satisfaction, concerns for reimbursement or liability, encounters best suited for telemedicine, and demographic information. The results were analyzed with descriptive statistics and a multivariable logistic linear regression model to determine odds ratios.
Results: A total of 325 patients were surveyed, demonstrating high satisfaction with telemedicine (average score, 4.49 of 5 [best possible answer]). Patients perceived “no negative impact” or “minor negative impact” on the encounter due to the lack of a physical examination or face-to-face interaction (1.86 and 1.95 of 5, respectively). High satisfaction was consistent across groups for distance to travel, age, and reason for referral. A total of 25 providers were surveyed, with an average satisfaction score of 3.44 of 5. Providers reported “slight” to “somewhat” concern about reimbursement (40%) and liability (32%).
Conclusion: Given patients’ and providers’ levels of satisfaction, there is likely a role for telemedicine in otolaryngology practice that may benefit patient care independent of the COVID-19 pandemic.
Portable HEPA Purifiers to Eliminate Airborne SARS-CoV-2: A Systematic Review
David T. Liu, MD (Presenter); Katie M. Phillips, MD; Marlene Speth, MD, MA; Gerold Besser, MD, PhD; Christian A. Mueller, MD; Ahmad R. Sedaghat, MD, PhD
Introduction: Current epidemiologic predictions of COVID-19 suggest SARS-CoV-2 mitigation strategies must be implemented long term. In-office aerosol-generating procedures (AGPs) pose a risk to staff and patients while also necessitating exam room shutdown to allow aerosol decontamination by indwelling ventilation. This review summarizes the current state of knowledge on portable high-efficiency particulate air (HEPA) purifiers’ effectiveness in eliminating airborne SARS-CoV-2 from indoor environments.
Method: Medline, Embase, Cochrane databases, and the World Health Organization COVID-19 Global literature on coronavirus disease were systematically searched for original English-language published studies on (“HEPA” OR “Purifier” OR “Filter” OR “Cleaner” OR “Filtration) AND (“COVID” OR “COVID-19” OR “SARS-CoV-2” OR “Coronavirus”) indexed up to January 14, 2021. Additional relevant studies were identified by searching the reference lists of included articles. Two authors (D.T.L. and A.R.S.) independently reviewed abstracts and full-text studies.
Results: Ten published studies have evaluated the effectiveness of portable HEPA purifiers in eliminating airborne SARS-CoV-2 using relevantly sized surrogate particles. Nine studies evaluated aerosols and submicron particles similar in size to SARS-CoV-2 virions, while 1 study evaluated particles with diameters up to the submillimeter range. In all studies, portable HEPA purifiers were able to significantly reduce airborne SARS-CoV-2–surrogate particles. The addition of portable HEPA purifiers augmented other decontamination strategies such as ventilation.
Conclusion: Experimental studies provide evidence for portable HEPA air purifiers’ potential to eliminate airborne SARS-CoV-2 and augment primary decontamination strategies such as ventilation. Based on filtration rates, additional air exchanges provided by portable HEPA purifiers may be calculated and room shutdown times after AGPs potentially reduced.
Recalls of Otolaryngologic Devices Approved by US FDA, 2003-2019
Keon M. Parsa, MD (Presenter); Ish Talati; William Gao
Introduction: Medical devices used in otolaryngology are regulated by the US Food and Drug Administration (FDA) via a 2-tiered pathway (510[k] vs premarket application [PMA]) based on risk to patients. Recall rates of otolaryngologic devices approved via different pathways have not previously been studied.
Method: This retrospective cross-sectional analysis used the publicly available FDA Ear, Nose, and Throat Devices Panel to query all 510(k) and PMA approvals for moderate- and high-risk otolaryngologic devices between 1976 and 2019. Associated recall events available from 2003 to 2019 were extracted. Approvals were categorized by subspecialty, device type, supporting clinical data, and PMA supplement type. Logistic regression characterized the odds of recall for each device type and subspecialty.
Results: A total of 1061 (57.8%) 510(k) and 778 (42.3%) PMA device applications and modifications were approved. Most (56.4%) of 510(k) clearances provided supporting evidence, with surgical devices least likely to be accompanied by clinical data (3.1%), closely followed by diagnostic devices (4.3%). There were 120 recall events associated with 42 (3.96%) unique otolaryngologic devices cleared via the 510(k) pathway, compared with 25 recall events for 5 (0.64%) unique PMA devices. The 510(k) device approvals were more likely to be recalled than PMA device approvals (odds ratio [OR] 3.67; 95% CI, 2.38–5.88; P < .0001). 510(k) surgical devices (OR 2.1; 95% CI, 1.1–4.4; P = .03) were more likely to be recalled than diagnostic devices. Devices designated for laryngology (70.0%) and general otolaryngology (25.0%) made up most recalls.
Conclusion: Otolaryngologic devices approved by the FDA via the 510(k) pathway exhibit greater recalls than those approved via the PMA pathway. However, overall recall rates for FDA-approved devices are low. Given the balance between regulation and innovation, postmarket surveillance and ongoing regulatory improvements are critical to ensure optimal safety of medical devices.
