Hard-to-Heal Wounds: Steps for Interventions

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Delayed wound healing occurs in various wound types and in patients with significant comorbidities. Hard-to-heal wounds have proven to be a challenging and worldwide crisis resulting in high financial burdens.

The term “hard-to-heal wound” is a wound that fails to heal with standard therapy in an orderly and timely manner and may be used to replace the term “chronic wound.” This term applies to both acute and chronic wounds and encompasses all wounds that are “stalled” or delayed, and it is known that the majority of these wounds contain biofilm.1,2

The wound healing process should progress through four phases: hemostasis, inflammation, proliferation, and remodeling or maturation. Inflammation is necessary for healing but is harmful if prolonged or stimulated by other causes, such as infection; it is in this phase that wound healing often stalls. Wounds that do not move through the four phases are considered hard to heal. Other factors than can cause stalled healing include the presence of comorbidities, severe pain, sex, age, reduced mobility, and a history of wounds. Wound size, depth, location of the wound, and wound duration also impact the healing process as a result of the presence of biofilm.3

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Patient evaluations should be conducted regularly, but if a wound stalls, it is important to perform a reassessment. Patient assessments should be accurate and detailed for treatment to be planned effectively.4

Identifying Barriers to Wound Healing and Creating a Plan of Care

The initial assessment should include wound assessment, diagnosis, and considerations of comorbidities, medications, and resource requirements. Resource, skill, and concordance issues—such as equipment, dressings, specialists or skills, mental state, pain, and patient tolerance—should be considered. Systemic and/or regional issues that may affect outcomes such as ischemia, paralysis, or deformity are important in creating a plan of care.3

Action plans should not be static; they should be consistently re-evaluated as the patient heals or fails to heal and updated to address the evolving status of the wound. When measuring wound healing outcomes, the key issues to evaluate are whether symptoms have been reduced, goals have been met, wound size has reduced, and the wound bed tissue and periwound or wound edges have improved.3

Nutrition is a vital part of wound healing. The nutritional assessment is essential in closing potential gaps in patient planning and reducing risk of complications. Utilizing a screening tool and nutritional assessment will help identify risks for malnutrition and identify supplemental needs. Various nutritional supplements (liquid formulas, powders, tablets, etc.) are designed to correct nutritional deficiencies and enhance metabolic levels needed for wound healing. Always consult a registered dietitian for complete nutritional assessment recommendations.

Strategies for wound patients should include supporting and promoting wound healing with macronutrients (protein, carbohydrate, fat) and micronutrients (vitamins and minerals). Water is a vital component of nutrition and is often referred to as the “forgotten nutrient.”

Offloading diabetic foot ulcers and other foot wounds is critical in moving them toward a healing trajectory. The gold standard for offloading diabetic foot ulcers is total-contact casting, but this treatment modality is not always used for reasons such as the clinical setting. Various offloading devices are available, such as half shoes, healing sandals, removable cast walkers, and custom-built braces. Selecting the appropriate offloading device can be challenging for providers. Many factors play into product selection, such as the location and type of foot ulcer, foot deformity, patient activity level, ambulatory status, resources available, patient preferences, and patient tolerance level.

Turning and repositioning comprise changes in a person’s position with or without assistance at frequent time intervals to relieve pressure on bony prominences, and they are key measures in pressure injury prevention. The goal of turning and repositioning is to reduce, relieve, or redistribute pressure away from the at-risk area. Turning and repositioning also ensure that general tissue integrity and adequate blood supply are maintained to the area. It is vital to identify a person’s risk status and implement preventative measures early on to avoid development of pressure injury.5

Infection or Biofilm
Hard-to-heal wounds with high loads of bacteria or the presence of biofilm can lead to infection if not managed early on. Wound infection is diagnosed by clinical assessment of the wound and the whole patient. There is no single test that will diagnose infection. Clinicians must use their clinical judgment to interpret signs and symptoms of infection. Classic signs of wound infection include6:

  • Inflammation
  • Local heat
  • New or increasing pain
  • Advancing redness
  • Swelling
  • Purulence

Biofilms cannot be identified with the naked eye; therefore, detecting and managing biofilms pose a challenge for clinicians. To assess the wound bed accurately, clinicians must be able to identify viable (granulation, epithelial) and non-viable (slough, eschar) tissue. Non-viable tissue impairs wound healing and should be removed.

