Where to refer a patient with a new pressure ulcer?

Where to Refer Patients with New Pressure Ulcers

Most patients with new pressure ulcers can be managed in their current care setting with a multidisciplinary team approach involving nurses, physicians, dietitians, and physical therapists, without requiring specialist referral initially. 1

Initial Management in Current Setting

For newly diagnosed pressure ulcers, begin treatment immediately without specialist referral by implementing:

• Pressure redistribution: Use advanced static mattresses or overlays (strong recommendation, moderate-quality evidence) rather than alternating-air systems 1
• Wound dressings: Apply hydrocolloid or foam dressings to reduce wound size 1
• Nutritional support: Provide protein or amino acid supplementation at 1.2-1.5 g/kg/day 1
• Debridement: Remove all necrotic tissue, slough, and callus using sharp debridement when present 2
• Adjunctive therapy: Consider electrical stimulation to accelerate wound healing 1

When to Refer to a Wound Specialist

Immediate consultation is required for:

• Advancing infection requiring urgent intervention (spreading cellulitis, sepsis, or systemic signs of infection) 3
• Stage III-IV ulcers that may require surgical debridement or reconstruction 3
• Undrained abscess or unidentified necrotic soft tissue/bone 3
• Wounds requiring extensive debridement beyond bedside capabilities 3
• Atypical or recalcitrant wounds requiring biopsy to rule out malignancy (melanoma, Kaposi sarcoma) 3

Delayed consultation after 6 weeks if:

• The ulcer fails to show signs of healing after 6 weeks of optimal standard management 3
• Before referring, verify that all standard interventions have been properly implemented: adequate pressure offloading, proper debridement, appropriate dressings, nutritional supplementation, adequate limb perfusion, and infection control 3

Additional Specialist Consultations

Vascular surgeon: When vascular compromise is suspected or limb perfusion is inadequate 3

Podiatrist or orthopedic surgeon: For pressure offloading evaluation, especially with diabetic foot ulcers or complex anatomical considerations 3

Infectious disease specialist: For suspected osteomyelitis or polymicrobial infections requiring coverage of Gram-positive, Gram-negative, and anaerobic organisms 1, 2

Common Pitfalls to Avoid

• Do not delay consultation beyond 6 weeks while continuing ineffective standard treatments 3
• Do not overlook underlying osteomyelitis as a cause of treatment failure—this requires systemic antibiotics and potentially surgical intervention 2, 4
• Do not miss malignancy masquerading as a pressure ulcer in atypical presentations 3
• Do not refer prematurely before implementing basic standard care measures, as most ulcers will respond to appropriate local wound care 1

Special Populations Requiring Earlier Consultation

• Patients with ischial ulcers: These have higher dehiscence rates after surgical repair and may benefit from earlier specialist involvement 3
• Patients with suspected vascular compromise: Earlier referral to vascular surgery may prevent treatment failure 3