Implementing remote monitoring of surgical wounds using smartphones

Wound infections are one of the most common complications patients experience after surgery.

Most can be dealt with using tablet antibiotics, but if not caught early enough, these can develop into severe infections which require treatment in hospital. Early identification and treatment of infections gives the best chance of ensuring severe infections do not happen.

Situation

Patients often must self-assess their wound and make an educated guess on who to seek help from should there be a problem (e.g. their GP or an emergency department). With increasing access to smartphones across the population, wound monitoring and patient support can be provided directly after patients have been discharged home.

Aspiration

NHS Lothian wanted to explore the use of smartphones to help monitor wounds remotely, and to detect potential wound infections sooner than the patient might have done alone. These patients would be directed to the appropriate service for assessment and management (e.g. to their GP or to hospital).

Solution

The Tracking Wound Infection with Smartphone Technology (TWIST) tool is an online form which allows patients to report key symptoms of wound infection and submit photographs of their surgical wound. These are reviewed by the clinical team who inform the patient if there are any signs of infection and if so, what the patient should do next.

Patients can complete this online form anytime in the 30 days after surgery but are also encouraged to do so routinely (currently receiving a reminder every 3 days), even if they have no wound concerns.

This tool is hosted on the ISLA platform (ISLA Care Ltd), which provides secure cloud storage where clinicians can receive, review and store online questionnaires and image and video files directly from patients. The ISLA platform can be accessed from any device which has an internet connection.

Impact

NHS Lothian is a large health board in Scotland, serving a mixed urban and rural population of over 800,000 with two tertiary hospitals and 125 GP practices.

This form of wound monitoring has been found to have 4 main benefits for patients in NHS Lothian within the context of a randomised control trial of approximately 500 patients:

• Wound infections were diagnosed earlier - more patients with infections were diagnosed in the first 7 days after surgery, compared to routine care (67% [n=14/21] vs 35% [n=7/20]).
• Fewer people needed to use healthcare services – GP attendances were almost halved (11% [n=25/223] vs 18% [n=49/269]), without increasing hospital attendances (3% [n=7/223] vs 4% [n=11/269]).
• More people who needed readmission attended emergency hospital services – for those who attended emergency services, 71% (n=5/7) needed re-admission, compared to 27% (n=3/11) in routine care.
• Patients reported more a positive experience – overall they found it easier (58% [n=65] vs 43% [n=48]) and faster (60% [n=54] vs 40% [n=36]) to access care, and felt they got better-quality advice (58% [n=77] vs 42% [n=55]).

Functionality

The cloud-based ISLA platform:

• Hosts patient-specific forms which are accessed via an online link, rather than requiring an app to be downloaded.
• Works on all devices with an internet connection and avoids local storage of patient data on personal devices.
• Allows patient and clinician upload of questionnaires and visual data (videos and photos).
• Can be integrated into hospital and community patient records using through HL7 or FHIR interfaces as well as through direct supplier integrations. This allows patient details to be automatically populated on the ISLA platform and allows information within ISLA to be automatically pushed back to the EPR.

Capabilities

• Longitudinal follow-up of patient wounds can be conducted, and the record accessed by primary and secondary care.
• Requests to patients to submit a response can be scheduled in advance (with reminders).
• Machine learning can be integrated, for example to detect image blur and automatically request a new photo submission.
• Extracts of the record showing the wound at the point of discharge and bespoke clinical advice can be securely emailed to the patient
• Automatic notifications can be set for clinical teams to review the submitted response.
• Text messages are fully configurable and can be sent in multiple languages. Multi-language support is currently being added to the platform to support the full patient flow.

Scope

The cloud-based ISLA platform:

• Can be used across primary and secondary care settings.
• Can be applied to other use cases (not limited to monitoring for wound infection).

Key learning points

• Routine reminders were appreciated by patients to help prompt them to respond.
• There must be engagement from primary as well as secondary healthcare providers for postoperative care.
• The ISLA platform should ideally be integrated into the electronic patient record.
• There must be consideration on the burden on staff to review in a timely manner when outside of a research context.
• Training/support must be available for staff and patients who require (provided by ISLA care Ltd).

Digital equalities

The TWIST solution should be viewed as a supplement rather than a replacement to clinical services – general practice and NHS 111 triage services remain available to all patients irrespective of their digital access or literacy.

Furthermore, the ISLA platform allows the online form to be accessed using any device which has an internet connection rather than requiring all patients to have smartphones.

Key figures and quotes

“It would have been very tricky for me to say I think I have an infection, and I would probably not have done anything about it. It maybe would have gone slightly further down the line; it might have gone a couple days … I ultimately would have noticed [the infection] but … it could have been I ended up back in hospital, I don’t know.”

Wendy Langlands, patient participant

“The [early post-discharge period] often does generate quite a few questions or little bits of uncertainty with surgical site infections, actually the people that you want to manage those are surgeons or people involved in a surgical team and actually having that ease of access would definitely facilitate that.”

Dr Luke Daines, General Practitioner, NHS Lothian

Find out more

Publication: Remote diagnosis of surgical-site infection using a mobile digital intervention: a randomised controlled trial in emergency surgery patients

Television coverage

Key contact

Dr Kenneth McLean, Clinical Research Fellow at NHS Lothian and TWIST Trial Coordinator

k.a.mclean@ed.ac.uk

Professor Ewen Harrison, Consultant Surgeon at NHS Lothian and TWIST Chief Investigator

ewen.harrison@ed.ac.uk

Mr Peter Hansell, Cofounder ISLA Care Ltd. 

pete@islacare.co.uk