Chronic wounds, such as pressure ulcers, diabetic foot ulcers, venous ulcers, and arterial ulcers are a common problem among older individuals. These wounds can be difficult to heal and can lead to cellulitis, osteomyelitis (Bryan, Dew, & Reynolds, 1983), and sepsis (Galpin, Chow, Bayer, & Guze, 1976). Proper management of chronic wounds requires frequent, routine monitoring for wound healing progress to optimize healing and ensure early recognition of impending complications. The clinical practice guideline (Bergstrom et al., 1994) published by the Agency for Health Care Policy and Research (AHCPR) recommends weekly assessments of pressure ulcers. Unfortunately, many older adults with chronic wounds reside at home or in nursing homes where access to health professionals with expertise specific to assessment and management of chronic wounds is lacking. Although specialty education and certification in chronic wound management is available to clinicians from multiple health care professions, the benefit of this expertise is often not available to older persons with chronic wounds or their caregivers.
Telecommunications technologies provide a viable solution to access and monitor obstacles because they can routinely transfer audio and visual patient information from remote locations to health professionals with specialized knowledge and skill. As noted in the introductory article, the use of telecommunications technology in this manner is often referred to as telehealth or telemedicine (Preston, Brown, & Hartley, 1992). In the case of chronic wound consultations, nurse experts can provide diagnostic and evaluative support to nurses caring for patients with chronic wounds located in home-health and nursing home settings. In addition to improving chronic wound outcomes, these consultations also provide an opportunity to enhance the skills and knowledge of the remotely located nurse.
Figure 1. Teledoc ™ machine with screen, room camera, hand-held camera, and light source.
Although several telehealth systems have been adopted and evaluated for chronic wound consultation, all have employed the transfer of still-wound images from the remote location to the consultant (Lowery, Rees, & Hamill, 1997; Vesmarovich, Walker, Hauber, Temkin, & Burns, 1999; Wirthlin et al., 1998). However, many telehealth systems are capable of supporting an exchange of audio and video data between the two sites. These interactive, video technologies have been employed successfully in dermatological applications (Phillips et al., 1997) and can be used for chronic wound consultations as well. However, before widespread adoption of this technology could be considered for chronic wound consultation, its accuracy for conducting wound assessments must be determined. Because wound assessment is based largely on observation of the wound itself, the video resolution of the telehealth system is of utmost importance.
This pilot project was undertaken to examine the accuracy of chronic wound assessments made using an interactive, video telecommunications system developed specifically for telehealth applications (Teledoc 5000, NEC America, Inc., Irving, TX). Establishing that a wound assessment made using this telehealth system is equivalent to an assessment made in-person increases the confidence one can place in the treatment decisions arising from those assessments.
CHRONIC WOUND CLINIC
Prior to this project, one of the authors (RAF) had been conducting chronic wound healing research and supervising students at a state-owned, long-term care facility for veterans. To reciprocate the nursing staff for their cooperation with her research and teaching endeavors, the nurse expert provided consultations for residents with problematic chronic wounds. During these on-site consultations, the nurse expert assessed residents' wounds, reviewed patient records, and made treatment recommendations to the nursing staff.
Unfortunately, the 85-mile distance between the university where the nurse expert was based and the long-term care facility deterred frequent and routine monitoring of these residents by the nurse expert. Although the nursing staff at the long-term care facility perceived the consultations as useful, timely follow-up of wound healing progress was difficult to achieve.
The acquisition of an interactive video Teledoc system by the longterm care facility and its affiliated Veterans Administration Medical Centers (VAMC) was viewed as an opportunity for the nurse expert to conduct wound consultations on a more frequent, routine basis without having to travel to the site. In this way, the nursing staff at the facility had greater access to the nurse expert for problematic chronic wounds and more timely followup of wound healing progress was possible. Although the use of this technology would enhance access to specialized expertise, the benefits of using this technology for chronic wound consultations would be negated if wound assessments were faulty, leading to inappropriate treatment recommendations.
To examine the accuracy of wound assessments made using the Teledoc system, this pilot project compared the nurse expert's in-person wound assessments with wound assessments she made from taped Teledoc sessions. Taped Teledoc sessions were used so these assessments could be made after a substantial period of time had elapsed from the ín-person assessments. In this way, the nurse expert's memory of the inperson assessments would be greatly diminished and have little or no influence on her Teledoc assessments.
