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How to Determine Healability of a Chronic Wound

How to Determine Healability of a Chronic Wound

How to Determine Healability of a Chronic Wound

INTRODUCTION

Overview

This topic serves 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

1. Can underlying cause be treated?(*) 2. How is blood supply to the wound?(**) 3. Co-existing medical conditions/drugs... Then wound is:
Yes Adequate ...are not an obstacle for healing Healable
No  Adequate ...may or may not prevent healing Maintenance
No Usually inadequate ...may inhibit healing Non-healable

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]

1. Can the underlying cause be treated? 
Common ulcers......their main causes...      ....and main interventions to address the causes
Venous ulcer
 Venous hypertension
 Chronic venous insufficiency
   Compression therapy to promote healing and prevent recurrence
Pressure ulcer/injury Intense and/or prolonged pressure 
 Pressure in combination with shear
 Low tolerance of soft tissue for
 pressure and shear
   Pressure redistribution
   Patient repositioning
   Optimize nutrition
   Manage excessive moisture and shear
 Peripheral neuropathy, local
 pressure, friction, shear forces
   Eliminate pressure/ friction/ shear forces (offloading, correction of foot deformities)
   Tighten glycemic control
   Address nutritional deficiencies
If causes can be treated, ulcer may be healable, provided blood supply is adequate and no other obstacles preventing wound from healing exist
2. How is the blood supply to the wound? 
 If on lower extremity, are there clinical signs and symptoms of acute or critical limb ischemia? 
  Acute limb ischemia (onset < 2 weeks): six ‘Ps’ = pain, pallor, pulselessness, poikilothermia (cold), paresthesias, and paralysis.
  Critical limb ischemia (onset > 2 weeks): Foot with ischemic rest pain, non-healing wound/ulcers, or gangrene attributable to objectively
 proven arterial occlusive disease.
 If on lower extremity, is objective assessment with an appropriate non-invasive arterial test indicative of severe ischemia? 
 For persons without diabetes: inadequate blood supply is objectively confirmed by one of the tests below: 
        - Ankle-brachial index (ABI) < 0.5
        - Skin perfusion pressure (SPP) < 30mmHg
        - Transcutaneous oxygen (TcPO2) < 30mmHg 
        - Absolute systolic ankle pressure < 50 mmHg 
        - Toe pressure < 30mmHg
 For persons with diabetes: ABI can be falsely elevated, thus any of the other tests listed above except for ABI may be used to assess 
 wound blood supply. If blood supply is inadequate refer to vascular specialist. See 'Bedside non-invasive arterial tests' 
If answer is YES to any of these questions, ulcer is likely non-healable 
3. Does the patient have co-existing medical conditions/ drugs that....
...include comorbidities related to:    If so, ask questions below:
Cancer
   Is the ulcer a malignant ulcer?      
Major organ failure   Does the patient have end stage heart, lung, kidney or liver disease?                                    
If answer is YES to any of these questions, ulcer is likely non-healable 
...include co-factors related to:          If so, ask questions below:
Diabetes Does the patient have an HgbA1c value > 6.5? 
Venous disease Does the patient have venous leg ulcer and is unable to tolerate compression?
Lymphedema Does the patient have lymphedema and is unable to tolerate compression?
Immunosuppressive state
 Does the patient have a condition leading to immunosuppression? 
 (e.g., HIV, chronic illness for > 6 months)
Morbid obesity Does the patient have a BMI of or > 40?
Nutritional deficiency Does the person have 2 or more of the 6 parameters below? 
   1. Insufficient energy intake; 2. unintended weight loss; 3. loss of muscle mass; 4. loss of
   subcutaneous fat; 5. localized or generalized fluid accumulation that may mask weight loss;
   6. decreased functional status measured by hand grip
 Does the patient have altered serum protein values? 
   Normal values: albumin: 3.5-5.0 gm/dL, pre-albumin: 16-40 mg/dL
Cognition Does the patient have cognitive deficits that impair their ability to adhere to treatment?
Lack of adherence to plan Does the patient have any other co-factors that prevent adherence to care plan? 
  (e.g., uncontrollable chronic pain, psychosocial issues, lack of caregiver resources, etc)
...include drugs such as:                  If so, ask questions below:  
Steroids Has the medication been in use for more than 3 months? 
 Will it need to continue to be used during the wound management period?
Chemotherapy agents Will chemotherapy need to be continued during the wound management period?                
 Radiotherapy Will radiotherapy to the area of the wound need to be continued during the wound
  management period? 
 Has the wounded area received high doses of radiation in the past?    
If answer is YES to any of these questions, ulcer is likely 
maintenance
 
