Abstract
Background:
Pressure injuries (PIs) represent a frequent, often preventable, secondary complication of spinal cord injury (SCI) with serious consequences to health, societal participation, and quality of life. Specialized knowledge and service delivery related to treatment and prevention are typically located within major health centers.
Introduction:
For persons with SCI living at home, it can be challenging to access specialized PI care. A telehealth approach could help mitigate this challenge. This multisite pilot investigation assessed the feasibility of integrating information technologies within the management of PIs.
Materials and Methods:
Each study site formed a specialized interdisciplinary care team that identified components of their standard clinical care pathway and examined how they could be integrated with study technologies. A monitoring system was utilized to enable patients and caregivers to exchange clinical information with the care team.
Results:
Clinician and patient focus groups were completed to identify facilitators and barriers for long-term implementation. Findings demonstrate that this method of service delivery is feasible but requires further development.
Discussion:
This model of care requires refinement to address technological, regulatory, and clinician acceptance barriers; however, increased access to these services has the potential for improving PI healing or prevention rates in comparison with those not able to access specialized services.
Conclusions:
This project demonstrates that PI treatment services can be delivered effectively through the internet. Future trials can investigate efficacy and cost-effectiveness of this model of care to inform sustained implementation.
Introduction
Pressure injuries (PIs) represent a frequent and serious secondary complication of spinal cord injury (SCI). In Canada, the prevalence of PIs for individuals with SCI living in the community has been reported to range from 15.1% to 27.8%. 1,2 In addition, 85% of people with SCI will develop a PI at least once in their life. 3 PIs negatively impacts quality of life, self-esteem, activities of daily living, and community activities. 4,5 PIs are a significant cost for the health care system. The estimated average monthly cost for PI care is $4,745 (CAN) for community dwelling individuals with SCI in Canada. 6 In the United States, the estimated annual cost of PIs for all individuals is $1.2–1.3 billion (USD). 7,8 The development of a PI for an individual with SCI living at home may lead to rehospitalization and result in higher outpatient health care utilization. 4,9 –11
In Canada, specialized knowledge and service delivery for PI prevention and management are clustered around relatively few centers that specialize in SCI care. Currently, the majority of health care interactions for individuals with SCI require visits to an institution. This is a barrier for individuals living far from health centers. This could be mitigated through a telehealth strategy—that is, care delivered through information and communication technologies. A telehealth approach may also improve the continuity of care and reduce isolation for patients and caregivers. 12
Literature 13 –18 has suggested that assessment and diagnosis of PIs through digital images and phone conversation compare well with in-person assessment; however, accurate assessments can be difficult with stages 3 and 4 PIs. 13,15 Some studies demonstrated the utility of videoconferencing with patients and caregivers to facilitate more accurate assessment of stages 3 and 4 PIs. 14,18,19 These technologies can provide clinicians with a view of the patient's home environment, which may help identify factors that prevent healing or contribute to PI development and assist with prevention and treatment planning. 17 There is evidence that telehealth may be as effective as face-to-face interventions and can be less expensive than standard care when using low-cost technology. 20,21
This study, conducted at four institutions across Canada, aimed to enhance access to a specialized interdisciplinary team through the creation of an internet clinic addressing the treatment of PIs in persons with SCI. The intent was to deliver these services directly into the participant's home, thereby reducing the need for in-person clinic visits. The primary objective of the study was to assess the feasibility of this model of care.
Materials and Methods
Study Technologies
An agreement was formed with a technology vendor to utilize a monitoring system. The monitoring system comprises clinical protocol development software, clinician software, and patient website. This system supported the exchange of clinical information between patients and an interdisciplinary team. This clinical information enabled the interdisciplinary team to develop a treatment plan and monitor the patient's status remotely.
Clinical protocol development software
This supported the creation of logic driven assessments—that is, questions to the patient based on previous responses. Clinicians at each site collaboratively developed assessments to gather information from patients. Assessments comprised questions typically asked of patients during outpatient appointments.
Clinician software
This software was used to assign assessments for each patient. Once an assessment was assigned, an automated e-mail and/or text message was sent to the patients asking them to log onto the patient website. Home care nurses used the software during home visits to enter assessment data and upload PI photographs. The interdisciplinary team used this software to review all assessment information and enter relevant clinical notes.
Patient website
Patients accessed this website from their home computer to complete their assigned assessments. Patients were also able to upload images (e.g., seating cushion) that could be viewed by the interdisciplinary team.
