Abstract
Introduction
We present this case of a British patient living and working in Africa who used audiovisual (SKYPE) equipment as a treatment option for remote consultation. This was investigated in response to a request by the patient for further postoperative support at a distance after a complex hand surgery procedure.
Methods
Audiovisual (SKYPE) equipment was used by the team in combination with manual therapy as a means of seeking advice, progressing treatment and liaison with a specialist hand therapist and surgeon. The audiovisual equipment was used to complete follow-up of treatment episodes once the patient had returned to Africa.
Results
After five months of audiovisual consultations with the surgeon and clinical specialist hand therapist, the patient reported significant reductions in anxiety regarding the management of his extensive hand injury. The patient's active and passive range of movement and Disabilities of the Arm Shoulder and Hand scores had all improved. The wider multidisciplinary team in his local area was supported by a specialist service and evidence was gathered to support the organizational benefits of using audiovisual equipment.
Conclusion
This case report highlights the potential, clinical and cost benefits of utilizing audiovisual equipment in conjunction with other treatments in the management of remote hand injury patients.
Introduction
Millions of pounds are wasted each year in missed National Health Service (NHS) appointments. With the political and financial demands on services, innovative ways to reform services and promote effective practices are required. 1 The nature of reconstructive surgery requires many patients to travel long distances to attend specialist hand surgery and therapy centres. This is often at considerable cost to the patient, particularly if they are unable to drive as a result of their injuries. This, in turn, can lead to reduced compliance with attendance and an increased risk of postoperative complications and further episodes of treatment.
The difficulties in treating these already complex hand injuries can lead to a delayed return to function and productivity.
There are 14 million wrist and hand injuries in the UK each year accounting for over 20% of the UK recorded trauma injuries, each case costing between £1500 and £4000 for medical and therapeutic care. 2 It is now estimated that 96% of the mean cost of all total treatment expenses of the injury are indirect expenses to the patient, family, employer and government 3 (e.g. lost earnings, travel expenses and benefits claimed).
Micheals et al. 4 suggested that the greatest burden to society and the individual after a hand injury comes in the form of the economic costs from prolonged treatment and sick leave. It has been established that these indirect costs are best addressed by optimal care at specialist centres using all available contemporary equipment and methods available. 3
The £20 billion efficiency savings to be made by the NHS in 2012 often leaves clinicians struggling to balance best practice with productivity. 5 It, therefore, becomes our duty of care to explore all modern equipment to determine its pertinence. This includes the World Wide Web 6 and possible use of secure audiovisual equipment to facilitate the patient experience and address the ever-increasing costs of health-care provision. The potential for the use of audiovisual equipment (SKYPE) was recognized in the University of California San Francisco Children's hospital in the USA in 2008 for its role in health care for patients whose families were unable to travel in from a distance to visit. 7 An ABC news report on Good Morning America in 2009 highlighted the role that SKYPE has played for clinicians in remote consultations and giving direct access to specialist clinicians for advice. In this report, Mr Spero Thodorou, a plastic surgeon who uses SKYPE for interview and education of his patients reported improved patient satisfaction and reduced waiting times. Similarly, psychiatrist Dr Loren has recently been exploring the use of SKYPE in the UK with dementia patients and their families. 8
Case
A 48-year-old man living and working for a British non-governmental organization in East Africa sustained a complex hand injury as a result of a road-traffic accident. The injuries were caused as the patient de-gloved the dorsum of the right hand on the road surface during impact. He was initially managed surgically by a local team; however, with complications and little recovery of hand function after six months a second opinion was requested in the UK.
