Management of Nonhealable and Maintenance Wounds: A Systematic Integrative Review and Referral Pathway.

GENERAL PURPOSE: To synthesize the evidence regarding nonhealable and maintenance wound management and propose an interprofessional referral pathway for wound management. TARGET AUDIENCE: This continuing education activity is intended for physicians, physician assistants, nurse practitioners, and nurses with an interest in skin and wound care. LEARNING OBJECTIVES: After participating in this continuing professional development activity, the participant will apply knowledge gained to:1. Identify the ideas from the authors' systematic review that could prove useful in understanding nonhealable and maintenance wound management.2. Select evidence-based management strategies for nonhealable and maintenance wound management. ABSTRACT: OBJECTIVEThis systematic integrative review aims to identify, appraise, analyze, and synthesize evidence regarding nonhealable and maintenance wound management to guide clinical practice. An interprofessional referral pathway for wound management is proposed. DATA SOURCES: An electronic search of Scopus, Web of Science, PubMed, Academic Search Ultimate, Africa-Wide Information, Cumulative Index of Nursing and Allied Health Literature database with Full Text, Health Source: ConsumerEdition, Health Source: Nursing/Academic Edition, and MEDLINE was conducted for publications from 2011 to 2019. Search terms included (nonhealable/nonhealing, chronic, stalled, recurring, delayed healing, hard-to-heal) and wound types most associated with nonhealable or maintenance wounds. Published studies were hand searched by the authors. STUDY SELECTION: Studies were appraised using two quality appraisal tools. Thirteen reviews, six best-practice guidelines, three consensus studies, and six original nonexperimental studies were selected. DATA EXTRACTION: Data were extracted using a coding framework including treatment of underlying causes, patient-centered concerns, local wound care, alternative outcomes, health dialogue needs, challenges within resource restricted contexts, and prevention. DATA SYNTHESIS: Data were clustered by five wound types and local wound bed factors; further, commonalities were identified and reported as themes and subthemes. CONCLUSIONS: Strong evidence on the clinical management of nonhealable wounds is limited. Few studies describe outcomes specific to maintenance care. Patient-centered care, timely intervention by skilled healthcare providers, and involvement of the interprofessional team emerged as the central themes of effective management of maintenance and nonhealable wounds.

This systematic integrative review aims to identify, appraise, analyze, and synthesize evidence regarding nonhealable and maintenance wound management to guide clinical practice. An interprofessional referral pathway for wound management is proposed. An electronic search of Scopus, Web of Science, PubMed, Academic Search Ultimate, Africa-Wide Information, Cumulative Index of Nursing and Allied Health Literature database with Full Text, Health Source: Consumer Edition, Health Source: Nursing/Academic Edition, and MEDLINE was conducted for publications from 2011 to 2019. Search terms included (nonhealable/nonhealing, chronic, stalled, recurring, delayed healing, hard-to-heal) and wound types most associated with nonhealable or maintenance wounds. Published studies were hand searched by the authors. Studies were appraised using two quality appraisal tools. Thirteen reviews, six best-practice guidelines, three consensus studies, and six original nonexperimental studies were selected. Data were extracted using a coding framework including treatment of underlying causes, patient-centered concerns, local wound care, alternative outcomes, health dialogue needs, challenges within resource restricted contexts, and prevention. Data were clustered by five wound types and local wound bed factors; further, commonalities were identified and reported as themes and subthemes. Strong evidence on the clinical management of nonhealable wounds is limited. Few studies describe outcomes specific to maintenance care. Patient-centered care, timely intervention by skilled healthcare providers, and involvement of the interprofessional team emerged as the central themes of effective management of maintenance and nonhealable wounds.

The Ears of a Hippopotamus: Quality of Venous Leg Ulcer Care in Gauteng, South Africa.

OBJECTIVE: To describe venous ulcer care and wound care practices in Gauteng, a province of South Africa, according to the Donabedian structure-process-outcome quality improvement model. METHODS: Forty-eight facilities were selected randomly from public and private wound care practices in Gauteng. Structured interviews were conducted with care providers via questionnaire to assess the structural aspects of the Donabedian model. Within these facilities, investigators randomly selected 160 patient files and extracted data using a checklist to assess processes implemented and outcomes reached for patients who had previously presented with lower-leg venous ulcers. RESULTS: Facilities lack the necessary equipment to perform vital assessments. Handheld Dopplers were available in 66% (n = 48) of the facilities. Sixty-one percent (n = 48) of the personnel at the facilities indicated that they had no formal wound care training. Although the majority of files (92%, n = 147) indicated that an assessment tool was used, many elements were not evaluated comprehensively according to the best available evidence. Aspects such as smoking, body mass index, and anemia were assessed in fewer than 30% of the patients. Distinguishing between superficial and deep infection and the accompanying overuse of antimicrobials and antibiotics were among the challenges identified. Further, 71% of patients received compression therapy, although the ankle-brachial pressure index of only 30% of patients was known. In 27 cases (17%), the outcome was amputation. CONCLUSIONS: From this survey, it is evident that not all clinicians providing wound care in Gauteng are adequately trained or fully implementing best practice guidelines, and the consequences are detrimental to patients, particularly in terms of amputation. This article highlights the need for improved legislation and regulation for practitioners who deliver wound care services.