Can a smartphone app help manage wounds in primary care?
Can a smartphone app help manage wounds in primary care?
Pavel S. Kulikov, MSN, Prabjot K. Sandhu, DNP (Professor), & Karen A. Van Leuven, DNP
Journal of the American Association of Nurse Practitioners
Background and purpose: Although wound care guidelines are available for primary care providers, barriers to assessment and treatment remain. This article examines current evidence supporting wound management, wound guidelines, and provider comfort with wound management in primary care and discusses the need for improved training, education, and the development of a simplified approach to wound management in primary care.
Methods:This review of evidence examines knowledge of wound care, wound curriculum, and the current availability of guidelines for health care providers at the frontlines.
Few primary care curriculums and institutions require wound careeducation. Access to guidelines, pathways, and educational resources is limited, which negatively effects primary care provider's knowledge and comfort level in treating wounds in current clinical practice.
Implications for practice: Educating the general practitioner on evidence-based wound management and providing adequate resources remain a priority. Increasing awareness of available electronic wound care applications (apps) can improve a timely wound careassessment, diagnosis, and initiation of treatment.
The geriatric population is expected to increase as the baby boomers' life span increases. The Centers for Disease Control (CDC) (2013) identifies that the American population aged 65 years and older will double over the next 25 years to reach approximately 72 million. This number will account for almost 20% of the U.S. population by 2030. Primary care offices and clinics will remain the main access point for health care for patients seeking care. As the population ages, the number of chronic diseases will also increase (CDC, 2013). There are a number of chronic conditions that give rise to chronic wounds. As of 2015, approximately 14% of all adults, aged 18–64 years, have 2–3 chronic health conditions (CDC, 2016). Chronic diseases are considered the most preventable form of disease yet remain the most costly to treat (CDC, 2013). The most common chronic conditions include heart disease, diabetes, obesity, stroke, and arthritis (CDC, 2013). As of 2014, the percentage of obese adults, aged 20 years and older, surpassed 37% of the U.S. population (CDC, 2016). The prevalence of diabetes is approximately 12% of the U.S. population (CDC, 2016) and the American Diabetes Association (ADA) (2015), approximates that 30 million Americans have diabetes, but at least 7.2 million are still undiagnosed. For those aged 65 years and older, the rates of diabetes are approximately 25.2% (ADA, 2015).
Diabetes and obesity could lead to complications including chronic wounds, and patients will present with these complications to primary care providers. Chronic wounds are defined as wounds, which have failed to proceed through an orderly and timely reparative process to produce anatomic and functional integrity of the injured site (Sen et al., 2009). These include diabetic ulcers, venous ulcers, arterial ulcers, and pressure ulcers. Currently, chronic woundsaffect 6.5 million patients in the United States. (Sen et al., 2009). The American College of Foot and Ankle Surgeons (ACFAS) (2017) projects that 15 percent of diabetic patients will develop a foot ulcer during their lifetime. ACFAS (2017) apprises the pathology of the diabetic ulcer to pressure that goes unnoticed related to sensory neuropathy, not always a direct result from trauma or injury to the foot. Pressure sites can cause calluses, and without attention, the callous may progress into an ulcer. Poor vascular function in diabetes impedes healing, and the wound, if left untreated, can become infected (ACFAS, 2017). Venous ulcers, which result from compromised circulation resulting from diabetes or heart disease, account for approximately 70% of all leg ulcers and affect 2.2 million Americans annually (Alavai et al., 2016). Over a 10-year period, recurrence of leg ulcers remains high at 50% (O'Donnell et al., 2014).
There is a significant economic burden of treating chronic wounds because up to 25 billion dollars are spent on wound care annually (Sen et al., 2009). The increase in cost is attributed to the aging population and a sharp increase in diabetes and obesity worldwide (Sen et al., 2009). More than half of all foot ulcers will become infected, and 25% of those will require an amputation ACFAS (2017). Eighty percent of documented nontraumatic amputations are a result of diabetes (ACFAS, 2017). For chronic wounds that need amputation, the cost of care can be as high as $52,000 per patient annually, estimated from 12 visits to the outpatient provider and 2 hospitalizations (Margolis et al., 2011).