Procedures
The patient underwent complex reconstructive surgery to the hand in Oxford, UK (Table 1). There were no intraoperative complications and referral was made to the hand therapy team within 24 hours. The patient was seen by the therapy team in the UK at four, seven and 12 days for postoperative treatment including:
extensive discussion regarding operative procedure, healing timescales and expectation of outcome; initial wound review and dressing change as well as stitch removal and advice regarding further dressing and (postwound healing) scar management; pain management was encouraged via ongoing analgesia supplied by the medical team. Distraction and visualization techniques were also used to assist patient with anxiety regarding pain. Literature was provided to consolidate this; oedema management advice including elevation, resting splint, CobanTM wrap and a combination of lymphatic and retrograde massage techniques were taught; basic active exercise including tenodesis and differential gliding exercises were carried out to maintain tendon glide. Also place and hold exercises for the extensor mechanism and gentle passive stretches to specific joints as deemed appropriate; written timescales and progression of exercise exertion level were given to patient including recommended timescale for resisted exercise and passive stretches to be commenced. Procedures carried out PIPJ, proximal interphalangeal joint
Initial consultation was lead by the specialist hand therapist in which communication and consent was established, subjective feedback was taken and advice and education given in the form of discussion with the patient via SKYPE. The computer terminal was fixed, so in order to maintain the patient's confidentiality, appointments were held at a time when there were no other patients in the same room. Space limitations in the department prevented the use of a mobile terminal, or a separate room, problems that will be addressed should this type of technology be used on an ongoing basis to treat patients. The Trust's information technology department was contacted to support and approve the SKYPE installation and the company policies for data security and protection were checked. There were several free at the point of use audiovisual companies available and discussed with the team; however, SKYPE was used due to the patient in this case already having the programme installed.
The further seven therapeutic consultations were carried out over the next four months, where specialist advice, a patient-specific exercise plan and functional rehabilitation ideas were implemented. The visual element of the process allowed for correction of technique and monitoring of movement patterns and ‘bad habits’. Remote treatment focused on:
educating and reassuring patient about their condition; progressing active and passive range of movement (ROM) of the digits; increasing the repertoire of strengthening exercise for both intrinsic and extrinsic muscle groups; functional hand grip and span work with patient-centred goals around activities of daily living; guide to material options and patterns (as well as review) of splinting to assist African team.
Multidisciplinary team (MDT) meetings were held between the patient, consultant hand surgeon and hand therapist via SKYPE in order to discuss progress and any postoperative complications the patient encountered.
These remote meetings meant that the team could hand over daily care to a local African physiotherapist who was advised and supported through specific postoperative considerations and expectations, with written and practical sessions. Email correspondence was established for the patient and therapy team for updates and ongoing treatment plans. This meant that the patient was able to continue a daily regimen and receive weekly ‘hands on’ therapy with supervision from a remote specialist treatment centre.
Objective measures
Consultation via audiovisual assessment provided the ability to monitor changes in the patient's objective measures. It was originally planned that the patient would complete his assessment independently with a kit including goniometer and questionnaires provided via post. However, once links were made via SKYPE it was determined that the assessment was better carried out by the local qualified therapist in Africa who completed the proforma. The assessment data were then emailed to the team in the UK, allowing the MDT in virtual case conference to make decisions and proceed with the patient-centred care plan.
The chosen patient assessment outcomes were goniometry for (ROM), Numerical Rating Score (NRS) for pain and the Disabilities of the Arm, Shoulder and Hand (DASH) 11 questionnaire, along with patient feedback. The organizational outcomes were compliance with quality and cost-efficiency guidelines.
Results
After five months of consultations via the audiovisual equipment, the patient has undergone eight hand therapy consultations, two combined surgical consultations and two combined therapeutic consultations. During this time, therapy treatment had been initiated, maintained and progressed.
Patient outcomes
Assessment results
AROM, active range of movement; PROM, passive range of movement; NRS, numerical rating score; PIPJ, proximal interphalangeal joint; DIPJ, distal interphalangeal joint; MCPJ, metacarpophalangeal joint
The functional scores (Table 2) improved significantly over the five months of care. DASH scores demonstrated a significant improvement of 68.5 points with areas of ongoing input required in:
The prehensile power in tripod grip, due to ongoing issues with the quality of joint at the metacarpophalangeal joint (MCPJ) of the middle finger; Composite flexion of the index and middle finger, which despite tenolysis demonstrated some residual issues with tethering from extensive scarring and previous surgery; Composite grip strength due to lack of end-of-range active flexion in the index and middle finger. Functional outcome DASH, disability of the arm shoulder and hand; N/A, not applicable
This was reflected in the remaining functional score of 21.75 points (Table 3). The patient will return for further surgery in several months to allow for further surgical correction to the remaining tissue of the hand as required.
Subjectively, NRS for pain was reduced and the patient expressed a reduction in anxiety regarding prognosis when in contact with the team. Unfortunately, no objective measure was taken to assess anxiety levels in the early stages of treatment. For future assessments the Hospital Anxiety and Depression 12 score and Revised Impact of Events Score 13 would be used.
