Incorporating Telemedicine into a Surgical Practice

Incorporating Telemedicine into a Surgical recitationKristen HarkeyComplex s apprisedalises digest create a ch bo hencege for the unhurried of as healthy as the surgeon. The challenges faced involve operative give carry offment, cosmesis, coarse-term management, effects on lifestyle for patient of and guardianshipgiver, and self-image (Park, Copeland, Henry Barbul, 2010). Hospitalized patients depart constitute the operative team up, the displease c atomic number 18 specialist, and a bedside throw to worry them in their cursory care. When these patients are ready to leave the infirmary they keister feel anxiety about providing care for themselves, especially if they put one over a abstruse bruise present. This anxiety nominate slump once they learn how to care for themselves at stead dapple having the readily avail sufficient supplies, merely and then they moldiness leave their floors to get going to come to the operative comp matchlessnt for a b ruise check. This can be a heart and soul to non alone the patient but their primary caregiver. The subprogram of this paper is to introduce an evidence- found change vagabond that focuses on providing patients with the option of telemedicine office visits.BackgroundIn 2010, approximately 51.4 cardinal inpatient surgeries were performed in the US according to the national Center for considerablyness Statistics (CDC/NCHS, 2010). Wound complications can be an valu fit catch of operative morbidity pas bit a laparotomy (Mizeell, Sanfrey, Collins, 2014). Acute harm care is needed in all patients with surgical and traumatic shocks, when an incision is made this creates a injury which allow need yet attention. There are a deal of moods to address these contuses such(prenominal) as wet to wry dressings, dry packing strips, breach vac systems, and if needed barely surgical procedure such as a skin graft. These wounds can then constrain degenerative when they inge st failed to proceed through the reparative process to produce anatomic and functional uprightness in 12 weeks (Sen, 2009). Both acute and chronic wounds can become a significant fiscal burden on both the closelynesscare system and the patients themselves.SignificanceWith the sheer number of surgeries listed above, this depart create wounds that need to be managed appropriately. Not altogether are wounds created by surgery, they can also be created by trauma or capacious balmy tissue transmittings (Park, Copeland, Henry Barbul, 2010). Part of this management whitethorn be further surgical interventions to re memory board the fascia or maybe lively waiting. In our quickness in 2014, 3349 patients were evaluated by our wound care specialist. Of these 695 patients had surgically created wounds and approximately 656 were managed with wound vacs (G. Cald strong, personal communication, January 20, 2015). These patients allow for need to be followed in the outpatient settin g for ongoing wound assessments, possible change in wound management, or further surgical intervention if indicated. The outpatient care to these patients pass on hold discussions on proper nutrition to promote wound healing, activity trains, clock of dressing changes, and ongoing assessments of the wounds. It can create a significant burden to patient and caregiver to travel to office visits for ongoing assessment of the wounds which can take as little as ten to fifteen transactions to scrutinyine once they have arrived back to the exam room. This short office visit can create a significant burden to the patient and their caregiver, this burden can include ability to keep themselves clean passim the trip, financial, and while-strain.PICO Question and CompvirtuosontsEvidence-based practice (EBP) can be described as a life-long problem solving approach to clinical decision-making that involves the conscientious use of the crush operable evidence with ones own clinical exper tise and patient values and preferences to improve outcomes for persons, free radicals, communities, and systems (Melnyk Fineout-Overholt, 2011). EBP go away help to ensure racy timbre, safe, relevant, and up-to-date care while at the same time better patient outcomes (Robb Shellenbarger, 2014). iodin of the ways to create EBP in a way that allow for yield the most relevant in dression from a see is to form a question in the PICOT format. The PICOT format is composed of the following P exit describe the patient population, I allow for set off the intervention or issue of matter to, C depart reveal the comparing intervention or status, O ordaining reveal the outcome, and T will reveal the time frame in which the intervention/issue of interest will accomplish the outcome (Melnyk Fineout-Overholt, 2011). For the purpose of this paper, the author will