Off-site examinations reduce pressure ulcers

Atlanta center expands its care continuum

It’s a common routine: A staff nurse examines a recently discharged spinal cord patient to make sure his posture in the wheelchair isn’t putting him in danger of developing pressure ulcers. But this is no ordinary follow-up consultation. The difference is that the nurse,Susan Vesmarovich, RN, BSN, CRRN, is at the Shepherd Center in Atlanta, and the patient is 90 miles south in Macon, GA. 

This kind of scenario took place many times among the 45 participants in Shepherd’s pressure ulcer prevention telemedicine research project, which concluded recently. Shepherd Center, a specialty hospital providing care for spinal cord and traumatic brain injury patients, includes outpatient and subacute rehabilitation services in addition to inpatient rehabilitation. 

Shepherd began experimenting with telemedicine in 1995 as a way of serving patients whose lengths of stay were dramatically declining due to managed care, says Ann Temkin, MA, ACSW, manager of the telemedicine program. The study was funded by the Dole Foundation Funding Partnerships, based in Washington, DC. 

During the nine-month project, a third of the patients received interventions by telemedicine, a third received weekly telephone calls, and the control group was told to call Shepherd when they experienced any problems. Those in the telemedicine group were visited on a regular basis by an engineer who carried a portable telemedicine unit that was used to establish a link with a similar unit at Shepherd. 

None of the telemedicine study subjects had to return to Shepherd for any wound-related interventions, and only a couple of patients developed Stage I or Stage II pressure ulcers. In addition, Shepherd’s researchers discovered that telemedicine offered a range of benefits beyond the clinical examination, such as enabling the staff to evaluate the condition of patients’ homes and get a feel for family dynamics. 

In one case, clinicians at Shepherd modified a patient’s wheelchair after they noticed, through telemedicine images, that the patient’s posture in the chair put him at risk for developing pressure ulcers. 

Shepherd continues to use telemedicine and intends to expand its program significantly. 

Pressure ulcers are a particularly crucial concern with spinal cord injuries because they can quickly worsen to the point that surgery is necessary, which can boost the cost of care by tens of thousand of dollars and cause patients to remain on their stomachs for months. The purpose of the pressure ulcer prevention program was to catch ulcers in the early stages and refer patients for treatment if necessary. 

"Pressure ulcers are very frustrating to the patients because they take so long to heal. With telemedicine, we can bring up a picture of how the pressure ulcer looked a few weeks ago, and patients can actually see the healing process going on," says Temkin. Besides teaching patients to care for their wounds at home, she hopes telemedicine can help avoid surgery for patients who already have ulcers. 

At the technological heart of Shepherd’s telemedicine initiative was the Picasso Still Image Phone system, which was developed by AT&T, says Susan Vesmarovich, RN, BSN, CRRN, Shepherd’s telemedicine nurse coordinator. Picasso uses ordinary telephone lines to transmit audio and still images, which can be viewed on a small monitor that is integral to the Picasso unit, or on a television set or a computer monitor. Vesmarovich says the pictures are so clear she can see the pores in a patient’s skin. 

Shepherd owns five Picassos: one unit that remains at the hospital, two that a technician takes to patients’ homes in a 90-mile radius of Atlanta, and two that are installed in the homes of patients too far away from the hospital. Temkin would like to install Picassos routinely in patients’ homes for three to six weeks after discharge, then assign them to other newly discharged patients. 

"Our goal in telemedicine at Shepherd isn’t to be tied to one particular bandwidth, electronic device, or hardware, or to have exciting technology for its own sake," says Richard Burns, Shepherd’s telemedicine engineer. "We consider it linking people to people, and the choice of technology is what works best." 

"When people experience a catastrophic injury, they have an enormous amount to learn in order to live full lives in a new way. We are trying to continue our relationship with the patients after they are discharged to assist with the post-injury adjustment period," Temkin says. Because Shepherd is a specialty center, patients often travel from across the country to receive care; follow-up visits are therefore extremely difficult to make. 

"With the use of telemedicine, we hope to be able to move everything down the continuum of care so that what has traditionally been treated in outpatient clinics can be treated at home, and the more serious ulcers can be treated on an outpatient basis instead of requiring hospitalization and surgery," Temkin says. 

During the study, Burns transported the equipment to the patients. Trained caregivers were assigned to the two patients who had Picassos installed in their homes. At first, patients were skeptical when Burns arrived with a suitcase full of gear and took out the video camera. "Not everybody likes to be photographed, but when they saw the picture of the nurse and talked to her on the telephone, it all clicked," he says. 

Vesmarovich began each session by transmitting a picture of herself, then referred to a set of written questions as a guide to discuss what had been going on in the patient’s life that week. "Just by seeing them sit there I can tell what their mood is that day, how they interact with their caregivers, and what is going on in the household," Vesmarovich says. 

She had Burns shoot an overall picture of the patient, followed by images of areas where pressure ulcers are likely to occur. A typical session with the Picasso takes one to two hours — about the same amount of time required for a face-to-face assessment. 

Although the Picasso transmits only still photos, it can be used to shoot a rapid series of still images, a technique that might be used to analyze how a patient transfers into and out of a wheelchair.