Remote wound care

INTRODUCTION — 

Remote wound care (eg, telehealth) is an alternative to traditional wound care practices that can help ease patient and clinician burdens and may improve patient and clinician engagement and satisfaction.

The aspects of telehealth management important to the care of wounds requiring an extended period of care are reviewed. The clinical evaluation and specific wound management, which varies depending on the etiology of the wound, are reviewed separately. (See "Principles of acute wound management" and "Clinical assessment of chronic wounds" and "Overview of treatment of chronic wounds".)

OPEN WOUNDS — 

A wound is a disruption of the normal structure and function of the skin, possibly extending more deeply. For those who do not have risk factors for nonhealing, acute wounds resolve through defined stages with basic wound care. However, patients with complex acute wounds may require an extended period of wound management that may be amenable to remote care services (See "Basic principles of wound healing" and "Principles of acute wound management".)

Chronic wounds are those that are physiologically impaired due to a disruption of the inflammatory, proliferative, or regenerative phase of wound healing and typically occur in individuals with risk factors for nonhealing (figure 1). A nonhealing wound is often a culmination of multiple underlying medical problems. Most patients with chronic wounds have multiple medical comorbidities (eg, diabetes, hypertension, chronic kidney disease). (See "Risk factors for impaired wound healing and wound complications".)

Chronic wounds are common and occur in 1 to 2 per 100,000 people in the United States [1]. Lower extremity chronic ulcers predominate, and patients with diabetes and those over 65 years of age are particularly affected [2,3]. Chronic wounds place a considerable burden on health care systems and individuals. In addition to the direct costs, indirect costs such as lost productivity, decreased quality of life, and the psychological toll on patients receiving frequent wound care further compound the issues. Typical etiologies for chronic wounds include the following:

●Chronic venous insufficiency – (See "Evaluation and management of chronic venous insufficiency including venous leg ulcer".)

●Pressure-induced skin and soft tissue injury – (See "Clinical staging and general management of pressure-induced skin and soft tissue injury".)

●Diabetes – (See "Management of diabetic foot ulcers".)

●Peripheral artery disease – (See "Management of chronic limb-threatening ischemia".)

●Malignancy or radiation – (See "Overview of the care of adult patients with nonhealable wounds", section on 'Malignant wounds' and "Management of radiation injury", section on 'Cutaneous syndrome'.)

●Surgical site infection – (See "Overview of the evaluation and management of surgical site infection" and "Complications of abdominal surgical incisions" and "Wound infection following repair of abdominal wall hernia".)

●Other soft tissue infections – (See "Surgical management of necrotizing soft tissue infections", section on 'Wound care'.)

●Trauma

•(See "Patient management following extremity fasciotomy", section on 'Wound management'.)

•(See "Surgical management of severe upper extremity injury", section on 'Wound coverage and reconstruction'.)

•(See "Surgical management of severe lower extremity injury", section on 'Wound care and coverage'.)

●Complications of flap reconstruction – (See "Complications of reconstructive and aesthetic breast surgery", section on 'Flap-related complications'.)

●Others – Others (eg, vasculopathy, pyoderma gangrenosum) that may lead to ulceration. (See "Approach to the differential diagnosis of leg ulcers", section on 'Less common causes'.)

Wound care settings — The appropriate setting for wound care depends on the severity of the wound, the presence of complications, and the overall condition of the patient. For some patients, an inpatient setting is the most appropriate, and the use of various classifications is useful for triaging patients. (See 'Useful classifications' below.)

For those who do not require a high level of care, wounds can be treated in a variety of settings. Wound care centers are a common model that improves outcomes. For chronic lower extremity wounds, the need for amputation is reduced when care is undertaken at a dedicated wound center [4-6]. However, when wound care services are not readily available or become disrupted, alternative methods of wound care delivery are needed (figure 2) [7-9]. The tremendous stress put on health care systems as a result of the coronavirus disease 2019 (COVID-19) pandemic underscored the need for systems to triage patients to maximize resource utilization [10,11].

Remote care — For eligible patients, home health services can be arranged during the initial patient encounter with the clinician, which can either be a face-to-face encounter or a virtual visit. Remote wound care can take place in the home (self-care, using nursing services) or at an extended care facility.

●Self-care – Self-care is an acceptable option if the patient (or family or other caregiver) can perform wound cleansing and dressing changes with ease and can communicate any problems or complications with their clinician as they arise. Proper instruction in techniques for wound care is essential. As an example, a patient or family caregiver may be able to provide routine dressing changes for a small surgical site that has become infected or for a clean traumatic wound that requires superficial packing.

