Conclusions and Summary

Wound care is a medical and economic challenge to the health care systems worldwide. In an effort to improve outcomes, guidelines are evaluated according to strength of evidence to support a particular recommendation.

There are many recommendations for assessment, treatment, and follow-up for wound prevention and management. More general recommendations, such as “assess the wound” could easily cross over between guidelines. However, specific information on evidence-supported ways to assess and document wounds would require separate sets of sub-guidelines for various wound types. Similarly, efforts to assess risk factors, provide appropriate modern dressings, and develop realistic goals in communication with patients and their caregivers can be applied to many wound prevention and management guidelines.

The first paper (Levi et al) reviews literature to describe the management of pressure ulcers from a surgical point of view. The descriptions included items on pathogenesis, such as pressure, shear, and ischemic reperfusion damage; ulcer classification; risk factors; bacterial colonization and infection; and management approaches according to stage. Descriptions of flap surgeries were included along with management suggestions for post-operative complications. This paper summarizes management of the largest classification of ulcers from a particular point of view. This paper sets the framework and illustrates the need for standardization and guidelines based on evidence with consideration to the clinical experience of practitioners. A set of pressure ulcer management guidelines was recently updated from the RNAO[1] which has seven major classifications of recommendations. The level of evidence for most of the recommendations was at the lowest end, except for the use of nutritional supplements, assessment of pain, prevention of ulcers with specific mattresses, the use of pressure management in the operating room, control of bacterial infection, appropriate irrigation, dressing choices, and the use of selected adjunctive therapies as indicated. The guidelines were generally in agreement with the paper reviewed.

The second paper (Burrows et al) is an example of an updated guidelines publication that described recommendations for the management of venous ulcers. In venous wound care, the strongest evidence was found to support recommendations for physical assessment, compression therapy, surgical management, local wound care, and the inclusion of multiple disciplines in management activities. Lower levels of support were seen in the updated recommendations for taking a careful patient history and the assessment of pain, determining the cause of venous ulcers, medical therapy for chronic venous insufficiency, and patient communication to address their concerns. While this group of level C evidence (expert opinion) recommendations is worthwhile, there is more research needed to strengthen the support.