Project aims for far-reaching prevention

Telemedicine goal is preventing pressure ulcers

A staff nurse is examining a recently discharged spinal cord patient to make sure his wheelchair position isn’t putting him in danger of developing pressure ulcers.

It sounds like an ordinary follow-up consultation that practitioners perform every day, but the difference is that Susan Vesmarovich, RN, BSN, CRRN, is at the Shepherd Center in Atlanta, and the patient is 90 miles away in Macon, GA.

The patient is one of 45 participants in Shepherd’s pressure ulcer prevention research project using telemedicine. 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. (See related story, p. 28.)

During the nine-month project, one-third of the patients receive interventions by telemedicine, a third receive weekly telephone calls, and the control group is told to call Shepherd when they experience any problems.

The project is funded by the Washington, DC-based Dole Foundation. Shepherd is funding a similar project aimed at treating pressure ulcers via telemedicine which started at the same time.

For the project, Vesmarovich, Shepherd’s telemedicine nurse coordinator, uses a Picasso, a device developed by AT&T that transmits still images and audio across ordinary home telephone lines.

The easy-to-operate Picasso looks much like an ordinary telephone and uses an off-the-shelf camcorder that plugs into it. It includes a small monitor but also can be plugged into a television set. The images are so clear, Vesmarovich says she can see the pores in a patient’s skin.

Shepherd owns five Picassos: one unit that remains at the specialty hospital, two that are transported by a technician 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 and other patients to share a unit.

Shepherd began experimenting with tele-medicine in mid-1995 as a way of continuing to provide services to patients whose lengths of stay were dramatically declining, says Ann Temkin, MA, ACSW, manager of the telemedicine program.

"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 patient after they are discharged to assist with the post-injury adjustment period," Temkin says.

Because Shepherd is a specialty center, patients often come to the center from around the country, making it difficult for them to return for follow-up.

"With the two pilot studies, 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.

The prevention project’s aim is to catch pressure ulcers in the beginning stages and teach patients via Picasso to care for them at home. When the ulcers have already developed, Temkin hopes the patients can avoid surgery.

Among the statistics Shepherd is tracking are whether participants are hospitalized or have surgery for skin problems, whether they have outpatient treatment, what costs they incur, how much time they lose from work, and how much time their family members lose from work because of skin problems.

Avoiding surgery

Pressure ulcers are a particularly crucial concern with spinal cord injuries because they can quickly develop to the point that surgery is necessary, Temkin notes. Surgery and the ensuing hospitalization and care can cost as much as $50,000 and may mean that the patients must lie on their stomachs for as long as three months.

The purpose of the pressure ulcer prevention program is to catch pressure ulcers in the early stages and refer the patient for treatment.

For the pressure ulcer prevention program, which began last April, Vesmarovich has a weekly appointment, via telemedicine, with 15 patients to check their posture and their seating, and to answer any questions.

Protocols from the Rockville, MD-based Agency for Health Care Policy and Research (part of the U. S. Department of Health and Human Services Public Health Service Division) recommend that patients with wounds be monitored weekly. Wounds can take as long as nine months to heal properly.

Patients in Shepherd’s research project come in weekly part of the time and are observed with the Picasso part of the time.

"Pressure ulcers are very frustrating to the patients because they take so long to heal. With the Picasso, we can bring up a picture of how the pressure ulcer looked a few weeks ago and they can actually see the healing process going on," Temkin says.

Richard Burns, telemedicine engineer for Shepherd, transports the equipment to the patients and has trained caregivers for the two patients who have Picassos permanently installed in their homes.

At first, patients are skeptical when Burns arrives with his suitcase full of gear and takes out the video camera, he says. "Not everybody loves to be photographed, but when they see the picture of the nurse and talk to her on the telephone, it all clicks."

Vesmarovich begins each session by transmitting a picture of herself and then uses a written set of questions as a guide to discuss what has been going on in the patient’s life that week.

Vesmarovich has Burns shoot an overall picture of the patient and focus in on skin areas where pressure ulcers are likely to occur.

A typical session with the Picasso takes one to two hours, during which a tremendous exchange of information takes place, Burns says. This is about the same amount of time a face-to-face assessment would take.

Although the Picasso transmits only still photos captured from the videotape, Burns can shoot a rapid series of still images while the patient is transferring from a wheelchair. This enables Vesmarovich to observe how the patient is transferring.

"Just by seeing them sitting 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.

Although the purpose of the telemedicine intervention is to prevent or treat pressure ulcers, Vesmarovich has helped people in unexpected ways.

For instance, one patient was leaning against a leg rest without protecting her leg by padding.

"We might not have thought to ask about it on a telephone follow-up, and she could have developed a pressure ulcer before she came in for the eight-week check up," Temkin says.

When she saw another patient, who was still in a loaner wheelchair, Vesmarovich noticed his leg rests were uneven.

The Shepherd staff were able to coach the patient through an adjustment to the leg rests without having him travel two hours to a seating clinic.

Picassos cost about $4,000 each, but the cost doesn’t seem so high when compared with the cost of transporting a spinal cord patient 90 miles to Shepherd or sending out a home health nurse trained in caring for spinal cord patients, Temkin points out.

Temkin would like to have Picassos routinely installed in patients’ homes three to six weeks after discharge and then moved to another newly discharged person.

The research project will last nine months to give Shepherd an idea of exactly how long the Picasso is useful for patients.