Implementation of a successful electronic wound documentation system in rural Victoria, Australia: a subject of collaboration and community engagement

Telehealth-guided provider-to-provider communication to improve rural health: A systematic review

INTRODUCTION

Telehealth may address healthcare disparities for rural populations. This systematic review assesses the use, effectiveness, and implementation of telehealth-supported provider-to-provider collaboration to improve rural healthcare.

METHODS

We searched Ovid MEDLINE®, CINAHL®, EMBASE, and Cochrane CENTRAL from 1 January 2010 to 12 October 2021 for trials and observational studies of rural provider-to-provider telehealth. Abstracts and full text were dual-reviewed. We assessed the risk of bias for individual studies and strength of evidence for studies with similar outcomes.

RESULTS

Seven studies of rural uptake of provider-to-provider telehealth documented increases over time but variability across geographic regions. In 97 effectiveness studies, outcomes were similar with rural provider-to-provider telehealth versus without for inpatient consultations, neonatal care, outpatient depression and diabetes, and emergency care. Better or similar results were reported for changes in rural clinician behavior, knowledge, confidence, and self-efficacy. Evidence was insufficient for other clinical uses and outcomes. Sixty-seven (67) evaluation and qualitative studies identified barriers and facilitators to implementing rural provider-to-provider telehealth. Success was linked to well-functioning technology, sufficient resources, and adequate payment. Barriers included lack of understanding of rural context and resources. Methodologic weaknesses of studies included less rigorous study designs and small samples.

DISCUSSION

Rural provider-to-provider telehealth produces similar or better results versus care without telehealth. Barriers to rural provider-to-provider telehealth implementation are common to practice change but include some specific to rural adaptation and adoption. Evidence gaps are partially due to studies that do not address differences in the groups compared or do not include sufficient sample sizes.

Wound Image Quality From a Mobile Health Tool for Home-Based Chronic Wound Management With Real-Time Quality Feedback: Randomized Feasibility Study

Background

Travel to clinics for chronic wound management is burdensome to patients. Remote assessment and management of wounds using mobile and telehealth approaches can reduce this burden and improve patient outcomes. An essential step in wound documentation is the capture of wound images, but poor image quality can have a negative influence on the reliability of the assessment. To date, no study has investigated the quality of remotely acquired wound images and whether these are suitable for wound self-management and telemedical interpretation of wound status.

Objective

Our goal was to develop a mobile health (mHealth) tool for the remote self-assessment of digital ulcers (DUs) in patients with systemic sclerosis (SSc). We aimed to define and validate objective measures for assessing the image quality, evaluate whether an automated feedback feature based on real-time assessment of image quality improves the overall quality of acquired wound images, and evaluate the feasibility of deploying the mHealth tool for home-based chronic wound self-monitoring by patients with SSc.

Methods

We developed an mHealth tool composed of a wound imaging and management app, a custom color reference sticker, and a smartphone holder. We introduced 2 objective image quality parameters based on the sharpness and presence of the color checker to assess the quality of the image during acquisition and enable a quality feedback mechanism in an advanced version of the app. We randomly assigned patients with SSc and DU to the 2 device groups (basic and feedback) to self-document their DU at home over 8 weeks. The color checker detection ratio (CCDR) and color checker sharpness (CCS) were compared between the 2 groups. We evaluated the feasibility of the mHealth tool by analyzing the usability feedback from questionnaires, user behavior and timings, and the overall quality of the wound images.

Results

A total of 21 patients were enrolled, of which 15 patients were included in the image quality analysis. The average CCDR was 0.96 (191/199) in the feedback group and 0.86 (158/183) in the basic group. The feedback group showed significantly higher (P<.001) CCS compared to the basic group. The usability questionnaire results showed that the majority of patients were satisfied with the tool, but could benefit from disease-specific adaptations. The median assessment duration was <50 seconds in all patients, indicating the mHealth tool was efficient to use and could be integrated into the daily routine of patients.

