R. Gunter1,3, J. Wiseman1, S. Fernandes-Taylor1, Y. Ma2, S. Saha2, S. Clarkson3, D. Yamanouchi4, K. C. Kent1,3 1University Of Wisconsin,Wisconsin Institute Of Surgical Outcomes Research,Madison, WI, USA 2University Of Wisconsin,Department Of Biostatistics,Madison, WI, USA 3University Of Wisconsin,Department Of Surgery,Madison, WI, USA 4University Of Wisconsin,Department Of Surgery, Division Of Vascular Surgery,Madison, WI, USA
Introduction
Surgical site infection (SSI) is the most common nosocomial infection and reason for readmission in surgical patients, particularly in vascular surgery patients who experience the highest readmission rate for surgical populations. Technology-based transitional care that allows digital image-based wound monitoring has the potential to detect and facilitate treatment of SSI at an early stage. We undertake a study to validate the use of smartphone digital photography to evaluate postoperative vascular surgery wounds.
Methods
We developed a wound assessment checklist using previously validated criteria. All patients 18 and older who underwent a vascular surgery procedure involving a surgical incision at least 3cm in size between May and December 2014 were recruited from a high-volume tertiary-care academic vascular surgery service. Vascular surgery attending surgeons, physician assistants, nurse practitioners, and registered nurses evaluated wounds using the assessment checklist in-person; a different group of providers evaluated the wound via a Smartphone digital photograph. Inter-rater reliability for (1) wound assessment and (2) treatment plan was measured using Gwet’s Agreement Coefficient (AC) for the in-person group, the photograph group, and between groups. We used 1000 bootstrap samples with replacement to calculate 95% CI of Gwet’s AC; the samples were drawn by wound.
Results
We assessed 80 wounds (23 lower extremity wounds, 20 groin wounds, 18 abdominal wounds, 10 neck wounds, 5 upper extremity wounds, and 4 amputation stumps) in-person with a median 2 raters per wound (minimum of 1 rater and maximum of 4 raters), and via photograph with 9 raters per wound. Agreement between in-person and image-based assessments was high with respect to course of treatment with substantial agreement for antibiotics (AC=0.76) and need for debridement (AC=0.89). Relative to in-person raters, raters evaluating high-quality images were more likely to detect redness (OR=2.23, p<0.001), drainage (OR=2.1, p<0.01), and indicate the need for an ED visit (OR=6.42, p<0.001). Raters evaluating low-quality images were more likely to indicate the need for an ED visit (OR=5.69, p<0.001), but less likely to detect drainage (OR 0.13, p=0.005), than in-person raters. Less experienced clinicians were more likely to indicate the presence of ecchymosis (OR=1.47, p=0.03), more likely to indicate a need for wound drainage (OR=1.89, p=0.03), and less likely to suggest surgical debridement (OR=0.51, p=0.03).
Conclusions
Smartphone digital photography is a valid method for evaluating postoperative vascular surgery wounds that is comparable to in-person evaluation across most domains of wound abnormality. The inter-rater reliability for determining treatment recommendations was universally high. Remote wound monitoring and assessment may play an integral role in future transitional care models to decrease readmission for SSI in vascular surgery patients.