Amid the COVID-19 pandemic, many in-person consultations in the preadmission clinic (PAC) at our tertiary academic centers of London Health Sciences Centre (LHSC) and St. Joseph’s Health Care in London, Ontario, Canada, shifted to telephone consultations. Telephone consultations were instrumental in reducing unnecessary hospital visits and in-person interactions, thereby mitigating the risk of COVID-19 transmission. While phone consultations facilitate thorough patient history–taking and chart review, they inherently lack the capability for a physical examination, which is essential in preanesthesia evaluations. Specifically, an airway assessment, which is critical for anesthesia planning, cannot be conducted effectively over the phone. By integrating a telemedicine model that includes audio and visual components in the PAC, several significant advantages emerge, including (1) an enhanced physical assessment, as the visual capability over video calls ensures a more accurate and comprehensive evaluation than phone consultations; (2) improved patient interaction given that nonverbal communication plays a crucial role in interpreting patient concerns and responses, which is lost in phone consultations; (3) increased diagnostic accuracy, since visual examinations can aid in identifying physical signs that might indicate underlying health issues, which may not be apparent through phone calls; and (4) enhanced patient engagement and education, as visual tools can be used to educate patients about their procedure and anesthesia plan, making it easier for them to understand complex information [1,2].

Telehealth involves electronic video communication between patients and health care providers to improve patient health remotely [3,4]. While telemedicine has long been used in rural areas without access to specialists, its prevalence increased widely during the COVID-19 pandemic [5,6]. When strategically deployed, virtual care enhances the quality and effectiveness of patient care and enables dynamic risk stratification through big data and machine learning [7].

LHSC and St. Joseph’s Health Care collectively handle approximately 50,000 surgical cases annually across various subspecialties. The PAC is a designated setting for multidisciplinary preoperative assessments and optimization of operating room efficiency. Notably, not all patients receive preoperative assessments in the PAC, as limitations in time, office space, and human resources restrict the number of patients seen. The PAC team, comprising professionals from medicine, anesthesia, nursing, pharmacy, occupational therapy, and physiotherapy, offers preoperative evaluation and education to surgical patients, totaling approximately 8000 consultations annually across 3 hospital locations.

Over the years, the PAC has undergone alterations in office location, size, caseload, and staffing. The PAC team’s preoperative consultations often include internal medicine and/or anesthesiology consultations and cover all surgical subspecialties. Some consultations are time-sensitive or involve mandatory in-person visits due to combined procedures such as x-rays, electrocardiograms, echocardiography, surgical team consultations, and blood work. Therefore, implementing video consultations requires meticulous planning and decision-making to ensure smooth clinic operations [8].

On a national and global level, virtual care video appointments have become a popular alternative to in-person and phone appointments during the COVID-19 pandemic [9,10]. Patients benefit from time and cost savings, increased communication with providers, improved access to care, and involvement of family members or caregivers [1,11]. Telemedicine has been shown to reduce missed appointments, wait times, and readmissions; enhance office efficiency with fewer front desk phone calls; and increase medication adherence. The ability of health care providers to make eye contact, assess body language, discuss sensitive topics, and conduct a limited physical examination over a virtual video platform can improve the patient-physician relationship [12]. This approach aligns with the trend toward digital health care solutions and ensures that patient safety and care quality are maintained at the highest standards.

During the COVID-19 pandemic, the PAC adapted by implementing telephone visits due to a lack of infrastructure for video consultations. While the pandemic significantly increased the use of virtual care, including video appointments as an alternative to in-person consultations, our PAC had not used video consultations for preoperative assessments. A preliminary assessment indicated room for development and improvement of video consultations before routine integration. The initiative focused on enhancing preoperative care without direct patient participation or using identifiable data, potentially offering valuable insights to the broader health care community. This project aimed to develop, implement, and integrate structured steps and process changes using Cisco DX80 Webex devices, measuring the impact on the number or percentage of video consultations through validated continuous quality improvement Plan-Do-Study-Act (PDSA) cycles.

Our initial workup indicated that our PAC did not have a video consultation platform before initiating this project. Following the first and second PDSA cycles, the interventions consistently enhanced this metric to a 17% utilization rate, signaling positive developments. As PDSA cycle 3 commenced, there was a substantial increase to a 29% utilization rate during the initial phase. This trend continued, reaching a 38% utilization rate of virtual video consultations in the later phase of the cycle. Utilization was persistently maintained at a high level throughout the entirety of 2023, highlighting the sustained success of our interventions (Figure 2).

