Teledermatology May Play a Role in Reducing Severity of Pressure Ulcers in Both Rural and Urban Settings

Introduction. Teledermatology is already thought to be a valuable tool for patients in rural areas due to their lack of easy access to specialty care providers. This study explored the benefit of teledermatology for bedridden patients living in both rural and urban areas. Methods. The following 4 studies were evaluated: 1) evaluation of conditions of 83 patients who had developed pressure ulcers before being admitted to the hospital; 2) evaluation of the circumstances of 53 patients with pressure ulcers who received home care; 3) survey of 321 home care nurses regarding their concerns about wound care; and 4) results of a teledermatology system aiming at early intervention for chronic wound treatment. Results. 1) Sixty-three percent of patients who developed pressure ulcers were over 70 years old, 84% of them were bedridden, and 66% developed at home. 2) Seventy-four percent of patients who received home care and developed pressure ulcers lived alone or with an elderly spouse, and only 19% consulted a specialist. 3) A survey of 321 home care nurses revealed that they have difficulties with consulting a specialist, with their complaints against home care doctors amounting to 70% of their responses. 4) Seventeen consultations were sent to a new teledermatology system, 82% by patients, families, and home care nurses. About half of these patients were bedridden, and 82% were currently living at home. Twelve cases (70.6%) were from urban areas. Conclusion. Because of the potential for teledermatology to prevent the worsening of ulcers, teledermatological wound consultations should be utilized by all bedridden patients who have a wound.

  Teledermatology has been defined as the use of telecommunication and information technology to provide health services of dermatologic care to persons at some distance from a dermatological specialist.^1-3 The potential for telemedicine is clear in remote and inaccessible environments, such as Antarctica, where its implication has emphatically improved health care in this population by providing a crucial link to specialists.^3,4 While teledermatology has already been proven effective in rural areas, its ability to provide similar results in urban areas warrants exploration.

  This article evaluates the potential benefit of teledermatology for patients in urban home care settings, an area that is now seeing more pressure ulcer development than hospitals.⁵

  The following studies were investigated: 1) evaluation of conditions and circumstances (ie, age, setting where patients developed pressure ulcers, degree of self-help, risk assessment scale scores, and usage of mattresses) of 83 patients who had developed pressure ulcers before being admitted to the hospital; 2) evaluation of daily life of 53 patients who received home care and developed pressure ulcers; 3) survey of 321 home care nurses and home care managers, performed at the Fifth Nagasaki Pressure Ulcer Care and Management Congress in Omura City, Japan, regarding their worries about the care and treatment of pressure ulcers; and 4) results of the authors’ teledermatology system aiming at early intervention for pressure ulcers and chronic wound treatment.

  The authors created and managed a electronic medical consulting network to provide advice for patients. The system can be used by both medical professionals and layperson caregivers, including patients and their family members.

  When using the teledermatology system, patients or their caregivers send an image of the wound via e-mail. After images are received, 3 specialists in either plastic surgery or wound care review the images. The specialists are able to visually determine the existence of infection, necrotic tissue, pocket formation, inflammation, and the size of the wound from the provided photos. Based on this information, they are able to make a diagnosis, provide therapeutic recommendations, and advise the patient or caregiver about wound care and management. The system also allows the user to store and forward teledermatological e-consultations using asynchronous still digital images for evaluation.

  Presented here are the outcomes of consultations (ie, client, type of wounds, patient health status, and residence) using the authors’ teledermatology system. In the current study, patients were considered to be living in an urban area if they were within 10 km of the nearest dermatology clinic.