Study Protocol
This study was conducted at four Canadian centers: (1) Foothills Medical Centre (Calgary, AB), (2) Parkwood Institute (London, ON), (3) Stan Cassidy Centre for Rehabilitation (Fredericton, NB), and (4) Winnipeg Health Sciences Centre (Winnipeg, MB). Each site had a lead, coordinator, and interdisciplinary team that worked collaboratively with the principle investigator and project coordinator. The interdisciplinary team composition varied across sites and could include physicians (family physician or specialized in physiatry), nurses, occupational therapists, physiotherapists, registered dietitians, and home care nurses.
Each site's interdisciplinary team identified components of their standard clinical care pathway and determined how they could be integrated with the study technologies. Each interdisciplinary team developed a set of clinical assessments that would be completed by the patient or their caregiver. Before beginning recruitment, all team members completed training with study technologies.
Upon participant enrolment, a standardized clinical and study protocol was administered.
Initiation: The site coordinator visited the participant's home to set up a webcam and install antivirus protection on the participant's personal computer. The participant completed a tutorial on how to use the patient website and webcam for videoconferencing. After this visit, participants were asked to complete their initial assessment.
In-Home Assessment: After the participants completed their initial assessment, the home care nurse visited the participant's home to complete an assessment of their PI(s) (e.g., measuring wound size) and capture wound photographs. This information was collected and shared with the interdisciplinary care team through the clinician software.
Videoconference & Treatment Plan: Within a week of the in-home assessment, the participant, caregiver(s), and home care nurse (in the participant's home) videoconferenced with the interdisciplinary team (in the same room or their own offices at the institution). During the videoconference, the team asked follow-up questions stemming from assessment information. There was also an opportunity for the participant, caregiver, and home care nurse to ask questions of the interdisciplinary team. After this discussion a treatment plan was presented.
Follow-up Visits: As per the treatment plan, the participant and home care nurse completed follow-up assessments. The assessment information continued to be shared with the interdisciplinary team to enable monitoring of the PI(s). The participant, home care nurse, and interdisciplinary team could request additional videoconferences if issues arose.
Completion: Participants were followed for a maximum of 6 months. If the PI remained, standard clinical pathways were continued without using study technologies.
Upon study completion, participants and clinicians completed satisfaction and self-confidence surveys. The satisfaction survey was adapted from the System and Use Survey 22 developed by Canada Health Infoway, and a custom self-confidence survey was developed for the study. Both surveys assessed five aspects: overall use of study technologies, wound photography, videoconferencing, online assessments, and automated alerts/reminders. Participants and clinicians could decline to rate any aspect.
Results
The satisfaction survey used a 5 point scale ranging from highly satisfied (5) to not at all satisfied (1). Wound photography was the category with the highest percentage of satisfied scores (i.e., combination of 5 and 4) for both participants and clinicians (81.25% and 78.95%, respectively). The categories with the highest percentage of dissatisfied scores (i.e., combination of 1 and 2) were automated alerts/reminders for participants (33.33%) and overall use of study technologies for clinicians (25%). Automated alerts/reminders received the lowest number of responses from both participants (n = 9) and clinicians (n = 11) on the satisfaction survey. See Tables 1 and 2.
Participant Satisfaction Survey Results
Satisfaction scale: 1, not at all satisfied; 2, moderately dissatisfied; 3, neither satisfied nor dissatisfied; 4, moderately satisfied; 5, highly satisfied.
Clinician Satisfaction Survey Results
Satisfaction scale: 1, not at all satisfied; 2, moderately dissatisfied; 3, neither satisfied nor dissatisfied; 4, moderately satisfied; 5, highly satisfied.
The self-confidence survey used a 5 point scale ranging from very confident (5) to not at all confident (1). Although wound photography received the lowest number of responses from participants (n = 15), it received the highest percentage (80%) of confidence scores (i.e., combination of 5 and 4). Videoconferencing was the category with the highest percentage (20%) of nonconfidence scores (i.e., combination of 1 and 2) for participants. For clinicians, videoconferencing received the highest percentage (83.33%) of confidence scores. Automated alerts/reminders received the lowest number of responses (n = 9), and also received the highest percentage (22.22%) of nonconfidence scores from clinicians. See Tables 3 and 4.
Participant Self-Confidence Survey Results
Self-confidence scale: 1, not at all confident; 2, somewhat not confident; 3, undecided; 4, somewhat confident; 5, very confident.
Clinician Self-Confidence Survey Results
Self-confidence scale: 1, not at all confident; 2, somewhat not confident; 3, undecided; 4, somewhat confident; 5, very confident.