Participants and Wound Sample
Participants in this study were selected from the population of residents at the long-term care facility who had one or more chronic wounds (e.g., pressure ulcer, venous ulcer, diabetic foot ulcer, arterial ulcer, incision healing by secondary intention). The facility's skin/wound nurse selected participants and preference was given to residents who could give their own consent to participate and who could respond to a satisfaction questionnaire. The skin/wound nurse approached potential participants on the unit and explained the study, including the use of videotaping. If they agreed to participate, a consent form was signed. Legal representatives signed for participants unable to give their own consent. The majority participated in the study twice with a 3 -week interval between consultations. Participants with more than one chronic wound had each wound assessed and each wound assessment was included in the study.
Participant and Wound Data
A data collectiori form was developed and used during the in-person and Teledoc consultation sessions. Each data collection form was labeled with participant number, wound number, consultation number (e.g., first or second), and session type (e.g., in-person or taped Teledoc). Participant data were collected including age, gender, ethnicity, medical history, and medications. Wound assessment information was recorded for each wound, and included wound location, length, and width. In addition, data on the absence or presence of nine wound characteristics instrumental in guiding treatment (i.e., tunneling, undermining, granulation tissue, necrotîc tissue, epithelial tissue, purulent exúdate, erythema, edema, induration) were collected.
Figure 2. Telehealth session: Consultant-site view, patient and nurse (left). Remotesite view, consultant (right).
The nurse expert (RAF) traveled to the facility and conducted in-person wound assessments of each participant in an area adjacent to the room where the Teledoc equipment is housed at the facility. During these in-person assessments, the nurse expert had access to the patient record and the nursing staff providing care to the participant. Participant and wound assessment data were recorded by the nurse expert on the data collection form during the in-person consultations.
Immediately after the in-person consultation with the nurse expert, the participant was transported to the room housing the patient-site Teledoc equipment, which was linked with the Teledoc equipment at the VAMC (consultant-site). A second nurse expert in chronic wound management (SG), stationed at the consultant-site, directed a realtime assessment of each participant and wound. The patient-site remote and handheld cameras were used to transmit audio and video of the participant and wound to the consultant-site Teledoc screen (Figure 1). The skin/wound nurse (KB) at the long-term care facility operated the patient-site cameras and performed the wound manipulations. The twoway audio allowed the consultantsite nurse expert to direct camera angles, lighting, and wound manipulation at the patient-site location. The audio exchange was also used to verify wound location and visual observations being made at the consultant-site and to ascertain additional patient history information. Parts of the patient record (e.g., laboratory data, Braden scores, medical history) had been faxed to the consultant- site prior to transmission.
Figure 3a. Consultant-site view; room camera focused on wound.
Figure 3b. Consultant-site view; hand-held camera on wound.
Figure 3c . Consultant-site view; hand-held camera on tunneled wound.
The real-time Teledoc sessions began with a room view of the facility's telemedicine room with the participant and skin/wound nurse in view of the consultant-site nurse (Figure 2). The consultant-site remote camera was used to transmit the video and audio image of the nurse expert to the patient-site Teledoc screen (Figure 2). During this time, the skin/wound nurse introduced the participant and the consultant nurse expert, and then presented background information on the participant and wound.
The patient-site remote camera was then zoomed in on the wound area so the consultant nurse was oriented to wound location and position (Figure 3a). The patient-site camera was then switched to the hand-held camera and light source, which transmits a close up view of the wound (Figure 3b). Using this camera and light source, visualization of tunnels and undermining was possible (Figure 3c).
The VHS recorder located on the Teledoc equipment was used to record the video and audio transmission from the remote and hand-held cameras, as the examination was conducted by the consultant nurse expert. Each tape was labeled with participant number and dare. Six months after the in-person and realtime Teledoc sessions, the in-person nurse expert (RAF) viewed the taped Teledoc sessions and documented participant and wound assessment data on the data collection form.
All participant and wound assessments were entered into the statistical software program, Statistical Package for the Social Sciences (SPSS) (Version 6.0). The in-person assessments were considered to be the "gold standard" assessments in this study because these assessments represent current clinical practice. Therefore, the Teledoc assessments were compared against this standard to determine the suitability of this technology for making accurate assessments and appropriate treatment recommendations. Taped Teledoc assessments were used to examine accuracy because these assessments were made by the same nurse expert who made the in-person assessments - thus ensuring any discrepancies found between the in-person and Teledoc sessions are not caused by differences in clinician skill or training. Using this study design, discrepancies between the in-person and Teledoc sessions can be validly attributed to the telehealth medium.
