Francis Derk1, Troy Wilde2, Tim Pham2, Mike Griffiths3 1South Texas VA Medical Center (San Antonio, United States) 2UTHSC (San Antonio, United States) 3AOTI (Oceanside, United States)

1. Francis Derk1, Troy Wilde2,
Tim Pham2, Mike Griffiths3
1South Texas VA Medical Center (San Antonio, United States)
2UTHSC (San Antonio, United States)
3AOTI (Oceanside, United States)

2. To develop a structured and detailed evidence based
wound conversion algorithm, incorporating advanced
present day wound therapies & utilizing the University
of Texas Wound classification system as its matrix.
The algorithm is evidenced based and formulates a
singular or multi modal approach from simple to
highly complex phases.
The algorithm is intended to provide the clinician with
a retrograde methodology, intended to drive the
wound to healing by converting higher grade wounds
to lesser grade levels and finally to full healing.

3. The authors conducted evidence based research
analysis using various treatment approaches, including
all available wound modalities; evidence based
analysis, and numerous clinical applications with
established wound protocols, single and or multi
modal processes, wound treatments and outcomes.
The University of Texas Wound Classification system
serves as the framework, along with standardized
definitions of infection, laboratory test limits, and
ischemia parameters.

4. >1.30 Poorly compressible vessels,
arterial calcification
0.90–1.30 Normal
0.60–0.89 Mild arterial obstruction
0.40–0.59 Moderate obstruction
<0.40 Severe obstruction
Classic signs:
Inflammation (erythema,
warmth, tenderness,
ain or induration
purulent secretions
Presence of systemic findings
of infection (fever, chills,
night sweat, nausea, vomiting,
malaise)
Secondary signs:
Non-purulent secretions,
friable or discolored
granulation tissue,
undermining of wound edges,
foul odor)
Stages
Stage A: No infection or ischemia
Stage B: Infection present
Stage C: Ischemia present
Stage D: Infection and ischemia present
Grading
Grade 0: Epithelialized wound
Grade 1: Superficial wound
Grade 2: Penetrates to tendon or capsule
Grade 3: Penetrates to bone or joint
UTHSCA WOUND CLASSIFICATION SYSTEM
ERYTHROCYTE
SEDIMENTATION
RATE (ESR)
TEST
Westergren
NORMAL
VALUE
Child 0-10 mm/hour
Adult (male) 0-15 mm/hour
Adult (female 0-20 mm/hour
Adult 4.5-11.0
Neutrophils Bands
3-5% (total
WBC count)
Segs 54-62%
Lymphocytes 25-33%
Monocytes 3-7%
Eosinophils 1-3%
Basophils 0-0.75%
Leukocyte (WBC) Normal Values
Ischemia, PVD and PAD: Defined by ABI/NIV studies, ultrasound, clinical wound assessment including
necrosis, eschar, gangrene, lack of lower extremity and pedal pulses, findings consisting of pallor,
cyanosis, lack of digital hair growth, and advanced studies including MRA and Angiography.
Definitions
Ankle-brachial Index (ABI)
Interpretation
Infected wound: per infectious disease
guidelines the presence of infection is
defined by ≥ 2 classic findings of
inflammation or purulence

5. In clinical practice within a large wound care center, the
algorithm has validated and has been found to be
especially useful when treating higher grade wounds
which may require surgical intervention, a multi-
disciplinary team approach, wound staging, and
advanced adjunctive therapies.
We found that classifying a wound, determining
etiology, and taking a holistic approach that progressed
the wound from more severe to less severe grades
resulted in better outcomes.

6. Wounds
Stage C
Location
GRADE 1
Stage BStage A Stage D
Size
Assessment
of edema
Nutritional
Status
PMH
Biologicals
TWO2
Offloading
Wound
Debridement
Wound Bed
preparation
Topicals
Daily wound
care
Monitor decrease in size
Wound
Conversion to
lesser grade
Montior WBC, CRP,
Sed Rate
X-rayC&S
Surgery/debridement
Eliminate
Infection
Consider Infectious
Disease consult prn
Vascular Assessment
NIVs/ABIs
Transcutaneous O2
Angiogram/MRA
No Vascular
Intervention
Vascular
intervention
TWO2
Build Wound Matrix
Wound
Conversion
Montior WBC, CRP,
Sed Rate
C&S X-rays
Eliminate
Infection
Antibiosis
Surgical Debridement
TWO2
Vascular Assessment
NIVs/ABIs
Transcutaneous O2
Angiogram/MRA
Wound
Conversion
Depth
Wound base
Granular/Non-granular
Non-Granular / FibrousGranular
Conversion to Granular
Wound Bed
Denotes Multi-modality
Therapy: prn
TWO2
(2)
(10, 17, 19)
(10, 17, 19) (13, 19)
(12, 18)
(1,10, 19)
(12, 18)
(5, 9)
(3, 5) (8)
(10, 17, 19)
(5, 16)
(6, 19)
(6, 19)
(12,18)
(10, 11, 13, 17, 19)
(5, 9)
(3,5) (8)
(10, 17, 19)
(12,18)
(6, 19)
(6, 19)
Evidence Based Wound Conversion
Algorithm for
University of Texas Grade 1 Wounds
and Classification System
Infected Ischemic Infected / IschemicNo Infection or Ischemia
(11,15)
(11,15)
TWO2
Topical Wound Oxygen