Analysis was limited to simple descriptive and visual inspection of the data. In addition to study surveys, separate clinician and participant focus groups were completed at each site. Focus groups were conducted using the nominal group technique (NGT), which is a formal method for developing collective decisions and consensus. 23 The NGT was used to gain consensus for which long-term implementation barriers and facilitators were the highest priority. This began with each participant recording his or her ideas independently and then sharing them with the group. Each idea was discussed among the group followed by blinded voting. If needed, additional rounds of voting were completed to refine the results. The facilitators and barriers described are an amalgamation of the highest priorities across all sites.
Facilitators
Videoconferencing
Videoconferences were beneficial for various reasons. Eliminating travel to a clinic resulted in cost savings and eliminated transportation time that may negatively impact PI healing. Participants found videoconferences informative because of discussions with the specialized interdisciplinary team and self-management recommendations they received. For the interdisciplinary team, interacting with patients, caregivers, and home care nurses all at the same time enabled them to gain a better understanding of the group dynamics and to develop a treatment plan agreed on by all parties. Some sites utilized the videoconference to show the interdisciplinary team the patient's home environment (commode, bed, etc.), which was valuable for determining factors that may lead to a negative impact on PI healing. In one instance, the videoconference enabled a wound care nurse to provide training to a home care nurse for proper techniques in wound assessment. This resulted in more accurate PI assessment information being collected.
Interdisciplinary care
The creation of a specialized interdisciplinary team led to a treatment plan developed and supported by the entire team. Although this was not the typical approach in study sites for outpatients, in some instances this expertise led to the healing of chronic PIs that were present for years. Interdisciplinary team interaction led to a positive experience for the patient who felt encouraged to have directed team expertise. This interaction also created a link, which typically does not exist, between clinicians at the institution and the patient's home care nurse. This enabled the interdisciplinary team to communicate directly with the home care nurse to develop and implement the treatment plan.
Online assessment completion
This assessment information provided by the patient and home care nurse was used by the interdisciplinary team to develop the treatment plan. In typical clinical practice, this information would be collected during an outpatient visit with a nurse or physician asking the patient questions and documenting their responses. Collecting assessment information online resulted in significant time savings for clinicians (∼1 h per patient) and enabled the interdisciplinary team to review assessment information and consider the treatment plan before the videoconference. An added benefit of this system was that it allowed ongoing assessment of PIs. The patient and home care nurse would complete PI assessments and upload PI photographs on an ongoing basis, allowing the interdisciplinary team to remotely monitor the patient's progress in a manner currently unavailable.
Local coordination
Each site had a local coordinator tasked with a number of responsibilities, including, but not limited to, technical support, coordinating home care nurse visits, and ensuring assessments were completed, displaying assessment information into a user-friendly format for clinicians, organizing team meetings, organizing videoconferences, and keeping everyone informed of progress. The clinicians and patients indicated that the role of the coordinator was pivotal in keeping everyone organized, facilitating use of the technology, and helping individuals feel comfortable with processes with which they were unfamiliar.
Barriers
Technology
Team members across all sites noted challenges with using the monitoring system. In particular, the clinician software was not intuitive and although the assessments were customized for SCI PI care, the software was not conducive for monitoring PIs. In addition, the clinician software was not integrated with existing software utilized by the interdisciplinary team (e.g., electronic medical records). Clinicians and patients indicated that at times there were speed and performance issues with the clinician software and patient website. Occasionally there were internet bandwidth issues during videoconferences, resulting in poor audio and video communication. Furthermore, some clinicians indicated that photographs of the wound could be misleading and may not accurately reflect the wound's true status. Some patients and clinicians indicated that they are not comfortable using technology, which meant using technology for clinical care was challenging at times.
Health system issues
Teams noted a number of significant system issues that would need to be addressed to achieve successful long-term implementation. One issue is that current reimbursement policies for clinicians do not address this model of service delivery. Although telemedicine is becoming more common, there are unique elements of this study that may require health care organizations, clinician unions, and hospital funders to develop appropriate reimbursement structures. Another challenge is having dedicated time for clinicians to work in an interdisciplinary team. Interdisciplinary care was a significant benefit in this study but this was not typical practice in outpatient visits for the study sites. Many clinicians mentioned that adding dedicated time for interdisciplinary care would be difficult given their current demands. Finally, although each site indicated that local coordination was essential for facilitating progress, continued funding for this position may be difficult. Grant funding supported coordinators during the study but in the absence of grant funding it may be difficult for institutions to support this position.
PI expertise in the community
All sites indicated that in order for this model to be successful, the home care nurse needs to be skilled clinically and technically. This could be a challenge due to a lack of specialized providers in the community, especially for specialized knowledge of SCI or PI management. This meant that some assessments completed by home care nurses in the community were inconsistent or inaccurate; however, a benefit of this pilot study was the ability to connect interdisciplinary teams with home care nurses to support a better understanding of PI assessments and treatments.
