Wound Bed Preparation

Background

 
 
 
 
 

Wound Bed Preparation is an essential process to obtain maximum benefits from today's advanced wound care products. Preparing the wound bed can be achieved by the removal of barriers. Removing these barriers may accelerate healing or facilitate the effectiveness of other therapeutic measures.

 

Wound Bed Preparation can be defined as the process of removing local barriers which may facilitate healing and provide a more efficient means of wound management.

 

The TIME principle provides a systematic approach to the management of wounds, by focussing on each stage of wound healing and therefore by removing these barriers allows the wounds to heal.

TIME is based on intervention in four clinical areas and leads to an optimal well vascularised wound bed.

 

T - Tissue non viable or deficient
 

Does the wound contain non viable tissue sometimes referred to as necrotic?

 

I - Infection or Inflammation
 

Does the wound indicate signs of increasing bacterial contamination or inflammation?

 

M - Moisture Imbalance
 

Does the wound indicate the production of excess exudate or is the wound too dry?

 

E - Edge of wound non advancing or undermined
  Are the edges of the wound undermined and is the epidermis failing to migrate across the granulation tissue?

 

Click on one of the above clinical observations to find out more information.

To better explain the principles of TIME click on the link to reveal a pdf of the TIME Table.

 

Courtesy of The International Advisory Board on Wound Bed Preparation. Adapted from table 6 - Schultz GS, Sibbald, RG, Falanga V et al (2003) Wound bed preparation: systematic approach to wound management Wound Rep Reg 11; 1-28

 

To summarise, Wound Bed Preparation provides a structured and systematic approach to the management of non healing wounds. The removal of barriers through the principles of TIME should faciliate endogeous healing.

 

Debridement, reduction of bioburden and exudate management are collectively referred to as Wound Bed Preparation. It is these processes that prepare the wound bed to support the activities necessary for wound healing. All practitioners who are, or will, become involved in both assessing patients for, and initiating techniques relevant to wound bed preparation, should understand the need to remove these barriers.

 

Typical assessment questions that should be answered in order to start the process of Wound Bed Preparation are:

 

  • Is the wound bed clean or is there necrotic tissue to be removed?
  • Are there any clinical signs that there is a problem with bacterial bioburden?
  • Does the wound environment seem dry and is there risk for desiccation of cells?
  • Is absorption or drainage the objective for topical therapy?

 

To learn more about the clinical relevance of Wound Bed Preparation, visit the

 


^ Courtesy of International Advisory Board on Wound Bed Preparation 2003

References

 
 