●In-home visits – For more complicated wounds (eg, deep wound packing, negative pressure wound therapy, compression therapy) or circumstances in which the patient (or lay caregivers) cannot or do not wish to engage in wound care, home health services will be required.

●Extended care facilities – Staff at extended care facilities should be trained to provide wound care that meets the goal of stabilizing wounds and preventing infection. When questions arise, or expertise with more complex wounds is not available, virtual consultation can help guide treatment.

For many patients, an initial face-to-face encounter certification is required before remote care services can be initiated. The patient is generally evaluated either in an office or hospital setting by a clinician who has deemed that the patient should receive care at home due to:

●Pain severely limiting mobility

●Requirement of an assistive device for mobility

●Safety risk due to gait instability

●Immunocompromised status secondary to oncologic diagnosis

●Open wound potential for infection

The initial patient encounter might be initiated via a virtual visit if a telehealth platform is available and if the patient is capable of doing so. The treating clinician directs the care of the patient and reorders any supplies as needed through home health services. Home services also include social services and physical therapy. Office-based or wound care center resources are required to follow up with home care providers to ensure that more complex home plans of care are properly followed.

Social services also provide at-home meals to those eligible. The goals of skilled nursing care at home typically include assessment of pain, monitoring for adverse reactions to wound treatments, and patient education regarding signs and symptoms of infection. In addition to typical in-home services (blood draws for laboratory testing, wound cultures), a visiting clinician may also be able to provide other services more typically performed in a clinic setting, such as wound debridement, complete vascular assessment, and more advanced wound care (eg, contact casting).

For some patients, telehealth may be sufficient by itself, but for most, a combination of home-based approaches is anticipated. A streamlined process can be created to establish wound care in the home or a nursing facility with a combination of telehealth and face-to-face encounters when necessary. At the author's institution, the hospital mandated that telehealth comprise 30 percent of clinical practice, including wound services. (See 'Modes' below.)

Outpatient care — When home visits cannot be performed or are inadequate, as in the case of complicated wounds (see 'Useful classifications' below), the patient will need to be seen in the clinician's office, which may or may not be located at a wound care center. A complete examination can be performed, and laboratory studies obtained. In some settings, noninvasive vascular testing (eg, pulse volume recordings, ankle-brachial indices, duplex ultrasound, perfusion studies) can also be obtained.

Basic procedures such as surgical debridement, application of skin substitutes, and other therapies can also be performed in the office setting. To reduce the utilization of hospital services, it may be desirable to expand the procedural capability in the office or wound center setting to include other procedures (eg, more extensive debridement, minor amputation, abscess drainage). To accomplish this, appropriate space, as well as additional equipment and medications, are needed to safely perform these procedures.

In addition to the ability to perform more extensive debridement, other advantages of the wound center include better access to subspecialty care (eg, infectious disease specialists, podiatry, vascular surgery). Typically, there are more options for wound care, and supplies are typically more plentiful. Other therapies may also be initiated more easily (eg, hyperbaric oxygen, negative pressure wound therapy, compression therapy, offloading).

Inpatient care — Hospitalization may be required for patients with complicated wounds. Patients who have or develop any of the following conditions associated with wounds should be treated in a hospital setting (see 'Useful classifications' below):

●Severe infection with systemic symptoms

●Moderate infections unresponsive to initial outpatient treatment

●Wet or gas gangrene

●Higher stage limb-threatening ischemia (eg, Wound, Ischemia, foot Infection [WIfI] stages 3 and 4)

The presence of infection increases the need for hospitalization, surgery, and amputation for lower extremity wounds [12].

As the acute issues that led to hospitalization begin to resolve, wound care services are coordinated with discharge planning. Step-by-step instructions are provided for follow-up either in person or via telehealth. Discharge planning includes coordination of care with home health agencies and home durable medical equipment and supply companies. In addition, follow-up laboratory tests, procedures, or other services can be coordinated to facilitate discharge and help reduce the length of hospital stay [7].

Useful classifications — Potentially useful classifications to help determine the best setting for chronic wound care are briefly reviewed.