During discussions between the patient and the team, the patient reported feeling empowered in the decisions made, which was demonstrated qualitatively in the patient's diary of progress via email. This was translated into increased levels of motivation and compliance with often quite uncomfortable treatments.
Organization
Using the conventional consultation model, SKYPE demonstrated a potential cost benefit to the department and wider trust by achieving satisfaction of Maxwell's six domains of ‘quality in health-care’ provision, 10 which included: (i) reduced costs compared with a conventional clinic consultation with no administrative costs; (ii) increased productivity; allowing the department to ‘see’ more patients in a given amount of time; (iii) increased efficacy requiring fewer appointments to complete an episode of care from assessment to discharge, with ability to see person in their own environment, promoting more focused interventions and proposed reduction in complications.
Discussion
The aim of this case study was to explore the use of an innovative method alongside or in place of traditional methods of following up or treating patients remotely. The use of audiovisual equipment (SKYPE) was used effectively to facilitate patient follow-up post hand surgery. The opportunity for advice, assessment and education alongside progression of exercises was invaluable in supporting the patient through their treatment pathway. The ability to participate in joint sessions with several health professionals such as the African physiotherapists and the British surgeon allowed for a smooth translation of information and the opportunity to plan as a multidisciplinary team. Being unable to physically alter the patient's position or use tactile stimulation as a treatment aid was at times frustrating. However, having an experienced specialist health care professional to monitor and advise was very important to the patient and he reported feeling more confident having this support.
The costs incurred by the patient were minimal each time (a cold drink at the local café in order to use their Internet facilities). Physically attending an appointment would have incurred costs for transport including flights, accommodation and daily use of amenities. As with many long-distance patients, this would also have wider-reaching consequences, with time taken from work, loss of earnings and psychosocial pressures. It would also not have allowed a local team to be present at the appointments. Although this may be an exceptional case these indirect costs could be directly transferred to other patient groups.
Experience from this case can be applied to other specialties and in line with government initiative to encourage innovation among staff and seek out value for money for patients and our services. 10 Other health-care service providers could consider use of this modality to allow easier access to specialist care. It has been proposed that audiovisual equipment could be used in consultant clinics, allowing appointed or ‘drop in’ style clinics for patients to ask questions regarding their going care and help formulate plans. This could be transferable to basic wound advice for community staff in dressing clinics or general practitioner access to specialist services when a visual element of explanation assists in decision making, for example, with onward referral.
It is acknowledged that SKYPE cannot replace the face-to-face time and physical assessment and treatment completed by experienced clinicians. However, remote patients may be less likely to develop unnoticed complications and can be monitored during interim periods in alignment with the Department of Health initiative to ‘be responsive to patient needs and change the service models accordingly’. 13–15
Another potential use of SKYPE the department plans to explore will be supporting patients on an open appointment/S.O.S drop in clinic. This facilitates patients, in a set time allocated by the therapist, to ask questions to clarify symptoms and recover confidence and control from a home environment. Seasonal advantages also may be found during periods of extended inclement weather, with new Government Health media campaigns around encouraging older and vulnerable patients to avoid unnecessary travel.
The appointments booked for this purpose often do not require a full appointment but are helpful for both therapist and patient to optimize the patient care experience. The costs to both the patient and the department are minimal for an audiovisual episode of care and significantly more patients can be treated during the session with shorter consultations.
The limitations revealed in this report include the subjective nature of some of the success noted and the single patient experience. Further case studies would be useful to ascertain the effectiveness in other patient caseloads such as drop in clinics, postoperative reviews and advice centres for established patients. It also relies on the patient group having access to the audiovisual equipment to link with the specialist centre.
The overwhelming success from a team's point of view was the patient's satisfaction and the opportunity to share specialist knowledge. Although economic and political considerations are institution and nation specific, patient experience and satisfaction are globally transferable. With emphasis in the current climate on patient-centred care, these outcome measures are arguably the most important.
Conclusions
This report is intended to reflect on the experience of using this modality in clinical practice and to promote discussion around its use. The findings are case specific and future investigation should be carried out to evaluate the use of this equipment for optimizing patient care.
The use of audiovisual equipment may have implications for the wider health-care services as we are challenged to find more cost-effective ways of accessing and treating patients.
Footnotes
Acknowledgements
The authors received written permission from the patient to discuss and submit the case for publication and presentation.