Early identification of potentially infected wounds allows for the application of interventions to manage and resolve infection. High numbers of bacteria delay healing and may increase exudate. Most hard-to-heal wounds contain biofilm; steps should be taken early on to prevent the development of biofilm or to manage it once suspected. Biofilms increase the risk of infection through possible increased microbial virulence, antibiotic or antimicrobial resistance, and tolerance, as well as when host defenses are impaired by factors such as diabetes and obesity.

There is no-one-size-fits-all solution for the treatment of biofilms or a gold standard test to determine the presence of biofilm in a wound.7 Evidence suggests that physical removal techniques such as debridement and vigorous physical cleansing are the best methods for reducing biofilm and bioburden.8 However, no debridement method or cleansing technique is likely to remove all a biofilm; thus, biofilm has the potential to re-grow and re-form mature biofilm colonies in a matter of days.9 Utilizing an antibiofilm strategy such as wound hygiene may help to prevent the re-formation of biofilm. The stages of wound hygiene are (1) cleanse, (2) debride, (3) refashion the wound edges, and (4) dress the wound. This strategy helps reduce antibiotic usage, as well as prevent and manage existing biofilms that can lead to infection.3

Monitoring hard-to-heal wounds requires regular reassessment and practical knowledge of the diagnostic process and appropriateness of the treatment plan. If there has been no wound healing progress in two to four weeks, review the treatment plan and ensure that current treatments have been correctly applied and that the patient has adhered to the plan of care. Patients should also be involved in their care and decision making to promote better results. Treatment outcomes should be evaluated and designed for the specific wound type.2,3


Hard-to-heal wounds have created an ongoing global crisis that challenges clinicians while health care costs are racking up. It is imperative to be proactive and identify factors and potential barriers that stall wounds early on. In managing patients with hard-to-heal wounds, it is paramount to be consistent with wound care basics. Regularly monitoring wounds and adjusting the plan of care as necessary are also essential in optimizing wound healing outcomes.

January is Infection Control and Wound Management Month

1. Troxler M, Vowden K, Vowden P. Integrating adjunctive therapy into practice: the importance of recognising ‘hard-to-heal’ wounds. World Wide Wounds 2006. http://www.worldwidewounds.com/2006/december/Troxler/Integrating-Adjunct.... Accessed December 21, 2020.
2. Murphy C, Atkin L, Swanson T, et al. International consensus document. Defying hard-to-heal wounds with an early antibiofilm intervention strategy: wound hygiene. J Wound Care. 2020;29(Suppl 3b):S1–28.
3. Vowden P. Hard-to-heal wounds made easy. Wounds Int. 2011;2(4). https://www.woundsinternational.com/uploads/resources/8b209a588e74f81cc9....
4. Stremitzer S, Wild T, Hoelzenbein T. How precise is the evaluation of chronic wounds by healthcare professionals? Int Wound J. 2007;4(2):156-611.
5. National Clinical Guideline Centre (UK). The Prevention and Management of Pressure Ulcers in Primary and Secondary Care. London: National Institute for Health and Care Excellence (UK); 2014 Apr. (NICE Clinical Guidelines, No. 179.) 9, Repositioning. Available from: https://www.ncbi.nlm.nih.gov/books/NBK333122/
6. Swanson T, Grothier L, Schultz G. Wound infection made easy. Wounds Int. 2014. https://www.woundsinternational.com/resources/details/wound-infection-ma.... Accessed December 22, 2020.
7. World Union of Wound Healing Societies (WUWHS). Florence Congress, Position Document. Management of Biofilm. London: Wounds International; 2016.
8. Wolcott RD, Kennedy JP, Dowd SE. Regular debridement is the main tool for maintaining a healthy wound bed in most chronic wounds. J Wound Care. 2009;18(2):54-56.
9. Wolcott RD, Rhoads DD. A study of biofilm-based wound management in subjects with critical limb ischaemia. J Wound Care. 2008; 17(4): 145-55.

The views and opinions expressed in this blog are solely those of the author, and do not represent the views of WoundSource, Kestrel Health Information, Inc., its affiliates, or subsidiary companies.

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