Treating Chronic Wounds in an Acute Care Setting: The Forgotten Diagnosis

A chronic wound is a wound that does not progress through the normal stages of healing within 3 months and is consequently identified as stalled.¹ Common chronic wounds are lower extremity ulcers, diabetic foot ulcers, and pressure injuries.² Chronic wounds can take months, or even years, to heal. 

Gupta et al³ reported that in the United States in 2009, more than 6.5 million patients had chronic wounds, at a cost to the health care system of $25 billion annually. In a typical hospital setting, it is estimated that patients with wounds occupy 25% to 40% of beds.³ Estimates of total Medicare spending for all wound types reportedly range from $28.1 billion to $96.8 billion.⁴

Most chronic wounds occur in older adults, in whom multiple comorbidities can cause chronic wounds or delay healing, with increasing wound prevalence numbers in persons older than 65 years, and even higher numbers in persons older than 75 years.⁴ With the continued increase in the aging population in the United States,⁵ as well as increased rates of diabetes, obesity, and COVID-19, the number of wound care patients is expected to increase significantly. An aging population with multiple comorbidities has led to an increasing prevalence of nonhealing wounds, hospitalizations, and clinic visits.¹

That demographic trends lead to more chronic wounds has been demonstrated by an updated cohort study in the United Kingdom, which showed an overall 50.2% increase in the number of chronic wounds between 2012/2013 and 2017/2018.⁶ Therefore, the percentage of Medicare spending attributed to the management of chronic wounds can be expected to increase with a growing older population.

The burden of chronic wounds within the inpatient setting is difficult to measure. Chronic wound diagnoses typically are considered a comorbidity or symptom of a primary diagnosis, leading to difficulty determining true incidence and cost of care. Many inpatients with a chronic wound are admitted for a separate primary diagnosis, with no additional reimbursement available to the hospital to care for the wound. This means the true costs are mostly unseen and unreported. The Medicare 5% Limited Data Set for 2014 projected estimated inpatient cost of $5 billion to $24.3 billion dollars annually, or approximately 17% to 25% of the total Medicare wound care expenditure.⁷

In March 2022, an expert panel of 7 members was convened in New Orleans, LA, all with extensive experience in wound and ostomy care. The panel discussed the effect of chronic, hard-to-heal wounds on a hospital system, and the effect that a short inpatient stay can have on the overall healing trajectory.

Hospitals play a key role in the treatment of chronic wounds. Elderly patients with skin breakdown do not always have access to wound care specialists in primary care settings, or even in skilled nursing facility or long-term acute care hospital settings. This often results in local wound bed management without consideration for underlying causes or comorbidities. This could lead to rapid deterioration and patient presentation at a hospital emergency department with a chronic wound that has worsened. The inpatient stay may be the first time the patient and wound are assessed by a wound care specialist. Appropriate assessment and treatment at this stage can significantly affect the healing trajectory.

Subsequent complications that can occur with a chronic wound in the acute care setting include infection, maceration, and deterioration of the wound, which may result in an increased length of stay or higher readmission rates. The National Center for Biotechnology Information data on 30-day all-cause readmissions from 2010 showed “Chronic ulcer of the skin” in the top 25 diagnoses with the highest readmission rates, at 21.3%.⁸ Initiating and following a suitable treatment pathway for a chronic wound, even during a short inpatient stay, can help prevent such complications and reduce the burden on the hospital.

             The longer-term care of a patient with a chronic wound is multifaceted and includes inpatient and outpatient settings. Patients in nursing homes and post-acute facilities are more complex than ever before. Hospitals can play a key role in the coordination of care for chronic wound care patients across care settings, creating treatment and discharge plans to help the patient achieve wound healing after discharge.⁹ Hospitals that do not adequately fulfill this role are at risk of readmissions or longer healing trajectories that could affect the wider integrated delivery network. 

