Wounds of traumatic aetiology

• Systemic Inflammatory Response Symptoms (SIRS) or clinically unwell (see Sepsis Clinical Tools )
• Wounds with complex foreign body involvement and significant damage to associated surrounding structures including blood vessels, nerves, muscles, joints and tendons.
• Wounds with associated compound fractures
• Persistent significant bleeding not controlled with usual measures
• Worsening pain and/or pain not in keeping with mechanism of injury
• Initial acute burns should be managed as per ANZBA guidelines
• Lacerations and wounds not suitable for primary health management e.g. lip lacerations, large facial lacerations, lacerations with altered sensation, large skin defects

Arterial/ischaemic ulcer

• Systemic Inflammatory Response Symptoms (SIRS) or clinically unwell (see Sepsis Clinical Tools
• Worsening pain and/or pain not in keeping with progression of the wound/ulcer
• Sepsis or acutely unwell due to infection3
• Acute or critical limb ischaemia with necrosis
• Rapidly deteriorating ulceration or necrosis.3
• Ulcers or wounds in a limb with markedly compromised circulation

Wounds on the High-Risk Foot

• Systemic inflammatory response symptoms (SIRS) or clinically unwell
• Worsening pain and/or pain not in keeping with progression of the wound/ulcer
• Progressive cellulitis despite initial treatment
• Acute or critical limb ischaemia with necrosis
• Acute Charcot arthropathy if access to podiatry is not accessible within 48 hours

Stoma related wounds

• Systemic Inflammatory Response Symptoms (SIRS) or clinically unwell (Sepsis Clinical Tools)
• Worsening pain and all pain not in keeping with current state of the wound
• Progressive cellulitis despite initial treatment
• Suspected incarcerated hernia or underlying abscess
• Suspected bowel obstruction resulting in non-functioning stoma
• Persistent significant bleeding, including peristomal varices, not controlled with usual measures
• Stomal change in colour from red / pink to blue or black
• Stomal prolapse causing circulatory compromise
• Ongoing high output stoma and signs of dehydration

NB: If the problem is with the stomal appliance the patient can self-refer to stomal therapy nurse. Patients not in contact with regular stomal therapy nurse/service can be referred by GP.

Pressure injury

• Systemic Inflammatory Response Symptoms (SIRS) or clinically unwell (Sepsis Clinical Tools)
• Worsening pain and all pain not in keeping with current state of the wound
• Pressure injury causing and systemic infection
• Patients with spinal injuries should be referred to Spinal Outreach Team (SPOT)

Patients from Residential Aged Care Facilities can access wound advice from RADAR services (Residential Aged Care District Assessment and Referral Service) where they are established

Post-operative wound/dehiscence

• Systemic Inflammatory Response Symptoms (SIRS) or clinically unwell (see Sepsis Clinical Tools )
• Worsening pain and/or pain not in keeping with progression of the wound/ulcer
• Prosthesis / metal work / mesh is on view/ vascular bypass procedure
• Tendon blood vessel or other structure on view
• Purulent discharge with associated fevers
• Immunocompromised patients
• Deep sinus or fistula present

Referral to Surgeon who performed operation/Surgical Clinic

Patients should have clearance from their surgeon for wound management alone if:

• Acute wound dehiscence in the post operative period (< 6 weeks)

Venous leg ulcer

• Systemic Inflammatory Response Symptoms (SIRS) or clinically unwell (see Sepsis Clinical Tools )
• Worsening pain and/or pain not in keeping with progression of the wound/ulcer
• Progressive cellulitis despite treatment – rapidly spreading cellulitis with peri-wound redness or erythema (colour change, warmth, tight oedema, or pain in pigmented skin tones) for > 2cm
• Uncontrollable bleeding from ulcer