Using Augmented Reality to Improve Patient Outcomes With Negative Pressure Wound Therapy

Digital technology is already immensely integrated within health care, but new innovations in this space could result in unconventional opportunities to improve patient outcomes. Augmented reality (AR), which is the enhancement of reality by virtual content, is one such innovation.¹ Augmented reality has many uses in health care, such as education, remote viewing, and hands-free imaging and/or data retrieval.² The AR device uses a heads-up display, which allows for information to be relayed and displayed in real time to the wearer via an Internet-connected device (Figure 1). The integrated cameras in the device enable the wearer to virtually livestream their point of view. The use of AR to virtually assess wounds has been found to have promising reliability.³

Negative pressure wound therapy (NPWT) is a wound care technique wherein an open-cell foam dressing is placed into the wound bed and controlled subatmospheric pressure is applied.⁴ The use of NPWT has been found to improve wound closure rates, shorten hospital stays, and decrease hospital readmissions.⁵ These benefits are sporadically hindered by technical or proficiency-related complications that typically arise when there is a deficiency in staff skill level needed to troubleshoot issues. This is noted most prominently when clinicians with advanced training are not readily available, such as at night and on weekends.

The purpose of this study was to determine whether the use of AR has the potential to improve outcomes in patients undergoing NPWT by means of decreasing the frequency and severity of complications that would result in failure of NPWT or premature dressing removal.

Patients

This case-control study consisted of convenience sampling via retrospective review of the electronic medical records of 27 patients in 1 rural hospital in Louisiana who underwent NPWT between January 1, 2020, and April 1, 2020 (control group [n = 15]) and between January 1, 2021, and April 1, 2021 (study group [n = 12]). Patients in the control group were identified via wound care records. This project was verbally explained to patients in the study group (or their legal representative), and verbal agreements to participate were obtained. Patient consent was sought out in accordance with the Declaration of Helsinki (adopted by the World Medical Association),⁶ and consent to the use of video or electronic device was obtained.

Study procedure

The patients in the study group were treated in the same manner as those in the control group and by the same wound care personnel. In the study group, however, the AR device (HoloLens 2; Microsoft Corp) was used during nights and/or weekends to address any complications that arose with the wound care therapy. When the bedside nurse identified complications, the nurse would don the AR headset, and the wound care personnel would connect remotely via computer. In this manner, the wound care personnel could audibly guide the bedside nurse through assessment of the dressing and provide visual cues to facilitate troubleshooting. These visual cues took multiple forms as the result of the nature of the AR device. The wound care personnel could upload reference photos into the nurse’s field of view, show the wound care clinician’s viewpoint (similar to that of a traditional video call), import a three-dimensional (3D) object that would help with visualizing anatomy, or guide the nurse by “drawing” directly on the patient in the 3D visual space (Figure 2).

Variables

The variables monitored in this study include the total NPWT days as well as the number of dressings performed, complications that arose, premature dressing removals, unplanned returns to the operating room (RTORs), and readmissions related to wound infection (Figure 3). Univariate analysis was performed using Excel (version 1808; Microsoft Corp).

Statistical significance was defined as P <.05. Analysis of variance (ANOVA) was performed between the control group and the study group showed a significant result (P =.002).⁶ Two-tailed t testing showed significance for the following variables: premature dressing removals (P =.01), readmissions related to wound infection (P =.004), and RTOR (P =.002). Two-tailed testing is significant if the correlation is less than or equal to .01.⁷

Correlational testing showed a significant correlation between the number of dressings performed and the number of complications that arose (0.71) as well as between premature dressing removals and number of readmissions related to infection (0.74). A score between 0.70 and 1.00 denotes a significant correlation.⁷

Nursing competency training with the AR device involved minimal time commitment (< 30 minutes), and none of the nurses who used AR noted barriers to its implementation. All bedside nurses who used the AR device to address complications reported increased comfort with the ability to manage advanced wound care modalities.

The visual cues that are possible in AR technology proved to be paramount in some cases. For example, during a dressing change in a challenging region (perineal), previous wound images were uploaded to familiarize the nurse before the dressing change was performed, and the wound care personnel used the 3D drawing capability to identify portions of the dressing that needed bolstering by flagging them within the nurse’s visual field. In another case, a 3D model of the NPWT device was imported so the nurse could virtually visualize which portions of the device to focus on before entering the room in which the patient was waiting.

Even though more dressings were performed in the study group, that group had fewer complications, premature dressing removals, and readmissions; in addition, the study group did not require further surgical interventions. However, there was no increase in rounding frequency within the study group; thus, these findings may suggest that the patients in the study group had positive outcomes related to AR use.

The noted correlation between premature dressing removals and readmissions may warrant further investigation. Determination of the contributing factors could help identify which cases would be at increased risk for failure of therapy.

The limitations of this study include an expectedly small sample size. Patient recruitment in wound care research is notoriously suboptimal, with no enablers to recruitment and a subsequent multitude of barriers.⁸

The collection of data from only 1 facility carries an inherent bias in population selection. This bias could also be compounded by the bias wrought by convenience sampling.

To avoid unexpected bias, the following variables were kept constant between the control group and the study group: relative time frames of patient care, the wound care clinician who performed assessments and dressing changes, wound care materials used, the surgeon, and the nursing staff involved. Although rounding frequency was not increased in the study group, it is difficult to ascertain whether the improvements in outcomes are solely related to the after-hours access to a wound care clinician.

The findings herein suggest that use of AR can positively influence patient outcomes when combined with NPWT, mainly via addressing barriers to a successful therapy course. Notably, use of AR appears to result in decreased readmissions and RTOR in this population. These results warrant further study to replicate the findings. Future research could be performed to assess whether use of AR with other advanced wound care modalities could be beneficial, potentially addressing barriers to their successful implementation. These beneficial findings also show the need to pursue further research on the use of AR technology with other advanced modalities or for other indications in the acute care setting

Authors: Richard Hill, MSN, APRN, FNP-C, CWCN, FACCWS

Affiliation: Natchitoches Regional Medical Center, Natchitoches, LA

Disclosure: Mr Hill serves as a paid consultant and is a member of the 3M Speaker’s Bureau.

Correspondence: Richard Hill, MSN, APRN, FNP-C, CWCN, FACCWS, Natchitoches Regional Medical Center, 501 Keyser Avenue, Natchitoches, LA 71457; hill.richardb@gmail.com