●Diabetic foot ulcer (and wounds in general) – For managing diabetic patients with foot problems, a triaging system was suggested to help inform the best setting in which to treat patients [13]. This system is applicable and can be extended to triaging a variety of wound etiologies and complications with only minor modifications [7]. Patients with wounds are categorized by wound severity as critical, serious, guarded, or stable (high- to low-priority groups 1 through 4, respectively) to determine the appropriate initial site of care (figure 3). Wound priority can be escalated or reduced depending on changes in the patient's condition. Low-priority wounds can be managed in the home by providing additional support to the patient through visiting nurse services with physician oversight through telehealth. Communication between providers can be assisted by using the SINBAD classification [14]. High-priority wounds will require additional services available in the clinic or hospital setting.  

The triage categories are as follows:

•Critical (priority 1) – Patients with Infectious Diseases Society of America (IDSA [15]) severe (systemic signs of infection such as temperature >38°C, tachycardia, tachypnea, abnormal white blood cell count, or failed initial therapy), and some moderate infections (systemic signs), gas gangrene, sepsis, and acute limb-threatening ischemia should receive care in a hospital setting.

•Serious (priority group 2) – Patients with IDSA mild and some moderate infections, including those with osteomyelitis, chronic limb ischemia, dry gangrene, worsening foot ulcers, and active Charcot foot, should receive care in an outpatient clinic, office-based lab, surgery center, or podiatry office.

•Guarded (priority group 3) – Patients with improving foot ulcers and inactive Charcot foot (not yet in stable footwear) can receive care in a podiatry office or at home, with oversight through telehealth.

•Stable (priority group 4) – Patients with uncomplicated venous leg ulcers, healed foot wounds or amputations, and inactive Charcot (in stable footwear) represent 94 percent of patients with diabetes who have wounds. These patients can be treated at home or through telehealth [13].

●Possible chronic limb-threatening ischemia – For patients with lower extremity wounds and possible chronic limb-threatening ischemia (figure 4), the Wound, Ischemia, foot Infection (WIfI) threatened limb classification system can also help stratify and triage patients. A higher clinical stage increases the risk of amputation. The presence of infection and advanced wound grades are the major drivers for higher clinical stages and the need for inpatient care. (See "Classification of acute and chronic lower extremity ischemia", section on 'WIfI (Wound, Ischemia, foot Infection)'.)

•For patients with low-stage limbs (stage 1/very low risk), monitor and treat via telehealth.

•For patients with intermediate-stage limbs (stage 2/low risk and some stage 3/moderate risk), provide face-to-face care in an office or wound care center.

•For patients with some stage 3/moderate risk and most high-stage limbs (stage 4/high risk), admit for inpatient care, provided the hospital has capacity.

●Pressure-induced skin and soft tissue injury – The National Pressure Injury Advisory Panel (NPIAP), the governing body for classification (table 1) and treatment of pressure-induced skin and soft tissue injuries (formerly called pressure ulcers), did not provide specific triage recommendations. However, patients with infected pressure-induced skin or soft tissue injury would classify as Priority 1, as described for the patient with diabetes foot ulcers above. Prevention of pressure-induced injury during prone positioning includes using pressure redistribution surface and positioning devices, repositioning medical devices, and avoiding contract over areas of prior pressure injury [16]. Adequate staffing to reposition the patient helps to avoid friction sheer. Positioning frequency is dependent on the patient's activity, ability to independently reposition, and tissue tolerance. "Turning" is limited to microshifts and changing the position of the head, arms, and upper body according to "swimmer position" protocols [17]. Soft silicone multilayered foam over pressure points and under medical devices is recommended.

Resource allocation in crisis events — During crisis events, the goals of surgical triage are to conserve critical supplies and equipment, reduce intensive care unit and inpatient bed usage, and free up staff [7,18]. Standalone ambulatory surgery centers may provide an alternative location for surgical care. When restrictions relax, surgical scheduling may require that patients who can wait continue to wait for surgical care.

The American College of Surgeons provided guidance to assist decision-making regarding the performance of surgery during the COVID-19 pandemic. These principles remain useful in the event of future crisis events [19]. Procedures are classified into three tiers:

●Tier 1 – Postpone surgery or perform at an ambulatory surgery center

●Tier 2 – Postpone surgery, if possible, or consider ambulatory surgery center

●Tier 3 – Do not postpone

For patients with chronic wounds, some examples of implementation include:

●For patients presenting with lower extremity wounds and without evidence of limb-threatening infection (eg, wet gangrene) or severe ischemia, if surgical revascularization is indicated, it may be deferred until after managing the acute wound issue.

