INTRODUCTION

Overview

This topic serves as a tool to help clinicians assess wound healability, that is, the ability of a wound to undergo functional healing. This determination should be based on a comprehensive patient assessment, prior to setting appropriate goals of care and selecting treatment interventions. Classification will facilitate responsible use of available resources along with realistic treatment goals.

Background

A holistic and patient-centered approach to managing chronic ulcers is one that treats the whole patient, and not just the 'hole' in the patient.[1]  As a prerequisite to setting realistic treatment objectives, chronic wounds should be classified according to their ability to heal, that is, as healable, nonhealable, or maintenance.[2] Despite intensive team efforts, preparation and optimization of the wound bed for functional healing may not always result in complete healing.[1] Thus, classification allows clinicians and patients to set expectations and appropriate care plans.

Definitions:

• Healability: The term 'healability', coined and evangelized by R. Gary Sibbald, refers to a person’s ability to heal a wound.[1][2]  According to Sibbald, a wound can be categorized as healable, maintenace or non-healable.[1][2]  
• Healable wound: is a wound that has adequate blood supply, and can be healed if the underlying cause is addressed.[1][2][3]
• To properly address the underlying cause of the ulcer, it is important that barriers to healing be assessed and addressed as well. Those include comorbidities, medications and wound factors (e.g., necrotic tissue) that may interfere with the healing process.[3] If barriers can be removed/ minimized to the point where they do not pose an obstacle for healing, the ulcer can be considered healable.
• Maintenance wound: is a wound that may have the potential to heal, however the underlying cause of the wound cannot be corrected due to  patient unwillingness to adhere to treatment, or to limitations, errors or barriers of healthcare resources (e.g., no foot offloading device is provided in the form of footwear, or the patient cannot afford the device). These factors may change over time, so they should be monitored and re-evaluated periodically.[1][2]
• Maintenance wounds have the potential to heal, but they will require more resources to do so.[3] These wounds usually have adequate blood supply to the wound bed, and co-existing medical conditions and current medications may or may not be an obstacle to wound healing.[1]
• A wound may be labeled as 'maintenance' if the patient is unwilling to adhere to treatment. In these cases, it is helpful to understand why the patient is not able to follow the prescribed plan and discuss other alternatives accordingly.[3]
• Non-healable wound: is a wound that cannot heal because of inadequate blood supply to the wound bed, or due to irreversible causes or associated illnesses, including critical ischemia or non-treatable malignancy. It is important to note that [1]:
• Palliative wound care often includes non-healable wounds, but patients undergoing palliative care may have maintenance or even healable wounds.
• As for stalled, non-healing wounds, the presence of multiple comorbidities and/or persistent inflammation may be the cause, which in some cases may not be correctable, rendering the wound non-healable. 

Relevance:

• Categorization of wound healability (i.e., healable, maintenance, or non-healable) is of particular importance.[4] This designation defines for the clinician, patient, and family an expected course of action, plan of care, and healing rate. It facilitates responsible use of available resources along with realistic treatment goals. For instance, categorization may influence decisions on:
• Debridement methods: healable wounds require active sharp or surgical debridement; maintenance wounds may be debrided conservatively; non-healable wounds should not be actively debrided, but loose non-viable tissue should be removed.[2]  
• Moisture management: healable wounds need a moist environment and dressings that promote moisture balance and healing; maintenance and non-viable wounds may benefit from moisture reduction, to help prevent infection.[2]  
• Advanced therapies: are not routinely indicated for maintenance or non-healable wounds.
• Although not suitable for all settings/realities, one may have an idea of the expected prevalence of the three categories: the distribution pattern of these three categories was studied by Woo et al in a prospective cohort study that included 111 home care patients with lower leg and foot ulcers.[5] Authors assessed the patients and utilized a handheld Doppler to measure either the ankle-brachial pressure index (ABPI) for leg/foot ulcer or toe pressure for foot ulcers. Results showed that Woo et al[5]:
• Healable ulcers (that is, had a demonstrated ability to correct the cause and achieve adequate circulation for healing) were present in 69% of the subjects
• Non-healable ulcers were present in 5.2% of the subjects
• Maintenance ulcers were present in 24.9% of subjects 

DETERMINING THE HEALABILITY OF A WOUND

Comprehensive patient assessment

• In order to determine healability of a wound, a comprehensive patient and wound assessment should be performed first, including history and physical examination, patient's concerns and blood supply assessment.

Framework for determining healability of an ulcer

(*) As determined by comprehensive patient assessment; (**) Assess blood supply with history and physical, if ulcer on lower extremity, utilize bedside non-invasive arterial tests

Modified from Sibbald RG et al. 2011.[1]       

Guidance on how to answer questions of the Framework for Determining Healability of an Ulcer

The tables below provide guidance on how to answer the 3 questions of the framework.[1][2][6][7][8][9]