include all components listed except for time which will be intercommunicate at an otherwise juncture.PopulationThe population of focus will be outpatient postoperative patients in the home health setting. The patient population will be those with acute/chronic wounds, ages eighteen and up, both male and female patients with no restrictions on ethnicity. The wounds will likely be compromised of Gordian group AB wounds, in time no limit will be placed on the quality/cause of the wound. The patients will live in join Carolina or southwestward Carolina and reside within a 4 hr drive from Charlotte, NC. No restrictions will be placed on the commission providing home health services to the patient.InterventionTelemedicine is defined by the realism Health Organization (WHO) to be the practice of health care victimization video, interactive audio, and/or data communications (Chanussot-Deprez Contreras-Ruiz, 2008). With the use of telemedicine the patients will be able to stay in their own home. This will also win an deepen team based approach because we will have both the patient, patient s caregiver if applicable, and the home health nurse. This will tolerate perfect documentation of wound measurements. The appropriate wound care will then be provided by the home health nurse, and if applicable the wound vac will be re-applied.ComparisonThe comparison group will be a measurement office visit. The stock office visit will lie down of the patient and their caregiver coming to our surgical practice, in one of our devil locations. The patient will be necessitated to wait for their grant time and wait as supplicated for the supplier to see them. If a wound vac is present, this will be re rund in the office and will not be re-applied per standard operating unconscious processs. The patient will have a temporary dressing replaced and will then need the home health nurse to come to their home upon their arrival to re-apply the wound vac. This consists of a standard office visit in our practice.OutcomeThe anticipated outcome, will be no effect on wound healing when victimization telemedicine. For the practitioner, one important aspect of examination of the wound is not only using your sense of sight but also your sense of smell. The smell of a wound can be indicative of necrotic tissue that rents further debridement or possibly a wound infection. This sense will be missing with telemedicine and the practitioner will need to rely heavily on the home health nurse for this aspect of assessment. Another outcome for this mull all over will be increased patient satisfaction. The patient with a complex abdominal wound may have obstacle at service line noteing adequate coverage for the drainage, this is more of a challenge when you add shop position changes associated with traveling to a health care suppliers office.In summary, a postoperative surgical patient will require care for the surgical wound in an outpatient setting. This care can be frustrating for the patient, the patients caregiver, and the home health nurse. With the amplificatio n of telemedicine to a surgical practice this will decrease the burden of traveling to a standard office visit as well as conjure multi-disciplinary care for the patient. It is the hope of the author that for complex wounds that tarry difficult to manage in the outpatient setting, the inpatient wound ostomy nurses who provided care inpatient will be able to assist more in the outpatient setting by providing doggedness of care.ConclusionWith every surgery performed a resultant wound is created. Wounds can also be created by trauma or massive necrotizing soft tissue infections (Park, Copeland, Henry Barbul, 2010). The surgical wound can heal without difficulty and the patient returns to his activities of daily living, however a multitude of wound complications can occur delaying wound healing. Some wound complications will require further surgery, however due to the nature of these wounds surgery may need to be delayed for up to one year or longer. This can cause caregiver strain and for the patient can take away many another(prenominal) of the freedoms we enjoy on a daily basis. As part of a standard office visit the patient is expected to arrange exile to our office, wait for his/her appointment time, have their wound examined, and then if a wound vac is used they are expected to have this re-applied when they get back to their home by the home health nurse. With the addition of telemedicine to the patients postoperative care, they would be able to have a multidisciplinary team visit them in the home using telemedicine imagerys. This would significantly decrease the burden travel can create for these patients with complex wounds.ReferencesCDC/NCHS National Hospital Discharge Survey (2010). Retrieved