Immediately after the COVID-19 outbreak was declared a pandemic by the World Health Organization,1 an administrative decision was made in our department to minimize unnecessary exposure of patients and staff while ensuring the continued standard medical care. We began by allocating the patients scheduled for the general plastic surgery clinic during the following weeks into separate groups according to their main reason for attendance. The indications for patients’ arrival to the scheduled clinic visit are summarized in Table 1. Biopsy-proven lesions requiring excision or wide excision, or those with positive margins, were automatically scheduled for surgery. Table 1. - Indications to Arrive to the Scheduled Clinic Appointment First postoperative visit following procedures under general anesthesia Signs of infection Signs of delayed wound healing Lesion suspicious of malignancy (e.g., malignant melanoma, SCC, BCC) Active burn/wound care Biopsy-proven lesion requiring wide excision SCC, squamous cell carcinoma; BCC, basal cell carcinoma. The results of our triage are summarized in Table 2. Our study period included the first 3 weeks of the COVID-19 pandemic, in which we had two planned clinics per week for a total of six clinics. Two hundred thirteen patients were contacted by telephone by the residents. Twenty-one patients did not respond to the phone call. Of a total of 213 patients, 28 (13 percent) met the indication to arrive, and 26 (12.2 percent) eventually arrived. Six patients did not show up despite existent indication and four insisted on attending contrary to medical recommendation. Most appointments were rescheduled for either future visit or telemedicine video appointment, and cancellation was done only in cases of complete healing and benign pathology report. Table 2. - Outcome of Forward Triage of the Patients Scheduled for the General Plastic Surgery Clinic during the First 3 Weeks of the COVID-19 Pandemic Reason for Clinic Visit No. of Patients No. of Patients with Indication to Arrive (%) No. of Patients Who Arrived (%) Immediately postoperatively after general anesthesia 10 7 (70) 5 (50) Immediately postoperatively after local anesthesia 63 5 (7.9) 7 (11.1) Late postoperatively after general anesthesia 30 2 (6.6) 3 (10) Late postoperatively after local anesthesia 28 1 (3.6) 0 (0) Scar follow-up 17 0 (0) 0 (0) Burn follow-up 8 1 (12.5) 1 (12.5) Wound follow-up 19 8 (42.1) 7 (36.8) Skin lesion follow-up 23 3 (13) 2 (8.7) First time visit 15 1 (6.6) 1 (6.6) Total 213 28 (13) 26 (12.2) In general, we managed to reduce visits to our general plastic surgery clinic by 87.8 percent during the first 3 weeks of the COVID-19 pandemic. None of the patients who rescheduled or cancelled visits attended the emergency room during this period and 1 week after. A main strategy for health care surge control is “forward triage”—the sorting of patients before they arrive in the emergency department. Direct-to-consumer (on demand) telemedicine, a twenty-first–century approach to forward triage that allows patients to be efficiently screened, is both patient-centered and conducive to self-quarantine, and protecting patients, clinicians, and the community from exposure.2 The concept of forward triage has been drawn to our field as a bridge to a fully implemented telemedicine system ready to be operated by the plastic surgery staff. A systematic review found 23 articles focused on telemedicine in plastic surgery, specifically, in wound management, free flap care, and cleft lip/palate repair. The benefits include reductions in the number of unnecessary clinic visits and improvement in triage decisions.3 However, we also recognize the fear “that the implementation of telemedicine may introduce organizational changes and have a negative impact on quality of care” as expressed by Gignon.4 We believe that forward triage, deferring or reducing surveillance visits, must be considered as a means to minimize exposure. Rescheduled visits must be tracked to avoid patients being lost to follow-up. For further aspects of telemedicine in plastic surgery, we recommend following the “12 important considerations for plastic surgeons regarding the use of electronic communication” proposed by Eberlin et al. in 2018.5 Our purpose was to share our experience regarding the first step to telemedicine, forward triage, in the time of the current COVID-19 pandemic. DISCLOSURE No funding was provided for this article. Dr. Barnea is a speaker for Johnson Medical. None of the other authors has a financial interest or personal relationship to declare in relation to the content of this article.
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Apr 1, 2024
Rahim Nazerali + 7