until conditions are mitigated or reversed
If answer is YES to any of these questions, ulcer is likely maintenance until effects on wound have been mitigated 
...include issues related to:                  If so, ask questions below:
Use of tobacco Does the patient smoke?
Mobility Does the person have limited mobility? 
 Does the person have lack of caregiver resources to ensure adherence to repositioning schedule?
Financial resources Does the patient have financial limitations preventing adherence to the prescribed care plan?
If answer is YES to any of these questions, ulcer is likely maintenance until life style issues are resolved  
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NOTE: This is a controlled document. This document is not a substitute for proper training, experience, and exercising of professional judgment. While every effort has been made to ensure the accuracy of the contents, neither the authors nor the Wound Reference, Inc. give any guarantee as to the accuracy of the information contained in them nor accept any liability, with respect to loss, damage, injury or expense arising from any such errors or omissions in the contents of the work.

REFERENCES

  1. Sibbald, R Gary; Goodman, Laurie; Woo, Kevin Y; Krasner, Diane L; Smart, Hiske; Tariq, Gulnaz; Ayello, Elizabeth A; Burrell, Robert E; Keast, David H; Mayer, Dieter; Norton, Linda; Salcido, ... et al. Special considerations in wound bed preparation 2011: an update©. Advances in skin & wound care. 2011;volume 24(9):415-36; quiz 437.
  2. Sibbald RG, Elliott JA, Ayello EA, Somayaji R et al. Optimizing the Moisture Management Tightrope with Wound Bed Preparation 2015©. Advances in skin & wound care. 2015;volume 28(10):466-76; quiz 477-8.
  3. Weir, D. et al. Sensible Decision Making Wound Management and Prevention. 2019;volume 65(6):.
  4. Sibbald RG, Goodman L, Norton L, Krasner DL, Ayello EA et al. Prevention and treatment of pressure ulcers. Skin therapy letter. 2012;volume 17(8):4-7.
  5. Woo K, Alavi A, Botros M, IIWCC, Kozody L, Fierheller M, Wiltshire K, Hons, Sibbald G, Derm FRCPC et al. A Transprofessional Comprehensive Assessment Model for Persons with Lower Extremity Leg and Foot Ulcers Wound Care Canada. 2007;volume 5 (suppl 1)():S35-47.
  6. Gerhard-Herman, Marie D; Gornik, Heather L; Barrett, Coletta; Barshes, Neal R; Corriere, Matthew A; Drachman, Douglas E; Fleisher, Lee A; Fowkes, Francis Gerry R; Hamburg, Naomi M; Kinlay, S... et al. 2016 AHA/ACC guideline on the management of patients with lower extremity peripheral artery disease: executive summary: A report of the american college of cardiology/american heart association task force on clinical practice guidelines. Circulation. 2017;volume 135(12):e686-e725.
  7. South West Regional Wound Care Program. Determining Healability Tool . 2014;.
  8. Mills, Joseph L; Conte, Michael S; Armstrong, David G; Pomposelli, Frank B; Schanzer, Andres; Sidawy, Anton N; Andros, George; Society for Vascular Surgery Lower Extremity Guidelines Committ... et al. The Society for Vascular Surgery Lower Extremity Threatened Limb Classification System: risk stratification based on wound, ischemia, and foot infection (WIfI). Journal of Vascular Surgery. 2014;volume 59(1):220-34.e1.
  9. Hinchliffe, R J; Brownrigg, J R W; Apelqvist, J; Boyko, E J; Fitridge, R; Mills, J L; Reekers, J; Shearman, C P; Zierler, R E; Schaper, N C; International Working Group on the Diabetic Foot et al. IWGDF guidance on the diagnosis, prognosis and management of peripheral artery disease in patients with foot ulcers in diabetes. Diabetes/Metabolism Research and Reviews. 2016;volume 32 Suppl 1():37-44.
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