Like those of most Visiting Nurse Associations (VNAs) across the country, clients of VNA of Chittenden and Grand Isle Counties in Colchester, VT, have been offered telehealth innovations.

Each morning, patients who use the remote monitoring system step on a scale, wrap their arm in a blood-pressure cuff and place a pulse oximeter on a finger while nurses in the VNA office receive their weight, blood pressure, heart rate and O2 saturation measurements on a computer.

"The system directs them each step of the way what to do," said Barbara Paggi, RN, CWOCN, staff nurse. "We monitor those measurements for any abnormalities. We can send a report directly to the physician if we see any trends or changes. If the patient, for example, has CHF, and we notice their weight is going up incrementally, like three pounds a day, and we notice more breathing difficulty, we notify the physician."

For the past five years, Paggi and her nursing colleagues have adapted telemedicine technology for patients with non-healing wounds. Equipped with the usual wound-healing equipment - gauze, bandages, cleansers and antiseptics - visiting nurses also bring digital cameras into the patients' homes to document wound progress, or lack thereof.

A photo of the wound is taken upon admission and the visiting nurse will take another photo of the wound to track its progress once every 2-4 weeks, Paggi said.

"Based on that, either I or the other wound care nurse can consult with the case manager to see whether there is an alternate treatment we should try," she said. "If there is no progression of the wound within those two weeks, we might get another product, or if we see the wound degrading, we might get orders for another wound care treatment."

Benefits All Around
Asked who benefits the most from providing wound care in the home, Paggi said patients, nurses and physicians have all reaped the rewards.

"It has made us more efficient with our time," she said of the nurses. "It allows us to consult more effectively with the wound care specialists to design the right care plan for the patient.

"We can do most of the communication over the computer, but most of the time, we talk with the visiting nurse over the phone or in the office. With the physicians, it's helped a lot. We can do that communication over the computer, and if needed, we have the phone conversation with the physician or their nurse in the office."

Patients who are homebound have benefited greatly from wound care in the home, Paggi said.

"We will use the photo assessments on those patients," she continued. "We'll send the photo to the physician over a secure line with the information encrypted with our assessment and recommendations for treatment."

Digital photos are ideal for patients whose wounds are in an area of their body they can't physically see, Paggi said.

"We can show them the picture so the patient knows what is going on with the wound," she explained. "It decreases their fear and increases their knowledge to improve what they need to do."

Another advantage to wound care photography has been educating fellow nurses.

"[The pictures] are a great teaching resource, as well," Paggi said. "When teaching new nurses, doing inservices for the community health centers, we'll use the pictures when describing different wound stages. It's all confidential. The patient's faces aren't seen, and they sign a consent form to allow us to use them." 

Effective And Convenient
Studies of Web-based wound care verify the system is effective and convenient. In 2006, researchers from the University of California, San Diego, studied telemedicine wound care of 120 residents of long-term care facilities, skilled nursing facilities or patients at home in Southern California.¹

After the patients were referred to the program, a wound care nurse visited them to obtain a history of the wound, assess it and take digital photographs. Surgeons then devised the treatment plans based on the photos and the nurse's evaluation. Treatment plans ranged from general management using topical treatment to surgical interventions, including biopsy and skin-graft surgery.

When the patients were later seen in a hospital-based wound care center, only two care plans significantly changed during the face-to-face consultations - one from conservative measures to surgery, the other from a surgical recommendation to topical care.

"Ultimately, in no cases were decisions made that would lead to significant, unnecessary risks or morbidity," the study authors wrote. "Even in the case of the patient with a seemingly healing wound who required surgical intervention, the telemedicine consult did not really delay her care; rather, it only led to assumptions and expectations not reaffirmed during direct consultation." 

Photography Lessons
Recognizing the value telehealth brings to wound care, the American Professional Wound Care Association has issued guidelines on its Web site on taking effective photographs of wounds (www.apwca.org/guidelines/photographic.cfm).

The association recommends nurses remain consistent in their picture taking by using the same camera at the same resolution in the same light at the same angle each visit to get accurate successive images.

Nurses should also select the same magnification on the zoom lens. They also needn't bother using the flash on the camera. Digital cameras are sensitive to light, and a flash is usually not required and may obscure essential detail in the glare of moist surfaces, the association advised.

Computer software packages with image-analysis algorithms help document wound healing by precisely measuring wound dimensions. New image acquisition capabilities within cell phones will undoubtedly play a part in telehealth wound care in the coming years, the association predicts.

Complementary Care
University of California researchers caution against relying solely on telemedicine for wound care.

"Telemedicine-based assessment will not replace a face-to-face and comprehensive assessment of a patient with a chronic wound with members of a multidisciplinary wound management team; but will, however, streamline the management," they wrote.¹ Errors based on telemedicine could lead to litigation, the authors warn.

Regardless, with technology increasing connectivity like it has, it is possible for patients with non-healing wounds to receive all their care at home.

"It has become accepted, and the patients really appreciate it," Paggi said. "The nurses are receptive to the new technology. It makes our response time better, and the wounds heal better."

Reference
1. Dobke, M., et al. (2006). Telemedicine for problematic wound management: Enhancing communication between long-term care, skilled nursing, and home caregivers and a surgical wound specialist. Wounds, 18(9): 256-261.

Stacey Miller is associate editor at ADVANCE.