The accuracy of the Teledoc technology was examined by calculating the amount of agreement between the i?-person and taped Teledoc assessments for each of the nine characteristics (i.e., absence or presence of tunneling, undermining, granulation tissue, necrotic tissue, epithelial tissue, purulent exúdate, erythema, edema, induration). Amount of agreement was expressed as percent agreement (ranging from 0% to 100%) and was calculated by dividing the number of actual agreements by the number of possible agreements and multiplying by 100.
Eleven individuals participated in the study with eight participating twice. The mean age of the participants was 72 years (±10.55), 10 were male, and all were White. Nine participants had one chronic wound; two participants had two wounds each. Although there were 22 in-person and real-time Teledoc wound assessments, technical problems with the VHS recordings resulted in the loss of nine wound assessments as taped Teledoc sessions. Therefore, the comparison of in-person and taped Teledoc wound assessments was based on a sample of 13 paired wound observations.
Data on agreement between inperson and taped Teledoc wound assessments are presented in the Table. Perfect agreement was achieved for three wound characteristics, while eight of the nine had greater than 75% agreement. Presence or absence of epithelial tissue had the lowest agreement.
This project evaluated interactive video technology as a telehealth medium to access chronic wound expertise. The paramount issue is whether wound assessments made using this technology are equivalent to those resulting from in-person assessments. For this study, amount of agreement exceeding 75% was an acceptable level from which to conclude accuracy of the telehealth medium. Eight of the nine wound characteristics exceeded this level of agreement, suggesting the wound expert's ability to ascertain the absence or presence of these wound characteristics was not substantially diminished by the telehealth medium.
PERCENT AGREEMENT FOR EACH WOUND CHARACTERISTIC
Surprisingly, the absence or presence of epithelial tissue revealed a level of agreement only slightly above 50%. A level of 50% agreement could be expected from chance alone. However, four of six incongruent assessments of the epithelial characteristic were made on a single participant. This participant was assessed twice (3 weeks apart) and had two wounds (both included in the analysis twice). The wounds of this participant were extremely small in surface area, but very deep, making their assessment difficult under even the best of circumstances. Moreover, for these assessments, it is unclear whether the inperson assessments were more accurate than the Teledoc assessments because the handheld camera allows much better visualization of a tunneled wound than can be achieved without it (Figure 3b). Regardless, the influence of a single participant on the amount of agreement should be taken into account when drawing conclusions about the accuracy of the Teledoc system in assessing epithelial tissue.
The influence of this participant on the amount of agreement observed for the characteristic of epithelial tissue highlights three limitations of this pilot project. First, the use of participants more than once in conjunction with a small participant sample allows the peculiarities of a single participant to unduly influence the findings. Participants were included in this pilot project more than once because they were part of larger study designed to evaluate the Teledoc system, including the evaluation of resident and staff satisfaction with telehealth. Because the novelty of the telehealth sessions may have influenced satisfaction, participants were assigned to two sessions to diminish this as a confounding variable.
Second, the small sample size limits the confidence one can place in the findings of this pilot project. Further study with a larger, independent wound sample is needed to examine accuracy more fully. Finally, the use of a single nurse expert to examine accuracy limits the ability of this study to be generalized to all chronic wound experts. Additional studies need to include multiple wound experts as a part of the study design.
Despite its limitations, an exciting aspect of this pilot project was its demonstration of a nursing application of telehealth technology. It established that remotely based nurses could access nursing expertise to improve patient care. An additional positive, though unforeseen, result was the transfer of knowledge to the facility's skin/wound nurse during this project. Because the facility's skin/wound nurse operated the patient-site cameras and performed wound manipulations as directed by the consultant-site nurse expert, she gained valuable experience and expertise in both chronic wound assessment skills and use of telehealth equipment.
Through the telehealth sessions, the facility nurse was able to have wound assessments and treatment strategies reinforced and validated on a regular basis. This illustrates that telehealth technology may be a useful tool for transferring knowledge to remotely based nurses in a variety of care environments, in addition to improving access to nurse experts. This may be especially important for nurses working in long-term care settings where legal and regulatory mandates require the prevention and appropriate management of pressure ulcers.
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PERCENT AGREEMENT FOR EACH WOUND CHARACTERISTIC