fromhttp//www.cdc.gov/nchs/data/nhds/4procedures/2010pro4_numberprocedureage.pdfChanussot-Deprez, C. Contreras-Ruiz, J. (2008). Telemedicine in wound care. InternationalWound diary, 5(5), 651-654.Melnyk, B. Fineout-Overholt, E. (2011). Evidence-based prac tice in care for healthcare A describe to best practice (2nd ed.). Philadelphia, PA Wolters KluwerLippincott Williams Wilkins.Mizell, J., Sanfrey, H., Collins, K. (2014). Complications of abdominal surgery. Retrievedfrom http//www.uptodate.com.Park, H., Copeland, C., Henry, S., Barbul, A. (2010). Complex wounds and theirmanagement. The Surgical Clinics of North America, 90(6), 1181-1194.doi 10.1016/j.suc.2010.08.001Rob, M., Shellenbarger, T. (2014). Strategies for searching and managing evidence-basedpractice resources. The Journal of Continuing Education in Nursing, 45(10), 461-466.Sen, C. K., Gordillo, G. M., Roy, S., Kirsner, R., Lambert, L., Hunt, T. K., Longaker, M. T.(2009). Human skin wounds A study and snowballing scourge to public health and theeconomy. Wound Repair Regeneration, 17(6), 763-771. doi10.1111/j.1524-475X.2009.00543.xIncorporating Telemedicine into a Surgical PracticeIncorporating Telemedicine into a Surgical PracticeKristen HarkeyImagine presenting t o the hospital for your planned ces theatre of operationsn section, a time of great anxiety and joy. During the procedure you unfortunately have a complication and an enterotomy (cut into the intestines) is made, but lost(p) at the time. Hours later you develop change magnitude abdominal pain and a rash spreads rapidly across your abdomen. Your healthcare providers explain you have an infection called necrotizing fasciitis and this requires further surgery to treat the condition. The individual then wakes up possibly weeks later with most of their abdominal wall, upper thigh skin, approximately brawniness layers missing of both the abdomen and thigh, as well as slew draining from the middle of the wound. The individual is informed they have an enterocutaneous fistula that will likely not be able to be repaired for several months to a year. This person is finally able to transition home with their newborn, a look abdominal wound, stool draining from the wound, not allowed to h ave anything to eat or drink, and are attached to intravenous nutrition twenty-four hours a day. This would be overwhelming for the most health literate patient, much less an individual with limited resources and low health literacy.Our health can change quickly with an unexpected surgery that causes a complex surgical wound. This wound essential be monitored closely in the outpatient setting to prevent further complications including firing of limb or possibly life. Typically the patients wound care has been provided in the home by a home health nurse. Subsequently the patient and family caregiver are then expected to travel to the doctors office for intermittent follow-up examinations of the wound over a weekly to monthly schedule which could last up to one year or more postoperatively. Leaving the patients home with these complex wounds can be a burden due to factors such as increased pain, time-consumption, financial monetary values, and possible embarrassment if the wound or ostomy appliance leaks. Some of this burden could be relieved with practical(prenominal) visits.Overview of problem of InterestIn the United States 6.5 million individuals are affected with chronic wounds that require ongoing care (Sen et al., 2009). Patients are expected to travel to their healthcare providers office for follow-up examinations and whatsoevertimes this requires a long care ride, wait in the office, and then travel home. It is difficult to maintain a dressing on the wound in the most base of circumstances, such as during times of everyday activity in their home. With the addition of traveling this can become an overwhelming and untidy endeavor while the healthcare provider will likely only spend minutes examining you. Due to this some(prenominal) patients will not come to their follow-up appointment and this can be detrimental to their health by prolonging wound healing, increasing risk for infection, and delay future surgical repairs. When the individual is at home, they require home health services for ongoing wound care as well as provision of supplies. The home health nurse sees the patient on a more regular basis than the healthcare provider and will call the providers office with important changes they note. alas this process may take several phone calls which takes valuable time for the home health nurse and increases wait time for care of the patient.Most patients have an antepast that surgery will help them heal or cure their disease. Unfortunately approximately 22% of patients may experience moderate to complete postoperative disability (Shulman