  Evaluation of conditions of patients who had developed pressure ulcers before being admitted to the hospital.Eighty-three patients (39 males, 44 females) who had developed pressure ulcers before being admitted to the author’s medical center (Nagasaki Medical Center, Nagasaki, Japan) were treated from January 2009 through December 2010. They ranged in age from 12-94 years (mean age 75.9 ± 12.3 years), with 63% over 70 years old (Figure 1). The settings where patients developed their pressure ulcers are shown in Figure 2. The most pressure ulcers (66%) developed at home. Patients’ degrees of self-help are presented in Figure 3. Eighty-four percent of them were bedridden. All patients were evaluated and classified using the OH scale for preventive measures against pressure ulcers, as described by Ohura and Horita.⁶ Patients’ physical status, including spontaneous body turning, sacral bony prominences, and edema and joint contraction, were checked and evaluated numerically.⁶ This risk-assessment scale indicates pressure ulcers will develop in less than 25% of patients with a low risk (risk score: 1-3 points), 26%-65% of patients with a moderate risk (risk score: 4-6 points), and more than 66% of patients with a high risk (risk score: 7-10 points).^6-8

  Risk-assessment scale scores in patients who developed pressure ulcers before being admitted to the hospital are shown in Figure 4. Although more than half of patients were classified into the moderate or high-risk groups, 89% of patients who developed pressure ulcers did not use a body pressure dispersion mattress as a preventive measure.

  Evaluation of daily life of 53 patients who received home care and developed pressure ulcers. According to companions, friends, or family members of patients who developed pressure ulcers while at home and were then admitted to the National Hospital Organization Nagasazki Medical Center, 74% of those patients lived alone or with an elderly spouse. Conferees of patients who developed pressure ulcers at home are shown in Figure 5. Only 19% of them consulted in-person with a wound specialist (ie, wound ostomy and continence nurse, dermatologist, or plastic surgeon). The authors felt these survey results supported the need for a teledermatology service.

  Survey of 321 home care nurses and home care managers regarding their concerns about the care and treatment of pressure ulcers (Figure 6).Questionnaires were provided to home care nurses and home care managers at the Fifth Nagasaki Pressure Ulcer and Management Congress, and 321 persons replied. According to survey results, home care nurses have difficulties with wound management because of a shortage of dressing materials as well as difficulty in doing a debridement procedure in the home setting, due to possible complications from localized anesthesia or postsurgical bleeding. The home care practitioners also indicated they did not receive proper training in debridement techniques.

  In addition, the survey respondents indicated they struggle with consulting specialists, either because of the absence of a wound care specialist or the unreliability of the specialist, and disagreements with the home care doctor. Their complaints against doctors accounted for 70% of all answers.

  Results of a teledermatology system aiming at early intervention for pressure ulcer treatment.Seventeen consultations were sent to the authors’ teledermatology system, and all cases were responded to. Fourteen (82%) of the 17 teledermatological consultations were requested by patients, family members, or home care nurses and managers. Physician-requested consultations comprised only 3 cases. Eight (47%) of the 17 patients were bedridden, and 14 (82%) were in home care. Three consultations were directed from a far district (more than 1,000 km from the authors’ medical center), and 2 consultations were directed from isolated islands. Another 12 cases (70.6%) were from relatively nearby urban areas in the same prefecture, within 100 km of the authors’ medical center).

  The Japanese population shows marked longevity; however, these elderly people are not always in good health,⁹ and may remain sick in bed for long periods, or experience weakness of the legs that forces them to use a wheelchair or cane. Elderly people do not always live with younger family members who can help with their care; the current study showed that 74% of patients who developed pressure ulcers at home lived alone or with an elderly partner (Figure 7). Even though elderly patients who were bedridden were at risk of developing pressure ulcers, preventive measures were not taken because of staff shortages and a lack of knowledge on the part of the patient about avoiding the development of a pressure ulcer. Many elderly patients in this study also found it difficult to visit a hospital because they are not able to drive, are not able to take public transportation, or do not have close family or friends who are able to take them to appointments, so, once a pressure ulcer develops an infection, it can worsen rapidly, and may lead to sepsis. Fujioka¹⁰ evaluated 18 patients who developed pressure ulcers with severe infection, and concluded they should have undergone earlier diagnosis and treatment using teledermatology.¹⁰