●For patients with wound infection or cellulitis in association with chronic venous insufficiency or lymphedema, wound debridement, compression therapy, and antimicrobial therapy can be initiated. Vascular evaluation can be deferred to an outpatient setting.

●For patients with localized osteomyelitis, debridement and antimicrobial therapy may be sufficient in the interim, allowing definitive management to be delayed

If supplies of wound dressings, orthotics, and other adjuncts to wound care become limited, a change in wound care practices or requiring sourcing from other suppliers may be necessary. National mail-order suppliers are a useful alternative. In addition, internet sourcing of some products can supplement or supplant local sources temporarily.

REMOTE WOUND CARE

Goals — From a clinical perspective, remote wound care aims to achieve optimal healing outcomes with less overall burden to the patient and clinician [20]. By enabling frequent remote monitoring, clinicians can assess wound healing progress, identify potential complications earlier, and adjust treatment plans accordingly. This can include optimizing dressing selection, increasing dressing change frequency, or implementing infection control measures. Using remote care services (eg, telehealth, other virtual services) enables the clinician to schedule patients for timely in-person visits or interventions, as needed, which can help avoid unnecessary hospitalization.

Remote wound care services also facilitate communication and education for both patients and caregivers. Real-time consultations allow clinicians to provide clear instructions on wound care techniques, answer questions, and address concerns promptly. This collaborative approach empowers patients to actively participate in their healing process, potentially leading to improved adherence to treatment protocols and overall better clinical outcomes.

Other ways remote wound care services can enhance wound care include the following:

●Accessibility – Telehealth increases accessibility, bridging the gap for patients living far from wound centers or living in extended facilities, increasing access to wound care experts. Accessibility also plays a role in patients with limited mobility due to their wounds or other conditions who cannot easily access care away from the home.

When wound care expertise is not available, wound consultation via telehealth also can be extended to patients who are hospitalized in the emergency department.

●Convenience – Convenience and comfort to the patient receiving wound care is an important consideration. Receiving care at home can be more comfortable and less stressful for patients [21]. In addition, caregivers can be more involved remotely, aiding in wound dressing changes or monitoring, which may be particularly important for older adult patients. In addition, patients do not have to physically travel to clinics, reducing travel time and costs and potentially discomfort [21]. Telehealth appointments also offer flexibility for patients with work or other commitments because telehealth visits can often be scheduled outside of standard clinic hours.

●Patient engagement – Telehealth can involve improved patient engagement through self-monitoring and real-time feedback with the potential for cost savings [21]. Patients may be more actively involved in their wound care through telehealth education and at-home monitoring tools. Active participation helps with timely wound assessments and allows clinicians to make adjustments to treatment plans, potentially preventing complications.

Efficacy — Multiple studies have pointed to the efficacy of remote wound care for improving wound outcomes as well as high patient satisfaction rates with these services [22-25].

Telehealth has been used to care for patients with diabetes for over two decades with good results [26]. In a meta-analysis of two trials, 213 patients treated using telehealth were compared with 301 patients treated with usual care [22,27,28]. The telehealth system is comprised of a trained nurse who collects data and takes digital images of the wound. Collected data included questions about quality of life, such as nutrition, movement, and pain levels, as well as patient satisfaction with the treatment. The information was then sent to the physician for decision-making. Complete ulcer healing (odds ratio 0.86, 95% CI 0.57-1.33), healing time (43 versus 45 days), and amputation rate (6.2 versus 7.7 percent) were similar between the groups. No adverse events were attributed to using telehealth; however, the telehealth group had a higher mortality rate (4.1 percent [8 of 193] versus 1.2 [1 of 181]) without clear underlying reasons. The studies in the systematic review also reported that supplementing outpatient clinic visits with telehealth consultations increased the frequency of complete healing and the healing rate of diabetic foot ulcers, as well as reduced frequency of limb amputation. Several studies reported good patient satisfaction with their telehealth experience [23-25].

Telehealth has also been widely used in many countries to provide cost-effective and less resource-demanding medical care. The first conceptual framework for implementation during infectious disease outbreaks was published in 2015 [29]. Telehealth was helpful in treating patients during the severe acute respiratory syndrome-associated coronavirus (SARS-CoV), Middle East respiratory syndrome coronavirus (MERS-CoV), Ebola, and Zika viruses [30,31]. At the time of the COVID-19 pandemic, telehealth, especially video consultation, was promoted to reduce the risk of COVID-19 transmission. However, most countries lack a regulatory framework to authorize, integrate, and reimburse the service. A call was made to adopt the necessary regulatory changes supporting the wide implementation of telehealth during the COVID-19 pandemic for countries without integrated services [29].