et al., 2015). Home health nursing will provide some relief for the patient and a multidisciplinary approach is necessary to manage complex treatment modalities (Wilkins, Lowery, Goldfarb, 2007). In Carolinas Medical Center Main in 2014, 3229 patients had wound care provided by our wound ostomy care nurse team and of those 820 were surgical patients (G. Caldwell, personal communication , January 25, 2015). These are many of the patients that require ongoing care in the outpatient setting to prevent further complications.In the United States (US) in 2000, forty million inpatient surgical procedures were performed and at that time the need for post-surgical wound care was sharply on the rise (Chittoria, 2012). In the US the derive of money spent on wound care, diminished quality of life, and the release of productivity for the individual and caregiver comes at a great cost to our society (Sen et al., 2009). Therefore it is in our best interest as providers to provide safe and effective care to our patients in the most convenient format for both the patient, caregiver, home health nurse, and the healthcare provider. criticism of Literature one(a) of the first steps to address a problem is reviewing evidence usable to support the proposed intervention. Virtual care is currently being used in many different programmes such as urgent care, psychiatric care provided in ERs, preventing readmissions in heart failure patients, and many other venues. The examination of acute and chronic wounds is one venue that has found success. In the plastic surgery population where visual exam is heavily relied upon for decision-making, telemedicine has been shown to have great potential. Gardiner and Hartzell (2012) performed a systematic review of twenty-nine articles. Twenty-eight of the articles state a benefit including improved access to expertise and cost lessening through conserving hospital resources and avoiding unnecessary transfers (Gardiner Hartzell, 2012). Wallace, Hussain, Khan and Wilson (2012) had similar findings in the fly off the handle population where they far-famed improved assessment and triage, avoidance of unnecessary transfers and a potential for health care savings when using realistic care. In the trauma population a 90% accuracy was noted in assessing traumatic plastic surgery injuries whether the practitioner was using beds ide visual exam or transmitted digital images (Gardiner Hartzell, 2012).Wilkins, Lowery, and Goldfarb (2007) used their initial investigation to hold back the feasibility of realistic wound care and then moved onward with performing a pilot study using a store and forward technique. At the time of initial referral the mean wound heighten area was noted to be 5.85 cm2. Using virtual care the authors noted in 58.2% of the wounds, the diagnosis or treatment plan was changed. This change in diagnosis or treatment plan resulted in an average decrease of 58% from the initial wound size over an average time period of 40.2 days. The authors went on to note 95.5% of patients found telemedicine consultation more convenient than traveling and 98.2% of patients were either satisfied or very satisfied with the care they received (Wilkins, Lowery, Goldfarb, 2007).An article published in 2014 by Kidholm, Dineseen, Dyrvig, Rasmussen, and Yderstraede was noted to be the largest and most compre hensive research honk to evaluate telemedicine effectiveness and be for patients with chronic diseases. The results revealed telehealth reduced mortality with an odds ratio of 0.54. Mortality in the control group was noted to be 8.3% while the intervention group was 4.6%. The authors also noted a 10.8% lower hospital admission rank in the intervention group with an odds ratio of 0.82 (Kidholm, Dinessen, Dyrvig, Rasmussen, Yderstraede, 2014).Telemedicine may be applied to many different aspects of medicine, but a benefit has been shown in the examination and long-term treatment of wounds (Wilkins, Lowery, Goldfarb, 2007). Telemedicine has been shown to satisfy both the clinician as well as the patient, while continuing to provide quality care. Therefore a solution to the burden of traveling to the doctors office, decreasing financial strain, decreasing caregiver strain, and improving access to care are all potential benefits of providing care using virtual visits.Purpose of tra mpThe purpose of incorporating telemedicine into our surgical practice is to provide our patients with the most economic high quality care in the most appropriate setting for the patient. A standard office visit consists of the patient traveling to our office, being evaluated by the checkup team, and then having to travel back to their home. This evidenced based honk will allow the patient to stay in their own home and have the providers visit them