Procedure-Based Telehealth Utilization in General Surgery

The authors hypothesize that standardized telehealth (TH) scheduling processes will improve TH utilization without increasing adverse events. Fifty visits preimplementation and 67 visits postimplementation were audited from June 2021 to January 2022. Both leadership and frontline stakeholders were engaged to identify current workflows and potential interventions targeting outpatient elective procedures. Process mapping outlined current TH scheduling workflows. Outcomes related to TH completion, cost, and TH scheduling were collected after implementation. Preimplementation TH scheduling rate was 32%. The intervention required TH postoperative appointments to be scheduled in clinic at the time of surgery scheduling with TH being the default postsurgical appointment for a standardized list of eligible procedures. Following implementation, 95% of patients undergoing eligible procedures had TH follow-up. This provided improved access to surgical follow-up care, by reducing travel needs to the Veterans Affairs facility. Secondarily, this intervention increased clinic appointment availability and resulted in possible increased revenue for billable visits. Standardizing TH scheduling based on the procedure improves the utilization of TH resulting in improved clinic efficiency and increased revenue, without increasing adverse events.

Deglutition syncope: a manifestation of vagal hyperactivity following carotid endarterectomy

A 61-year-old man with left amaurosis fugax and bilateral >80% internal carotid artery stenoses underwent a left carotid endarterectomy. On the first postoperative day, he developed hypotension, bradycardia, and chest pain with food ingestion. He was diagnosed as having deglutition syncope and was treated with oral anticholinergics. Similar symptoms occurred when he underwent a right carotid endarterectomy. Deglutition syncope is a neurally mediated situational syncope resulting from vagus nerve over-activity. This is the first report of deglutition syncope associated with carotid endarterectomy. It is important to recognize and differentiate these symptoms from other causes of postendarterectomy hemodynamic instability.