The crystalline clarity with which smartphones can now capture images has been put to another innovative use: monitoring patients who’ve undergone emergency abdominal surgery for surgical-site infections (SSIs) and allowing physicians to diagnose them earlier in the postoperative period before they morph into a much bigger problem.
“Since the COVID-19 pandemic started, there have been big changes in how care after surgery is delivered,” Kenneth McLean, MBChB, University of Edinburgh, Scotland, observed in a statement.
“Patients and staff have become used to having remote consultations and we’ve shown we can effectively and safely monitor wounds after surgery while patients recover at home — this is likely to become the new normal,” he added.
“Recovery can be an anxious time for everybody and these approaches provide reassurance,” senior author Ewen Harrison, PhD, professor of surgery and data science, University of Edinburgh, Scotland, added in the same statement.
“We hope that picking up wound problems early can result in treatments that limit complications,” he added.
The study was published online November 18, 2021, in npj Digital Medicine.
TWIST Trial
A total of 492 patients were enrolled in the TWIST trial, the majority of whom had undergone major surgical procedures, almost three-quarters of them being done laparoscopically. Some 223 patients were randomized to the smartphone intervention, while the remaining 269 patients were randomized to routine care. Patients in the smartphone group were contacted on days 3, 7, and 15 postoperatively and directed to an online site where they were asked about their wound and any symptoms they were experiencing.
If symptomatic, they were then asked to take a picture of their wound and upload it to a secure website where a member of the surgical team would assess the photographs along with the patient’s responses for signs of wound infection. Patients were followed for 30 days after surgery to document whether they had subsequently been diagnosed with an SSI.
Routine-care patients were simply contacted 30 days after surgery to see whether or not they had been diagnosed with an infection. “Overall 8.3%…of the cohort developed surgical-site infections (SSI) in the 30-day postoperative period, with no significant difference in the SSI rate between the trial arms,” investigators report: at 9.4% in the smartphone arm and 7.4% in routine-care arm (P = .513).
However, the mean time-to-diagnosis of the SSI — the primary endpoint of the trial — was numerically shorter, at 9.3 days in the smartphone group versus 11.8 days in the routine-care group, although this difference again was not statistically significant. On the other hand, a post-hoc analysis showed that patients issued a smartphone were almost four times more likely to have their SSI diagnosed in the first 7 postoperative days, at an odds ratio (OR) of 3.7 (95% confidence interval [CI], 1.02 – 13.51; P = .043) compared with those assigned to routine care.
“These surgical wound infections typically worsen over time and can spread into the blood stream or deeper into the abdomen if left untreated,” McLean explained in an email to Medscape Medical News. “So if we can diagnose these infections before they become more pronounced, we can potentially avoid these more serious complications and the need for re-admissions.” The wound assessment tool also had a high negative predictive value — “meaning that an SSI could be ruled out with confidence,” as the authors stress.
Indeed, of the patients diagnosed with an SSI within the smartphone group, over one-third had used the tool 48 hours prior to diagnosis — five were diagnosed on the same day — and all of the infections that were identified were based on patient-reported symptoms. “Incorporation of wound images offered a significant improvement to specificity from 84.4% (95% CI, 80.5 – 88.3%) to 93.6% (95% CI, 90.9 – 96.2%),” the investigators add.
Researchers also compared the use of healthcare services between the two treatment groups. Overall, 14.3% of those who used a smartphone contacted a healthcare service — either community or hospital services — about their wound. This compared with 22.3% of patients in the routine-care group. Patients in the smartphone group also had 43% lower rates of needing community-care services, at an OR of 0.57 (95% CI, 0.34 – 0.94; P = .577), although their need for hospital emergency services was similar to that required by routine-care patients.
And in a comparison of the 30-day patient experience, those in the smartphone group reported significantly more positive experiences on all of the measures assessed, including access to care, ease of access to advice, and the quality of the advice received.
Some Did Not Use the Tool
The authors acknowledge that roughly one-third of those assigned to the smartphone assessment tool did not use the tool at all. However, as McLean pointed out, there will always be a proportion of patients who are less likely to use a service if they feel there’s no need for it — their wound was healing well, for example — so why bother? “Reassuringly,” he added, “there was no evidence that, for example, older patients with smartphones were less likely to use the tool,” he said.
The authors also pointed out that there are broader applications for the use of smartphones in the delivery of healthcare. For example, the remote follow-up approach could be expanded to encompass other potential complications after surgery. It could also be used to monitor chronic wounds like diabetic ulcers or other chronic conditions like asthma or chronic obstructive pulmonary disease.
“Delays to access to appropriate emergency healthcare, as well as unnecessary healthcare attendances, can lead to harm for patients and add more burden on healthcare services,” McLean said.
“By increasing the access of patients to advice, they are more likely to receive the right treatment at the right time and further work is currently underway to explore how they can be tailored to make [care] as accessible and inclusive as possible,” he added.
Rapid Adoption
Asked to comment on the findings, Josh Totty, MD, NIHR Clinical Lecturer in Plastic Surgery, Hull York Medical School, United Kingdom, noted that the way in which technology is used has changed significantly over the past 2 years.
“The rapid adoption of technology in healthcare, using powerful computers that the majority of people have access to in their pockets, has meant that patients and clinicians could be kept safe and risks reduced, productivity increased and patients have easier access to their clinicians,” he told Medscape Medical News in an email.
As we move on from the pandemic, Totty added, “we are constantly looking for ways of improving care that are acceptable to patients,” he said.
“And this study shows that smartphones might help diagnose significant infections earlier in the disease process. In turn, earlier treatment potentially leads to better outcomes and less morbidity as a result,” Totty added. He also said that the study was both important and well designed and adds to a growing body of evidence suggesting that smartphones have a crucial role to play in the way patients access healthcare.
And he emphasized, “Work now needs to be undertaken to ensure that everyone, young and old, wealthy or poor, has access to this technology.”
Npj Digital Med. Published online November 18, 2021. Full text
Totty and the study authors disclosed no relevant financial relationships.
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