Tips for a Successful Wound Care Telemedicine Consultation

The outbreak of the COVID-19 pandemic has accelerated the implementation of telemedicine in hospital and private settings. Telemedicine is the usage of a remote electronic interface to permit two-way, interactive communication between a patient and physician to discuss patient concerns and history.­^1,2 The widespread adoption of this technology has enabled flexible interaction with the patient regardless of time and location, and more importantly to limit unnecessary exposure, particularly for high-risk individuals.

One such population is wound care patients. Patients needing wound care treatment suffer from a multitude of underlying health issues, including renal disease, high blood pressure, and diabetes.³ According to the National Center for Immunization and Respiratory Diseases (NCIRD) of the CDC⁴, these conditions categorize a large majority of wound care patients as high-risk. Thus, a major motivation for wound care telemedicine services is allowing health care workers to triage the wound’s severity from the safety of the patient’s home. This reduces unnecessary exposure and improves clinical efficiency in reducing low urgency cases in times of high volume.

In the past, more frequent wound care visits have been shown to improve healing outcomes.¹ One study examining 39,750 diabetic foot ulcers associated with 17,849 patients found that monitoring at a frequency of 7.5 times or more within 4 weeks healed faster than wounds monitored with intervals of two weeks or less.⁵ Similarly, Warriner et al found that a weekly visitation group had increased diabetic foot and venous leg ulcer healing rates of up to twice as fast, relative to those of a biweekly visitation group.⁶

Telemedicine’s flexibility and ease of access for wound care patients can be leveraged to provide more frequent monitoring of wound development to improve healing outcomes. In application, a meta-analysis comparing 1,046 chronic wound patients receiving telemedicine intervention (eg, video consultation, telemonitoring, mobile application, telephone) to 880 patients receiving at-home or outpatient care found that telemedicine intervention significantly improved chronic wound healing and reduced adverse complications.⁷ When implemented properly, telemedicine can improve wound healing outcomes by allowing for more frequent physician monitoring.

To achieve a successful wound care telehealth consultation, we define such a virtual visitation two-fold: 1) acquiring sufficient information for accurate monitoring of wound development and 2) triaging for continuing telehealth options or necessary in-person consultation. 

Tips

1. Selection of appropriate patients for wound care teleconsultations. Given the severity and unique circumstances of their case, certain patients will be better suited for telemedicine. Prior examples of appropriate cases include postoperative patients having an unremarkable and uncomplicated recovery, chronic vascular patients who require frequent wound imaging, and new referral patients who require triaging to determine the urgency of their visitation.⁸ Determining if patients feel comfortable with and have the technology for telemedicine should be assessed early on. Providers should obtain verbal informed consent to teleconsultations as a form of care. If possible, a witness should be present.

2. Establishing guidelines for an assisted preparation of telemedicine infrastructure with patients and their care providers early. Early preparation of the patient for telemedicine will assist homecare services triage for necessary in-person visits, especially when physical access to patient and family members may be limited under pandemic conditions.¹ A standardized script of workflow process should be established for each telemedicine platform(s) to acquire the necessary information for each clinic, since each software may provide different types of information. A telemedicine workflow at our wound care institution in the outpatient setting can be seen in Figure 1.

If telemedicine is deemed suitable during the initial consultation, the appropriate telemedicine platform for a patient should be chosen and explained to the patient and their caregivers with a written copy of what to expect and what actions might be required. Some examples of secured HIPAA-compliant telemedicine platforms include Doxy.me, Google G Suite Hangouts Meet, GoToMeeting, InTouch Health, Mend, Mundaii, Skype for Business, swyMed, Updox, VSee, and Zoom for Healthcare.⁸
 
3. Efficient telemedicine workstation set-ups for physicians and other healthcare workers. Clinics and outpatient practices preparing to implement telemedicine should have private computer workstations with audio and video capabilities. To maximize efficiency, having multiple devices or screens would enable simultaneous chart assessment, reviewing images, and conducting teleconsultation. Having a clock or timer in view during visitation would assist in billing purposes.⁸
 
4. Virtual bedside manners and establishing patient comfort. Telemedicine should maintain the same principles as traditional care in establishing patient trust and comfort. If the first consultation is virtual, the provider should initiate a brief introduction before focusing on the concerns of the patient. To ensure patient privacy and comfort during the session, keep the office doors closed to eliminate potential distractions and maintain eye contact into the webcam. Lighting should be adjusted if needed.
 