Conclusions

We developed an mHealth tool that enables patients with SSc to acquire good-quality DU images and demonstrated that it is feasible to deploy such an app in this patient group. The feedback mechanism improved the overall image quality. The introduced technical solutions consist of a further step towards reliable and trustworthy digital health for home-based self-management of wounds.

Implementation of sustainable complex interventions in health care services: the triple C model

BACKGROUND

The changing and evolving healthcare environment means organisations are under increasing pressure to deliver value-based, high quality care to patients through enabling access, reducing costs and improving outcomes. These factors result in an increased pressure to deliver efficient and beneficial interventions to improve patient care and support sustainability beyond the scope of the implementation of such interventions. Additionally, the literature highlights the importance of coordination, cooperation and working together across areas is critical to achieving implementation success. This paper discusses the development of a triple C model for implementation that supports sustainability of complex interventions in health care services.

METHODS

In order to develop the proposed implementation model, we adapted the formal tradition of theory building that is described in sociology. Firstly, we conducted a review of the literature on complex interventions and the available implementation models used to embed these interventions to identify the key aspects relating to successful implementation. Secondly, we devised a framework that encompassed these findings into a simple and workable model that can be easily embedded into everyday practice. This proposed model uses clear, systemic explanation, adds to the current knowledge in this area and is fit for purpose, providing healthcare workers with a simple easy-to-follow framework to embed practice change.

RESULTS

A three-stage implementation model was devised based on the findings of the literature and named the Triple C model (Consultation, Collaboration and Consolidation). The three stages are interconnected and overlap to support sustainability is considered at all levels of the project ensuring its greater success. This model considers the sustainability within any implementation project. Sustainability of interventions are a key consideration for continuous and successful change in any health care organisation. A set of criteria were developed for each of the three stages to support adaptability and sustainment of interventions are maintained throughout the life of the intervention.

CONCLUSION

Ensuring sustainability of interventions requires continuing effort and embedding the need for sustainability throughout all stages of an implementation project. The Triple C model offers a new approach for healthcare clinicians to support sustainability of organizational change.

Successful implementation of a medication safety program for Aboriginal Health Practitioners in rural Australia

OBJECTIVE

This study describes the development and implementation of a medication safety program for Aboriginal Health Practitioners practising in rural Australia.

DESIGN

A two-stage process was used to develop and implement the medication safety program. Initially, a total of eight semi-structured interviews was undertaken with Aboriginal Health Practitioners to identify the main challenges faced while implementing medication safety in the organisation. This was followed by the development of a culturally appropriate medication safety program.

SETTING

Aboriginal Community Controlled Health Service.

PARTICIPANTS

Aboriginal Health Practitioners.

MAIN OUTCOME MEASURE

The participants' knowledge, confidence, behaviour, and utilisation of medication safety developed resources.

RESULTS

The development and implementation of the medication safety program in the Aboriginal Community Controlled Health Service consisted of addressing the barriers to medication safety cited by the Aboriginal Health Practitioner from the interviews, providing face-to-face educational sessions and developing a culturally appropriate educational resource to address the identified gaps. The program developed was evaluated by 17 Aboriginal Health Practitioners who took part in the study. The evaluation of Aboriginal Health Practitioners' knowledge, confidence, behaviour, utilisation of the medication safety program and resources was undertaken using an anonymous survey. A total of 31 participants completed the survey: 17 before the training and 14 at 6 months post-training. The data analysis, using t test, revealed a statistically significant change in the Aboriginal Health Practitioners' knowledge, confidence, behaviour and utilisation.

CONCLUSION

The success of the implementation of a collaborative medication safety program within the Aboriginal Community Controlled Health Service is dependent on understanding the barriers to medication safety in the workplace associated within the organisation and emphasising a wide culture of patient safety.

