Chronic wounds constitute a debilitating health care problem with significant clinical and social implications. Studies have shown that consistent, skilled care is the key to getting chronic wounds to heal, but this kind of care is expensive and typically unavailable. The authors propose a wound management system using telemedicine for evaluating remote patients. Home care via telemedicine shows promise for improving the quality of wound care, enhancing its availability, reducing costs, and generating valuable outcomes data.
The occurrence of chronic wounds, particularly pressure sores, has plagued humankind throughout recorded history1,2 and remains a major source of morbidity and mortality in several disciplines of clinical medicine. The increasing longevity of the American population has had the costly consequence of a growing number of individuals with indolent, nonhealing wounds. Extending the life expectancy of elderly, paralyzed, and insensate individuals has contributed to the very high incidence of pressure ulcers in these populations.
Pressure ulcers and other chronic wounds constitute an expensive and debilitating health care problem with significant clinical and social implications. These wounds are an expense to society in terms of money and human lives. Not only are pressure sores painful and a source for infection; they are also a marker for a greatly increased risk of death.7,8,11 Wounds resulting from skin breakdown also have great potential impact on a large number of quality-of-life issues, including life satisfaction, mental health, productive use of time, and caregiver burden. The emotional costs associated with the presence of a chronic wound compound the escalating financial burden of wound care for patients, families, and society.
Treatment for pressure ulcers consists of conservative care or surgical intervention. Conservative care involves debridement, various topical agents, protective dressings, and avoidance of pressure and shear forces. Surgical repair involves debridement and rotation or advancement of some kind of flap of tissue over the defect. Both surgical methods take weeks or months for final healing to occur, and patients have traditionally remained hospitalized for extended periods of time. There are approximately 140,000 patients hospitalized every year with wounds, with an average hospital stay of 20 to 30 days.12 These unnecessarily long stays represent an economic burden that must be remedied.
The current principal goals of wound management are to provide effective care and to contain cost. Health care professionals in all specialties strive for high standards of care for their patients, and specialists treating chronic wound patients are no exception. Major advances have been made over the past decade in the area of wound management; however, many areas for improvement remain.
The demand to optimize the quality and cost-effectiveness of health care delivery requires rethinking of traditional wound care paradigms. Presently there is a lack of data available to indicate the cost to heal wounds, the timing to heal wounds in various care settings, and the products that are most cost effective and that promote the best healing. All of this information is of interest to physicians and other caregivers, hospitals, managed care groups, and health insurance agencies.
The authors have developed a system for wound management that uses telemedicine and focuses on optimizing the care of chronic and short-term wounds in the home care setting. This wound care program shows great promise for improving the quality of care, enhancing its availability, and reducing the cost. The wound management system outlined below consequently will also provide valuable outcomes data on wound treatment protocols. Wound management via the Internet and easy-to-use desktop technology that involves a multidisciplinary team of health caregivers will be described.
The Medicare guideline requiring homebound status coupled with observed increasing acuity levels of patients discharged to the home health care setting makes the high percentage of pressure sores and surgical wounds seen in this market predictable. As the growing home care market is seeing more patients with wounds, wound care has increasingly become a more common part of the home health care nurse's practice. In a study involving four home care agencies, patients with pressure ulcers accounted for 31% of referrals to home health care.15 The increased involvement of home care agencies with patients with wounds has also led to an improved psychosocial aspect of care by allowing patients to remain at home.
Telemedicine in one form or another has been practiced for more than 30 years, beginning with a nurse providing clinical advice over the telephone.16 The focus of telemedicine activity today is on applications that involve advanced images, store-and- forward technology, and audio capabilities. Store-and-forward systems allow images and other data to be held and transmitted to a specialist for review and are especially appropriate for such situations as chronic wounds where direct contact is unnecessary. Because chronic wounds do not require immediate or acute intervention, batching of data gives clinicians the ability to review information from multiple patients in one sitting, at a convenient time. "Real time" transmission of information, which is extremely inefficient, is not required.
The goal of telemedicine in wound care is to keep patients at home while maintaining contact with their local practitioner. 16 This technology allows earlier hospital discharge in favor of nursing home visits documented with audiovisual aids (i.e., photographs and audio recording of clinical observations). The complex telemedicine of the past, which consisted of expensive and cumbersome systems, has become streamlined. Telemedicine of today and of the future is a tool physicians and health care organizations can use on a less grandiose scale and in a more manageable way to cut costs, increase access to care, and gain a competitive advantage.
In an outcomes comparison of wound care provided at home by ET nurses and wound care provided by non-ET nurses in the same setting, it was found that more than twice as many ET-nursed wounds healed in the same time frame.17 That is, delivering the appropriate wound care skills to patients increased the healing rate of wounds by 100%. Unfortunately, skilled home care under the supervision of a specialized wound therapist is expensive and often unavailable. The wound care model described in this article would greatly increase the number of patients that could be screened by a single ET nurse, thus reducing cost and increasing efficiency.