via a virtual visit. Upon discharge from the hospital the patient will be evaluated for inclusion into the virtual visit program. If the patient is determined to equip the criteria including living in NC, using Healthy at Home to provide home health services and have a complex surgical wound then an appointment will be made for the virtual visit. The home health nurse will proceed to the patients home at the assigned appointment time and use their pad for the visit. The provider will then join the home health nurse in the virtual set ting and the patients wound will be evaluated. Appropriate changes in the treatment plan for the wound will occur and the provider will assure all questions/concerns are addressed with the patient, caregiver, and home health nurse.One desired outcome for this design will be to maintain a high level of patient satisfaction, as we do in our office. As providers, we would like to provide more efficient care and this may be possible by having one provider performing postop visits virtually while another provider evaluates new consults in the office. It will be important for this project to provide the same level of care that we provide in the brick and mortar office, as well as following all current standards of care.Project managementThe facility where this project takes place is a Magnet facility. To receive this designation an organization mustiness prove they have several key characteristics including empirical outcomes as well as integrating evidenced based practice and research into useable and clinical processes (American Nurses Credentialing Center, 2014). An important goal for our organization this year will be to provide care in new ways, one of which will be providing more opportunities for our patients to experience virtual care. This innovative project is meant to assure that we are improving quality, enhancing value and dealing with the complexity of health care nowadays (Harris, Roussel, Walters, Dearman, 2011).Implementation TeamThe backbone of quality improvement work is the team and their teamwork (Ogrinc et al., 212). The team for this project will include individuals from different disciplines to ensure success. The author of this paper will serve as the operational lead on the project, assuring all aspects of the project are coordinated. Our administrative lead will be the practice manager for our outpatient sliding scale clinic. He will be able to assist the project in assuring we collect meaningful use standards as we do in the office , as well as building templates in our scheduling software, and facilitate changes in the organization. A management associate with the virtual care division will remain part of the team, as she has had past experience with implementing similar projects and has provided invaluable support. The adjoining member of the team will be a member of the IT discussion section and will assist the team in choosing the right technology/platform for this project. He will not only assist in the starting stages of this project but will be a constant resource for ongoing IT support. The administrator for the home health agency will be a member of this team, she will provide information regarding her organization and provide us with establishing workflow for the home health nurse. This will be an important step as this project is meant to provide multidisciplinary care, however it will not be beneficial for it to provide more efficiency for our team but not the home health team. The prexy of sur gery who also serves as the interim lead of the acute care surgery team, as well as the two surgeons who practice on the same service. This team will serve to bring virtual care visits to our surgical practice.Risk Management StrategyIt is important to examine every project to identify remote and internal items that either positively or negatively affect the project. One type of assessment that can be performed is the specialisms, weaknesses, opportunities, and threats abstract (SWOT analysis). During the SWOT analysis the system is fully examined from the clinical micro to the macrosystem perspective (Harris, Roussel, Walters, Dearman, 2011). For this project some strengths noted include other departments within the facility using virtual visits and a department dedicated to assisting new groups to use this technology. Another strength is the patients included in this project will remain in the ball-shaped ninety day postoperative fee which will not require reimbursement from insurance companies and keep the cost incurred limited. It is important to then examine some of the weaknesses which include removing a provider from an already overbooked clinic to participate in this project, the supernumerary cost of the technology, and surgical postoperative care has not been