Diagnosing Surgical Site Infection Using Wound Photography: A Scenario-Based Study

Abstract

Background Postoperative surgical site infections (SSI) are common and costly. Most occur post-discharge, and may result in potentially preventable readmission and/or unnecessary urgent evaluation. Mobile health approaches incorporating patient-generated wound photos are being implemented in an attempt to optimize triage and management. We assessed how adding wound photos to existing data sources modifies provider decision-making. Study Design Web-based simulation survey using convenience sample of providers with expertise in surgical infections. Participants viewed a range of scenarios including surgical history, physical exam and description of wound appearance. All participants reported SSI diagnosis, diagnostic confidence, and management recommendations (main outcomes), first without, and then with accompanying wound photos. At each step, participants ranked the most important features contributing to their decision. Results Eighty-three participants completed a median of 5 scenarios (IQR 4-7). Most participants were physicians in academic surgical specialties (N=70, 84%). Addition of photos improved overall diagnostic accuracy from 67% to 76% (p<0.001), and increased specificity from 77% to 92% (p<0.001) but did not significantly increase sensitivity (55% to 65%, p=0.16). Photos increased mean confidence in diagnosis from 5.9/10 to 7.4/10 (p<0.001). Overtreatment recommendations decreased from 48% to 16% (p<0.001) while undertreatment did not change (28% to 23%, p=0.20) with addition of photos. Conclusions Addition of wound photos to existing data as available via chart review and telephone consultation with patients significantly improved diagnostic accuracy and confidence, and prevented proposed overtreatment in scenarios without SSI. Post-discharge mobile health technologies have the potential to facilitate patient-centered care, decrease costs, and improve clinical outcomes.

Variability in the diagnosis of surgical‐site infections after full‐thickness skin grafting: an international survey

“…Another aim of this study was to examine the most important visual factors contributing to the decision of diagnosing a wound with an SSI. In a recent study, skin colour around the wound was ranked as the most important characteristic in diagnosing SSI following abdominal surgery . This is consistent with our assessments, in which those wounds with the most erythema were ultimately assessed as infected by the highest number of respondents.…”

“…However, the response rates are unknown, and those who responded to the survey might be more used to electronic services than nonresponders. The rapidly developing field of telemedicine holds promise in increasing the efficiency of postoperative care after skin surgery, and the addition of wound photographs to clinical data has been shown to improve accuracy in diagnosing SSIs . As most dermatological procedures are performed as outpatient surgery, postoperative wound assessments through teledermatology might help in the triage and management of complications without the need for extra face‐to‐face visits.…”

Evaluation of Wound Photography for Remote Postoperative Assessment of Surgical Site Infections

“…In this study, the overall accuracy of surgeons was lower than in prior studies, presumably owing to the use of patientgenerated data and the more general population of surgeons sampled. The aforementioned study of surgical infection experts demonstrated accurate SSI detection in 67% of cases without photographs and in 76% of cases with photographs 7 (vs 57% of cases without photographs and 58% of cases with photographs in our study). A study of vascular surgeons evaluating postoperative wounds found 66% to 95% agreement between in-person and remote assessments.…”

“…In studies performed in controlled settings, the addition of wound photography alongside clinical data increases diagnostic accuracy, improves clinicians' confidence in a diagnosis, and decreases overtreatment of SSIs. 4,6,7 A limitation of prior work is that study contexts have differed from the settings in which remote assessment of wounds is currently used on an informal basis and its likely use if it were widely adopted among surgical practices. Specifically, images in prior work have typically been obtained in a uniform fashion by trained photographers.…”

Circular pOlyethylene drape in preVEntion of suRgical site infection (COVER trial): study protocol for a randomised controlled trial

“…Assessments of wound condition will be performed by the observer and reviewed by other investigators via photographs documented in the eCRF. This will provide an objective and reliable method for the evaluation of wound infections 34. Finally, the risk that patients may experience from participating in this trial is minimal and will remain within the boundaries of routine clinical practice.…”