Surgical site infections (SSI) complicate up to 40% of procedures depending on operative type and procedure(1). Sequelae can be catastrophic, and lead to rehospitalisation, sepsis, limb amputation and mortality. Close monitoring and early identification of infection are associated with better outcomes, however over 60% of SSI do not become clinically apparent until after discharge, further obfuscating the diagnostic problem(2). The Sars-CoV-2 pandemic catalysed integration of digital health models worldwide, prohibiting non-urgent patient attendance at hospital and created an unparalleled paradigm shift in the interaction between patient and healthcare provider. This study aimed to appraise the current literature systematically and quantitatively for studies investigating telemedical methods of identifying wound infection post-discharge.
We undertook a PRISMA compliant and prospective PROSPERO registered systematic review of Medline, Embase, CENTRAL and CINAHL databases in addition to handsearching, for studies relevant to telemedicine and wound infection. Titles and abstracts, followed by full texts, were screened by two independent authors, and mediated by consensus review from a third. Risk of bias and applicability were assessed using the QUADAS-2 tool, which was validated for agreement by two authors individually. The primary outcome was summary sensitivity and specificity. Summary receiver operator characteristic (SROC) curves were plotted using metaDTA in an initial exploratory analysis. Planned subgroup investigation was conducted for photograph (digital) based methods and sources of heterogeneity explored.
Of 1888 studies identified during searches, 17 were suitable for inclusion in meta-analysis. There were 11,437 observations made in 19,090 patients. Studies were conducted worldwide across nine nations, five of which were in low- and middle-income countries. The weighted mean average age was 47.1 years. Risk of bias was present in at least one domain in all included studies, and there were high applicability concerns in nine studies. The mean sensitivity and specificity for all methods of telemedical follow-up for detecting SSI was 87.8% (95% CI, 68.4-96.1) and 96.8% (95% CI 93.5-98.4) respectively. The overall rate of SSI was 5.6% across studies. Five studies included in meta-analysis utilised photograph-based methods. 1638 observations were available in 2287 patients. The overall sensitivity and specificity for photograph-based telemedicine for diagnosis of SSI was 63.9% (95% CI 30.4-87.8) and 92.6% (95% CI, 89.9-94.5). Bivariate SROC curves for all and photograph-based telemedicine are displayed in figures 1 and 2 respectively.
The evidence suggests that using telemedicine to diagnose surgical site infection is highly specific and as such could be utilised as an effective screening tool in patients post discharge. However, the average age of participants here is relatively young and as such may under-represent the surgical population. Vascular patients are frequently much older and comorbid. Widespread adoption of telemedicine without strategies to improve inclusion may therefore disproportionately discriminate against the elderly or infirm. Further work is required to maximise engagement with telemedicine in digitally naïve or incapable populations.
1. Matatov T, Reddy KN, Doucet LD, et al. Experience with a new negative pressure incision management system in prevention of groin wound infection in vascular surgery patients. J Vasc Surg 2013;57(3):791-5. doi: 10.1016/j.jvs.2012.09.037 [published Online First: 2013/01/15]
2. Woelber E, Schrick EJ, Gessner BD, et al. Proportion of Surgical Site Infections Occuring after Hospital Discharge: A Systematic Review. Surgical Infections 2016;17(5) doi: 10.1089/sur.2015.241