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Chronic and non-healing wounds are those that do not progress through the healing process in a timely or predicted manner. They are a global problem and are becoming harder to treat. Medicare estimates that over 8 million Americans have chronic wounds that cost the national health care system between $18.1 and $96.8 billion dollars annually.

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Chronic and complex wounds of the lower extremity frequently recur. It is difficult to determine the precise recurrence rate across patients with different lower extremity wound types, including diabetic foot ulcers, arterial ulcers, pressure injuries, and venous ulcers. However, we know that recurrence rates are high; nearly 40% of patients with an ulcer will develop a recurrence within one year of healing. This percentage is 60% at three years after healing and 65% at the five-year mark.

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Growth factors and cytokines are secreted by the cells and are essential to the complex wound healing and tissue regeneration process. This process involves the interplay of growth factors with chemokines, cytokines, and other signaling molecules. Although there have been numerous advances that have increased our understanding of wound healing, the exact tissue regeneration mechanisms following an injury have yet to be determined.

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Angiogenesis: The complex process in which the growth of normal, stable, and functional vessels is critically dependent on the coordinated interplay in space and time of different cell types and growth factors. This process involves the forming of new blood vessels from preexisting vessels by invading the wound clot to organize in a microvascular network throughout granulation tissue.

Autologous cell therapy: A therapeutic intervention that uses an individual’s cells, which are cultured and expanded outside of the body and reintroduced into the donor as a bioengineered skin substitute to aid in wound closure.

Immunomodulation: Therapeutic interventions aimed at modifying the immune response. Healing in chronic and complex wounds can be enhanced with immunomodulating agents.

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Wound photo documentation captures a visual reference and helps provide a timeline for healing status for the patient’s medical record. Pictures in wound care can be used to ensure accuracy of measurements, to encourage objective assessments, to reduce the risk of misinterpreting the cause of the wound, as a teaching resource to both patients and new clinicians, and to encourage the use of evidence-based practices. In providing wound care from a distance such as through telewound services, wound photos are taken to help in diagnosis and treatment. The quality of the photo may vary depending on the person taking the photo (clinician, caregiver, patient). However, the emphasis is on using the photo in conjunction with the patient’s clinical wound descriptions and medical history, thereby evaluating the wound, treatment plan, and healing progress. Clinical documentation is a legal, moral, economic, and professional responsibility. Wound photos supplement the written record but should never replace it. Despite the value of wound photography, not all health care settings provide wound photo documentation software or include this as a part of their wound care policies and procedures. The facility or agency should always discuss this issue with the risk manager or legal counsel because each state has its own rules on the use of images.

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Benchmarking: Benchmarking is using published wound outcomes reported by others as a framework within which to assess your facility’s outcomes and potential need for improved care.

Chronic wound: A chronic wound is a wound that has failed to progress towards healing in 30 days or more. There are varying factors that can cause a wound to stall, such as infection or a prolonged inflammatory phase. It is important to document the wound’s progress, any stalling factors, and interventions put into place to restart the healing cascade.

Digital wound measuring tool: Digital wound measuring tools include devices that may provide two- or three-dimensional assessment (length, width, depth, surface area) of a wound with electronic medical record software integration and may not require physical contact.

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Multiple electronic medical record (EMR) systems are being utilized across the health care spectrum. However, these systems do not always contain documentation elements that capture specialty care such as wound care. Workflow and synchronization within the EMR are necessary to manage and support good wound care outcomes. When setting up the EMR system at your facility, consider documentation elements such as built-in templates, algorithms, and designs that are being used in the workflow analysis. Regulations should guide your decisions in this process because not all health care settings have the same requirements (outpatient wound care clinics, long-term care, home health care, etc.).

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Up to 20% of all US medicolegal claims and more than 10% of settlements are wound related. Documentation is essential for all health care settings; however, there are differences in each setting. Knowing your clinical setting’s requirements from a documentation standpoint is critical in meeting documentation needs. Every setting has policies and procedures for skin and wound care that reflect current clinical and operational guidelines approved by the facility. Facilities should consider standardized workflow to provide a systematic process to capture, generate, track, store, retrieve, and retain documents of the medical record. These clinical workflows should be reviewed and updated routinely to avoid denial of claims based on missing documentation elements.

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Continuity of care has always been the heart of practicing medicine and is especially important for wound care. Continuity of care in wound management equals better outcomes, cost-effectiveness, and satisfaction rates from patients. In providing continuity of care, wound care providers face challenges of time constraints to become acquainted with their patient and to build a rapport while simultaneously learning about their patient’s wound history. The electronic medical record (EMR) is vital in supporting continuity of care. These platforms enable the medical record to be in a central place for providers and clinicians to access, modify, and use to communicate about their patient’s progress.

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Prevention and management of biofilm and infection in wounds can be supported by using antimicrobial and antibiofilm dressings. Internationally, there has been a rising prevalence of antibiotic-resistant organisms; this has resulted in increased incorporation of antimicrobial dressings in wound management. These dressings offer many advantages because they are easy to use, are readily available, have a decreased risk of resistance, and deliver sustained release of antimicrobial agents to the wound bed. This mode of action allows for a lower concentration of the agent and thereby lowers the possibility of toxicity to host cells.

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