Management of non-healable and maintenance wounds: a systematic integrative review and referral pathway

  • G S Boersema University of South Africa
  • H Smart King Hamad University Hospital
  • M Giaquinto-Cilliers University of the Free State
  • M Mulder University of the Free State
  • G R Weir Life Eugene Marais Hospital
  • F A Bruwer
  • P J Idensohn University of the Free State
  • J E Sander 2nd Military Hospital
  • A Stavast
  • M Swart
  • S Thiart
  • Z van der Merwe
Keywords: atypical wound, diabetic foot ulcer, interprofessional team, maintenance wound, nonhealable wound, pressure injury, pressure ulcer, referral, venous leg ulcer


Objective: This systematic integrative review aims to identify, appraise, analyse, and synthesise evidence regarding non-healable and maintenance wound management to guide clinical practice. An interprofessional referral pathway for wound management is proposed.

Data sources: 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 (non-healable/non-healing, chronic, stalled, recurring, delayed healing, hard-to-heal) and wound types most associated with non-healable or maintenance wounds. Published studies were hand searched by the authors.

Study selection: Studies were appraised using two quality appraisal tools. Thirteen reviews, six best-practice guidelines, three consensus studies, and six original non-experimental studies were selected.

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

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

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

Author Biographies

G S Boersema, University of South Africa

University of South Africa, Pretoria, South Africa

H Smart, King Hamad University Hospital

Wound Care & Hyperbaric Oxygen Therapy Unit, King Hamad University Hospital, Kingdom of Bahrain

M Giaquinto-Cilliers, University of the Free State

Department of Plastic and Reconstructive Surgery, University of the Free State and Plastic and Reconstructive Surgery & Burns Unit, Robert Mangaliso Sobukwe Hospital, South Africa

M Mulder, University of the Free State

School of Nursing, University of the Free State, South Africa

G R Weir, Life Eugene Marais Hospital

Life Eugene Marais Hospital, South Africa

F A Bruwer

Clinical Nurse Specialist, South Africa

J E Sander, 2nd Military Hospital

2nd Military Hospital, South Africa

A Stavast

Clinical Nurse Specialist, South Africa

M Swart

Clinical Wound Care Nurse, South Africa

S Thiart

Clinical Wound Care Nurse, South Africa

Z van der Merwe

Clinical Wound Care Nurse, South Africa

General Review