The implementation of a successful medication safety program in a primary care

RATIONALE, AIMS, AND OBJECTIVES

Improving patient safety is now a government priority in many economically developed and underdeveloped countries. Various medication safety interventions and programs that have been described in the literature focus on hospital settings, and only very few studies report on the implementation of such interventions in primary care. The main objectives of this study were firstly to describe the steps involved for the successful implementation of a medication safety program in primary care in rural Australia and secondly to report on its evaluation and provide recommendations for future initiatives.

METHOD

The implementation of the medication safety program within the study organization included several steps, and these were as follows: collection of baseline medications incidents within the organization over the last 2 years, delivery of a medication safety training to clinicians working within the organization, formation of a medication safety group, and implementation of the newly developed medication safety guidelines within the organization. Clinicians' knowledge, behaviour, confidence, and satisfaction were also collected before and after the implementation.

RESULTS

The results show that medication safety training has improved clinicians' knowledge, confidence, behaviour, and utilization positively. There was a significant increase in the clinicians' confidence and satisfaction in applying the training to their daily practice (P value of 0.02). The implementation of the medication safety program across the study organization sites relied on 3 main stages. These were connect and communicate, collaboration, and consolidation. In the first stage of the project, we focused on identifying the key issues contributing to medication errors across the organization using an evidence-based approach to identify the types of medications errors.

CONCLUSION

The success of the implementation of a collaborative medication safety program within a large organization is dependent on emphasizing a wide culture of patient safety and understanding the medication incident reports within an organization.

District nurses' experiences of caring for leg ulcers in accordance with clinical guidelines: a grounded theory study

This qualitative study used the grounded theory method to investigate district nurses' experiences of caring for leg ulcers in accordance with clinical guidelines at seven primary health care centres in Stockholm, Sweden. Group interviews were conducted with 30 nurses. The results describe how district nurses strive to stay on track in order to follow clinical guidelines and remain motivated despite prolonged wound treatment and feelings of hopelessness. Three main obstacles to following the guidelines were found. District nurses used compensating strategies so the obstacles would not lead to negative consequences. If the compensating strategies were insufficient, perceived prolonged wound treatment and feelings of hopelessness could result. District nurses then used motivating strategies to overcome these feelings of hopelessness. Sometimes, despite the motivating strategies, treatment in accordance with guidelines could not be achieved. With some patients, district nurses had to compromise and follow the guidelines as far as possible.

Medications affecting healing: an evidence-based analysis

The purpose of this arm of the study was to investigate the impact of medication on healing times of the various wound types, including acute wounds and leg ulcers. A prospective longitudinal study design was used, with de-identified data collected using an electronic mobile wound care database system. Three main categories of data were collected, including patients' demographics, wounds types and treatment characteristics. For acute wounds, there was a total of 1732 patients with 2089 acute wounds. The average healing time was about 35 days. The only significant association was with chemotherapy, which increased healing time by 21 days (P = 0·048). There were non-significant trends towards reduced healing times with antibiotics (0·5 days; P = 0·853), anticoagulants (1·7 days, P = 0·673) and corticosteroids (4·98 days, P = 0·303). Non-steroidal anti-inflammatory drugs (NSAIDs) were associated with a non-significant increase in healing time (2·17 days, P = 0·707). For leg ulcers, there was a total of 264 patients with 370 leg ulcers. We only examined the impact of antibiotics, anticoagulants, corticosteroids and NSAIDs on healing times as they had an adequate number of wounds to analyse. The average healing times of leg ulcers were found to be 73 days. None of the classes of medications had any significant impact on healing time. Both anticoagulants and NSAIDs increased healing time by (22·5 days, P = 0·08) and (12·5 days, P = 0·03), respectively. On the other hand, antibiotics and corticosteroids decreased healing times non-significantly by (9·1 days, P = 0·33) and (21·6 days, P = 0·84), respectively.