Appropriate wound care management early in the course of disease can prevent complications associated with wounds. One notable barrier to this, however, is that primary care practitioners may be underprepared to treat wounds as they enter practice. According to Yelland (2014), not only is the practice of wound care complicated but access to guidelines, pathways, and educational resources is also limited. Yelland (2014) notes that primary care practitioners express a lack of confidence in wound management. According to the American Association of Colleges of Nursing, Nurse Practitioner (NP) education includes “skin integrity” as part of the Primary Care NP core competencies for 2016, but there is no standard on how to achieve this competency using a required amount of time or content on caring for “skin.” The National Organization of Nurse Practitioner Faculties (2017) core competencies content does not specify the need for education on chronic wounds or acute wounds. Moore and Clarke (2011) reviewed nursing school education at the undergraduate level and found that a maximum of one day was spent on the topic of wound care throughout the education that a nurse received while completing their Bachelor of Science in Nursing degree.
The knowledge deficit surrounding wound care also includes physicians. Patel et al. (2008) analyzed data from medical school curriculums in the United States through the American Association of Medical Colleges. They found that in the United States, medical schools averaged 9.2 hours of wound education in a 4-year curriculum pattern. Furthermore, the Accreditation Council for Graduate Medical Education does not require chronic wound care education training and not surprisingly, few family medicine residency programs provide specific wound care teaching for their residents (Little, Menawat, Worzniak, & Fetters, 2013).
Challenges and barriers
Limited support is available to primary care practitioners because very few publications exist about education and protocol on chronic wound care, from a primary care perspective, and if the literature exists, its primary focus is on prevention rather than treatment (Little et al., 2013). Other barriers to the effective treatment of chronic wounds includes guidelines that are based on small studies making it difficult to generalize the results to the public, indirect evidence as multiple competing comorbidities effect outcomes, or expert opinions, rather than evidence-based protocols (Little et al., 2013). Primary care providers are often very busy in clinic, and Yelland (2014) highlights that wound care knowledge is also not a high priority for primary care practitioners. It is clear, that given time constraints of clinical practice, with little base knowledge on wound care, it will be challenging for primary care providers to properly manage these patients or prevent delays and complications in caring for wounds.
Yelland (2014) emphasizes that the role of the primary care provider has a profound influence on both health outcomes and health expenditures. However, one of the major impediments to achieving positive health outcomes and lowering costs remains the lack of education for the general practitioner regarding wound care. Improvements in wound care, healing, and outcomes are dependent on the easy accessibility of evidence-based wound management resources or post-education training (Yelland, 2014). To further complicate the issue of competency and efficiency in care, wound care treatment resources, algorithms, and recommendations are available from a vast number of organizations and use different guiding information. The variety of resources available includes hard copy, electronic, and web-based tools and references (Table 1). Apart from references, several organizations offer training in wound management for the primary care practitioner with an option for national certification in wound care (Table 2). The national certification provides additional training relating to assessment, diagnosis, and treatment of wounds. This advanced training may be excessive and unnecessary for the role of primary care practitioner, in which case, a wound care specialist's referral would make more sense.
Having available resources does not increase knowledge because barriers continue in the actual utilization of that information. Practitioners are implementing more technology into their practice. As the complexity of disease becomes more apparent to us, primary care providers will need to use technology to navigate these complex and specialized referral pathways (Jameson & Longo, 2015). Precision medicine, a relatively new term, uses information technology and electronic health records for clinical care guideline creation (Jameson & Longo, 2015). The use of a personal digital assistant and technology in clinic has shown an increase in data collection quality, accurate diagnosis, and treatment course (Divall, 2013).
Managing wounds in the primary care setting while using technology must be considered and evaluated. Technology continues to evolve, and practitioners are beginning to incorporate its use. The Health Information Technology for Economic and Clinical Health Act aims to modernize the nation's infrastructure (CDC, 2017). The act began the push for meaningful use because more health care clinics and hospitals began to switch to electronic health care records and additional technology (CDC, 2017). A number of wound care software apps are available on different platforms and vary in their cost and function (Table 3).
To this point, technology can assist in wound management in primary care. Beitz (2014) demonstrated the effective use of a digital algorithm in ostomy care management. Implementing the digital algorithm to be used by nonexpert providers improved the accuracy of wound treatment to 84% and demonstrated increased quality in managing wound care with appropriate dressings. Smartphones have become more dominant because most practitioners own a device and are using them in patient care. Implementation of health care technology in primary care through software apps can improve patient care and wound care assessment, diagnosis, and treatment, thereby potentially reducing complications and increasing outcomes. Prompt and evidence-based wound care management in the primary care could potentially decrease the cost burden and prevent inappropriate wound care, reduce complications requiring an extended rehabilitation period, reduce the number of emergency department visits, and decrease hospital admissions.