provided in this mood in our facility prior to this. When further evaluating opportunities associated with this project, the ability to be the only surgical providers providing care virtually will set this team unconnected and appeal to more consumers and home health agencies. Another opportunity would be to include all home health care providers in our area and obtain licensure to be able to provide virtual visits in South Carolina. Some threats to this project include newer technology that hasnt been tested, a beloved working relationship with the home health agency must be in place, and is it possible for the team to provide confidential care to our patients using virtual visit techn ology.Organizational praise ProcessInitially this project was approved at the departmental level later on multiple discussions with the chairman of surgery for the metro division of our healthcare system. Prior to proceeding to the IRB process, the facility requires launching of your proposal to the Nursing Scientific Advisory Council (NSAC). Once NSAC has evaluated a proposal fully and any revisions have been completed you may move forward with your submission to the IRB.Role of Information Technology in this ProjectInformation technology will play an integral part of this project. Although virtual visits are used throughout the hospital system, they have not been structured into the surgical practices within our system. This project will include an IT tech to assist in choosing the best platform to serve our patient population while being user friendly for our home health nursing colleagues. It will be important for our platform to work well with the technology available to th e home health nursing team. This will assure we are able to provide the best quality visit and address not only the providers needs, but also the home health team, patient, and caregiver. The project needs IT support for both the onsite provider as well as the home health team in the patients home.Plans for IRB ApprovalAn institutional review board (IRB) is a committee that is mandated by the National Research Act, Public Law 93-948 and is required in institutions that conduct biomedical or behavioral research that involves human subjects (Harris, Roussel, Walters, Dearman, 2011). IRB approval will be sought for this project using the Carolinas Healthcare Systems IRB. The submission type will be expedited. This approach was chosen because it is evidenced based research and poses minimal human risk to the participants (Chatham University). Prior to approval by the IRB this project must be submitted to the NSAC therefore this will be performed in September 2015. Once approval has bee n obtained by the NSAC the information will then be submitted to the IRB for approval, likely in November 2015. This letter can be reviewed in Appendix A of this paper.ReferencesAmerican Nurses Credentialing Center. (2014). Magnet model. Retrievedfromhttp//www.nursecredentialing.org/Magnet/ProgramOverview/New-Magnet-ModelChatham University. (n.d.). Institutional Review Board (IRB). Retrieved fromhttp//my.chatham.edu/tools/irb/Chittoria, R. (2012). Telemedicine for wound management. Indian Journal of Plastic mathematical process,45(2), 412-417.Gardiner, S., Hartzell, T. L. (2012). Telemedicine and plastic surgery A review of itsapplications, limitations and legal pitfalls. Journal of Plastic, Reconstructive Aesthetic Surgery JPRAS, 65(3), 4753. doi10.1016/j.bjps.2011.11.048Harris, J., Roussel, L., Walters, S., Dearman, C. (2011). Project planning and managementA guide for CNLs, DNPs, and nurse executives. Sandbury, MA Jones BartlettLearning.Kidholm, K., Dinesen, B., Dyrving., A, Rasmussen, B., Yderstraede, K. (2014). Results fromthe worlds largest telemedicine project-The whole system demonstrator. EWMA journal,14(1), 43-48.Ogrinc, G., Headrick, L., Moore, S., Barton, A., Dolansky, M., Madigosky,W. (2012).Fundamentals of health care improvement A guide to improving yourpatients care(2nded.). Oakbrook Terrace, IL The Joint way and the Institutefor Healthcare Improvement.Sen, C. K., Gordillo, G. M., Roy, S., Kirsner, R., Lambert, L., Hunt, T., . . . Longaker, M. T.(2009). Human skin wounds A major and snowballing threat to public health and theeconomy. Wound Repair and Regeneration, 17, 763-771.Shulman, M. A., Myles, P. S., Chan, M. V., McIlroy, D. R., Wallace, S., Ponsford, J. (2015).Measurement of Disability-free Survival after Surgery.Anesthesiology,122(3), 524-536.doi10.1097/ALN.0000000000000586Wallace, D., Hussain, A., Khan, N., Wilson, Y. (2012). A systematic review of the evidencefor telemedicine in trim back care With a UK perspective. Burns, 3 8, 465-480.Wilkins, E., Lowery, J, Goldfarb, S. (2007). Feasibility of virtual wound care A pilot study.Advances in Skin Wound Care, 20(5), 275-278.