A successful inpatient wound program to help manage existing chronic wounds should consist of 3 components: the inclusion of wound specialists in the care team to aid in diagnosis and the development of treatment plans, empowerment of bedside nurses to follow care plans and wound management protocols, and development and implementation of a comprehensive care plan to ensure a smooth transition to the post-acute care setting. 

The challenges of diagnosing and managing chronic wounds are multifactorial. Chronic wounds often are associated with comorbidities that affect the ability of the wound to heal. Such comorbidities include, but are not limited to, diabetes, obesity, sickle cell anemia, autoimmune diseases, renal impairment, peripheral arterial disease, and venous disease. These comorbidities are more prevalent in elderly patients. Managing both the underlying causes of a chronic wound and related comorbidities can result in a long and complex healing process. Often, simply managing the local wound bed is not sufficient to achieve an efficient healing trajectory.

For example, a venous leg ulcer typically is caused by venous insufficiency, in which the valves in the leg do not return blood up the leg toward the heart. This may result in fluid beginning to pool in the leg, thus damaging the capillaries, seeping into the tissue, and ultimately causing a break in the skin from the inside out. These ulcers often require compression bandages to help with the venous return, and simply managing the local wound bed could prolong or worsen the situation. Conversely, healing of arterial leg ulcers often is difficult to achieve owing to lack of blood supply, and using compression bandages on such ulcers can have a severely damaging effect. Thus, accurate wound assessment and diagnosis are key to initiating the appropriate course of treatment.

The wound care skills that most clinicians develop are frequently the result of on-the-job training. This results in a relatively thin knowledge base with little scope that can affect the quality of patient care, treatment, and wound response. Medical students in the United States receive very little education on the science and care of wounds during their medical studies. An evaluation of 50 American medical schools showed the average number of hours of education in both physiology of tissue injury and wound healing combined over 4 years of medical education is approximately 4.7 hours.¹⁰ Woo¹¹ surveyed 88 practicing clinicians, the majority of whom were physicians, to assess their knowledge base as it relates to all aspects of wound care. Seventy percent of respondents acknowledged possessing a weak knowledge base while also expressing the desire to strengthen that knowledge base.

Variation in knowledge and practice leads to variation in outcomes. Limited education for medical providers may diminish specialized knowledge in identifying chronic wound treatment needs. Incorrect assessment of wounds leads to inadequate treatment recommendations that fail or are marginally successful in effecting healing, which can lead to increased complications.

Wound care nurse specialists are key members of a multidisciplinary team approach to promote positive outcomes. Their specialized knowledge in managing chronic wounds is the result of a certification process as well as years of education and practice that culminate in knowledge, skills, ability, and judgment to determine an effective, evidence-based practice plan of care for the patient.¹² This function of wound care nurse specialists is often under-resourced, however, with their responsibilities mostly measured by and focused on preventing pressure injuries, leaving insufficient time for assessing existing chronic wounds, creating adequate care plans, and setting up post-discharge plans to prevent 30-day readmissions. 

Wound ostomy continence nurses fulfill this wound specialist role and possess the knowledge, skills, and experience to offer appropriate diagnosis and treatment plans for chronic wounds. These nurses are ideally suited to collaborate with a multidisciplinary team that includes health care professionals with expertise in surgery, vascular care, orthopedics, plastic surgery, and trauma care, and use their expertise and judgment to help achieve successful outcomes.^13,14

Once a treatment plan has been created, the day-to-day management of chronic wounds often falls to staff nurses. Similar to that for medical students and physicians, formal wound care training for nurses often is limited, resulting in a thin and varied knowledge base. In some cases, knowledge comes from following practice, which in itself is not always best practice or evidence-based practice.² Sürme et al¹⁵ surveyed 393 nurses and found that more than 47% of the respondents “did not accept wound care as a nursing task.” Equally alarming is the finding that more than half of the nurses failed to provide wound care discharge education.

There is also a current trend of staff shortages, high staff turnover rates, nurses leaving the profession, and a projected shortage of registered nurses. This often leaves even less time for wound care education and performing tasks beyond basic patient care. Limited wound care knowledge and limited time to familiarize oneself with treatment plans can result in inadequate wound care and ensuing complications.