Retrospective Analysis of Post-tracheostomy Complications
Molly M. Murray (Presenter); Joseph Zenga, MD
Introduction: Tracheostomies are commonly performed by a variety of specialty physicians with a vast array of techniques, but there is a lack of granular data regarding the best tracheostomy practice. We aimed to elucidate surgical, disease, and patient factors that contribute to tracheostomy complications.
Method: A retrospective case series with chart review was performed for patients who underwent tracheostomy by any technique for any indication between 2011 and 2018 at a single academic tertiary care center. Data collection included patient, disease, provider, and surgical factors that may affect 90-day tracheostomy complications, hospital readmissions, subsequent surgeries, and mortality.
Results: A total of 697 patients were included. Of these, 521 (75%) had severe comorbidity (ACE-27 score of 3). In total, 70 (10%) patients had at least 1 tracheostomy-related complication within 90 days, of which postoperative hemorrhage was most common (n = 35), and the median time for complication was postoperative day 11. Only the presence of a known difficult airway was significantly associated with a 90-day complication (odds ratio 0.41; 95% CI, 0.20–0.86). Fourteen patients required immediate return to the operating room, and 3 patients died of their complication, all within 3 days of tracheostomy placement. Lastly, 263 (40%) patients died within 30 days of tracheostomy placement.
Conclusion: While complications after tracheostomy are infrequent, occurring in 10% of patients, they are often life-threatening. For patients with a known difficult airway preoperatively, a heightened level of preparedness to immediately manage complications, specifically accidental tracheostomy decannulation or hemorrhage, is required. Although tracheostomy complications may not directly result in the death of a patient, 30-day mortality is high: 40% of 697 patients. This underscores the urgent need for preoperative multidisciplinary, especially palliative care, evaluation to determine if the patient is a safe, reasonable candidate for tracheostomy.
Searching for Medical Information in the Age of Social Media
Deborah X. Xie, MD (Presenter); C. Matthew Stewart, MD, PhD
Introduction: Despite the ubiquity of the internet, no studies have investigated when, how, or why patients turn to online websites for medical information. The aim of this study was to understand the patterns of usage surrounding these resources for health information.
Method: An online survey was distributed through Amazon Mechanical Turk asking individuals about their general usage patterns of social media and their use of social media and online resources for health care information. Descriptive analyses were performed.
Results: A total of 765 responses were collected (mean age 41.5 ± 13.4 years, 56.7% female). Nearly all (98.0%) respondents report using any form of social media. Approximately half (48.1%) of social media users posted medical or health-related content within the past year. Common motivations for posting include connecting with others who have similar conditions and searching for treatment options or advice. Of all respondents, 576 (75.3%) received care from a medical provider (physician, nurse practitioner, physician assistant) in the past year. Most of these patients (94.8%) looked up information about their provider, symptoms, diagnosis, or treatment on the internet. While search engines were the most commonly used platform (86.8%), 76.9% of patients searched at least 1 platform of social media for this information.
Conclusion: Approximately half of social media users post medical or health-related content, often in search of support and advice. Nearly all people who had a medical appointment in the past year searched online for information related to their symptoms, diagnosis, treatment, or medical provider.
Shared Decision-Making and Decisional Conflict in Otolaryngologic Surgery During COVID-19
Nneoma Wamkpah, MD (Presenter); Sophie Gerndt; Dorina Kallogjeri; Jay Piccirillo; John Chi
Introduction: The unpredictable nature of the COVID-19 pandemic portends further uncertainty in patient decision-making. This study explores decisional conflict and patient-specific concerns for people undergoing otolaryngologic surgery during the pandemic.
Method: This was a prospective, single-institution, cross-sectional study of English-speaking adults undergoing otolaryngologic surgery, conducted from April 22 to August 31, 2020. Individuals who were non-English speaking, lacked autonomous medical decision-making capacity, underwent emergent surgery, or had a communitive disability were excluded. The primary outcome of decisional conflict was measured using the validated “SURE” screening questionnaire. Relationships between decisional conflict and patient demographics were assessed via bivariate analyses, multivariable logistic regression, and conjunctive consolidation. The secondary outcome of patient-specific concerns was obtained through open-ended interview and qualitatively assessed using thematic analysis with open coding.
Results: There was a 41% response rate (182 of 444 patients). The median age was 60.5 years (range 18–88); 92 patients (51%) were women. Decisional conflict was more prevalent in non-White compared with White participants (difference 18%; 95% CI, 0.6%–37.0% and adjusted odds ratio 3.0; 95% CI, 1.2–7.4). Combining information from multiple variables through conjunctive consolidation, the group with the highest rate of decisional conflict was non-White patients with no college education, receiving urgent surgery. “Intraoperative” and “postoperative concerns” were the most common patient-specific concerns. Among those patients reporting concerns about COVID-19, the majority had decisional conflict.
Conclusion: This study highlighted factors associated with decisional conflict and emphasized the need for physicians to engage in shared-decision making with patients. The COVID-19 pandemic contributed to decisional conflict. Consistent discussion of risks and benefits is essential. The role of race and decisional conflict needs further study.