7. Wound
Stage C
Location
GRADE 2
Stage BStage A Stage D
Size
Assessment
of edema
Nutritional
Status
PMH
Biologicals TWO2
Offloading
Wound Matrix
Assessment
Wound Bed
preparation
Topicals
Monitor decrease in
size and depth
Wound
Conversion to
Grade 1
Montior WBC, CRP,
Sed Rate
X-raysC&S
Surgery/debridement
Eliminate
Infection ID Consult
Vascular Assessment
NIVs/ABIs
Transcutaneous O2
Angiogram/MRA
No Vascular
Intervention
Vascular
intervention
TWO2
Build Wound Matrix
Wound
debridement
Montior WBC, CRP,
Sed Rate
C&S X-rays
Eliminate
Infection
Antibiosis
Surgical Intervention
TWO2
Vascular Assessment
NIVs/ABIs
Transcutaneous O2
Angiogram/MRA
Depth
Granular
Bed
Tendon / Capsule
Exposure
Negative
Pressure
Build Wound Matrix
Multi-modal
Therapy
Cam Boot
TCC
MRI
Serial Films
Monitor Labs
Monitor wound
Monitor C&S
Manage necrotic /
escharotic tissue prn
Monitor
granulation tissue
Consider Negative
Pressure adjunct
Ascertain elimination of
Infection
Vascular intervention
or Non-intervention
Continue TWO2
Wound base
Granular/Non-granular
Denotes Multi-modality
Therapy: prn
MRI
Negative
Pressure
Monitor wound
Build wound matrix
TWO2
(2)
(10, 11, 19)
(13, 19)
(10, 17, 19)
(12, 18)
(12, 18)
(12, 18)
(12, 18)
(4, 19)
(4, 19)
(4, 19)
(10, 11, 13, 17, 19)
(1)(10, 11, 17, 19)
(5, 9)
(3, 5)
(8)
(10, 17, 19)
(5, 16)
(10, 11, 13,
17, 19)
(10, 11, 13,
17, 19)
(10, 17, 19)
(6, 19)
(6, 19)
(6, 19)
(10, 17, 19)
(3, 5) (8)
(5, 9)
Infected / IschemicNo Infection or Ischemia Infected Ischemic
(11,15) (11,15)
TWO2
Topical Wound Oxygen
Evidence Based Wound Conversion
Algorithm for
University of Texas Grade 2 Wounds
and Classification System

8. Wound
Stage C
Location
GRADE 3 Stage BStage A Stage D
Size
Assessment
of edema
Nutritional
Status
PMH
Biologicals
TWO2
Offloading
Wound Matrix
Assessment
Wound Bed
preparation
Topicals
Monitor decrease in size and depth
Wound Conversion to
lesser grade/lesser depth
Monitor WBC, CRP,
Sed Rate
X-raysC&S
Surgery/debridement
Eliminate Infection
ID Consult prn
Vascular Assessment
NIVs/ABIs
Transcutaneous O2
Angiogram/MRA
Vascular intervention
TWO2
Build Wound Matrix
Wound
debridement
Montior WBC, CRP,
Sed Rate
C&S X-rays
Eliminate
Infection
Antibiosis
Surgical /Vascular
Intervention
TWO2
NIVs/ABIs
Transcutaneous O2
Angiogram/MRA
Depth
Granular Wound
Base
Negative
Pressure
Build Wound Matrix
Multi-modal
Therapy
Cam Boot /TCC
MRI
Serial Films
Monitor Labs
Monitor wound Manage necrotic
/escharotic tissue
Monitor
granulation tissue
Consider Negative
Pressure adjunct
Limb Salvage
Amputation prn
Fibrous
Tissue
Surgery/debridement prn
TWO2
Wound Conversion
to lesser grade
Amputation
TWO2
HBO2
May not be
a Candidate
HBO2
May Stage for
further Surgery
Continue with
TWO2
Wound base
Granular/Non-granular
Bone
(2)
(10, 11, 19)
(10, 11,
19)
(10, 17, 19)
(10, 17,
19)
(10, 17, 19)
(12, 18)
(12, 18)
(12, 18)
(12, 18)
(10, 11, 19)
(4, 19)
(4, 19)
(10, 17, 19)
(12, 18)
(13, 19)
(10, 11,
17, 19)
(1)
(5, 9)
(3, 5) (3, 5)(8)
(8)
(5, 9)
(5, 16)
(6, 10)
(6, 19)
(7, 14)
(7, 14)
(6, 19)
(6, 19) (6, 19)
Denotes Multi-modality
Therapy: prn
No Infection or Ischemia Infected Ischemic Infected / Ischemic
(11,15)
(11,15)
TWO2 Topical Wound Oxygen
Evidence Based Wound Conversion
Algorithm for
University of Texas Grade 3 Wounds
and Classification System

9. The authors propose a holistic Wound Conversion Algorithm as a
retrograde, step-wise therapeutic intervention guide for wound
healing, that has been validated in daily clinical practice in a busy
wound care center.
The wound conversion algorithm utilizes a blended approach of
evidenced based modality use, advanced wound therapies, and
practical field application which have yielded positive results.
Future publication encompassing clinical based outcome evidence
utilizing the algorithm will be forthcoming.
The authors fully expect modification of this algorithm with future
advances with modalities in wound care, but propose a useful tool
in wound care at the present.

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