Author Title Journal
Falanga V (2000) Classification for Wound Bed Preparation and Stimulation of Chronic Wounds Wound Repair and Regeneration; 8 (5): 347 - 352 (Editorial)
Sibbald RG, Williamson D, Orsted HL et al. (2000) Preparing the Wound Bed - Debridement, Bacterial Balance, and Moisture Balance OstomyWound Management; 46 (11): 14 - 35
Brem H, Balledux J, Bloom T et al. (2000) Optimal Wound Bed preparation for the successful use of bioengineered skin in Venous Ulcers, 10th Annual Meeting of the Wound Healing Society, Toronto, Canada, June 4-6, 2000. 10 th Annual Meeting of the Wound Healing Society, Toronto, Canada, June 4-6, 2000. Wound Repair and Regeneration; 8 (4): 322 - 345
Bello YM, Falabella AF, Eaglstein WH, et al. (2001) Tissue-engineered skin. Current Status in Wound Healing American Journal of Clinical Dermatology; 2(5): 305 - 313
Keast DH (2002) Preparing the Wound Bed before Dermagraft Use Canadian Journal of Plastic Surgery; 10, Suppl. A
Cherry GW, Harding KG, Ryan TJ (eds.) (2001) Wound Bed Preparation The Royal Society of Medicine, International Congress and Symposium Series 250
Falanga V, Harding KG (eds.) (2002) The Clinical Relevance of Wound Bed Preparation Springer Verlag (Cardiff ETRS 2001 proceedings)
Falanga V (eds) (2003) New Concepts in Wound Bed Preparation Joint Conference of the Wound Healing Society and the European Tissue Repair Society, Baltimore Joint Conference of the Wound Healing Society and the European Tissue Repair Society, Baltimore. Springer Verlag
Harding KG (chair) Wound Bed Preparation - A Focus on Debridement 12 th Congress of the European Wound Management Association, Granada, 23 rd - 25 th May, 2002
Sibbald RG (eds) (2003) Bacteria & Pressure Ulcers: The role of silver versus traditional antimicrobials Ostomy/Wound Management; 49(5A suppl): 3-33 (6 th European Pressure Ulcer Advisory Panel Open Meeting, Budapest 2002)
Dowsett C (2002) The Role of the Nurse in Wound Bed Preparation Nursing Standard; 16(44): 69 - 76
Krasner D (2001) How to Prepare the Wound Bed OstomyWound Management; 47 (4): 59 - 61
13 Vowden K, Vowden P Wound Bed Preparation, World Wide Wounds http://www.worldwidewounds.com/
2002/april/Vowden/
Romanelli M, Mastronicola D (2002) The Role of Wound Bed Preparation in Managing Chronic Pressure Ulcers Journal of Wound Care 11 (8)
Collier M (2002) Wound-Bed Preparation Nursing Times 98 (2)
Pudner R (2002) Wound-Bed Preparation Journal of Community Nursing 16 (5)
Romanelli M, Gaggio G, Coluggia M, et al. (2002) Technological Advances in Wound Bed Measurements Wounds 14 (2), 58 - 66
Mani R (2001) Is Wound Bed Preparation Assessable non invasively? The Royal Society of Medicine, International Congress and Symposium Series 250
Falanga V (2002) New Therapeutic Approaches in Wound Healing (Commentary) Wounds; 14(2): 45 - 46
Falanga V (2002) Wound Bed Preparation and the Role of Enzymes: A case for Multiple Actions of Therapeutic Agents Wounds; 14 (2): 47 - 57
Schultz GS, Sibbald RG, Falanga V et al. (2003) Wound Bed Preparation: A Systematic Approach to Wound Management Wound Repair and Regeneration; 11, Supplement : 1-28
Enoch S, Harding KG (2003) Science behind the removal of barriers to healing Wounds; 15 (7): 213 - 229
Fletcher J (2003) Managing the process of effective wound bed preparation Journal of Wound Care; Vol 12 No.9 Oct 2003 pg 347-349
Flanagan M (2003) Philosophy of wound bed preparation in clinical practice Smith & Nephew Medical Ltd: 1-34
Sibbald RG, Orsted H, Schultz GS, Coutts P and Keast D (2003) Preparing the Wound Bed 2003: Focus on infection and inflammation Ostomy/Wound management; 49(11):24-51
Moffat C, Falanga V, Vowden P
(2004)
EWMA Positioning Paper “Wound Bed Preparation in Practice” Published by MEP Ltd. 2004

 

^ Courtesy of International Advisory Board on Wound Bed Preparation 2003


Product Range

 

 

The healing of chronic wounds is a step by step process which involves a team of products designed to provide an effective environment to promote healing. Wound Bed Preparation is an essential step within the process. Smith & Nephew is able to offer a full range of products for Wound Bed Preparation.

 

Wound factors Clinical action Suggested product solution Wound healing Outcome
Image of wound T Tissue non-viable
necrotic tissue or slough present
Remove defective tissue

Intrasite* Gel Intrasite* Conformable
Iodoflex*/ Iodosorb*

Iruxol* Mono

Viable (vascularised) wound bed Image of wound
Image of wound I Inflamation and/or infection
increased exudate, surface discolouration or increased odour
Reduce bacterial load

Acticoat* 7
Acticoat
Acticoat Absorbent

Iodoflex/ Iodosorb

Iruxol Mono

Reduced bacterial burden and inflammation

Image of wound
Image of wound M Moisture Imbalance
heavy exudate - risk of maceration
Dry wound bed - risk of desiccation
Restore moisture balance

Allevyn* Range

Intrasite* Gel Intrasite* Conformable

Optimal moisture balance Image of wound
Image of wound E Edge of wound
non-advancing or undermining
e.g. chronic wound with prolonged inflammation
Reassess T,I and M
Cadesorb*
Use Visitrak* to accurately track the progress of the wound edge and measure the areas of the wound
Restoration of appropriate pH level and cell migration to advance wound edge
If wound still static after 2-4 weeks, reassesss intervention or refer for specialist treatment

 

 

To discuss the role of Smith & Nephew products in Wound Bed Preparation contact your local salesperson.


