Efficacy of using parent photographs of children's surgical wounds post discharge, for the diagnosis of infection and the affect on parental engagement: Woundies.

Parents of children undergoing a laparoscopic appendectomy will be trained on how to take medical photographs of their child’s wound site using a mobile phone the day after surgery and how to send them to a confidential email address. A professional medical photographer will administer face-to-face training with parents for 30 minutes. Parents will be provided with a training aid Training Session Time 1: Facilitated by Kara Burns. This training includes a demonstration how to take a medical photograph on a mobile phone. Parents will then undertake the following activities will with supervision of the researcher: Taking mobile phone photographs using a standardised methodology Equipment a. A Smart Phone: All smart phones have the technical ability to take medical images. The equipment you will use to take the images is the camera, the flash, the screen to focus the image and view your results and an email program to send the image to a secure email address b. 15cm white self-adhesive scales: These are places on the wound site to aid camera focus, colour correction and improve the accuracy of detecting healing rates. One is required per photo session. c. The Secure Email Address: woundies@health.qld.gov.au Mobile Phone Camera Settings 1. Turn on the phone 2. Open the camera application provided by your manufacturer 3. Turn the flash to ON 4. Turn off all other settings 5. Use the ‘Portrait’ image dimension setting Lighting conditions The main light source is the mobile phone camera flash. This provides a standard light source. Always photograph indoors, turn on all over head lights and open any curtains, however you should avoid direct sunlight and bright overhead spot lights to minimise over-exposure. Positioning of your child When working with children, prior to taking any photographs, reassure the child the process will be quick and painless. Position your child comfortably on the floor, bed or change table with a neutral background (preferably white) beneath the site to be photographed. Remove any clothing, nappies or dressings covering the surgical site. When photographing place yourself above the surgical site as shown in the illustration below. To maximise sharpness and depth of field, the camera lens plane must be positioned parallel to the wound plane. Photography technique Place a 15 cm white scale in a horizontally across the child’s abdomen as shown in the diagram below. The 0mm mark should be at the furthest left hand point of the wound site and as close as possible to the bottom of the lowest point of the wound site without obscuring any edges of the lesion. Position the camera to capture the scale with the 0 and 15 cm marking the edge of the photo frame making sure the camera is parallel to the abdomen. Once the frame is positioned place your finger on the screen to focus on the scale. Once focussed take an image. A minimum of three images should be taken at each time point to ensure that at least one adequate image was available for review, a technique known as bracketing. Check each image and if unclear, blurred, dark or too light, repeat the process until a satisfactory image is gained. Take follow up images of the same site using the same technique on day 2,4,6 and 10 after surgery (or if you are worried). For consistency of check the orientation of previous images before capturing the next image. Emailing the Images 1. Open the mail application provided by your manufacturer on your smart phone 2. Create an email and send to the address: woundies@health.qld.gov.au 3. Put in the subject line your participant ID number ( ) and day when the photo was taken (e.g. ID , Day 0) 4. Insert the image as an attachment into the email 5. Send the email Parents will be asked to repeat this process at home on day 2, 4, 6 and 10 days after the operation from home. Images will be assessed for infection by surgical staff Dr Bhavesh Patel and Dr Craig McBride using the standardised SSI criteria form the Centre for Disease Control (USA) http://www.cdc.gov/nhsn/PDFs/pscManual/9pscSSIcurrent.pdf This stipulates that an SSI must be an infection occurs within 30 days after any operative procedure (where day 1 = the procedure date) and involves only skin and subcutaneous tissue of the incision and the patient has at least one of the following: a. purulent drainage from the superficial incision. b. organisms identified from an aseptically-obtained specimen from the superficial incision or subcutaneous tissue by a culture or non-culture based microbiologic testing method which is performed for purposes of clinical diagnosis or treatment (e.g., not Active Surveillance Culture/Testing (ASC/AST). c. superficial incision that is deliberately opened by a surgeon, attending physician or other designee and culture or non-culture based testing is not performed. And the patient has at least one of the following signs or symptoms: a. pain or tenderness; localized swelling; erythema; or heat. b. diagnosis of a superficial incisional SSI by the surgeon or attending physician** or other designee. Adherence will not be monitored, however it will be assessed as a secondary outcome at the end of the trial using a questionnaire and interviews to establish parental engagement.