Digitizing the Future of Wounds: What Are the Challenges?

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Digitizing the Future of Wounds: What Are the Challenges?

Editorial Summary

The increasing burden of wound care is well established in evidence. It is essential for the clinician to be provided with the adequate tools to safely and effectively provide a high standard of clinical care to wound care patients. The deployment of the electronic patient record (EPR) has attempted to standardize documentation in care. However, it remains difficult to extract the suitable data required to provide evidence based medicine. An overview of the future of different digitizing wounds is explored in detail.

Introduction

The increasing burden of wound care is globally recognised. Many publications cite the rising economic costs and the rapidly increasing incidence of chronic wounds, and the impact that this has upon people and healthcare systems.1,2,3 Despite the increases in demand, the workforce required to deliver wound care is not expanding at the same rate; in fact, it appears to be contracting, driven by a global shortage of these professionals. Ousey et al. predicted a decline in the nursing workforce by 2016 due to reduced education commissions, attrition, rising retirements and net emigration of trained nurses.4 By 2020, 10% of community nursing posts in the UK were vacant.5 Given the mismatch between capacity and demand, it is vital to ensure that front line clinicians are provided with the correct tools to help manage these increasingly complex caseloads in as an efficient a manner as possible. Digital Wound Management Tools have the potential to achieve this.

Deciphering Wound Histories

I qualified as a Podiatrist in 2005, and still recall with a shudder being presented with a large volume of paper records for patients that I had to visit that day. The pressures on the service were such that I often did not know who I was going to visit in advance, giving little time for any forward planning, let alone working out the logistics of completing the round.

Obtaining simple information from nonstandardised assessments on crumpled sheets of paper was challenging and time-consuming.

I often found it hard to identify the key assessments that had been undertaken, and the resulting actions from them. Equally, deciphering the previous care plans to know what had been tried before, what worked, and equally what did not work was at times impossible. Fundamental questions such as how long the patient had the wound, what it looked like last week, last month and in some cases years before, took a long time to answer.

The deployment of Electronic Patient Records (EPR) had the potential to improve this by standardising the recording of wound assessments. In my view, many of the EPRs on the market use a primary care model of recording, where often singular interventions are recorded in free text boxes and templates that lack any form of validation.

This results in variation between clinicians in how and where things are recorded. If information is not in a consistent place, clinicians will have to hunt for it, potentially increasing the amount of time it will take them to get the information that they need. The secondary effect is that key data cannot be extracted for analysis of variables, such as healing rates.

Tracking the Wound

Wound dimensions are frequently used to determine the progression of a wound. Frequently, for lack of a better available method, paper rulers are used to obtain these measures, even though this can result in the over-estimation of the wound area by 40%.6

To highlight this, the United Kingdom and

35 Wound Masterclass - Vol 1 - September 2022
Mr Michael Oliver Programme Manager, Livewell Southwest Plymouth, United Kingdom

Uganda have similar land areas. The UK is approximately 1000km long and 500km wide on its longest axis.7 Uganda measures approximately 790km by 480km8. When the area of each country is estimated (length x width), the UK appears to be over 30% larger than Uganda; in reality, the UK is only 0.55% larger than Uganda.9

Given the variability of wound margins, and the high levels of intra-observer variability with wound measurement, it is easy to see how subtle changes in wound area could be missed, especially when the wound is attended to by multiple professionals.

I am not advocating that we teach clinical staff advanced mathematics to estimate wound areas, but provide them with digital tools to automate this process.

Beyond the Photograph

The need for digitizing wounds has not been lost on clinical staff. In the absence of a system, some resorted to using smartphones and digital cameras to take images of wounds, resulting in a variety of information governance headaches!

Even if the images obtained are downloaded and stored appropriately, clinical staff reviewing them must open, manipulate, and order images to judge progress, which is likely less efficient than working with paper records.

Although a paper ruler will often be included in the image, clinicians (likely hindered by varying lighting and wound orientation), still must note or memorise the dimensions from one image to the next to track healing.

An effective system needs to be capable of obtaining more than just a photograph of the wound; it needs to automate the process of assessment and measurement of key wound variables a consistent, reliable, and valid

manner.

What is crucial is that anything automated can be overridden if deemed to be inaccurate so as not to remove the clinical judgement of staff.

