18.3 Handoff Communication Across Settings

Wounds fail at the doorway between units as often as they fail in the bed. The receiving nurse who inherits "sacral wound, foam daily, wound nurse following" has no etiology, no size, no arterial numbers, no compression method, no offloading schedule, and no name to call at 02:00. Independent OpenExamPrep teaching for CWCN handoffs treats communication as part of the dressing. If the next setting cannot reproduce the plan, you did not finish the plan.

SBAR Built for Wounds

Use Situation-Background-Assessment-Recommendation (SBAR) so the essential pieces cannot be dropped into a friendly narrative.

Etiology is not optional color. A plantar DFU, a venous gaiter ulcer, and a sacral pressure injury do not share a dressing logic. If you omit etiology, the next site will treat whatever they see as "a hole."

Stage or thickness plus measurements must include the date. "Stage 3" copied forward for six weeks while the ulcer closed to a shallow open area is a documentation injury. Record length, width, depth, and the presence or absence of undermining and tunneling. If you could not fully visualize the base, say so.

Perfusion numbers with a date beat adjectives. "ABI 0.62 on 12 September 2026, TBI 0.41 on the same day, pulses dopplerable" is usable. "Circulation okay" is not. Compression decisions, vascular urgency, and whether a heel can be expected to heal all ride on those dated numbers. If perfusion was never measured, say it was never measured—do not invent reassurance.

Current dressing, compression, and offloading must be reproducible. Name the product category and the actual change frequency, not "advanced dressing." For compression, name the system (for example, a specific multilayer wrap or short-stretch bandage), how many layers, which direction, and when to unwrap. For offloading, name the device and the wear rule ("removable boot whenever upright, not only during physical therapy"). A receiving night shift cannot guess your wrap from a brand name they do not stock.

Goals must say heal, maintain, or palliate. A malignant fungating wound and a hospice pressure injury are harmed by a default "heal" pathway of daily aggressive debridement. A surgically closed, well-perfused incision is harmed by a default "comfort only" pathway that skips infection surveillance. Write the goal the team actually chose with the patient.

Pending studies prevent duplicate tests and prevent dropped tests. "MRI of the foot ordered, not yet done; hold empiric six-week antibiotics until imaging and ID review" is a handoff. "Labs pending" is not.

Who follows must be a person or a service with a contact path. "Wound nurse following" without a name, a visit frequency, or a stop date is how patients go three weeks with no one looking at the heel. State whether the CWCN is consulting only, whether home health owns daily care, whether the outpatient wound center owns weekly debridement, and who writes orders.

Hospital to SNF or Home: Send the Plan, Not a Rumor

Assume the next formulary is different, the next mattress is different, and the next nurse has never seen your wrap. Practical transfer habits:

• Send extra dressings for several days so a formulary lag does not become gauze-in-a-pinch by tonight.
• Send written wrap instructions, ideally with a simple diagram or a photo permitted by policy, because "continue compression" produces four different wraps by morning.
• Name surface needs: mattress type or overlay, wheelchair cushion, heel-offloading boots, and head-of-bed limits if they matter. "Pressure mattress" is not a surface order.
• Send the last measurements and a dated photo when policy allows, so the receiving team is not staging from memory.
• Include allergies and adhesive failures so the next foam does not recreate a contact dermatitis.

If the SNF cannot provide twice-daily packing or the home has no caregiver, the honest handoff is to stop the transfer or change the regimen to something the site can perform—not to hope. Advocacy from the previous section and handoff from this section are the same job on different paper.

What "Wound Nurse Following" Gets Wrong

That phrase comforts the discharging team and informs nobody. It does not state frequency, product, compression, offloading, goals, or a callback number. Replace it with a five-line plan: etiology and dated size; dated ABI or TBI if relevant; dressing and wrap and boot; heal versus palliate; owner and red flags ("call if odor, fever, wrap slippage, or boot nonadherence"). If no one is actually following, write that too, so the receiving site does not wait for a visitor who is not coming.

Telehealth and Photo Limits

Photographs help when lighting is even, the camera is roughly perpendicular, a measuring device is in the frame, and the peri-wound is visible. They fail when the image is dark, angled, covered with residue, or cropped to the hole. You cannot stage from a poor photo alone. Staging and thickness require a three-dimensional look at the deepest visible tissue, and undermining is often invisible on a snapshot. You also cannot take pulses, probe to bone, smell the wound, or feel crepitus through a portal. Telehealth is useful for interval checks when you already know the wound, the perfusion, and the caregiver. It is a dangerous substitute for a first-time full exam. If the photo is inadequate, say you cannot stage it and request a proper image or an in-person visit rather than guessing a stage that will live in the legal record.

Scope: Consults Are Not Attending Orders

A CWCN certification documents specialty knowledge. It does not, by itself, let you replace the attending, surgeon, or other authorized practitioner. You recommend dressings, surfaces, consults, and teaching. Prescriptions, procedural debridement beyond your facility privileges, imaging orders, discharge destination, and code status still require the person who has that authority under state practice rules and facility policy. Document the recommendation, the time, and whom you notified. If the attending declines a vascular consult on an ABI of 0.4 with rest pain, document the recommendation and the response; do not silently convert your note into a fake order, and do not abandon the patient—escalate through the chain the facility provides. Verbal "looks good" in a hallway is not an order and is not a handoff.

Scenario: The Transfer That Looked Complete

An 83-year-old leaves the hospital for a SNF with a mixed venous-arterial gaiter ulcer. The discharge summary says "wound nurse following, foam daily, ABI okay." No ABI date or value is attached. The wrap was a four-layer system the SNF does not stock. The specialty mattress stays on the inpatient floor. Two days later the wrap is a single elastic bandage applied over a dry gauze, the edema is worse, and a night nurse stages the ulcer from a blurry family photo sent by text. The preventable errors were the missing dated perfusion numbers, the missing wrap recipe, the missing extra supplies and surface, the empty "wound nurse following" line, and a photo used as if it were an exam. A usable SBAR would have read: mixed venous-arterial ulcer, 6.2 by 4.0 by 0.3 cm on 18 September 2026, ABI 0.68 on 17 September 2026, four-layer wrap with written steps and three extra kits, foam to the SNF formulary equivalent, heel-free mattress overlay required, goal is healing with modified compression, vascular follow-up Friday, call for new rest pain or purple toes. That paragraph is the treatment.