  Based on the results of the authors’ survey of home care nurses and managers, bedridden patients who live at home must receive visits from home care doctors or nurses, but most of these professionals specialize in internal medicine, not dermatological disorders. Thus, nurses sometimes had complaints related to the home care doctor’s treatment plan, such as that the plan was out-of-date or using an ineffective method. Home care nurses also had the added problem that they could not consult a specialist without obtaining a letter of introduction from the home care physician. In addition, the specialist would need to complete an in-person medical examination, thereby incurring the cost of such a consultation. (For the purposes of this study, the teleconsultation was provided free of charge.) This combination of factors may explain why complaints of home care nurses against doctors amounted to 70% of all answers in the survey used in this study (Figure 6). The survey results suggested that home care nurses and managers desire a free, easy-to-use, and reliable consultation system.

  In an effort to determine the reliability of teledermatology, Warshaw et al¹¹reviewed 78 studies and concluded the diagnostic accuracy of teledermatology is inferior to in-person dermatologic care, but that it may be superior to in-person dermatologic care provided by a non-dermatologist. The current study showed that 14 (82%) of the 17 teledermatological consultations were requested by patients, families, and home care nurses and managers, which suggested that they felt anxious about the treatments provided by their home care doctors. (Table 1).

  Among the consultations, 2 were from isolated islands, which demonstrated the known value of teleconsultation as a tool in rural areas where specialty services may not be available.^11,12 Three of the teledermatological consultations were receieved from further urban districts, which suggests that access to such a system broadens the geographical scope for which care can be given, even within the urban setting.

  Binder et al¹³ examined the feasibility of teledermatological monitoring for 45 patients with leg ulcers in cooperation with home care nurses and reported that 32 ulcers (71%) decreased in size. Among the wounds that decreased in size, 14 ulcers (31%) healed completely. They also concluded that the acceptance of teledermatological monitoring of wound care was very high by patients, home care nurses, and wound experts.¹³ This suggests that home care nursing, in combination with teledermatology, may help provide dermatological services without in-person access to a specialist.

  Teledermatological wound care is useful for all patients who cannot visit a clinic, as the consultation provides information to patients and families to help them manage wounds at home, thereby potentially preventing pressure ulcers, and avoiding the worsening of existing ones. These benefits can be seen regardless of the patient’s proximity to a clinic or hospital.

  The authors’ teledermatology system is incomplete, especially in the area of security of patients’ information and privacy. This teledermatology project was performed with good intentions, and patients’ images were kept exclusively on the computer at the National Hospital Organization Nagasaki Medical Center; however, the authors did correspond with patients via regular email without a special password or encryption. Moving forward, the authors plan to improve upon this deficit in security.

  The authors presented patient-centered teledermatology for bedridden patients with chronic wounds in Japan. Based on these preliminary findings, the authors conclude that teledermatological wound consultation has the potential to prevent the worsening of ulcers for patients who are bedridden at home, and offers increased safety and ease of treatment to patients and their families. These benefits can be received by bedridden patients with wounds in both rural and urban settings.

Kenji Hayashida, MD; and Chikako Senju, MD are from Department of Plastic and Reconstructive Surgery, National Hospital Organization Nagasaki Medical Center, Nagasaki, Japan. Masaki Fujioka, MD, PhD is from Department of Plastic and Reconstructive Surgery, National Hospital Organization Nagasaki Medical Center, Nagasaki, Japan and the Department of Plastic and Reconstructive Surgery, Nagasaki University, Nagasaki, Japan.

Address correspondence to:
Masaki Fujioka, MD, PhD
Director of Department of Plastic and Reconstructive Surgery
National Hospital Organization Nagasaki Medical Center
1001-1 Kubara 2 Ohmura City Japan
856-8562
mfujioka@nmc.hosp.go.jp

Disclosure: The authors disclose no financial or other conflicts of interest.