 

SILCRYST is a patented Technology of NUCRYST Pharmaceuticals Corp, used under license

^ Courtesy of International Advisory Board on Wound Bed Preparation 2003

Algorithm

 
 

 

 

Ref M Flanagan The Philosophy of Wound Bed Preparation in Clinical Practice 2003

 

To download a high quality copy of the above Algorithm, click on the image

(approx 5 seconds - Size 63KB).

 

Preparing the Wound Bed

 

Treat the cause
  1. Assess the patient for healability. Adequate blood supply must be present and host factors (coexisting diseases, drugs) must all be considered.
  2. Correct treatable cause of tissue damage.
Patient centred concerns
  1. Make the patient part of the decision making process. Pain and quality of life should be documented and should form part of the treatment plan.
  2. Provide education and support for patient centred care to increase coherence with a treatment process.
Local wound care
  1. Assess and monitor the wound history and physical characteristics (location, size, base, exudate, surrounding skin, staging and pain).
Debridement
  1. Debride healable wounds, removing necrotic and non-viable tissue (surgical, autolytic, enzymatic and mechanical). Non-healable wounds should have only non-viable tissue removed and active debridement to bleeding tissue is contraindicated.
Persistent inflammation and bacterial balance
  1. Assess the wound for bacterial balance, infection or persistent inflammation.
  2. Use only non-sensitising topical antibacterial agents for local symptoms and signs of increased bacterial burden.
  3. Use systemic antibiotics if symptoms or signs of infection extend beyond the wound margin, or the ulcer probes to bone.
  4. For persistent inflammation, topical and systemic anti-inflammatories should be considered based on superficial, local or systemic disease process.
Moisture balance
  1. Cleanse wounds with normal saline and water. The use of topical antiseptics should be reserved for wounds that are non-healable or those in which the local bacterial burden is of greater concern than the stimulation of healing.
  2. Select appropriate dressings for local moisture balance to stimulate granulation tissue and re-epithelialization.
Edge effect
  1. Evaluate expected rate of wound healing to determine if treatment is optimal. If sub-optimal healing is noted, re-assess the cause and patient centred concerns.
  2. Use active wound therapies (biological agents, skin grafts, adjunctive therapies) when other factors have been corrected and if healing still does not progress.
Overall
  1. For improved outcomes, education and evidence base must be tied to interdisciplinary teams with the cooperation of health care systems

 

From: Preparing the Wound Bed 2003: Focus on infection and inflammation

Ostomy Wound management; 49(11):24-51

Sibbald RG, Orsted H, Schultz GS, Coutts P and Keast D

 

^ Courtesy of International Advisory Board on Wound Bed Preparation 2003


KOL Activity

 
 

Key Opinion Leaders play a key role in the development of Wound Bed Preparation, it is thanks to their continued efforts and commitment to raising awareness that WBP is increasingly being recognised by healthcare professionals as the next great paradigm after moist wound healing. The concept of WBP identifies a number of barriers that obstruct wound healing and recognises that these need to be removed before wound healing can take place.

 

Research and publishing in Wound Bed Preparation has been taking place over recent years. Below are ten of the leading international clinicians in this field, who collectively make up an International Advisory Board

 

Vincent Falanga

Professor of Dermatology and Biochemistry,

Boston University
Chairman of Dermatology and Training Program,
Roger Williams Medical Centre, Rhode Island, USA

