The returning wound patient is in for reassessment. They are positioned for maximum visualization of the wound. You remove the dressing. Clean the wound. After a few additional steps, it's time to measure the wound's progress. Using your measurement tool, you take careful note of the wound’s measurements. In comparing the measurement with the previous visits, you realize that the wound has stalled out.

Tips to Prevent Chronic Wounds

Sometimes, no matter how good your wound treatment interventions are, your offloading, your care, and your attention, chronic wounds stall out. There are so many factors that impede wound healing. Some can be seen with the naked eye; some can't. What's important to remember is how to mitigate or eliminate as many factors as possible to keep wounds progressing to a resurfaced state. Following are some strategies to make sure the above described scenario is rarely if ever experienced by your patients:

1. MANAGE BIOFILM: Biofilm can be present in a wound. Although it's something often discussed by wound professionals and recognized more and more, it can't really be seen with the naked eye. The Global Wound Biofilm Expert Panel issued consensus statements that included the following statement: "Biofilms are present in most chronic wounds and are likely to be located both on the surface and in deeper wound layers…" This means the majority of the time (if not all the time) clinicians should be combating or treating biofilm so wounds don't become stalled in the healing process. Additionally, clinicians can't take a singular approach at treating and managing biofilm.¹ The same panel noted that "...debridement is one of the most important treatment strategies against biofilms, but does not remove all biofilm, and therefore cannot be used alone-this is one of the critical principles of wound bed preparation." Pairing sharp debridement (when medically appropriate or necessary) with other interventions such as cleansing with a non-cytotoxic agent may support moving chronic wounds along the healing trajectory. ²
2. REMOVE EPIBOLES: Rolled wound edges prevent cells from proliferating and migrating across the wound. That rolled edge acts like a brick wall, and cells just can't move past it. If you have already encouraged granulation tissue to fill in the wound and all that's left is the rolled edge, then removal may be necessary. If the wound has depth and the client doesn't have a lot of tissue stores, then it may be advisable to wait until the wound is more filled in and the client's nutritional status improves. Some dressing manufacturers state their product helps remove the epibole (also spelled epiboly) or rolled edges, which may be an appropriate intervention. If dressings aren't working, then a specialist will need to remove the epibole with a scalpel or other appropriate instrument.
3. REMOVE NON-VIABLE TISSUE: Are slough or eschar getting in the way of your client's wound progression? Removal of non-viable tissue may be in order. There are many products available that help remove non-viable tissue. Sharp debridement is the fastest and considered the gold standard for quickly getting rid of the unhealthy tissue (when adequate blood flow is confirmed). Enzymatic debridement is a common method of debridement because it is selective (doesn't harm healthy tissue). Numerous products on the market assist with autolytic debridement. Mechanical debridement is helpful for loose debris or detritus. The message: there are many options available to remove non-viable tissue from the wound bed. Slough or unstable eschar can be prevented from infringing on your patient's wound healing.
4. TREAT INFECTION: Make sure it is an infection first, however. The gold standard for confirming infection is tissue cultures, not swab cultures. Only swab cultures using the Levine technique are reliable. The Centers for Medicare & Medicaid Services published this in 1992. Tissue cultures are the gold standard to confirm the presence of bacteria and to identify which bacteria are present. Additionally, there are numerous companies that can extract DNA from the microbes to see exactly what the bacteria are sensitive to, becoming resistant to, or are already resistant to, and this test is generally covered by most insurance companies.
5. BASIC RULES: The wound speaks; we listen. If we listen well, the wound tells us what it needs.
   1. "I'm too wet." Dry it.
   2. "I'm too dry." Wet it.
   3. "I'm moist." Cover and protect.
   4. "I'm infected." Cure the infection.
   5. "I'm arterial." Restore blood flow (if surgical candidate).
   6. "I have a venous component." Compress it (after checking that the arterial blood flow can tolerate compression without cutting off the arterial supply).
   7. "Pressure is preventing me from healing." Offload it.
   8. "I'm diabetic." Manage blood glucose levels (and offload diabetic foot ulcers on the plantar surface).
   9. "I have necrotic tissue." Remove down to healthy tissue.
   10. "I'm not healable." (i.e., malignant lesion or needs aggressive treatment but not a candidate). Place in palliative wound status, and continue the basic principles of wound healing.³

Conclusion

These basic ideas and principles are not all encompassing, but they are a good place to start. Some wounds are multifactorial and so need multiple approaches. Good wound healing principles start with the basics, and the basics can keep our wounds from stalling—no magic wand needed.

References

1. Schultz G, Bjarnsholt T, James G A, et al. Consensus guidelines for the identification and treatment of biofilms in chronic nonhealing wounds. Wound Repair Regen. 2017;25:744–57.

2. Armstrong DG, Bohn G, Glat P, Kavros SJ, Kirsner R, Snyder R, Tettelbach W. Expert recommendations for the use of hypochlorous solution: science and clinical application. Ostomy Wound Manage. 2015 May;61(5):S2-S19. https://www.ncbi.nlm.nih.gov/pubmed/28692424 Accessed March 29, 2019.

3. Centers for Medicare & Medicaid Services. State Operations Manual. Appendix PP - Guidance to Surveyors for Long Term Care Facilities Table of Contents (Rev. 173, 11-22-17). https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads…. Accessed March 12, 2019.