What is the ideal management of wound care for a patient in a hospital setting and how can a physician assistant contribute to managing chronic wounds?

Ideal Hospital-Based Wound Care Management and the Physician Assistant's Role

Optimal wound care in the hospital setting requires a nurse-led multidisciplinary team approach with standardized protocols focused on infection prevention, appropriate debridement, moisture-balanced dressings, and early patient/caregiver education—areas where physician assistants can provide critical coordination, procedural expertise, and continuity of care. 1

Core Components of Hospital Wound Care

Initial Wound Assessment and Management

All wounds require systematic evaluation for underlying structural damage (nerves, tendons, vasculature) and meticulous foreign body removal to prevent complications and reduce malpractice risk. 2

• Cleanse wounds with sterile normal saline only—iodine or antibiotic-containing solutions are unnecessary 1
• Perform conservative debridement cautiously to avoid excising healthy tissue and increasing bone/tendon exposure 1
• Avoid aggressive surgical debridement in complex wounds, as this may impair healing and lead to chronic osteomyelitis or amputation 1
• Do not close infected wounds—approximation with Steri-Strips followed by delayed primary or secondary closure is preferred 1

Infection Management

Prompt diagnosis and treatment of wound infections is essential, as infections are the most common and most preventable hospital-acquired complication, directly impacting morbidity, mortality, and costs ranging from $1,300-$30,000 per infection. 3, 1

• Surgical debridement is mandatory for wounds with abscess, gas, or necrotizing fasciitis 1
• Not all wounds require antibiotics—many can be managed effectively with topical wound care alone 1
• Hospitalization is necessary for wounds with known or suspected superficial or deep infections 1
• Maintain wound dressings undisturbed for minimum 48 hours post-operatively unless leakage occurs 3

Wound Dressing Strategy

Maintain a moist wound bed while controlling drainage and avoiding tissue maceration, using nonadherent and absorptive dressings. 1

• Apply antimicrobial ointment with nonadherent dressings for wounds requiring topical management 1
• Consider negative pressure wound therapy (NPWT) after revascularization and minor amputation when primary closure is not feasible 1
• Delay wound closure with skin grafts until patients are stabilized, particularly in substance use contexts 1

Chronic Wound Management Algorithm

Step 1: Establish Adequate Perfusion

• Revascularization must precede definitive wound treatment in chronic limb-threatening ischemia 1
• Verify adequate blood supply (TcpO2 >30 mmHg) before initiating advanced therapies 4

Step 2: Optimize the Wound Bed

• Perform repeated wound assessment and frequent debridement to identify biofilm, infection, and determine optimal local care 1
• Debridement techniques include: surgical, sharp/conservative-sharp, autolytic, mechanical, enzymatic, or biosurgical methods 1
• Control edema and provide pressure offloading when appropriate 1

Step 3: Medical Optimization

Address modifiable host factors that directly impact healing outcomes: 1

• Smoking cessation
• Glycemic control in diabetes
• Nutritional optimization
• Cardiovascular risk factor modification
• Pain control

Step 4: Consider Adjunctive Therapies

For diabetic lower extremity ulcers that fail standard care, becaplermin gel 0.01% (REGRANEX) applied once daily with good ulcer care increases complete healing rates from 35-37% to 50% by 20 weeks. 4

• REGRANEX is indicated only for diabetic neuropathic ulcers extending into subcutaneous tissue with adequate blood supply 4
• REGRANEX showed no efficacy in pressure ulcers or venous stasis ulcers 4
• Hyperbaric oxygen therapy may be considered for nonhealing diabetic foot ulcers after revascularization 1

The Physician Assistant's Critical Contributions

Clinical Coordination and Team Leadership

Physician assistants serve as essential coordinators within the nurse-led multidisciplinary wound care team, facilitating communication between specialties and ensuring protocol adherence. 1, 5

• Coordinate daily multidisciplinary rounds in hospital-based wound care centers where colocation enables efficient quality care delivery 5
• Bridge communication gaps between nursing, surgery, infectious disease, vascular surgery, and rehabilitation services 1, 5
• Ensure continuity from outpatient clinic through admission, surgery, and post-operative care 5

Procedural Expertise and Direct Care

Physician assistants provide hands-on wound management including debridement, dressing changes, and minor procedures. 1, 2

• Perform conservative sharp debridement while preserving healthy tissue 1
• Execute wound closure techniques using appropriate sutures, adhesives, strips, or staples 2
• Manage post-operative wound complications and recognize early signs of infection 2

Patient and Caregiver Education

One-in-four patients develop complications within 14 days of discharge, making patient education a critical mortality and morbidity reduction strategy that physician assistants are uniquely positioned to deliver. 3, 1

• Implement active educational strategies (academic detailing, consensus building) rather than passive information delivery 3
• Teach patients to recognize early infection signs and understand when to seek medical attention 3, 2
• Provide wound care training for patients and informal caregivers managing chronic wounds at home 6
• Ensure 48-hour wound checks for all patients to optimize outcomes 2

Prevention and Risk Stratification

Early evaluation of perioperative SSI risk factors assists clinical decision-making and helps patients understand their individual risk profile. 3

• Assess patient-level risk factors: age, diabetes, smoking, obesity, malnutrition, immunosuppression 3
• Identify procedure-related factors: emergency surgery, contaminated wounds, prolonged operation duration 3
• Implement evidence-based prevention protocols to address the considerable variability in surgical wound care practice 1

Critical Pitfalls to Avoid

Overly aggressive debridement in complex wounds can lead to tendon/bone exposure, chronic osteomyelitis, and amputation—conservative tissue-preserving approaches are superior. 1

Applying advanced therapies like skin substitutes or becaplermin to actively infected wounds will fail—infection must be controlled first. 7, 4

Closing wounds prematurely (within 8 hours) without meticulous irrigation and prophylactic antibiotics increases infection risk, except for facial wounds managed by plastic surgery. 1

Failing to ensure adequate blood supply before chronic wound treatment wastes resources and delays healing—verify perfusion first. 1, 4

Passive patient education without behavior change strategies fails to modify established behaviors—use active educational workshops and consensus building. 3