Key Takeaways
1. Understanding wound healing phases improves treatment decisions.
Recognizing whether a wound is in inflammation, proliferation, or remodeling helps clinicians select appropriate interventions and identify barriers to healing earlier.
2. A wound assessment should always go beyond the wound bed.
Factors such as nutrition, vascular status, immune function, pressure, and infection often determine whether a wound progresses or stalls.
3. Accurate diagnosis and team-based care drive better outcomes.
Correctly identifying wound type and collaborating across disciplines can prevent treatment delays and improve healing trajectories for patients.
Transcript
Please note: This content is a direct transcript, capturing the authentic conversation without edits. Some language may reflect the flow of live discussion rather than polished text.
Catherine Milne:
Hello and welcome to Wound Conversations, the podcast where we share actionable insights from leaders in wound healing. I'm Cathy Milne and today we're diving into something every clinician learns early on but doesn't always apply in practice the phases of wound healing and what they actually mean in real life. We've all learned those stages, hemostasis, inflammation, proliferation, remodeling, but wounds don't always follow that textbook. So today we're going to talk about how to recognize these phases at the bedside and more importantly, how to adjust your care when things don't go as expected. I'm really excited to be joined by Dr. Jeanine Maguire. Dr. Maguire is a really good friend and a wonderful woman and she's also a physical therapist and a certified wound specialist with extensive experience in clinical practice education and research all related to wound healing and tissue repair. She's known for translating complex science into practical strategies that you can use at the point of care and is the president of the Post Acute Wound and Skin Integrity Council. That's also known as PAWSIC. She has been a valued contributor to wound care education through platforms like WoundCon and WoundSource. I've known her for years. Welcome, Jeanine. It's great to have you here.
Jeanine Maguire:
Thank you, Kathy. And truly it's an honor to get to be called your friend and thank you for this opportunity to be on this podcast. Thank you to you, Woundcon, and SAWC.
Catherine Milne:
We've had so many conversations on Zoom and the phone and about all sorts of wound healing issues. WoundConversations is brought to you by WoundSource, the trusted resource for wound care professionals and WoundCon, your connection to global virtual education and wound management. Let's get started so we can listen today and apply tomorrow. Before we dive into the science, we always like to start these sessions by getting to know the people who we're talking to. So Janine, what is your wound care why? What got you into this field? What continues to motivate you to show up to work every day?
Jeanine Maguire:
I love that question and it's personal. When I was a young girl, my father had experienced a traumatic brain injury. And so from that experience, I knew I wanted to be part of change for people, for patients that experience our healthcare system. As a young person, first I was a physical therapist assistant and then a PT. I thought I wanted traditional rehab because of that. But it turned out what I noticed in all my internships, whether it was people who suffered a traumatic brain injury or a stroke or they're in the ICU, whatever that setting was, there was one common denominator. They had these wounds. And so I started to recognize was this is something I can actually help with and it's a quick help. Unlike a traumatic brain injury, I could actually see progress. Not only that, I realized that a wound represents their system is just struggling and the system around them is struggling.
So I started to understand over years that the wound represents something so much bigger to help people individually and to help systems.
Catherine Milne:
So then you started working in long-term care.
Jeanine Maguire:
That was a one-year plan that turned into 23 years. So initially I was in outpatient wound centers. I worked out of Philadelphia at St. Agnes for seven years. They had a burn unit. They had a wound center, traditional rehab. I was lucky enough to get to work in Reading with the infamous Pam Unger. So that was an internship. But you're right. Then I moved out of the city and begrudgingly thought, well, I'll work in a nursing home. That's where all the wounds are. And had a very different mindset around the role of wound management and skilled nursing, which really wasn't accurate or kind. And then getting into that space, not only did I fall in love with long-term care and skilled nursing and that whole space, but I also realized it was my first experience of a true team approach. So one year quickly turned into 20 something and I learned the role of nurses, RNs, LPNs, CNAs, social service, the providers. What I could bring as a therapist really understood that together we are so much better at getting to that outcome.
Catherine Milne:
That's what's always impressed me about you is that you value that team approach. And if we could just spread that throughout the entire world and wound healing folks, it would be so beneficial for our patients. So let's actually talk about what we're here to talk about today. That's the phases of wound healing, what they actually mean in day-to-day practice. So we all learn the classic phases of wound healing in our education or training. And from your perspective, where do you see the biggest disconnect between how these phases are taught and how we see wounds in actual clinical practice?