Vincent Falanga, MD, FACP is a Professor at Boston University School of Medicine and Chairman of the Department of Dermatology and Training Program at the Roger Williams Medical Centre, Providence, Rhode Island. Dr Falanga graduated from Harvard Medical School in 1977 and is board certified in Internal Medicine and Dermatology. An internationally recognised expert in chronic wounds, he has over 200 publications and has co-authored four textbooks on wound healing. Dr Falanga oversees clinical investigation for the development of new approaches to wound healing and the treatment of diabetic, venous and pressure ulcers. He is a consultant for the National Institute of Health and other granting agencies, and oversees a basic science program dedicated to wound healing and fibrosis. He is a member of the American Dermatological Association, Society of Investigative Dermatology, American Federation of Clinical Research, American Academy of Dermatology, American College of Physicians and the American College of Rheumatology.

www.bu.edu/woundbiotech/

 

R. Gary Sibbald

Professor of Medicine and Public Health Science,

Director of Continuing Education,
Department of Medicine, University of Toronto
Director, Dermatology Day Care and Wound Healing Clinic,
Sunnybrook and Women's College Health Sciences,

Toronto, Canada

Professor R. Gary Sibbald is a specialist in internal medicine and dermatology with a special interest in chronic wound care and a master's degree in education. He was a founding board member of the Association for Advancement of Wound Care in the United States and a co-founder and past chairman of the Canadian Association of Wound Care. His dermatology expertise led to his roles as advisory council executive member for Canada of the American Academy of Dermatology and a previous president of the Toronto Dermatological Association. Professor Sibbald is the director of continuing education for the Department of Medicine at the University of Toronto and chair of the Faculty Continuing Education Committee and a board member of the Canadian Association of Continuing Health Education.

Presently, Professor Sibbald is the director of the Dermatology Daycare and Wound Healing Clinic at the Women's College Campus of Sunnybrook and Women's College Health Sciences Centre. He is the director of the International Interdisciplinary Wound Care Course at the University of Toronto and co-editor of the Third Edition of Chronic Wound Care: A Clinical Source Book for Healthcare Professionals.

On the international scene, he is the chair of the Education Committee of the World Union of Wound Healing Societies. Dr. Sibbald has lectured and presented at over 500 scientific meetings on five continents. He has published over 100 articles and book chapters.

www.twhc.ca

 

Keith Harding

Professor of Rehabilitation Medicine (Wound Healing)
University of Wales College of Medicine, UK

Keith Harding, MB ChB, MRCGP, FRCS is a professor of Rehabilitation Medicine at the University of Wales College of Medicine with an expertise in basic science and prevention and treatment of all chronic wounds. For the past ten years he has been director of the Wound Healing Research Unit, a self funded unit within the College of Medicine, designed to provide academic and clinical focus in wound healing. Professor Harding is a founding member of the European Wound Management Association, President of the European Tissue Repair Society. He has authored over 200 publications in peer review journals. From 1980-1990 he was principal in General Practice in Cardiff, UK.

www.whru.co.uk

 

Gregory S. Schultz

Professor of Obstetrics and Gynaecology,

University of Florida USA

Dr Schultz is the Director of the Institute for Wound Research at the University of Florida. Dr Schultz's research focuses on the role of growth factors, cytokines and proteases in normal and chronic wound healing in the skin and in the eye. He has published over 170 research papers, chapters and review articles, which have been cited more than 4,400 times. He has been continuously funded by grants form the National Institutes of Health, has multiple patents in the areas of wound healing, and is a consultant for pharmaceutical and biotechnical companies. He served as President of the Wound Healing Society from 1999-2001.

www.obgyn.ufl.edu/research

 

Michael Stacey

Associate Professor of Surgery, Fremantle Hospital,

Australia

Michael Stacey is a general and vascular surgeon and has a research interest in wound healing and chronic venous disease. His specific research interests are in the biochemistry and molecular biology of impaired healing in chronic venous ulcers. He also has research interests in venous physiology, pressure ulcers and diabetic foot ulcers. He was Inaugural President of the Australian Wound Management Association. He is currently Chairman of the World Union of Wound Healing Societies, and is on the Editorial Board of a number of journals associated with wound healing, in particular Wound Repair and Regeneration, The Journal of Wound Care, and Primary Intention.

www.woundheal.org

 

Luc Teot

Professor of Surgery, Montpellier University, France

Luc Teot is qualified in general, orthopaedic and plastic surgery. He is Founding President of the French Society for Wound Care, Board member of the European Tissue Repair Society and President and organiser of The 2nd World Wound Healing Congress, to take place in Paris in 2004. He has authored over 20 international publications and 47 French publications on several aspects of surgery. He is on a number of journal editorial boards, has authoured eight books and written 17 chapters in French and international publications.