A successful inpatient wound program is designed to empower bedside nurses to deliver advanced wound care. Protocols or policies that are easy to understand, as well as education that is quick, relevant, and easy to access can play a key role in elevating the daily care delivered by a larger group of nurses. Promoting appropriate dressing selection from an easy-to-understand formulary with products designed to optimize healing could help reduce the risk of complications during hospital stay and after hospital discharge. Strong foundational wound care principles that are easy to access can make a difference when wound specialists or treatment plans are not available, such as when immediate wound care is required, treatment plans are inaccessible, or patients are admitted outside of specialists’ working hours. 

A final integral component of the plan of care is to ensure a smooth transition of care to provide the patient with ongoing wound care in the post-acute care setting. Patients with chronic wounds often are discharged to long-term care facilities or to home, and the continuity of the wound regimen can be easily confused or may rest on the inexperienced caregiver to complete. A collaborative effort between family and health care teams is required to ensure a smooth transition of care from the acute care setting to the post-acute care setting.

Ensuring the availability of wound care products for the patient after discharge is equally vital to ensuring continuity of care and decreasing the risk of rehospitalization. Chronic wounds constitute a complex disease state, and care does not stop after a patient is discharged from the hospital. When wounds are not treated uniformly and there is no clear plan of care, patients may be lost to care, which can lead to increased admissions, amputations, and mortality. 

Hospitals, in particular those that are part of an integrated delivery network that includes a variety of care settings, can play a key role in the coordination of care across care settings. A solid discharge plan requires interdisciplinary collaboration within the acute care setting, as well as within the post-acute care setting. Members of the multidisciplinary team include the wound specialist nurse, nurse practitioners, physicians, physician’s assistants, case managers, and social workers. Effective communication and patient education are imperative for continuity of care. Strong coordination of inpatient to outpatient care improves patient outcomes, decreases cost of care, reduces length of stay, and can prevent readmission. 

The effect of chronic wounds on acute care facilities can be significant and can include unseen costs that often are absorbed by reimbursement for separate primary diagnosis, the use of 25% to 40% of hospital beds by patients requiring some form of wound management, demands on bedside nurses with limited time or knowledge to provide adequate wound care, and the risk of wound complications that could lead to longer stays or readmissions.

A successful inpatient wound program for chronic wounds should consist of 3 components. First, early identification and diagnosis of chronic wounds should be enabled, with a wound specialist included in a multidisciplinary team to help identify relevant comorbidities and design a multifaceted treatment plan. Second, bedside nurses should be empowered to follow the treatment plan, through protocols or policies that are easy to understand; education that is quick, relevant, and easy to access; and a formulary that promotes easy dressing selection from products designed to optimize healing and minimize complications. Finally, it is necessary to ensure that treatment plans are followed through after hospital discharge for continuity of care, by coordinating across care settings and providing clear discharge instructions.

Affiliations: ¹Essentia Health, Fargo, ND; ²Pennsylvania Hospital, Philadelphia, PA; ³Providence Sacred Heart Medical Center, Spokane, WA; ⁴NewYork-Presbyterian Brooklyn Methodist Hospital, Brooklyn, NY; ⁵Barnes Jewish Hospital, St Louis, MO; ⁶Brigham and Women’s Hospital, Boston, MA; ⁷Lenox Hill Hospital, New York, NY; ⁸Coloplast Corp., Minneapolis, MN

Address all correspondence to: Emily Sue Greenstein, MSN, APRN, CNP, 4425 168^th Ave SE Horace, ND 58047; egreenst8@gmail.com

Potential conflicts of interest: Emily Greenstein, William Falone, Teresa Patterson, Katherine Cesario, Linda Mitchell, Tanya Martel, and Julie Rivera are paid advisory board members for Coloplast Corp. Maarten Vooijs and Sarah Norton are employed by Coloplast Corp.

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