VISN 11 Wound Care Teleconsultation Program

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VISN 11 Wound Care Teleconsultation Program

• Julie Lowery, PhD
• Implementation Research Coordinator
• Leah Gillon, MSW
• Administrative Coordinator
• Diabetes Mellitus QUERI
• Center for Clinical Management Research
• HSRD CoE
• VA Ann Arbor Healthcare System

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Objectives

• Determine feasibility of store-forward
  telemedicine system for providing consultations
  on chronic wounds.
• Significance Patients with chronic wounds have
  problems accessing specialized wound care
  centers.

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Background

• Pressure Ulcer Assessment via Telemedicine
• (HSRD funded study)
• Evaluation of accuracy of Web-based,
  store-forward telemedicine system for monitoring
  status of patients with chronic wounds

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Feasibility Study Methods

• October September 2008
• Ann Arbor VAMC wound care team wound care NP,
  plastic surgeon, ID specialist
• Referring centers Battle Creek and Grand Rapids
• Wound care nurse requested consultations via CPRS
• Digital images uploaded to VISTA Imaging
• Additional clinical data entered into CPRS wound
  care template

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Feasibility Study Methods

• Ann Arbor wound care NP
• Screened all consultations
• Discussed complicated cases with plastic surgeon
  or ID physician
• Forwarded diagnostic and treatment
  recommendations back to nurse via CPRS

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Feasibility Study Results

• 100 patients
• All male
• Mean age 64 (range 36 89)
• 100 initial visits, 366 follow-up visits
• 254 tele-consultations sent
• 1.95 mean wounds (range 1-7 per patient)

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Feasibility Study Results

• Wound type (N 181 wounds, 100 patients)
• 43 (78) Diabetic lower extremity ulcers
• 4 (8) Pressure ulcers
• 8 (14) Non-diabetic PV lower extremity ulcers
• 34 (62) Venous stasis ulcers
• 11 (20) Misc (trauma, burn, surgical)

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Feasibility Study Results

• Mean wound surface area 10.59 cm2
• (range .01 404.22)
• In FY07, there were 44 Ann Arbor wound care
  clinic appointments for Battle Creek and Grand
  Rapids patients vs. 5 in FY08

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Feasibility Study Results

• Average response time for diagnostic treatment
  recommendations 3.72 days (range 0-12 days)
• Increased observed use of debridements, biopsies
  for culture, topical antimicrobials, topical
  growth factors.

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Feasibility Study Results

• Patient Satisfaction Surveys
• 97 First Visits

Did not mind having photographs taken of their wound. 94
Expressed some level of concern about the privacy of their medical information. 26
Felt it was more convenient to receive care at home site 94
Felt that had received good care during their visit 98
Would have been more confident of care in Ann Arbor 9
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Feasibility Study Results

• Patient Satisfaction Surveys
• 277 Subsequent Visits by 59 Patients

Visits during which patient felt they had received good care 98
Visits during which patient wanted services that were not provided (total of 10 patients, most of which were for supplies, not services) 6


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Retrospective and study patient chart review at
remote site

• January-May 2005
• 39 wound care patients
• 31 with one wound
• 8 with two wounds
• Random sample of 31 study patients, February
  2007-August 20008
• 27 wound care patients
• 15 with one wound
• 9 with two wounds
• 3 with three wounds

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Retrospective and study patient chart review at
remote site
Wound care 2005 Study period
Dimensions of wound noted 60 100
Wound bed described 45 100
Debridement performed when appropriate 94 91
Pulses checked when appropriate 54 81

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Retrospective and study patient chart review at
remote site
Wound care 2005 Study period
Antibiotics prescribed w/ no infection noted 21 14
Culture and/or antibiotics when infection suspected 98 98
Offloading plan noted with foot ulcers 96 100
HbA1c ordered when appropriate 95 100
Dressing plan noted 62 100
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Feasibility Study Conclusion

• Increasing access to specialty care via
  telemedicine
• Increases probability of identifying a problem
• Increases likelihood of aggressive treatment, and
  provides this treatment sooner
• Identifies unnecessary treatmentespecially use
  of antibiotics
• Note Telemedicine management takes place in
  collaboration with local clinician. It is
  designed to supplementnot supplantexisting care
  by local provider. (Important in cases where
  sensitivity of telemedicine diagnosis is only
  fair.)

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Feasibility Study Challenges and Limitations

• Substantial support necessary from local DSS
  coordinators, clinical applications coordinators,
  coding specialists, and Vista Imaging and medical
  media experts
• Ensuring capture of both direct patient care and
  tele-consultation workload credit
• Time constraints on staff providing consultation
• Difficulty in scheduling live consultations
• Challenges of working with remote IT staff to
  install hard- and software
• Procedures to adequately capture response to
  consultation suggestions need development
• Has not been piloted with nurses untrained in
  wound care

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Challenge to VA

• To improve access to high quality health care
  (with corresponding improvement in outcomes)
  within financial constraints.
• Can teleconsultation provide the solution?
• Who will take the lead in implementing these
  solutions?

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Next Steps

• Implement in Saginaw VAMC (with wound care NP).
• Implement in CBOCs (no wound care NPs).
• Training?
• Credentialing?
• Hold wound care symposium.
• Track amputations.

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New Wound Template, page 1
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New Wound Template, page 2
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New Wound Template, page 3
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Follow-up Wound Template, page 1
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Follow-up Wound Template, page 2