Dataset Information

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

ABSTRACT:

Importance

Surgeons are increasingly interested in using mobile and online applications with wound photography to monitor patients after surgery. Early work using remote care to diagnose surgical site infections (SSIs) demonstrated improved diagnostic accuracy using wound photographs to augment patients' electronic reports of symptoms, but it is unclear whether these findings are reproducible in real-world practice.

Objective

To determine how wound photography affects surgeons' abilities to diagnose SSIs in a pragmatic setting.

Design, setting, and participants

This prospective study compared surgeons' paired assessments of postabdominal surgery case vignettes with vs without wound photography for detection of SSIs. Data for case vignettes were collected prospectively from May 1, 2007, to January 31, 2009, at Erasmus University Medical Center, Rotterdam, the Netherlands, and from July 1, 2015, to February 29, 2016, at Vanderbilt University Medical Center, Nashville, Tennessee. The surgeons were members of the American Medical Association whose self-designated specialty is general, abdominal, colorectal, oncologic, or vascular surgery and who completed internet-based assessments from May 21 to June 10, 2016.

Intervention

Surgeons reviewed online clinical vignettes with or without wound photography.

Main outcomes and measures

Surgeons' diagnostic accuracy, sensitivity, specificity, confidence, and proposed management with respect to SSIs.

Results

A total of 523 surgeons (113 women and 410 men; mean [SD] age, 53 [10] years) completed a mean of 2.9 clinical vignettes. For the diagnosis of SSIs, the addition of wound photography did not change accuracy (863 of 1512 [57.1%] without and 878 of 1512 [58.1%] with photographs). Photographs decreased sensitivity (from 0.58 to 0.50) but increased specificity (from 0.56 to 0.63). In 415 of 1512 cases (27.4%), the addition of wound photography changed the surgeons' assessment (215 of 1512 [14.2%] changed from incorrect to correct and 200 of 1512 [13.2%] changed from correct to incorrect). Surgeons reported greater confidence when vignettes included a wound photograph compared with vignettes without a wound photograph, regardless of whether they correctly identified an SSI (median, 8 [interquartile range, 6-9] vs median, 8 [interquartile range, 7-9]; P < .001) but they were more likely to undertriage patients when vignettes included a wound photograph, regardless of whether they correctly identified an SSI.

Conclusions and relevance

In a practical simulation, wound photography increased specificity and surgeon confidence, but worsened sensitivity for detection of SSIs. Remote evaluation of patient-generated wound photographs may not accurately reflect the clinical state of surgical incisions. Effective widespread implementation of remote postoperative assessment with photography may require additional development of tools, participant training, and mechanisms to verify image quality.

SUBMITTER: Kummerow Broman K

PROVIDER: S-EPMC6439665 | biostudies-literature |

REPOSITORIES: biostudies-literature

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Project description:BackgroundSurgical site infection (SSI) remains a common, costly, and morbid health care-associated infection. Early detection can improve outcomes, yet previous risk models consider only baseline risk factors (BF) not incorporating a proximate and timely data source-the wound itself. We hypothesize that incorporation of daily wound assessment improves the accuracy of SSI identification compared with traditional BF alone.Study designA prospective cohort of 1,000 post open abdominal surgery patients at an academic teaching hospital were examined daily for serial features (SF), for example, wound characteristics and vital signs, in addition to standard BF, for example, wound class. Using supervised machine learning, we trained 3 Naïve Bayes classifiers (BF, SF, and BF+SF) using patient data from 1 to 5 days before diagnosis to classify SSI on the following day. For comparison, we also created a simplified SF model that used logistic regression. Control patients without SSI were matched on 5 similar consecutive postoperative days to avoid confounding by length of stay. Accuracy, sensitivity/specificity, and area under the receiver operating characteristic curve were calculated on a training and hold-out testing set.ResultsOf 851 patients, 19.4% had inpatient SSIs. Univariate analysis showed differences in C-reactive protein, surgery duration, and contamination, but no differences in American Society of Anesthesiologists scores, diabetes, or emergency surgery. The BF, SF, and BF+SF classifiers had area under the receiver operating characteristic curves of 0.67, 0.76, and 0.76, respectively. The best-performing classifier (SF) had optimal sensitivity of 0.80, specificity of 0.64, positive predictive value of 0.35, and negative predictive value of 0.93. Features most associated with subsequent SSI diagnosis were granulation degree, exudate amount, nasogastric tube presence, and heart rate.ConclusionsSerial features provided moderate positive predictive value and high negative predictive value for early identification of SSI. Addition of baseline risk factors did not improve identification. Features of evolving wound infection are discernable before the day of diagnosis, based primarily on visual inspection.

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