Modes — Remote wound care services use two primary communication modes: synchronous and asynchronous [32]. Understanding these communication modes and the tools associated with each is crucial for effective strategizing and implementation of remote care initiatives. For the clinician, it is important to note that coding and billing reimbursement differ for these types of communications.

●Synchronous communication occurs in real-time, facilitating direct interaction between the patient and health care provider. Typical tools include videoconferencing platforms and telephone calls (ie, telehealth visits), which foster a sense of immediacy and personal connection. The patient can receive care in any health care facility or in their home, and the patients can be new or established. This type of visit is considered the same as an in-person visit and is paid at the same rate as an in-person visit.

●Asynchronous communication offers increased flexibility, as communications can be exchanged without both parties being present simultaneously (eg, virtual check-ins, e-visits). Typical tools include secure messaging platforms via electronic medical records, emails, prerecorded patient videos, and audio recordings [33]. This mode is especially useful for follow-up questions, nonurgent updates, or routine communication. It can help avoid unnecessary trips to the doctor's office. Asynchronous communication allows patients and clinicians to compose thoughtful questions and comprehensive responses, reinforcing trust and confidence in each other.

Verbal consent from the patient or legal guardian is required [34]. It is also important to note that while chat functions can be convenient, they should be managed carefully to ensure that only licensed health care providers are delivering clinical advice. All forms of communication should be Health Insurance Portability and Accountability Act (HIPPA) compliant.

Any of three types of remote services (ie, telehealth visits, virtual check-ins, e-visits) allow a virtual appointment with the patient, during which the patient can discuss their history and concerns [33]. The accessibility of the provider, home care agency, and patient will dictate what form of telehealth is provided. Telehealth visits appear to be the most useful in evaluating the wound patient [7]. The patient can be scheduled for a weekly telehealth visit with a nurse, and patients with deterioration of wound progress can be directed back to the office for further evaluation (algorithm 1). (See 'Wound care settings' above and 'Technology' below.)

Technology — The main requirement for initiating remote wound care is patient accessibility via smartphone or computer. Any of several online computer/smartphone applications and services, as well as hospital-based telehealth platforms, can be used.

Clinicians who care for wounds often have access to a telehealth communication platform that can help track medical information such as vital signs, physical examination findings, wound measurements, and other ways to document the progress of wound healing. High-quality image and video transmission enable providers to assess wounds accurately, while patient-reported outcome measures can provide insights into pain levels and other quality-of-life factors that impact healing.

Some telehealth technologies in the early stages are advancing steadily toward clinical implementation and may become useful as telehealth tools for effectively managing wound conditions. Digital wound applications are available for smart devices to help take and transfer images and aid the provider with wound tissue type and measurements. Artificial intelligence tools could potentially analyze wound images for progress with healing or risk factors for nonhealing [21]. Additionally, wearable sensors might be able to track temperature, moisture, and other parameters.

The development of such tools signifies a shift towards more personalized and data-driven wound care [35]. By accurately predicting healing trajectories or early signs of infection, clinicians can make informed triage decisions. This means efficiently identifying wounds that would benefit the most from urgent in-person evaluation while potentially managing others remotely with frequent monitoring, thus optimizing resource use and improving patient outcomes.

Challenges and barriers — Although there have been improvements in face-to-face telehealth communication, there can be many technical barriers. Adequate internet capability, whether wired (ethernet) or wireless, of the provider and patient is essential and determines the speed and image quality in demonstrating wounds to the provider.

Some patients are unable to download the appropriate applications (eg, if using an older device), and some devices have less memory capacity than is needed for telehealth. Increasing broadband capability improves the transmission of video images and is subject to less "freezing." Poor image quality makes it difficult to provide a proper diagnosis. Patients who lack resources for data transmission and photos via a smartphone can alternatively use correspondence via the hospital or patient portal system, if available. The patient can instead email photos and then discuss their concerns directly with their provider over the phone.