Patient preferences
Many participants expected more frequent communication with the interdisciplinary team with this new service delivery model. Participants were disappointed that they did not have more opportunities to speak with the interdisciplinary team through videoconference. In addition, some participants indicated that completing assessments online was too time consuming, that some of the assessments were too repetitive, and they were not comfortable answering some questions online.
Discussion and Conclusions
Although videoconferencing was identified as a key facilitator in this study, there were mixed results with self-confidence related to videoconferencing. Of the five aspects assessed on the self-confidence survey, clinicians rated videoconferencing the highest while participants rated it lowest. During the study, the local coordinator typically facilitated the set-up and execution of videoconferences at the institution. Support from the local coordinator may have contributed to clinician self-confidence. Conversely, the participants (and their caregivers) joined the videoconference by themselves, which may have been challenging if participants were not familiar with videoconferencing or with the system being used. Given that each participant engaged in relatively few videoconferences, they may not have had the opportunity to build their self-confidence with the system. Participants were provided with a demonstration for videoconferencing upon study initiation, but perhaps additional trial runs would help participants.
Although wound photography was not identified as a key facilitator in focus groups, it was rated highly by participants and clinicians on satisfaction and self-confidence surveys. This is likely because wound photography was necessary for this model of care to function effectively. In many cases, patients were unable to see their PI because of its location on the body (ischial tuberosities, coccyx, etc.). In this study, wound photography enabled participants to see a visual of their wound, which may have contributed to satisfaction.
In general, participants and clinicians were not satisfied or confident with the use of automated alerts/reminders. For participants, alerts/reminders consisted of e-mails and/or text messages asking participants to complete online assessments and reminders for PI self-management provided on the patient website. Although this was not discussed during focus groups, it is possible that very few patients utilized e-mails or text messages alerts or did not find self-management reminders useful. For clinicians, the clinician software provided an alert if patient assessment data fell outside of a normal range (e.g., an assessment indicating very high risk for developing a PI). These alerts were not triggered often during the study, which may have led to low satisfaction and confidence. The utility of these features should be re-examined in greater detail in future studies.
Currently, this method of service delivery requires further development and refinement as there are technological, regulatory, and clinician acceptance barriers to overcome; however, initial findings have demonstrated this as a feasible approach for PI management. This is consistent with the findings of a systematic review that concluded telehealth care can be as effective as in-person care. 20 Some literature has postulated that the incidence of stage 3 and stage 4 PIs can be reduced by increasing the utilization of telehealth technologies. 21 In this study, the resolution of chronic PIs occurred for some participants and this was attributed to the access to specialized PI care that is otherwise not easily accessible. This was felt to be a significant impact to these participants. Future studies should include an economic analysis for this model of care in persons with SCI to determine potential cost savings associated with the reduction of home care nursing needs, rehospitalizations, travel to institutions for clinic appointments, surgeries to promote PI healing (e.g., skin-flap surgeries), and the potential to improve individuals' overall health and quality of life. 21,24,25 Further discussion and planning are required with health care leaders and potential funders to examine how costs associated with this approach (technology, personnel, and reimbursement policies) will be addressed going forward.
This study highlighted the need for continuing education for home care nurses. In some cases, home care nurses did not have specialized knowledge or expertise in caring for persons with SCI with a PI. This is understandable given that home care nurses provide care for a number of patients with different health conditions. Feedback from specialist care providers in this study suggested that providing education to community providers could enhance care in the community. A telehealth approach necessitates that home care nurses to have specialized knowledge to properly assess (e.g., examine risk factors, measure the PI, and capture photographs) and manage (e.g., clean and dress) the PI. This is necessary given that assessment information is required for the specialist team to develop a treatment plan and the patient will not be seen in-person. In this study, some education was provided live during videoconferences; however, some aspects of care would be best learned through in-person training.
There is also evidence that a telehealth approach can be utilized beyond PI management to address other secondary complications (bladder management, pain, etc.) as well. 26 A model of care and telehealth system that adopts a broad approach to health may lead to economies of scale and synergies in training and capacity building. Future studies could examine optimal telehealth models of care that could be utilized to address a number of secondary complications for persons with SCI. 25
Footnotes
Acknowledgments
Funding support was provided by Alberta Paraplegic Foundation, Ontario Neurotrauma Foundation, Government of Manitoba, Canadian Paraplegic Association Manitoba, and Rick Hansen Institute—Grant No. 2010-79S.
Disclosure Statement
No competing financial interests exist.