Caring for hard-to-heal wounds
Panel recommendations for community-based caregivers
A group of wound care experts published a manuscript in the International Wound Journal, titled The Role Community-Based Healthcare Providers Play in Managing Hard-to-Heal Wounds.1 The published manuscript provides a list of actionable recommendations specifically tailored to community-based caregivers who encounter wounds. The goal is to shed new light on the critical role these best practices play in managing and preventing hard-to-heal wounds.
Hard-to-heal wounds:
- “Fail to progress towards healing with standard therapy in an orderly and timely manner and should be referred to a qualified wound care provider for advanced assessment and diagnosis if not healed or reduced in size by 40-50% within 4 weeks.”
- “Community-based healthcare providers can play an important initial role by seeing the individual’s hard-to-heal wound risk, addressing local infection, and providing an optimal wound environment.”
The simplified algorithm is to help community-based caregivers systematically identify, evaluate and treat hard-to-heal wounds.
Follow the TIMERS framework for optimal preparation of the hard-to-heal wound and periwound for healing.
The TIMERS framework is intended to guide clinicians in optimal assessment and preparation of the wound and periwound for healing.
- Tissue.3 Tissue debridement.
- Inflammation with or without infection.4,5
- Moisture/exudate. Moisture balance.
- Edge of wound. Edge effect to advance epithelialization and wound closure.
- Repair/regeneration of tissue to close a wound.
- Social factors to be considered.
- Tissue
- Inflammation
- Moisture/exudate
- Edge of wound
- Repair/regeneration
- Social
Cleanse: Cleanse wound and periwound with antiseptic solution cleanser +/- surfactant, e.g., hypochlorous PHMB acid
Debride: Remove nonviable tissue (slough) mechanically with gauze or debridement pad and/or consider autolytic debridement as appropriate In presence of full-thickness eschar,* referral to a qualified wound care provider is recommended
Address excess protease and use protease modulating dressing (collagen) with or without topical antimicrobial if appropriate
Local infection
Covert
- Topical antimicrobial dressing per exudate level
- Careful monitoring
Overt*
- Topical antimicrobial dressing per exudate level
Spreading and systemic infection
- Consider systemic treatment as per sensitivity/susceptibility culture
- Topical antimicrobial dressing per exudate level and sensitivity/susceptibility
Proceed to Moisture/exudate section
Toolbox:
- Barrier product
- Foam dressing
3M™ Cavilon™ Advanced Skin Protectant
3M™ Tegaderm™ High Performance Foam Adhesive Dressing
- If unattached, clean underneath wound edge with gauze
- If edges rolled, cliffed or callused, debride as appropriate or refer to qualified wound care provider for debridement*
- If tunneling or undermining noted, ensure these spaces are loosely packed with selected dressing material and refer to qualified wound care provider*
- If periwound maceration noted, ensure the correctly sized dressing is appropriately applied and use barrier product on wound edge
Refer to a qualified wound care provider if the wound has not healed or the wound size has not reduced by 40-50% by week 4 for advanced therapies.*
If the ulcer shows <50% area reduction (per Local Coverage Determination), they may consider skin substitute grafts alongside standard of care.
- Comprehensive patient assessment
- Systemic disease management
- Cleansing
- Debridement
- Offloading (DFU) or compression (VLU)
- Proper nutrition
- Smoking cessation
Bolstering solutions for skin substitutes, flaps & grafts
Solventum™ V.A.C.® Peel and Place Dressing**
Solventum™ V.A.C.® Granufoam™ Dressing††
Assess patient and family dynamics:
Probe to determine patient’s ideas, concerns and expectations;6 identify biggest impediments to wound healing such as nicotine use
Odor:
See wound cleansing and infection
Pain:
Assess and collaborate with appropriate healthcare professionals
NOTE: Specific indications, contraindications, warnings, precautions, and safety information exist for these products and therapies, some of which may be Rx only. Please consult a clinician and product instructions for use prior to application
*Recommended referral to qualified wound care clinician.
†Carefully observe and refer if worsens or no improvement.
§Cannot be combined with Negative Pressure Wound Therapy.
**Promogran Prisma Matrix is not labeled for use under V.A.C.® Peel and Place Dressing.
††Must be used with a protective layer, such as 3M™ V.A.C.® Whitefoam™ Dressing, for bolstering.
Content of this guide is licensed under a Creative Commons Attribution 4.0 International license (https://creativecommons.org/licenses/by/4.0/) with flowchart adapted by Solventum.1
PJ Idensohn, Cathy Milne and Dot Weir are all paid consultants of Solventum. All images provided are courtesy of PJ Idensohn, Cathy Milne and Dot Weir.
References
- Beeckman D, Cooper M, Greenstein E, et al. The role community-based healthcare providers play in managing hard-to-heal wounds. Int Wound J. 2023 Sep 15.
- Atkin L, Bucko Z, Conde Montero E, et al. Implementing TIMERS: the race against hard-to-heal wounds. J Wound Care. 2019;23(Suppl 3a):S1-S50.
- Murphy C, Atkin L, Swanson T, et al. International Consensus Document. Defying hard-to-heal wounds with an early antibiofilm intervention strategy: Wound hygiene. J Wound Care. 2020;29:S1-S28.
- Malone M, Bjarnsholt T, McBain AJ, et al. The prevalence of biofilms in chronic wounds: a systematic review and meta-analysis of published data. J Wound Care. 2017;26(1):20-5.
- Swanson T, Ousey K, Haesler E, et al. International Wound Infection Institute Wound Infection In Clinical Practice: Principles of best practice. London, UK; 2022.
- Matthys J, Elwyn G, Van Nuland M, et al. Patients’ ideas, concerns, and expectations (ICE) in general practice: impact on prescribing. Br J Gen Pract. 2009;59(558):29-36.