Jeanine Maguire:
I was never taught the phases of wound healing in PTA school or PT school. And my curriculum was pretty heavy duty with understanding modalities from a vascular musculoskeletal level for wound healing. But I'm sure there was a section, but I don't recollect it. So when I decided to really focus on wounds, I had to seek out that education in order to become wound certified. And so flash forward, I had opportunities where I was teaching at an RN program, their wound program, an LPN and a PT. And I started to realize that nobody's getting that information, at least in my small sample size. So for me, I had to learn those phases on my own and this was before ChatGPT, so I had to really seek out all those right resources and it wasn't easy.
Catherine Milne:
So do you think ChatGPT identifies these phases of wound healing?
Jeanine Maguire:
We could check right now. I'm guessing probably yes, but it's not a closed system so it may not be accurate. You really do need to look for evidence-based resources to inform yourself.
Catherine Milne:
So when you're evaluating a wound, what key signs help you determine which phase is it in or is it if it's stalled?
Jeanine Maguire:
Yeah.
Catherine Milne:
Let's take the first one first. How do you know which stage that wound might be in? Inflammation, proliferation, remodeling.
Jeanine Maguire:
It's so important to understand that phase because it really does inform your treatment and sometimes your interventions. Unfortunately, it's not just about the wound. So first and foremost, I highly encourage imaging because that's incredibly helpful because even if the bedside user isn't able to recognize certain characteristics, then it can easily phone a friend if you have that HIPAA protected image to help you. But the image is just a puzzle piece, right? Because let's say there's a ring of inflammation around the wound and you might immediately react and think, infection, bioburden. But what if that ring of inflammation is the normal inflammatory phase? Do you really want to throw an atomic bomb on that thing with antibiotics and increase your risk of resistance when the human body was just trying to do what the human body should do? But in order to know that, you need to know the why, the deeper why of that human being.
So how old is that wound? If it's only a few days old, maybe it is the inflammatory phase. How healthy is that human? Do they have the ability to pull in neutrophils and macrophages? What's their immune system like? And what's the vascularity to the wound site to actually cause that all to happen? But what if it's not even inflammation? What if the redness around it is because there's pressure on that wound that has not been mitigated and you're actually increasing hypoxia, has nothing to do with inflammation. You need to offload. So I guess the long answer or the short answer to that is you have to dive deep. And I always ask why at least five times keep going further, never make a knee jerk response, reaction, or decision. And certainly if it's inflamed, something's not right. So you do need to figure out what that is and there are key indicators.
So if there's a halo of inflammation, even if it's new and it's starting to streak away from home base and there's purulence coming out and odor after you've cleaned it, that's pretty easy. You know you have an infection. So there are some clear indicators, but you do always want to ask deeper questions.
Catherine Milne:
So what about the proliferative stage? Yeah. If you were to just walk into a room and say, "That person's proliferative."
Jeanine Maguire:
Yeah. So it's a beautiful wound. It's healthy granulation tissue. So some of the key findings there is how long has it been in proliferation? Because you should be making new life in the wound. You shouldn't be at status quo. So is it constantly progressing? What is the wound edge looking like? Is it looking like it's trying to migrate? I also would want to know what's the characteristic of that granulation. If you touch it, does it bleed? So is there a high risk of friability and bioburden in it? And if it's been stuck there, so you have to know with the phases of healing, how long to expect each phase to be in. And so if you're in proliferation and you've had no change in that wound for one week, two week, three week, four week, not only are you in trouble, if you're in certain settings like long-term care, it's been four weeks and it's a healable wound and you're not changing anything, you're going to get a tag. So something's not right there and we need to evaluate the deeper why.
Catherine Milne:
Are there anything that you see? I mean, you've taught hundreds and thousands of people that actually that people always kind of falter on some kind of misperceptions, misdiagnosis. Is there something that really confuses people?
Jeanine Maguire:
I think misdiagnosis is huge. And in one of my previous worlds where I had the privilege of getting to support hundreds of nursing homes, I would say that there was almost zero nursing home I would go into and review their wound log where I didn't find errors in wound types that were obvious, like a venous ulcer on the sacral area. So really easiest, obvious errors and not because any of us want to make an error because there really is a lack of education.
And so if we don't have the wound type right, we're probably not going to have the treatments and interventions, right? We probably don't know the phases of healing. So I would say the wound type is huge. Think about wound type and phases of healing. If you're calling it say an arterial ulcer, that ulcer occurred because you don't have enough blood flow to get from A to Z and now in the documentation you're saying it's 100% granulated closing and proliferation. Unless there's been revascularization or some miracle, it's not arterial most of the time, right? So there are clues that a wound specialist can really help to make sure that we're getting closer to the accurate diagnosis, but I think that's probably the biggest thing. I feel like people are getting better in recognizing the difference between granulation, slough and eschar. I think we've made progress there, but wound type is I think still a bigger issue and I could be wrong.