The UK National Wound Care Strategy Programme aims to eliminate unnecessary variation, and this is one of the ways that this can be achieved.10

Clinical Buy In

When implementing a digital wound management solution, the buy in from clinical staff is imperative. This type of solution cannot be simply taken out of the box and deployed. The culture of a team and organisation must change if it is to be used to its maximal effect.

My organisation adopted a digital wound management system in April 2020. Some early adopters of the solution became champions for the system, and through push or pull, they have enabled their teams to start to use the solution and see its benefits. Without this buy in, I would not be able to write this editorial!

Standardizing Assessments

Digital solution must allow for the download of data from every assessment that a clinician undertakes. The reliability of this will be facilitated by a standardized, linear assessment flow that makes it obvious where data should be recorded.

Dashboard-style information at wound level will provide the clinician with a series of aligned photographs, progress charts and assessment notes in one place, making the process of working out the status of the wound more efficient, giving some time back to put into either direct patient care, or perhaps allowing the clinician to take the break that they often do not have time for.

36 Wound Masterclass - Vol 1 - September 2022
“What is crucial is that anything automated can be overridden if deemed to be inaccurate so as not to remove the clinical judgement of staff.”
Digitizing the Future of Wounds: What Are the Challenges?

“Early evidence suggests that the solution is supporting a different skill mix, where we can provide one fewer ‘senior’ visit to every three visits from a junior member of staff... the objective is not to remove senior posts, but to ensure that their time is used effectively.”

At a more strategic level, simple questions, such as wound time, recurrences rates, etc., can be obtained with ease, accuracy, and reliability, in ways that are either impossible or complicated, currently.

In my experience, clinicians do not like collecting data for the sake of collecting it, especially if the collection of this data adds additional time pressures onto their already pressured day. There does, however, need to be a balance of recording of data pertinent to the assessment, and data that will support the wider analysis of data from the entire caseload. The ethos we have adopted is that this data needs to be turned into information that can drive decision making from front line to strategic levels.

Day to Day Use of Data

Clinical oversight of caseloads is more important now that it has ever been. The changing staff profiles in services has left potential gaps in skills and knowledge at more senior clinical levels, leaving a smaller pool of clinicians overseeing increasingly larger and more complex caseloads of people with wounds.

The time of these staff is more of a commodity, and needs to be used in an effective manner, given the size and varying geographic areas that organisations serve. Skill mixing within workforces means that care is often provided by assistant/ associate level staff, who follow care plans developed by registered staff.

If a member of staff spots that a wound’s characteristics have changed, they will require the support of a more senior clinician to review the care plan. The availability of senior staff might mean that this review could take days (if not longer) to happen. The patient however needs that input now to potentially prevent further deterioration.

Digital Wound Management facilitates this. As soon as an image of the wound is captured, the senior clinician can view the image and may be able to provide advice and guidance there and then; this may make an additional visit from them unnecessary. In some cases, the advice may be to continue the care plan. It is incredibly frustrating for the senior clinician to have spent an hour or more travelling and not actually need to do anything - it is not a good use of their time.

The roll out of our digital solution is still underway, but early evidence suggests that the solution is supporting a different skill mix, where we can provide one fewer ‘senior’ visit to every three visits from a junior member of staff, releasing significant amounts of time that can be used more effectively. The objective is not to remove senior posts, but to ensure that their time is used effectively.

As discussed, changes to wound area can be hard to spot over periods of time. The data that our clinicians record at each assessment is downloaded and used to identify people who have been seen in the previous week, have wounds that are increasing at an average of 10% by area per week, have a pain score of 7 (quality of life is as important as healing rate) or more, or have developed a new infection.

This is currently a crude model, but identifies about 15 - 20% of people seen in the last week that need to have a review. This helps our senior clinicians identify those in most need of their time. From a patient perspective, we have anecdotal evidence of this supporting expedited referrals into Vascular Services and getting people onto the right pathway where the original diagnosis of wound aetiology may not have been correct. In other cases, this will support a visit from a senior clinician to provide further assessment, and hopefully stabilise and get the patient onto a healing trajectory.

Challenges? Wound Masterclass - Vol 1 - September 2022 37
Digitizing the Future of Wounds: What Are the

Research Opportunities

I have always felt that many research studies are limited by small sample sizes and can only follow people over relatively short periods of time. It is difficult and expensive to put together large studies, find suitable populations, and then get clinicians to collect the data.

