In this episode of Hospital Medicine Unplugged, we get hands-on with evidence-based wound care—assess precisely, prevent infection, match the dressing to the wound, and escalate smartly for the tough ones.

We start with the do-firsts: identify wound type (SSI, pressure injury, DFU, traumatic), map size/depth/exudate, scan for infection signs, and hunt barriers (ischemia, diabetes, edema, malnutrition, meds, pressure). Document with photos and a consistent ruler; add ABI/pulses for leg ulcers. Classification guides action (CDC/NHSN class, SSI depth; Wagner/UT/WIfI for DFU).

Cleanse like you mean it: tap water or normal saline for most; high-pressure irrigation for gross contamination. Skip routine antiseptics—use them selectively (e.g., intra-op lavage or NPWT-instillation protocols). Debride early and often: sharp debridement is the fast reset for necrosis/biofilm; enzymatic (collagenase), autolytic (hydrogels/hydrocolloids), pulsed-lavage, and maggots are context plays. Weekly (or tighter) debridement intervals correlate with better healing.

Infection control = stewardship + technique. All wounds are colonized; reserve systemic antibiotics for clinical infection and culture tissue (not swabs) when it matters. Short courses, narrow when able. Topical antimicrobials (silver/iodine) only short-term for critically colonized wounds. Obsess over hand hygiene, contact precautions, and SSI bundles (glucose control, hair clippers, wound protectors, povidone-iodine lavage where appropriate).

Build the moisture-smart dressing plan—no single product wins:
• Dry → hydrogels/hydrocolloids (donate moisture, autolysis).
• Moderate–heavy exudate → foams, alginates, hydrofibers (absorb, protect peri-wound).
• Superficial/low exudate → films/nonadherent covers.
• Critically colonized/infected → short-term antimicrobial dressings.
Reassess often; change strategy if area isn’t shrinking by ~30–50% in 4 weeks.

When the basics stall, escalate:
• NPWT: reduces edema/bioburden, accelerates granulation, lowers SSI in complex/incisional wounds.
• NPWT with instillation (polyhexanide, dilute povidone-iodine, acetic acid, silver nitrate) for sloughy, bioburdened wounds.
• Biologics/skin substitutes (amniotic/placental matrices, bilayered constructs) for refractory DFU/venous ulcers.
• Growth factors/PRP: targeted use in select chronic ulcers.
• Oxygen therapies (topical ± hyperbaric) when ischemia coexists and standard care fails.
Pick the right patient, right indication, right cost.

Anchor the plan with TIME: Tissue (debride), Inflammation/Infection (control), Moisture (balance), Edge (advance). If the edge isn’t migrating, re-debride, offload/compress, or step up therapy.

Pressure injury prevention is everyone’s job: early Braden, advanced support surfaces, heel offloading, q2h repositioning (tailor to risk), barrier creams, and prophylactic silicone foams at bony points. Bundle it, audit it.

Don’t forget the systemic levers:
• Glycemic control, perfusion fixes (revascularize when WIfI says so), edema management.
• Nutrition: screen on admit; target 25–30 kcal/kg/day and 1.2–1.5 (up to 2.0) g/kg/day protein; consider high-protein, micronutrient-enriched supplements (vitamin C, zinc, A/D/E) when deficient.
• Med review: minimize corticosteroids/immunosuppressants if feasible.

Patient-centered care drives adherence: choose dressings that are comfortable, cost-aware, and easy to change; set clear change intervals; teach signs of infection and offloading/compression techniques.

Disposition & follow-up that stick: photo-track weekly, screen for occult DVT in high-risk leg wounds, and trigger consults early (vascular, ID, plastics, podiatry, rehab). Define success up front (closure vs durable reduction) and time-box each step—no improvement, escalate.

We close with the bedside bundle that moves the needle: (1) classify & measure; (2) cleanse + early debridement; (3) moisture-balanced dressing matched to exudate; (4) antibiotic stewardship; (5) NPWT/escalation for non-progression; (6) pressure-injury bundle hospital-wide; (7) perfusion + glucose + nutrition optimization; (8) weekly team huddles with photos and milestones.

Assess precisely, keep it moist, cut the necrosis, control infection, escalate on time, and never forget the patient factors. That’s how hospitalized wounds heal—reliably and fast.