Current available resources for primary care use
Several phone-based apps are currently available to help reduce the knowledge gap for managing wounds in primary care. While browsing through applications, a provider may not be able to establish what is evidence based, what is easy to use, and which are relevant to practice in their own setting. The app applicability also varies from wound specialist to general practitioner. Some functions of apps may include documentation of wound healing through photographs, which are automatically uploaded to the medical record. A basic wound knowledge app for reference is more fitting for primary care practitioners without excessive specialty information. Implementation of an app for novice users must have features including ease of applicability and access to wound-based knowledge. A review of the available wound care apps and their best utilization is shown in Table 3.
Primary care providers are ineffectively prepared to provide optimal wound care to the aging population based on the lack of rigorous curriculum and training. Furthermore, the varying organizational guidelines pose barriers to a standardized delivery of care. The use of a mobile application, addressing protocols and guidelines, which is continuously updated and easy to access, can potentially have numerous positive outcomes. The app would increase the accuracy of diagnosis and early intervention for wounds while preventing further wound deterioration. The app would also benefit the provider because it would serve as a much-needed reference, which can increase comfort and confidence level of the provider in assessing and developing treatment plan for the wounds. The use of technology will continue to be seen more commonly in health care, and primary care providers need to take advantage of these tools when available.
Alavi, A., Sibbald, R. G., Phillips, J. T., Miller, O. F., Margolis, J. D., Marston, … & Kirsner, S. R. (2016). What’s new: Management of venous leg ulcers. American Academy of Dermatology. 74, 643–664.
American College of Foot and Ankle Surgeons. (2017). Diabetic foot conditions. Retrieved from http://www.acfas.org/Media/MediaResources/Diabetic-Foot-Conditions/.
American Diabetes Association. (2015). Overall numbers, diabetes and prediabetes. Retrieved from http://www.diabetes.org/diabetesbasics/statistics/.
Beitz, M. J., Gerlach, A. M. & Schafer, V. (2014). Construct validation of an interactive digital algorithm for ostomy care. Journal of Wound, Ostomy and Continence Nursing, 41, 49–54.
Centers for Disease Control. (2013). The state of aging & health in America 2013. Retrieved from www.cdc.gov.
Centers for Disease Control. (2016). Health, United States, 2016, with chartbook on long-term trends in health. Retrieved from www.cdc.gov.
Centers for Disease Control. (2017). Chronic disease overview. Retrieved from https://www.cdc.gov.
Divall, P. (2013). The use of personal digital assistants in clinical decision making by health care professionals: A systematic review. Health Informatics Journal. 19, 16–28.
Little, H. S., Menawat, S. S., Worzniak, M. & Fetters, D. M. (2013). Teaching wound care to family residents on a wound care service. Advances in Medical Education and Practice, 4, 137–144.
Margolis, J. D., Malay, S., Hoffstad, J. O., Leonard, E. C., MaCurdy, T., Tan, Y., … Siegel, K. L. (2011). Economic burden of diabetic foot ulcers and amputations. Data Points Publication Series. Retrieved from http://www.ncbi.nlm.nih.gov/books/NBK65152/.
Moore, Z., & Clarke, E. (2011). A Survey of the provision of education in wound management to undergraduate nursing students. EWMA Journal, 11, 35–38.
O’Donnell Jr, T. F., Passman, A. M., Marston, A. W., Ennis, J. W., Dalsing, M., Kistner, L. R., … Gloviczki, P. (2014). Management of venous leg ulcers: Clinical practice guidelines of the Society for Vascular Surgery and the American Venous Form. Journal of Vascular Surgery, 60, 3s–59s
Patel, P. N., Granick, S. M., Kanakaris, K. N., Giannoudis, V. P., Werdin, F., & Rennekampff, H. (2008). Comparison of wound education in medical school in the United States, United Kingdom, and Germany. Journal of Plastic Surgery, 8, 61–67.
Sen, K. S., Gordillo, M. G., Roy, S., Kirsner, R., Lambert, L., Hunt, K. T.,… Longaker, T. M. (2009). Human skin wounds: A major and snowballing threat to public health and the economy. Wound Repair Regen, 17, 763–771.
Yelland, S. (2014). General practice and primary care: Making a difference at the coalface of wound management in Australia. Wound Practice and Research. 22, 104–107.