INTRODUCTION

Overview

This topic provides a sample policy on Wound Management. It serves as a starting point for organizations to tailor according to their specific needs and care settings, and shall not be considered as a detailed description of all elements that may be required by an organization.  It is recommended that all organizational stakeholders, including Quality and Legal departments provide input in the development and updates of wound care policies and procedures.  

WOUND MANAGEMENT

Goal

• To establish guidelines for the comprehensive management of wounds, ensuring optimal patient outcomes through standardized practices, effective treatment strategies, and appropriate documentation.

Scope

• This policy applies to all healthcare providers involved in the assessment, treatment, and management of patients with wounds within the wound care program.

Policy Elements

• All patients and wounds will be managed according to evidence-based practices to promote healing, prevent infection, and minimize complications. This includes proper assessment, treatment, documentation, and follow-up care. See operational policy "Wound Assessment, Documentation and Photography".
  
• A wound treatment plan will be initiated for a patient at the time of admission or upon development of a wound. The patient's treatment plan will be evaluated and revised as necessary, based on the principles outlined below.

Procedures

• A. Establishing Goals. See topics "How to Determine Healability of a Chronic Wound" and  "Standard of Care: Foundations for Wound Management".
• Collaborate with the patient, family, caregivers, and providers to establish realistic goals related to wound management.
• If wound healing is not a realistic goal, develop a care plan aimed at minimizing pain, odor, and infection while optimizing quality of life.
• If wound healing is achievable, incorporate the following interventions into the care plan.
• B. Control/Eliminate Causative Factors
• C. Optimize Nutrition:
• Conduct a nutritional screening upon admission per the nutritional assessment policy and procedure.
• Consult a registered dietitian (RD) as per the nutritional assessment policy and procedure.
• Reassess and consider an RD consult if the wound does not improve within one week of optimal wound management.
• D. Pain Management:
• Assess, prevent, or manage pain as needed.
• E. Tissue Management:
• Remove devitalized tissue when appropriate and if perfusion is adequate, through mechanical, autolytic, or enzymatic debridement.
• Heel ulcers with dry eschar need not be debrided if there are no signs of infection.
• Sharp debridement should be conducted by a qualified professional when indicated.
• F. Wound Cleansing:
• Cleanse the wound and periwound and at each dressing change using minimal mechanical force.
• Cleanse the wound before and after conservative sharp wound debridement
• Avoid using abrasive or antiseptic agents for cleaning wounds (avoid using cytotoxic agents for cleaning wounds).
• G. Wound Dressing and Environment:
• If blood supply to the wound site is adequate, maintain a moist wound bed.
• If blood supply is inadequate, keep the wound clean and dry.
• Manage exudate using appropriate dressings (see "Wound Prep and Dress Tool")
• Wound packing: eliminate dead space and avoid overpacking the wound.
• The purpose of wound packing is to fill dead space and avoid the potential of abscess formation by premature closure of the wound. Thus, packing materials should be conformable to the base and sides of the wound.
• For wound undermining:
• Impregnated gauze, alginate rope, or fiber gelling/hydrofiber dressings may be used to gently pack the space.
• For tunneling:
• Strip gauze may be used to fill narrow areas. Ensure packing is one continuous piece of gauze. Coil one end of the strip gauze on top of the dressing for easy removal.
• For exudative wounds:
• Absorbent packing dressings and wound fillers (e.g., alginate, fiber gelling/hydrofiber) are appropriate.
• For dry wounds:
• Use hydrating packing materials (e.g., hydrogel-impregnated gauze, collagen dressings).
• Packing technique:
• Fluff and loosely place packing material into the wound with a cotton-tipped applicator. Ensure packing material is in contact with wound edges and base.
• Avoid "overpacking" the wound.
• Keep periwound skin dry and intact.
• Consider caregiver time
• H. Manage Bacterial Colonization and Infection:
• Attend to the most contaminated wound last when treating multiple wounds on the same patient.
• Use clean techniques for chronic wounds and pressure ulcers/injuries (PU/PI).
• Consider a 2-week trial of topical antimicrobials for wounds not healing after 2 weeks of optimal care.
• Protect wounds from exogenous sources of contamination (e.g., feces).
• Immediately report any signs of infection to the provider.
• I. Patient/Family Education:
• Educate the patient, family, and/or caregivers on the following:
• Signs and symptoms of infection.
• Status or assessment of the wound.
• Skin inspection and preventive interventions for skin breakdown (refer to the policy on prevention of skin breakdown).
• PU/PI risk assessment findings (refer to the policy on prevention of skin breakdown).
• Dressing changes, if applicable.
• J.  Assessment of Treatment Plan Effectiveness
• Initial Evaluation: Ensure a comprehensive initial assessment is conducted and documented, to establish a baseline for wound characteristics and patient condition.
• Ongoing Monitoring:
• Regularly monitor and document wound progress at each dressing change or at least weekly.
• Assess for signs of healing, such as reduced wound size, decreased exudate, and improvement in surrounding skin condition.
• Use standardized documentation tools and measurements (e.g. same measurement and photography technique) to track changes in wound status accurately.
• Reassessing the Treatment Plan
• Generally, plan to reevaluate the treatment plan after 4 weeks of appropriate standard care or sooner if there are signs of a worsening clinical picture.
• Assess the effectiveness of the current modalities and their impact on wound healing.
• If there is no significant progress, if the wound condition worsens, or if there are new signs of infection or other complications, adjust the treatment plan accordingly.
• Consider possible barriers to healing such as infection, poor blood supply, or inadequate patient adherence to the care plan.
• Documentation:
• Record the reassessment findings, including any changes in wound characteristics and patient response to treatment.
• Update the wound care plan to reflect new strategies or interventions implemented.
• K. Adjunctive Therapies
• Consideration and Implementation:
• Patient Optimization: Ensure that the patient is optimized for wound healing, including addressing nutritional deficiencies, managing comorbid conditions, and ensuring adequate blood flow to the wound area.
• Complete wound bed preparation, including debridement of non-viable tissue (if no contraindications are present) and management of bioburden, to create an optimal environment for healing.
• Intervention Selection:
• Evaluate the evidence supporting use of each adjunctive therapy, potential risks, benefits, patient and clinician preference, cost-effectiveness, availability and insurance coverage of adjunctive therapies. Select appropriate adjunctive therapies accordingly.
• Compliance and Coverage:
• For Medicare beneficiaries, ensure eligibility and coverage requirements according to CMS Local Coverage Determinations/National Coverage Determinations (LCD/NCD).
• Document the rationale for selecting specific adjunctive therapies and obtain necessary approvals as required by regulatory and reimbursement guidelines.
• Monitoring and Evaluation
• Effectiveness of Adjunctive Therapies:
• Regularly assess the effectiveness of adjunctive therapies by monitoring wound progress and patient response.
• Adjust the treatment plan if the adjunctive therapy is not providing the expected benefits or if adverse effects occur.
• Continue to comply with clinical practice guidelines and CMS LCD/NCD to ensure appropriate use and reimbursement for adjunctive therapies.
• Documentation:
• Document all aspects of adjunctive therapy use, including the type of therapy, duration, patient response, and any modifications to the treatment plan.
• Maintain accurate records to support clinical decision-making and compliance with regulatory requirements.

REVIEW AND COMPLIANCE

• This policy will be reviewed annually and updated as necessary to reflect current best practices and guidelines in wound care management. Compliance with this policy will be monitored through regular audits and staff training sessions.

APPROVAL

Approved by: [Name]

Date: [Date]

Review Date: [Next Review Date]