Elements affecting wound healing time: An evidence based analysis

The purpose of this study was to identify the predominant client factors and comorbidities that affected the time taken for wounds to heal. A prospective study design used the Mobile Wound Care (MWC) database to capture and collate detailed medical histories, comorbidities, healing times and consumable costs for clients with wounds in Gippsland, Victoria. There were 3,726 wounds documented from 2,350 clients, so an average of 1.6 wounds per client. Half (49.6%) of all clients were females, indicating that there were no gender differences in terms of wound prevalence. The clients were primarily older people, with an average age of 64.3 years (ranging between 0.7 and 102.9 years). The majority of the wounds (56%) were acute and described as surgical, crush and trauma. The MWC database categorized the elements that influenced wound healing into 3 groups--factors affecting healing (FAH), comorbidities, and medications known to affect wound healing. While there were a multitude of significant associations, multiple linear regression identified the following key elements: age over 65 years, obesity, nonadherence to treatment plan, peripheral vascular disease, specific wounds associated with pressure/friction/shear, confirmed infection, and cerebrovascular accident (stroke). Wound healing is a complex process that requires a thorough understanding of influencing elements to improve healing times.© 2015 by the Wound Healing Society.

Reduction in wound healing times, cost of consumables and number of visits treated through the implementation of an electronic wound care system in rural Australia

Globally, wound care costs the health care system 2-3% of the total expenditure on health, which equates to several billion dollars annually. To date, there are little data on the cost and healing rates of various wounds. This has been partly because of the difficulty in tracking wound management as the majority of wound care data has been focused on retrospective data from hospitals, general practice clinics and aged care facilities. This study reports on wound healing and cost of wounds collected from a larger project using the mobile wound care (MWC) electronic documentation system, which has been described elsewhere. The study involved 2350 clients from four health service districts in the Gippsland region in rural Australia who received treatments as part of the MWC research project (2010-2012), with a total of 3726 wounds identified (so an average of 1·6 wounds per client). By the end of the data collection period, 81% of these wounds had healed. A significant drop in healing time, cost of consumables and number of visits was found across the 3-year period.

Identifying wound prevalence using the Mobile Wound Care program

Measuring the prevalence of wounds within health care systems is a challenging and complex undertaking. This is often compounded by the clinicians' training, the availability of the required data to collect, incomplete documentation and lack of reporting of this type of data across the various health care settings. To date, there is little published data on wound prevalence across regions or states. This study aims to identify the number and types of wounds treated in the Gippsland area using the Mobile Wound Care (MWC™) program. The MWC program has enabled clinicians in Gippsland to collect data on wounds managed by district nurses from four health services. The main outcomes measured were patient characteristics, wound characteristics and treatment characteristics of wounds in Gippsland. These data create several clinical and research opportunities. The identification of predominant wound aetiologies in Gippsland provides a basis on which to determine a regional wound prospective and the impact of the regional epidemiology. Training that incorporates best practice guidelines can be tailored to the most prevalent wound types. Clinical pathways that encompass the Australian and New Zealand clinical practice guidelines for the management of venous leg ulcers can be introduced and the clinical and economical outcomes can be quantitatively measured. The MWC allows healing times (days) to be benchmarked both regionally and against established literature, for example, venous leg ulcers.

Implementation of a successful electronic wound documentation system in rural Victoria, Australia: a subject of collaboration and community engagement

To describe the steps needed for a successful implementation of an e-health programme (the Mobile Wound Care system) in rural Victoria, Australia and to provide recommendations for future e-health initiatives. Wound care is a major burden on the health care system. Optimal wound care was found to be impeded by issues that included the limited access to health care providers, incomplete and inconsistent documentation and limited access to expert review. This study trialled the use of a shared electronic wound reporting and imaging system in combination with an expert remote wound consultation service for the management of patients with chronic and acute wounds in Gippsland. The trial sites included four rural Home and Community Health Care providers. Considerable effort was put into designing a best practice e-health care programme. There was support from managers and clinicians at regional and local levels to address an area of health care considered a priority. Various issues contributing to the successful implementation of the wound care project were identified: the training model, quality of data collected, demands associated with multiple sites across a vast geographic region, computer access, hardware and computer literacy.