Why should wounds be assessed and managed at home, particularly in patients with limited mobility, diabetes mellitus, peripheral arterial disease, or cognitive impairment?

Rationale for Home-Based Wound Assessment and Treatment

Home-based wound assessment and treatment is strongly justified because it eliminates barriers to care for patients with limited mobility, enables daily wound surveillance that is critical for early infection detection, and provides access to effective home-based advanced therapies like topical oxygen therapy that have demonstrated superior healing rates without requiring daily visits to specialized centers. 1

Primary Justifications for Home-Based Care

Access and Mobility Barriers

• Patients with limited mobility, diabetes mellitus, peripheral arterial disease, or cognitive impairment face substantial barriers to accessing facility-based wound care 1
• These populations require frequent wound assessment (every 2-5 days initially for outpatient wounds) which becomes logistically impossible when transportation or mobility is limited 2
• Home-based care eliminates the need for repeated travel to specialized centers, which is particularly important for patients requiring 30-45 minute supervised exercise sessions at least 3 times weekly for peripheral artery disease management 1

Daily Wound Surveillance Requirements

• Daily foot inspection is a fundamental recommendation for patients with PAD and diabetes mellitus, which is only feasible in the home setting 1
• Early detection of wound infection requires monitoring for subtle signs including increased exudate, odor, pain, surrounding erythema, warmth, or purulent drainage at every dressing change 2
• Prompt recognition of foot infection is critical to avoid amputation, and home-based daily inspection enables earlier detection than intermittent clinic visits 1

Availability of Effective Home-Based Advanced Therapies

• Topical oxygen therapy devices provide home-based therapy rather than requiring daily visits to specialized centers, with very high patient participation, very few reported adverse events, and improved healing rates at 12 weeks 1
• Three types of topical oxygen devices are available (continuous-delivery, low-constant-pressure, and cyclical-pressure modalities), all suitable for home use 1
• Multiple high-quality RCTs and at least five systematic reviews support the efficacy of topical oxygen therapy for chronic diabetic foot ulcers, making it an attractive option for home-based advanced wound care 1

Clinical Advantages of Home Assessment

Comprehensive Wound Monitoring

• Home-based care allows implementation of the MEASURE framework: monitoring length, width, depth, area, exudate quantity/quality, wound bed appearance, pain levels, undermining, and edge/surrounding skin condition 3
• Regular reassessment of progress toward healing with appropriate modification of interventions is necessary and more feasible with home-based care 3
• Wounds should be reassessed at least weekly to evaluate healing progress, identify signs of biofilm or persistent infection, and adjust treatment accordingly 4

Patient Education and Self-Care

• Home-based care facilitates teaching patients about healthy foot behaviors including daily inspection, wearing shoes and socks, avoidance of barefoot walking, and proper footwear selection 1
• Patients can be counseled about self-foot examination and healthy foot behaviors more effectively in their own environment 1
• Initial treatment recommendations including daily foot inspection, use of moisturizers for dry scaly skin, and avoidance of self-care of ingrown nails and calluses are best implemented at home 1

Early Infection Recognition

• Home care enables detection of subtle infection signs that may be missed with less frequent clinic visits, particularly in patients with diabetes and peripheral neuropathy where infection presentation is more subtle 1
• Infection is suspected if patients present with local pain/tenderness, periwound erythema, edema, induration, fluctuation, pretibial edema, discharge, foul odor, visible bone, or systemic inflammatory signs 1
• Early detection through home surveillance allows prompt treatment before progression to severe infection requiring hospitalization 5

Structured Home-Based Exercise Programs

Evidence for Community/Home-Based Programs

• Structured community or home-based exercise programs take place in the personal setting of the patient rather than clinical settings, with self-direction and guidance from healthcare providers 1
• These programs prescribe exercise regimens similar to supervised programs, with patient counseling ensuring understanding of how to begin, maintain, and progress the walking difficulty 1
• Programs may incorporate behavioral change techniques such as health coaching or use of activity monitors to enhance adherence 1

Critical Caveats for Home-Based Care

When Hospitalization is Required

• Hospitalization should be considered for patients with severe infection, systemic toxicity, metabolic instability, rapidly progressive infection, substantial necrosis, critical ischemia, or inability for self-care 2
• Patients with signs of foot infection should be referred urgently to a foot care specialist or interprofessional team 1
• Individuals with any open ulceration or unexplained swelling, erythema, or increased skin temperature require urgent specialist referral 1

Need for Interdisciplinary Coordination

• While home-based care is appropriate for many patients, treatment of chronic wounds is best managed in an interprofessional setting 1, 6
• Prompt referral to an interdisciplinary care team is beneficial for patients with PAD and signs of foot infection 1
• An interdisciplinary team should include wound care specialists, infectious disease, vascular surgery, and potentially plastic surgery for complex wounds 4

Limitations Requiring Facility-Based Care

• Hyperbaric oxygen therapy requires specialized centers and cannot be delivered at home, though evidence for its efficacy is limited 1, 4
• Negative pressure wound therapy, while useful for deep large wounds, may require initial facility-based setup and monitoring 6, 4
• Revascularization procedures for ischemic wounds must be performed in facility settings when ABI <0.5, ankle pressure <50 mmHg, or toe pressure <30 mmHg 2, 4