Wound Case Escalation & Referral

Indications of Wound Case Escalation & Referral

Here are listed summary of indications of wound case referral ^[1]Garispanduan Pengurusan Luka (Wound Care Manual) 20232023drive.google.com ↗:

Summary of Indications Based on MOH Wound Care Manual (2023)

General Indications (multiple wound types):

1. No signs of healing within 2–4 weeks after proper management.
2. Suspected malignant transformation in a non-healing wound; consider biopsy and multidisciplinary review.
3. Systemic symptoms or sepsis → urgent hospital referral.

Specific Indications:

Complex Wounds Requiring Advanced Closure (Plastic Surgery):

• Facial lacerations/infective wounds, wounds with skin loss not closable primarily, extensive post-debridement/excision wounds, exposed tendon/bone/vessels/nerves, necrosis near neurovascular structures requiring surgical debridement.

Burns:

• Deep partial thickness or higher → burn surgeon.
• Refer to tertiary/burn centre if: no healing after 3 weeks, persistent slough/necrosis/infection, hypertrophic scarring/contractures, special areas (face/hands/genitalia).
• Specialist referral criteria include thresholds for %TBSA by age, electrical/chemical burns, inhalational injury, significant comorbidities, concomitant trauma, or need for rehabilitative support.

Traumatic Wounds:

• Suspected vascular injury, open fractures/dislocations, tendon/nerve injury, special areas (face/neck/abdomen), crush injuries, deep wounds, or uncertainty in management.

Diabetic Foot Ulcers:

• Poor healing → re-evaluate vascular status and refer to vascular services.

Vascular Ulcers:

• Arterial: failure to heal 2–4 weeks despite normal toe pressure → further imaging; low ABSI/toe pressure → imaging and revascularization referral; gangrene or vascular insufficiency needs specialist debridement.
• Venous: early referral for complex cases; non-healing ulcers → evaluate for alternative diagnosis or DVS incompetence and vascular referral.
• Lymphoedema: early referral for intermittent pneumatic compression.
• Mixed: mandatory vascular centre referral to determine optimal surgical approach.

Pressure Injuries:

• Consider referral to OT/physiotherapist and dietitian as appropriate.

Atypical Wounds:

• Multidisciplinary involvement (dermatology, rheumatology, wound specialists); skin biopsy essential.

Malignant Wounds:

• Escalate to primary care physician for haemorrhage control if needed; urgent referral to treating team if local/systemic infection; consider PT/OT involvement.

Life-threatening Infections (NSTI, gas gangrene):

• Early diagnosis and urgent referral; look for rapidly spreading erythema, severe pain out of proportion, and toxicity.

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