Catherine Milne:
Yeah. So one of the things that I always see is with negative pressure wound therapy is that it isn't going towards closure or the wound color is still a dull red instead of a beefy red. And people still think, "Oh, it's smaller or my drainage has decreased so my wound is fine," when it really isn't fine. And then the other thing I see, especially with negative pressure wound therapy, I'll have beautiful granulation tissue except for one part of that wound, but everybody just sees the good part and doesn't see the dull pink. I'm like, "We probably should do a workup for an osteomyelitis or what is wrong with this part?" Bio burden, circulation, any of the others. Biopsy. I mean, there could be a million ways to go once you recognize it.
Jeanine Maguire:
Yes. I think that's important and I would agree with you. So negative pressure when the patient's ready for it can really do wonderful things for closure, but I think you're right, particularly and I'm only speaking my experience in long-term care, some people would use negative pressure for months. I had one patient for up to two years and despite my dismay, but they were using it as a maintenance. Not really what it's indicated for. And it was a lot of discomfort, frankly, for that patient.
Catherine Milne:
So let's move on here. So many wounds don't progress in the liner your way. How do you approach wounds that seem to be stuck, like lingering in that inflammatory phase?
Jeanine Maguire:
Okay. So the first thing would be that deeper why, try to find out why it's lingering there and look at that patient holistically, what's going on with their nutrition? Do they have infection elsewhere? Are they on antibiotics or do they have antibiotics, antibiotic resistance? So try to get a clearer picture of what's going on with them systemically. And then if it is still lingering, you need to find out the reason of that why. Are there issues with managing the drainage? Are there issues with doing proper cleansing of that wound to remove the bioburden effectively? Are they keeping the wound covered? And so there's no one right answer except you have to investigate and ask deep questions about the human and about the wound.
Catherine Milne:
Right. It's not usually about the wound. It's usually about the human. So how should the understanding of the phase of wound healing actually change? How do you think if you really understand wound healing and those phases, how do you think the wound healing will change overall?
Jeanine Maguire:
Well, I often think if I'm teaching somebody brand new to wound care, I try to use really simplistic analogies and one of the analogies I guess I use a lot is the dentist because I hate going to the dentist, I'm scared to death. And I think about, okay, if you have a cavity in your tooth and it hurts and it's infected, you're in that inflammatory phase. And so hopefully your dentist would not just throw a cap on top of that, right? So we wouldn't treat that like it was in proliferation and just put on a treatment that's going to maintain moist wound healing for a prolonged period of time. You need to take care of that inflammation. So I think really understanding the priorities. So during inflammation, you need to manage that, manage the bioburden and help push that wound into proliferation in order to grow those fibroblasts, fill in that wound base, and then start to reepithelialize.
But every single phase requires a different type of attention and different treatments.
Catherine Milne:
Yeah. And that's the other thing that I think people fall down on is that, "Oh, I'm just going to stay with plan A. " Or they make plan B, plan A, "Oh, they didn't respond to this silver, so I'm going to use another silver dressing."
Jeanine Maguire:
That's such a great point because if the treatment selection was accurate, you want to give it a little time to work before you just change and before you just change, find out if there was a deeper reason why the wound's not responding and maybe it has nothing to do with the treatment.
To your point. And back to the dentist, if your tooth is inflamed, you would definitely want to ... They clean that cavity out, right? But once it's no longer inflamed and they put that cap on, they don't keep cutting it out over and over and over again and giving you more and more antibiotics. So there's a time and a place for everything.
Catherine Milne:
That's well put. We're almost out of time. So as we wrap up, we always ask for a wound to the whys. So if listeners could just take one concept from today's discussion and immediate apply it tomorrow in their practice, what would that be?
Jeanine Maguire:
There's not one discipline that has all the answers here. So wound care is complex and the one thing I would say is find out who your team is and what do they know or what are they willing to learn so we can work together to get our patients closer to healing.
Catherine Milne:
Wonderful. Thank you so much for joining with us today and sharing your insights. This was a great, valuable and practical discussion.
Jeanine Maguire:
Thank you, Kathy.
Catherine Milne:
If you're looking to deepen your understanding of wound healing and improve your clinical decision making, please be sure to explore additional education and resources that are available through WoundCon and WoundSource. Stay connected with us on woundcon.com, SoundCloud, Spotify, and Apple Podcasts. And as always, explore resources available on woundsource.com and through WoundCon. Thank you for joining us today. So listen today and apply tomorrow.