Management of Nonhealable and Maintenance Wounds: A Systematic Integrative Review and Referral Pathway


To synthesize the evidence regarding nonhealable and maintenance wound management and propose an interprofessional referral pathway for wound management.


This continuing education activity is intended for physicians, physician assistants, nurse practitioners, and nurses with an interest in skin and wound care.


After participating in this continuing professional development activity, the participant will apply knowledge gained to:

1. Identify the ideas from the authors’ systematic review that could prove useful in understanding nonhealable and maintenance wound management.

2. Select evidence-based management strategies for nonhealable and maintenance wound management.


This systematic integrative review aims to identify, appraise, analyze, and synthesize evidence regarding nonhealable and maintenance wound management to guide clinical practice. An interprofessional referral pathway for wound management is proposed.


An electronic search of Scopus, Web of Science, PubMed, Academic Search Ultimate, Africa-Wide Information, Cumulative Index of Nursing and Allied Health Literature database with Full Text, Health Source: Consumer

Edition, Health Source: Nursing/Academic Edition, and MEDLINE was conducted for publications from 2011 to 2019. Search terms included (nonhealable/nonhealing, chronic, stalled, recurring, delayed healing, hard-to-heal) and wound types most associated with nonhealable or maintenance wounds. Published studies were hand searched by the authors.


Studies were appraised using two quality appraisal tools. Thirteen reviews, six best-practice guidelines, three consensus studies, and six original nonexperimental studies were selected.


Data were extracted using a coding framework including treatment of underlying causes, patient-centered concerns, local wound care, alternative outcomes, health dialogue needs, challenges within resource restricted contexts, and prevention.


Data were clustered by five wound types and local wound bed factors; further, commonalities were identified and reported as themes and subthemes.


Strong evidence on the clinical management of nonhealable wounds is limited. Few studies describe outcomes specific to maintenance care. Patient-centered care, timely intervention by skilled healthcare providers, and involvement of the interprofessional team emerged as the central themes of effective management of maintenance and nonhealable wounds.


Acute wounds follow an organized wound healing sequence and often heal between 3 and 4 weeks. When a wound is still present 4 weeks after wounding, it is defined as a chronic wound.1 Many research studies have been conducted on chronic wound management to address the rising demand for effective and affordable care. The healing trajectory of chronic wounds is expected to take 12 weeks.2,3 This period may be prolonged if the wound presents with an altered molecular environment, chronic inflammation or fibrosis,4 or uncorrected preexisting systemic factors.1

Patients who present with a wound not responding to conventional treatment are the topic of many best-practice guidelines using the umbrella terms “nonhealing” or “hard-to-heal.”5,6 Advanced modalities such as negative-pressure wound therapy (NPWT), ultrasound, laser, platelet-enriched plasma, hyperbaric oxygen (HBO), use of dermal substitutes, and reconstructive surgery are frequently advised as adjunctive intervention. Although appropriate to some wounds, there is a subgroup of patients for whom alternative approaches or endpoints are needed because advanced modalities either failed or are not feasible. This typically is the case when the patient presents with preexisting underlying systemic disease that cannot be controlled, is in need of additional physiologic support (eg, supplementary oxygen, renal dialysis), has difficulty performing activities of daily living without help, experiences financial and/or social difficulties, or lives in a resource-restricted environment without access to advanced care.

The wound bed preparation (WBP) paradigm2,7 guides wound care practitioners to determine wound healing potential as a vital first step of wound assessment. By accounting for both underlying causes and patient-centered concerns, providers can plan for realistic outcomes. The paradigm includes “problem wound” scenarios. Wounds with underlying cause(s) that cannot be corrected are categorized as nonhealable wounds (often attributable to critical ischemia, malignancy, or an untreatable underlying systemic condition).2,7 Wounds with correctable underlying cause(s) in the context of health system challenges (ie, lack of resources, skills, or expertise) or nonoptimal patient factors (ie, smoking, obesity, resistance to change) are categorized as maintenance wounds.2,7

Evidence-based guidance on nonhealable or maintenance wounds is needed. This systematic integrative review aims to identify, appraise, analyze, and synthesize evidence regarding nonhealable and maintenance wound management to guide clinical practice.


This study was granted ethical exemption (nr. 2019_19.8-5.3) by the University of South Africa Department of Health Studies Research Ethics Committee (no. REC-012714-039) because it did not involve human participants. The research question was: What is known from scientific literature regarding the management of nonhealable and maintenance wounds? …

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PROGETTO ITALIANO IN WOUND CARE 🇮🇹. SITO UFFICIALE DI LESIONI TOUR ®️. DAL 2017 Premio Eccellenze Italiane Assotutela 2020-2021.

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