Wound Management
Setting the Stage
Setting the Stage
Wound management is a horizontally integrated specialty practice. The key to effective wound management requires understanding the physiology of wound healing. It is essential that an ongoing process of assessment, clinical decision-making, intervention, and documentation occurs to facilitate optimal wound healing. There is scholarly work devoted to understanding the intricate, overlapping 4 phases of wound healing.1 Yet, to date, the practice of wound management has not been discussed in the literature in comprehensive terms. In my experience, wound care delivery can be categorized into 3 distinct but convergent stages: triage and stabilize, ongoing wound evaluation and treatment, and long-term care.
These staging criteria were developed based on my experience as the Woundtech National Director of Clinical Safety, Quality, and Education and are based on the level of patient care provided at each patient visit. Variables that were considered included technical skill, physical effort, mental effort and judgment, and time required to perform the services or procedures. Additionally, frequency of visits and utilization of clinical and nonclinical resources (including medical supplies and office supplies), clinical staff, and administrative staff were also appraised. This article details breaking wound management into various stages and expands on the essential components involved in each stage.
Triage and stabilize. This first stage of wound management consists of a thorough patient assessment during which the clinician gathers all pertinent information to identify patient factors and potential barriers to wound healing. It has been my experience that it can take up to 3 visits to perform a full evaluation of a patient with a chronic wound. A complete patient history is performed to identify any underlying disease states such as diabetes, autoimmune disorders, vascular impairment, inflammatory conditions, anemia, kidney disease, history of radiation therapy, or malignancy, which are factors that contribute to wound chronicity.2 These conditions often result in impaired collagen, impairment of angiogenesis, and delayed infiltration of inflammatory cells, macrophages, and lymphocytes due to decreased host resistance and poor cutaneous or epidermal vasculature.3 Current medications and dosage schedules are obtained in this stage. Nonsteroidal anti-inflammatory drugs, chemotherapy, immunosuppressive drugs, and corticosteroids are just a few agents that disrupt the healing cascade.4
Testing, lab work, and specialist referrals may be recommended as part of this process. Impaired perfusion, cardiac conditions, smoking, diabetes, hemorrhage, and deep venous thrombosis can lead to impaired tissue hypoxia.5 Baseline noninvasive vascular testing is often ordered to screen patients with chronic wounds for peripheral vascular disease.6 Disorders of sensation or movement, such as cerebral palsy, movement disorders, peripheral neuropathies, and spina bifida, often result in patients using a wheelchair or being bedfast. Evaluation using the Braden Scale to determine the risk of pressure injury development is another essential step at this stage.7
Malnutrition results when the supply of protein, carbohydrates, lipids, and trace elements is inadequate.8 Adequate nutrition is essential for all phases of wound healing.8 Body mass index calculations and blood tests to determine albumin and prealbumin levels are often ordered to determine nutritional status.8 A detailed wound assessment (Table 1) is performed after the history and physical examination is complete.9
The goal of the triage and stabilize stage is to evaluate the patient and collect all pertinent information needed to create a treatment plan to optimize the wound environment so healing can progress in a timely fashion. A high level of care is provided at this stage. Patient and caregiver education about barriers to wound healing, such as proper nutrition, exercise, pressure relief, and smoking cessation, is critical.
ONGOING WOUND EVALUATION AND TREATMENT
Wound management in this stage centers around promoting an optimal wound healing environment. Wound healing progresses most rapidly in an environment that is clean, moist, and protected from trauma and bacterial invasion.10 A wound requires different treatments at various stages of healing. No dressing is suitable for all wounds; therefore, frequent assessment of the wound is required. Appropriate dressing selection is based on the specific wound characteristics.11 Determining the goals of care is essential to managing expected outcomes. The basic principles of wound care memorialized in the TIMERS consensus document are an integral part of effective wound management and are outlined in Table 2.12
Long-term care. Not all wounds will heal. Thus, there is a need for palliative or long-term wound care pathways in a comprehensive wound management model.13 In the long-term care stage, the focus shifts toward providing patient comfort and dignity, preventing wound infection and deterioration, averting hospitalizations, and improving overall quality of life.13
Long-term care also decreases the need for trips to the emergency department and hospitalizations, thus reducing health care costs.13 Once a patient becomes enrolled in a long-term care pathway, the approach to care is focused on relieving pain and increasing overall quality of life. Although the main goal of palliative wound care is not necessarily wound healing, it does not mean that these wounds will never heal—it just may take longer to do so. A complete wound assessment is still performed at each long-term care visit. Clinicians should continually develop an evidence-based individualized treatment plan. Managing chronic wound symptoms helps to minimize the negative impact of living with a nonhealing wound and to increase patient well-being.
DISCUSSION
Wound management encompasses multiple dimensions of desired outcomes, from complete wound healing to symptom management and avoiding complications such as hospitalization and amputation. With rising health care costs in the setting of traditional fee-for-service payment models, value-based payment reform has been gaining traction within many medical specialties, including wound care. It is my belief that implementing wound management staging into value-based care algorithms will allow providers to deliver higher-quality care across the continuum.
REFERENCES
1. Eming SA, Martin P, Tomic-Canic M. Wound repair and regeneration: mechanisms, signaling and translation. Sci Transl Med. 2014;6:265.
2. Ackermann PW, Hart DA. Influence of comorbidities: neuropathy, vasculopathy, and diabetes on healing response quality. Adv Wound Care (New Rochelle). 2013;2(8):410-421.
3. Guo S, Dipietro LA. Factors affecting wound healing. J Dent Res. 2010;89(3):219-229.
4. Khalil H, Cullen M, Chambers H, McGrail M. Medications affecting healing: an evidence-based analysis. Int Wound J. 2017;14(6):1340-1345.
5. Watts ER, Walmsley SR. Inflammation and hypoxia: HIF and PHD isoform selectivity. Trends Mol Med. 2019;25(1):33-46.
6. Gibbons GW, Wheelock FC Jr, Siembieda C, Hoar CS Jr, Rowbotham JL, Persson AB. Noninvasive prediction of amputation level in diabetic patients. Arch Surg. 1979;114:1253-1257.
7. Huang C, Ma Y, Wang C, et al. Predictive validity of the Braden scale for pressure injury risk assessment in adults: a systematic review and meta-analysis. Nurs Open. 2021;8(5):2194-2207.
8. Chow O, Barbui A. Immunonutrition: role in wound healing and tissue regeneration. Adv Wound Care (New Rochelle). 2014;3:46-53.
9. Hess CT. Comprehensive patient and wound assessments. Adv Skin Wound Care. 2019;32(6):287-288.
10. Panuncialman J, Falanga V. The science of wound bed preparation. Clin Plast Surg. 2007;34:621-632.
11. Dabiri G, Damstetter E, Phillips T. Choosing a wound dressing based on common wound characteristics. Adv Wound Care (New Rochelle). 2016;5(1):32-41.
12. Atkin L, Bućko Z, Conde Montero E, et al. Implementing TIMERS: the race against hard-to-heal wounds. J Wound Care. 2019;23(suppl 3a):S1-S50.
13. Cole W. Palliative wound care: closing the gap. Podiatry Today. 2022;35(4).
Dr Cole is Director of Wound Care Research, Kent State University College of Podiatric Medicine, and National Director of Clinical Safety, Quality,
and Education, Woundtech.
The opinions and statements expressed herein are specific to the respective author and not necessarily those of Wound Management &
Prevention or HMP Global. This article was not subject to the Wound Management & Prevention peer-review process.