Figure 3 provides a comprehensive flow diagram detailing the steps and communication pathways involved in patients’ video consultations. Additionally, this figure highlights the specific changes introduced during the PDSA cycles within the project.

Our results demonstrated that following the interventions through 3 successive PDSA cycles, the utilization rate of video consultations increased to 17% and then to 29% and finally to 38%, maintaining this high level throughout 2023, confirming the sustained success of our quality improvement project.

The PAC under study is part of the perioperative process in a Canadian academic tertiary health sciences center within a publicly funded health care system. While this quality improvement program may have limited applicability to other institutions due to variations in staffing, office space, equipment, technology, expertise, scheduling, communication, patient volumes, and guidelines, the lessons learned here may still offer valuable insights into enhancing patient satisfaction through the introduction of video consultations during the perioperative period of care.

The primary objective of this quality improvement project was to explore, develop, implement, and integrate virtual video consultations within the PAC, ensuring that patient-centered care remains timely, efficient, and safe while preserving the importance of in-person consultations. Key to the project’s success was enhancing communication among PAC staff, patients, and surgeons’ offices; incorporating OneChart Video Webex Appointments; and aligning with provincial changes in rules and regulations. The surgeon’s office electronically communicated patients’ preference for video consultation to the PAC staff while requesting a preoperative consultation. This decentralized the work for the PAC booking clerk. Significant clinical enhancements in video consultations were achieved throughout the preoperative journey without compromising patient care, as evidenced by the increase of video consultations in the PAC from 0% to 38%. The sustainability of said video consultations was confirmed over the past 12 months, indicating enduring improvement and garnering ongoing support and acceptance from the staff. The groundwork for video consultations positions them for long-term continuation, providing a compelling case for improved staffing, IT support, and physical space. This successful implementation of innovative methods empowers stakeholders to advocate for PAC maintenance and further enhancement.

One prominent observation in our project stems from significant variability observed across PACs and within the same clinic on different days, resulting in total virtual video consultation fluctuations. Various factors contribute to this variability, including the volume of patients referred to the PAC from surgical specialties, medical comorbidities of patients rendering them ineligible for video consultations, specific surgical procedures necessitating in-person consultations, variations in the booking staff at the PAC responsible for sending email invitations for video consultations, the number of surgeries conducted during specific slow-down periods such as holidays, and fluctuations in the overall caseload seen in the PAC. Notably, certain days, labeled as “Super Wednesdays” and “Super Tuesdays” in our PAC, presented twice as many patients, leading to increased video consultations on those days. To mitigate the inconsistency in scheduling personnel, a specialized team member was assigned to facilitate clear communication between patients and surgeons’ offices, focusing on effectively organizing video consultations. Some of the other challenges that may be experienced while implementing the video consultations are (1) poor patient internet connectivity, (2) challenges in implementing hardware accessibility in all PAC rooms, and (3) lack of digital literacy among older patients and health care providers.

While the patient information system facilitated data collection, manual data collection remains necessary. Working closely with the hospital’s IT and virtual care teams and their resources proved essential in enhancing patient flow throughout the project by seamlessly integrating video calls into electronic records. In the continuous improvement process, communication options such as “virtual care appointments using Webex” were incorporated into electronic record views, enhancing the efficiency of joining video consultations for the multidisciplinary team in the PAC.

Changes in the PAC were noted during the project, coinciding with broader system and provincial changes. Increased acceptance rates among patients, PAC staff, and physicians led to higher numbers of video consultations. Workforce issues were addressed by assigning additional clerks to assist with the booking process, although no increase in medical and nursing staff occurred. These modifications underscored the clinic’s significance within larger hospitals and the provincial system, emphasizing the need for innovative methods to enhance patient flow, efficiency, and satisfaction without compromising safety.

A key limitation of our study is the lack of consideration for total virtual care usage, as we did not monitor the number of phone visits during the implementation period. Without this information, it is challenging to grasp the impact on overall virtual care usage fully. Another significant limitation is the provincial billing changes that disincentivized phone use, which occurred simultaneously with PDSA cycle 3. These changes substantially affected the PDSA cycle and should be considered when interpreting the results.

Virtual care video appointments offer a reasonable alternative to in-person and phone consultations, gaining prominence during the COVID-19 pandemic and likely continuing to play a significant role in health care [13]. Future directions involve advancing the newly implemented video consultation by integrating an app-based preoperative education system already used at our hospital. Additionally, expanding electronic communication options such as asynchronous preoperative messages will deliver real-time, crucial, and up-to-date information and education about the preoperative journey without interrupting a phone call. This approach aims to empower patients and enhance their compliance with preoperative instructions.