5. Collecting information to characterize wound severity and/or development. One of the major concerns for telemedicine in contrast to traditional care is acquiring necessary observations of the wound site. Provide sample pictures for the patient and their caretakers. To sufficiently monitor wound development, digital images should have three different zoom perspectives:

1. Macro: showing the wound(s) and surrounding peri-wound and healthy tissue in view
2. Close-up: showing the wound(s) as the central focus
3. Micro: showing a focused detail of the wound surface

From these images, wound characteristics, such as color, presence of necrotic or granulation tissue, foreign bodies, and edema in the peri-wound area, should be noted and allow longitudinal monitoring of wound progression.⁹ Orientation of the wound should be consistent over time. Additional observations of the wound include wound diameters (measured with a standardized ruler) and odor.

If possible, pictures of the wound can be sent to the provider to upload into the electronic medical records to serve as further documentation. More streamlined mobile solutions such as digital capture devices are calibrated to generate wound measurements through artificial image analysis for automatic transfer into the patient’s electronic medical record.

However, if pictures of the wound are not available, educating the patient or caregiver on how to take weekly measurements of the wound helps track progress.
 
6. Having a triage system for assessing patient needs. A successful wound care teleconsultation should be able to assess wound severity virtually and determine the next steps for the patient. A protocol that would categorize patient conditions into different priority levels of care should be established. In 2020, Rogers et al10 used the Infectious Diseases Society of America categorizations of disease severity into priority groups. Priority group 1 (eg, gas gangrene and sepsis) qualified for hospital care, and priority group 2 (eg, chronic limb ischemia and worsening foot ulcers) qualified for outpatient clinic or surgery center. Priority group 3 (eg, improving foot ulcers and inactive Charcot foot) and priority group 4 (eg, foot wounds in stable patients with diabetes) could be treated at home or through telemedicine.

In Conclusion

Being able to sufficiently assess wound conditions through telemedicine would direct care for non-urgent cases out of outpatient clinics and hospital settings by providing more support in the patient’s home.

Alisha Oropallo, MD FACS, FSVS, FAPWCA, FABWMS, is an Associate Professor, Zucker School of Medicine, Hofstra/Northwell Health; Associate Professor, Feinstein Institutes of Medical Research, Northwell Health; Director, Department of Vascular and Endovascular Surgery; Medical Director, Vascular lab, Department of Vascular Surgery; and Co-Chair, Northwell Wound Symposium, Department of Surgery.
 
Adrian Chen, BS, is a medical school student at the Donald and Barbara Zucker School of Medicine at Hofstra/Northwell Health.

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References
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3.    Beyene RT, Derryberry SL Jr, Barbul A. The effect of comorbidities on wound healing. Surg Clin North Am. 2020;100(4):695-705. doi:10.1016/j.suc.2020.05.002

4.    National Center for Immunization and Respiratory Diseases. People with Certain Medical Conditions. Centers for Disease Control and Prevention.

5.    Carter MJ, Fife CE. Clinic visit frequency in wound care matters: data from the US Wound Registry. J Wound Care. 2017;26(Sup1):S4-S10. doi:10.12968/jowc.2017.26.Sup1.S4
 
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7.    Huang Z, Wu S, Yu T, Hu A. Efficacy of telemedicine for patients with chronic wounds: a meta-analysis of randomized controlled trials. Adv Wound Care (New Rochelle). 2021;10(2):103-112. doi:10.1089/wound.2020.1169
 
8.    Lin JC, Humphries MD, Shutze WP, Aalami OO, Fischer UM, Hodgson KJ. Telemedicine platforms and their use in the coronavirus disease-19 era to deliver comprehensive vascular care. J Vasc Surg. 2021;73(2):392-398. doi:10.1016/j.jvs.2020.06.051
 
9.    Téot L, Geri C, Lano J, Cabrol M, Linet C, Mercier G. Complex wound healing outcomes for outpatients receiving care via telemedicine, home health, or wound clinic: a randomized controlled trial. Int J Low Extrem Wounds. 2020;19(2):197-204. doi:10.1177/1534734619894485
 
10. Rogers LC, Lavery LA, Joseph WS, Armstrong DG. All feet on deck—the role of podiatry during the COVID-19 Pandemic: Preventing hospitalizations in an overburdened healthcare system, reducing amputation and death in people with diabetes [published online ahead of print, 2020 Mar 25]. J Am Podiatr Med Assoc. 2020;10.7547/20-051. doi:10.7547/20-051