While internet access and device compatibility remain challenges for some patients, innovative solutions are emerging to bridge the digital divide. Public libraries are increasingly offering designated telehealth rooms with reliable internet connections and video conferencing equipment. This empowers patients who lack these resources at home to access consultations. In addition, initiatives like loaner tablet programs provide temporary devices preloaded with the necessary telehealth applications to address the software and hardware limitations of some patients. Furthermore, advancements in mobile technology allow for telehealth consultations via text-based messaging or phone calls, catering to those with limited internet access or outdated devices. These combined efforts aim to ensure equitable access to telehealth services regardless of technical proficiency or socioeconomic background.

DELIVERY OF WOUND CARE — 

Standard wound care practices can be followed in telehealth settings as with other settings. (See "Overview of treatment of chronic wounds".)

For clinicians with less experience with wound care, selecting a wound dressing can be aided by becoming familiar with the major categories of dressings and applications (table 2 and table 3), or by using a decision aid that may include using a smartphone app, or by using a protocolized approach such as from their local wound care center [36].

Wound dressings should be disposed of in a standard bin destined for medical waste disposal (but not sharps).

Frequency of wound care visits — With frequent wound care and monitoring, wound healing times are improved, reducing additional resources. Without adequate wound care, patients with chronic wounds are at risk for developing infection, which increases the risk of complications and potentially loss of life or limb [5,13,37-39]. Among those who do not receive adequate adjunctive care (eg, off-loading for diabetic foot ulcers, compression therapy for chronic venous ulcers), deterioration of the wound can also occur [7,39].

The frequency and level of care needed for wound healing should be maintained at a minimum, typically at least one- to two-week intervals, to prevent wound deterioration [40,41]. The optimal frequency of wound care visits differs for various types of wounds, and wound care visits may be needed at more frequent (eg, copious exudation) or less frequent (eg, dry stable eschar) intervals.

●In a large review, 39,750 wounds associated with 17,849 patients were seen in 115 clinics [40]. Diabetic foot ulcers seen at 7.5 times or more per four weeks healed faster than wounds seen at intervals of two weeks or less. More frequent wound care visits enabled clinicians to identify issues that impair wound healing, including patient compliance issues, challenges that might affect adherence to the treatment, early signs of infection, whether home nursing services are carried out appropriately, and whether the wound needed debridement. Increased patient interaction also reduced social isolation, which had a positive influence on patients. Another study found similar results with diabetic foot ulcers and venous leg ulcers closing more than twice as fast on average for weekly compared with the every-other-week visits [41].

●Even more frequent debridement may provide better results. In a review of over 150,000 wounds of all etiologies, wounds that were debrided more than once a week healed faster than wounds that were debrided every one to two weeks or greater than two weeks [42]. As an example, for diabetic foot ulcers, the median time to heal for weekly or higher-frequency debridement was 21 days compared with 64 and 76 days for one- to two-week or two-week or more intervals between debridement, respectively.

Escalation of care — Wound deterioration and the need for re-evaluation or intervention are determined by the discretion of the clinician. The criteria below indicate a need to escalate wound care (eg, more frequent wound care visits, dressing changes, or debridement) or possibly change the location of care. (See 'Wound care settings' above.)

●Increasing necrotic tissue

●Failure to show signs of healing in a timely manner

●Appearance of excessive fibrotic tissue that requires sharp surgical debridement

●Appearance of any signs of infection

The risk of infection is high for patients with certain types of wounds. In one review of patients with diabetic foot ulcers, more than 50 percent of patients had wounds that became infected during the course of treatment [43]. The indications for antibiotics and antibiotic selection follow standard protocols and are reviewed separately. Patients with appropriate indications should be hospitalized for intravenous antimicrobial therapy (eg, deep space foot infection). (See "Acute cellulitis and erysipelas in adults: Treatment" and "Diabetic foot infections, including osteomyelitis: Treatment".)

For some patients, wound care adjuncts such as hyperbaric oxygen, topical oxygen therapy, or negative pressure wound therapy may facilitate wound care and are used as indicated, provided they are available. (See "Negative pressure wound therapy" and "Overview of treatment of chronic wounds", section on 'Hyperbaric oxygen therapy/topical oxygen therapy'.)

Skin grafting/skin substitutes — Ample data have demonstrated the efficacy of cellular tissue-based products in accelerating wound healing compared with standard wound care (ie, wet to moist dressings) (table 4). Several types of cellular tissue-based products are available, some of which are processed from donor tissues (living, deceased) (figure 5). (See "Skin substitutes".)

