Guidelines for the best care of chronic wounds

Uniformity of quality of the care rendered to patients with wounds has been a paramount desire of clinicians, government regulators, and third-party payers. Whether it was for the best patient care, minimum standards to be met, or reimbursable therapies, guidelines for treatment have been sought. One of the goals of the founders of the Wound Healing Society (WHS) in 1991 was to establish guidelines for wound treatment. One of the first tasks of the WHS Board of Directors following the first annual meeting in Galveston, Texas, was to appoint a committee to develop treatment guidelines. This committee, under the direction of Gerald S. Lazarus, MD, realized that uniform care guidelines could not be developed because there was no uniformity in the definitions of wounds, wound healing, or wound attributes. The committee developed the necessary definitions and after holding several public hearings, published the ‘‘Definitions and Guidelines for Assessment of Wounds and Evaluation of Healing’’ in 1994. This publication defined a chronic wound as one that has failed to proceed through an orderly and timely reparative process to produce anatomic and functional integrity or that has proceeded through the repair process without establishing a sustained anatomic and functional result. Simply stated, wounds may be classified as those that can repair themselves or can be repaired in an orderly and timely process (acute wounds) and those that do not (chronic wounds). Because of continued interest by the WHS and a desire by the United States Food and Drug Administration (FDA), a Government Affairs Committee chaired by Richard A. F. Clark, MD, worked in conjunction with the FDA to establish guidelines for the conduct of clinical trials in wound healing. In 2003, the Wound Healing Foundation (WHF) distributed a Request for Application (RFA) for a grant to develop for the best treatment of chronic wounds. The WHS, with Adrian Barbul, MD, as Principal Investigator, was the successful applicant and became the grantee. The chronic wounds chosen for treatment guideline development were venous, diabetic, arterial, and pressure ulcers. Separate panels were appointed to develop the respective guidelines. Each panel was composed of academicians, private practice physicians, podiatrists, nurse clinicians, research nurses, industrial scientists, and epidemiologists representing most scientific, medical, and nursing societies/associations that have wound care as a major scope of interest. The charge to each panel was to develop guidelines for the best wound treatment as supported by evidence from the literature. To formulate these evidence-based guidelines, a common methodology was agreed upon by all four panels. Previous guidelines, meta-analyses, PubMed, MEDLINE, EMBASE, The Cochrane Database of Systematic Reviews, recent review articles of treatment of the ulcer under consideration, and the Medicare/CMS consensus of usual treatment of chronic wounds were all reviewed for evidence. Guidelines were formulated, underlying principle(s) enumerated, and evidence references listed and coded. The code abbreviations for evidence citations were as follows: