Introduction: An Interdisciplinary Approach

Wound management is a tremendous clinical challenge for many health care professionals. The World Health Organization has recognized that wound management is a worldwide public health issue best managed by an interprofessional team.¹

This interdisciplinary approach has been shown to increase healing and decrease wound recurrence. However, it requires shared decision making with many clinicians to create an optimal care plan.² It is important to gather information from many sources, especially from other health professionals within the interdisciplinary team. When working with specialists, their input and assessment can be critical in identifying underlying factors that may be impacting healing. This information is vital in developing a care plan that can support positive patient outcomes.

Communication and Accurate Wound Documentation

One important aspect of care plan creation is communicating all relevant data to all clinicians who are members of the patient’s interdisciplinary team. This communication requires extensive documentation of clinical findings, as well as used and considered treatment options and their respective results.³ Accurate, rapid, and concise wound documentation is at the core of good wound care.

Additionally, a great care plan can be created only when sufficient information is available. Therefore, considerations for the care plan should include comprehensive information about not only the wound, but also any factors that affect the patient.⁴ Comprehensive information about the wound can involve health factors and parameters that may affect wound healing and management. This dimension of information can include:

• Wound attributes (type, date of occurrence, details of previous management)
• Pain assessment information
• Relevant investigation summary
• Wound morphology (dimensions and appearance)
• Current management interventions (dressings, fixation, compression, pressure relief, equipment, etc)

Overall patient information and any comorbidities relevant to wound healing should also be included and factored into the overall care strategy. Assessment of the patient’s information includes:

• Medical or surgical history
• Allergies and any history of adverse reactions
• Medications and adjuvant therapies
• Blood glucose levels and hemoglobin A1c values
• Alcohol, smoking, or illicit substance use
• Functional ability and mobility
• Nutrition
• Any psychological and socioeconomic barriers (access to transportation, ability to afford dressings, etc)
• Lower leg, sacral, and other relevant assessment
• Physical measurements (ankle, calf, and thigh circumference, etc)
• The presence and involvement of caregiver(s)

This list of wound and patient information does not encompass all the factors that need to be considered for developing a plan of care. Clinicians should consult their facility’s protocols as they build the patient’s care plan and be vigilant of other factors that may affect wound healing. The use of technology can aid in the documentation and rapid communication of wound characteristics with the interdisciplinary team. Documentation technology may improve accuracy and access so that the plan of care can be developed for best outcomes.

Documentation: Wound Images and Characteristics

Wound images can be recorded and analyzed to give measures of surface area, depth, and other characteristic data. Many platforms that support wound documentation also have tools to encourage providers to implement appropriate measures for the wound. These systems can create an objective record of wound characteristics rather than relying on subjective descriptions. Documentation of wound characteristics should also include⁵:

• Etiology: surgical, laceration, burn, abrasion, traumatic, vasculopathy, neoplastic, etc
• Type of wound: chronic or acute
• Type of ulcer
• Location and condition of surrounding skin
• Any tissue loss
• Clinical appearance of the wound bed and wound edge
• Stage of healing
• The presence of signs of infection, biofilm, or exudate
• Pain-related information

Development of the Care Plan

Once information relating to a wound, as well as any patient factors, has been gathered and clinicians have reviewed their facility’s protocol, the wound management plan can be created. It is worth noting that information gathered must be shared with patient consent. Details of the management plan and any interventions should also be reported. Specifically, social information about the patient, including their ability to attend follow-up appointments or afford dressings or other required treatment, should be noted along with details about current strategies.

Using a 10-Step Approach

Using the foregoing information when developing a plan of care for wound management is aligned with the recommendation that a 10-step approach should be used for each wound. This strategy can be implemented when creating a care plan. The steps include⁶:

1. Conduct a holistic patient assessment: physical, psychological, spiritual, and social needs. This must include and identify the underlying pathophysiological cause(s) and risk factor(s).
2. Perform a wound assessment, including measurements.
3. Decide the desired outcome (healing or maintenance) and care plan.
4. Address and manage the underlying disorder or plan maintenance care.
5. Implement local wound care according to wound bed preparation protocols, the TIME (tissue, infection or inflammation, moisture, and edge) framework, etc, or maintenance or palliative care principles.
6. Follow up, reassess the patient, and measure the wound.
7. Modify the care pathway and refer, if necessary, to specialists or the multidisciplinary team.
8. Provide patient and family education throughout care.
9. Discharge or transition to maintenance treatment to prevent recurrence.
10. Record actions and outcomes at every episode of care.

Reassessing the Strategy

Once the care plan has been developed and implemented, clinicians should stay abreast of any factors that would call for the wound care plan to be modified. Wound management performance and outcomes should be reported and wound prevalence analyzed so that the strategy can be reassessed if necessary. When observing wound healing progress and changes to wound characteristics after interventions, you can identify specific factors that may require the care team to reassess the strategy. Wound stalling or healing, a change in the patient’s social circumstances, or the presence of infection and subsequent biofilm formation will require various plan modifications. Under these circumstances, the interdisciplinary team can modify the care plan to account for changing circumstances.

Conclusion

When working with wounds, one may maximize decision making by using a multidisciplinary and holistic approach that incorporates knowledge of the patient and clinical expertise. A one-size-fits-all approach is often ineffective. Having an understanding of patients’ preferences and past experiences may inform decisions.⁷ Wound care is complex, and getting to a point where a wound can make healing progress often requires individualized treatment plans that incorporate a broad range of data and information. However, when this process is implemented and is coordinated throughout the interdisciplinary team, it can lead to far more positive patient outcomes.

References

1. Serena TE. (2014). A global perspective on wound care. Adv Wound Care (New Rochelle). 2014;3(8):548-552.
2. Heerschap C, Nicholas A, Whitehead M. Wound management: Investigating the interprofessional decision-making process. Int Wound J. 2018;16(1):233-242.
3. Barakat-Johnson M, Jones A, Leong T, et al. Reshaping wound care: evaluation of artificial intelligence app to improve wound assessment and management amid the COVID-19 pandemic. Int Wound J. Published online February 25, 2022. doi:10.1111/iwj.13755
4. Glance SN, Prentice J, Fielder K. The development of an electronic wound management system for Western Australia. Wound Pract Res. 2010;18(4):174-179.
5. Davidson K. Wound assessment and management. The Royal Children’s Hospital Melbourne. 2019. Accessed May 17, 2022. https://www.rch.org.au/rchcpg/hospital_clinical_guideline_index/Wound_assessment_and_management/
6. Atkin L, Bucko Z, Conde Montero E, et al. Implementing TIMERS: the race against hard-to-heal wounds. J Wound Care. 2019;28( suppl 3a):S1-S52.
7. Gillespie BM, Chaboyer W, St. John W, Morley N, Nieuwenthoven P. Health professionals’ decision-making in wound management: a grounded theory. J Adv Nurs. 2015;71(6):1238-1248. doi:10.1111/jan.12598