The ability to extend the use of skin substitutes outside the typical care environments is limited. Most skin substitutes are applied at a wound center or in a surgical center since the use of cellular tissue-based products or biologics requires clinicians or facilities in the United States to have a tissue license. Licensing maintenance requires keeping a log of all living and nonliving skin equivalents, which includes the type of skin substitute, name of manufacturer, temperature monitoring for storage of cellular tissue-based products, dates received from the manufacturer, and date of application. In addition, the facility is inspected annually by the United States Department of Health.

Donated tissue for skin allografts is decellularized and rendered nonimmunogenic. Many of the processes used have antiviral properties. Respiratory viruses are not known to be transmitted via tissue allografts, and for COVID-19, severe acute respiratory syndrome-associated coronavirus (SARS-CoV), and Middle East respiratory syndrome coronavirus (MERS-CoV), there have been no documented cases of transmission through tissue transplantation [44]. (See "Skin substitutes" and "Reconstructive materials used in surgery: Classification and host response", section on 'Allograft processing'.)

SOCIETY GUIDELINE LINKS — 

Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Telehealth and telemedicine".)

INFORMATION FOR PATIENTS — 

UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5^th to 6^th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10^th to 12^th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)

●Basics topics (see "Patient education: COVID-19 overview (The Basics)" and "Patient education: COVID-19 and pregnancy (The Basics)" and "Patient education: COVID-19 and children (The Basics)" and "Patient education: COVID-19 vaccines (The Basics)")

SUMMARY AND RECOMMENDATIONS

●Chronic wounds – Wounds that require an extended period of management (complex acute wound, chronic wound/ulcer) may be amenable to remote wound care services. Chronic wounds are those that are physiologically impaired and typically occur in individuals with risk factors for nonhealing. Most patients with chronic wounds have contributing medical comorbidities (eg, diabetes, hypertension, chronic kidney disease). (See 'Open wounds' above.)

●Wound care setting – The appropriate setting for wound care depends on the severity of the wound, the presence of complications, and the overall condition of the patient.

•An inpatient setting may be the most appropriate setting, and various wound classifications can help triage patients. (See 'Useful classifications' above.)

•Patients who have or develop any of the following conditions associated with wounds should be treated in a hospital setting (see 'Inpatient care' above):

-Severe infection with systemic symptoms

-Moderate infections unresponsive to initial outpatient treatment

-Wet or gas gangrene

-Higher stage limb-threatening ischemia (eg, Wound, Ischemia, foot Infection [WIfI] stages 3 and 4)

•Patients without the above conditions who must stay at home qualify for remote services for wound care regardless of the type of wound. Remote wound care can take place in the home (self-care, in-home visits) or at an extended care facility. (See 'Remote care' above.)

•When remote care cannot be performed or is inadequate, as in the case of more complex wounds, the patient will need to be seen in the clinician's office or treated in the hospital. (See 'Outpatient care' above and 'Inpatient care' above.)

●Remote wound care – Any of three types of remote care services (ie, telehealth visits, virtual check-ins, e-visits) allow a virtual wound care appointment with the patient. Accessibility of the wound care clinician, home care agency, and patient will dictate what form is used. Telehealth visits appear to be the most useful in evaluating patients with wounds. (See 'Remote wound care' above.)

•Remote wound care can achieve healing outcomes similar to other care settings with less overall burden to the patient and clinician. Frequent remote wound monitoring enables clinicians to assess wound healing progress, identify potential complications earlier, and adjust treatment plans accordingly.

•The main requirement for remote wound care is accessibility via smartphone or computer. Any of several online computer/smartphone applications and services, as well as hospital-based telehealth platforms, can be used.

•Internet access and device compatibility remain challenges for some patients. Public resources (eg, local library) may offer internet and video conferencing through designated telehealth rooms to assist patient participation.

●Wound care delivery – The same standard wound care practices used in other settings can be followed in the remote wound care setting.

•While the optimal frequency of wound care visits differs for various types of wounds, the level of care and frequency needed for wound healing should be at one- to two-week intervals (at least) to prevent wound deterioration. Wound care visits may be needed at more frequent (eg, copious exudation) or less frequent (eg, dry stable eschar) intervals. (See 'Delivery of wound care' above.)

•Escalation of wound care (eg, more frequent wound care visits, dressing changes, debridement) or changing the location of care is indicated for the following (see 'Escalation of care' above):

-Increasing necrotic tissue

-Failure to show signs of healing in a timely manner

-Appearance of excessive fibrotic tissue that requires sharp surgical debridement

-Signs of infection