Other data suggest that the incidence of pressure ulcers can be dramatically reduced and the severity of ulcers that occur may be minimized when health care providers work together to address the problem in a given health care setting.18 The wound management system described herein outlines the structural framework, resources, and technology needed to appreciate the positive impact of coordinated care on wound healing.
An alternate use for wound photography by ET nurses involves sharing with patients pictures of their wounds, along with explanations of the findings and rationale for the treatment plan. 20 These visual reminders can facilitate patient education and place care in the proper context, with the hope of improving patient motivation and compliance with the treatment regimen.
[Insert Figure and text underneath]The procedure begins with the home care visiting nurse documenting the state of the wound (Figure: Step 1). An adequate description of the wound is essential to allow communication among members of the health care team in addition to providing serial documentation of the wound for educational and research purposes. Wound assessment includes a description of the wound and surrounding tissue, location, shape, and approximation of size and depth. The presence of odor as well as amounts and color of drainage should be noted. In addition, evaluation should document the presence or absence of granulation tissue and fibrinous and necrotic debris along with signs of infection and degree of undermining.
As part of routine patient care, the nurse takes images of the wound using a digital or video camera and makes an audio recording of clinical observations. The pictures are sent to the wound therapist either instantly as digital images by e-mail or in videotapes by overnight mail. The audio observations can be included in the video or forwarded to the wound therapist by voice mail.
The wound therapist (ideally an ET) processes the wound image, observations, and other information; diagnoses the state of the wound; and recommends a treatment plan to the wound care team ( Figure: Steps 1 and 2). The authors' wound management system database automatically presents all of the wound care team consultants with the clinical images and information as well as the recommended treatment plan (Figure: Steps 3 and 4). This communication is made possible by the use of standard Internet- based browsers. The attending physician and the wound therapist target wound care team members (such as occupational therapists, physical therapists, nutritionists, podiatrists, prosthetic technicians, and social service personnel) for consultation in their areas of expertise.
After all of the appropriate members of the wound care team have offered their input on a specific case, a treatment plan is formulated. The final treatment planning data are presented to the patient's attending physician for approval via standard Internet software (Figure: Steps 5 and 6).
After the preliminary wound care program is approved, the information is transmitted for implementation. This transmission entails "Internetting" the supporting images and data of the approved plan back to the visiting nurse to complete the cycle ( Figure: Step 7). Also, those patients who could benefit from other specialists in the wound management system are appropriately referred at this time. These health care members may play roles in the rehabilitation of an existing wound and the prevention of recurrence.
The system provides enhanced patient convenience, compliance, success, and satisfaction. It also allows for the development of practice guidelines to ensure specialized, current, state-of the art wound care. Patients can receive a comprehensive evaluation and specialty consultation in one encounter. The multidisciplinary team coordinates all of the patient's home health needs, resulting in efficient and effective delivery of care. Telemedicine makes it possible to accumulate data on several patients that can be reviewed in a delayed fashion, at the convenience of the wound management team.
Because wounds constantly change, ongoing thorough assessment of the wound using a standard system is one way to ensure that changes in care are made appropriately and in a timely fashion. Wounds that vary from the typical course of care may be identified much earlier with this system compared with wounds managed with traditional methods of documentation. In addition, the system provides a resource for the education of both patients and staff and allows the exploration of new treatment methods through research protocols. Much-needed outcomes data related to functional goal achievement and service utilization can be collected continuously.
Telemedicine technology is ideal for wound management at home. One of the keys to making telemedicine efficient and cost effective is using it as a remote diagnostic and treatment tool. Patients can be cared for in a variety of sites outside the hospital setting by transmitting high-resolution images to specialists at multiple locations that can be reviewed simultaneously at a convenient time. The process of batching data avoids the inefficiencies of sending data to be analyzed at the same time that it is being collected.
There is a great need for randomized, controlled clinical trials to define the most efficient, cost-effective, and practical approaches for treating wounds and pressure ulcers in different health care settings. More prospective data using a multidisciplinary approach are needed to define the natural history of wound healing in patients who move from one health care setting to another (i.e., from hospital to home) and to delineate the efficacy of moving patients out of the institutional setting for wound treatment.
Telemedicine will evolve from isolated government-funded studies and pilot projects to a field characterized by wide-spread use in hospitals, clinics, and individual practices. Specialized telemedicine centers used for "teleconsultations" will become obsolete. Physicians and other caregivers will ultimately all have access to simple, PC-like systems that function from their offices and clinics.
The continued emergence of technology will assist in the growth and change of home wound care. Although there is always an element of anxiety related to technical change, the evolution of wound care telemedicine technology has demonstrated a predictable maturation process.
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