Clinical staff have an eye for what could work and what does not. What they often lack are the tools and the time to prove it one way or another. We now have the potential to use the data from our digital wound management solutions to support research, audit, and quality assurance reviews. The standardised assessment flows will ensure that the data is available and issues relating to inter/ intra-user variability in measurement will be eliminated.

In the longer term, machine learning techniques could be applied to these large data sets. This will not only tell us how much of a variable is present, but it may also tell us which are the variables that we need to have the greatest affect upon to change the outcome for the patient, giving us insights that may be difficult to spot in small samples using standard statistical analysis.

References

1. Sen CK. Human Wounds and Its Burden: An Updated Compendium of Estimates. Adv Wound Care (New Rochelle). 2019 Feb 1;8(2):39-48. doi: 10.1089/wound.2019.0946. Epub 2019 Feb 13. PMID: 30809421; PMCID: PMC6389759.

2. Guest JF, Fuller GW, Vowden P. Cohort study evaluating the burden of wounds to the UK’s National Health Service in 2017/2018: update from 2012/2013. BMJ Open. 2020 Dec 22;10(12):e045253. doi: 10.1136/bmjopen-2020-045253. PMID: 33371051; PMCID: PMC7757484.

3. Martinengo L, Olsson M, Bajpai R, Soljak M, Upton Z, Schmidtchen A, Car J, Järbrink K. Prevalence of chronic wounds in the general population: systematic review and meta-analysis of observational studies. Ann Epidemiol. 2019 Jan;29:8-15. doi: 10.1016/j. annepidem.2018.10.005. Epub 2018 Nov 12. PMID: 30497932.

4. Ousey, Karen, Stephenson, John, Barrett, Simon, King, Brenda, Morton, Nicky, Fenwick, Kim and Carr, Caryn (2013) Wound care in five English NHS Trusts: Results of a survey. Wounds UK, 9 (4). pp. 20-28. ISSN 1746-6814

5. NHS Benchmarking Network-Deep dive report for Community / District Nursing. June 2020

Conclusion

The delivery of wound care is challenging across the globe, and despite differences in the way that services are commissioned and funded, the availability of appropriately qualified staff to manage these increasingly complex caseloads is diminishing. Digital Wound Management will help overcome this by providing tools that can pro-actively manage caseloads based on real time, reliable data and reduce variations in practice. This will help to ensure that a person with a wound gets the right care, at the right time, from the right professional.

Organisations need to move from reactive ways of managing caseloads to proactive methods, that identify the people with the variables that are predictive of a poor outcome and ensure that they receive the skills and expertise of highly experienced staff to optimise their care plans and put them onto the right trajectory.

A significant amount of time and effort is required to deliver a digital wound management system, but the potential benefits of this effort are enormous, and will only benefit people with wounds and those who provide care for them.

6. Rogers LC, Bevilacqua NJ, Armstrong DG, Andros G. Digital Planimetry Results in More Accurate Wound Measurements: A Comparison to Standard Ruler

EXTENT.html [Accessed 20 July 2022]

9. Worldometers.info. 2022. Largest Countries in the World by Area - Worldometer. [online] Available at: <https://www.worldometers.info/geography/largest-countries-in-the-world/> [Accessed 20 July 2022]

10. AHSN Network. 2022. National Wound Care Strategy Programme - AHSN Network. [online] Available at: <https://www.ahsnnetwork.com/about-academic-health-sciencenetworks/national-programmes-priorities/national-wound-care-strategy-programme> [Accessed 20 July 2022].

Measurements. Journal of Diabetes Science and Technology. 2010;4(4):799-802. doi:10.1177/193229681000400405 7. Encyclopaedia Britannica. 2022. United Kingdom | History, Population, Map, Flag, Capital, & Facts. [online] Available at: <https://www.britannica.com/place/United-Kingdom> [Accessed 20 July 2022]. 8. Nationsencyclopedia.com. 2022. Location, size, and extent - Uganda - area. [online] Available at: <https://www.nationsencyclopedia.com/Africa/Uganda-LOCATION-SIZE-AND-
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“The potential benefits of this effort are enormous, and will only benefit people with wounds and those who provide care for them.”
Digitizing the Future of Wounds: What Are the Challenges?

September - October 2022

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