 

Caroline Dowsett

Nurse Consultant Tissue Viability ,

Newham Primary Care Trust, London

Caroline Dowsett is a Nurse Consultant and has been working in the field of Tissue Viability for the past seven years. She won Wound Care Nurse of the Year in 1999. She also lectures on wound care courses at both City and South Bank Universities, London and is currently undertaking a PhD at City University, London. She is an Executive Committee member of the National Leg Ulcer Forum. She had authored numerous publications in peer-reviewed journals and is currently a member of the Tissue Viability Society.

 

Elizabeth Ayello

Clinical Associate Professor, Faculty of Nursing,

University of New York, USA.

Elizabeth is a clinical nurse specialist, her area of speciality is adult Medical-Surgical nursing. She is particularly focused on the care of patients with all types of wounds and ostomies. Elizabeth's research interests include Nursing Education, distance learning, Wound Care, Pressure Ulcer risk assessment.

Internationally known for her expertise in wound care Elizabeth has served as the President for the National Pressure Ulcer Advisory Panel (NPUAP), and as a past co-chair and now current member of the Wound, Ostomy, and Continence Nurses Society (WOCN) Accreditation Committee, Elizabeth has developed criteria for evaluating all the WOCN programs in the US.
For the past two years, Elizabeth has been a consultant to the Centres for Medicare and Medicaid Services (CMS) for their 3 year project to develop a scope and severity scale for Pressure Ulcers. She has authored several books and papers including: Pressure ulcers in America. Prevalence, Incidence, and implications for the future and "Skip the knife. Debriding wounds without surgery"

 

Professor Wolfgang Vanscheidt

Professor of Dermatology

Rheintalklinik Astoria-Privatkliniken, Bad Krozingen, Germany

Professor Wolfgang Vanscheidt is a Professor of Dermatology and President of the German Wound Healing Society (DGfW). In 2002 he was made a co-opted Member of the Board of the European Wound Management Association (EWMA). His main research topics are pathogenesis and therapy of venous leg ulcers, phlebology and laser therapy both experimentally and clinically. Since 1987 Professor Vanscheidt has participated in numerous international clinical multicentre studies in phebology and wound treatment, and has in some cases been the leader of the clinical study. He has published numerous papers and sits on the editorial board for a number of national and international publications.

 

Dr. Marco Romanelli

Consultant Dermatologist at the Department of Dermatology

and Head of Wound Healing Service at Azienda Ospedaliera

Pisana and University of Pisa.

Currently President and founding member of the European Pressure Ulcer Advisory Panel (EPUAP), he is also board member of the European Tissue Repair Society (ETRS), council member of the European wound Management Association (EWMA). He is member of the editorial board of the journal WOUNDS and referees several peer-reviewed journals in the field of chronic wounds. He is also member and fellow of several scientific societies. He is the author and co-author of numerous scientific papers and book chapters in the field of tissue repair. Research interests include tissue engineering for acute and chronic wounds, measurements in wound healing, management of pressure ulcers. Dr. Romanelli is the clinical project leader of a research program named DERMA which received a two years (2001-2003) research grant from the European Commission inside the Fifth Framework program. Partners in this project include Oxford Wound Healing Institute, Copenhagen Wound Healing Centre and Wound Healing Unit in Budapest. The study is devoted to the creation of an engineering prototype for the advanced measurements of wound physical and biochemical parameters. The Wound Healing Unit in Pisa is organised as a multi disciplinary team to serve as a centre of excellence for the central part of Italy. The team is working on acute and chronic wounds and has a special interest in research and continuing medical education in this field. An annual National Tissue Repair School in Pisa two years ago with the objective to create professional expertises in wound healing.

www.aiuc.it

 

 

To find out more about Smith and Nephew sponsored events internationally visit www.snevents.com

 

^ Courtesy of International Advisory Board on Wound Bed Preparation 2003