Wound bed preparation has become the gold standard model for proper wound assessment. It allows us clinicians to identify and breakdown local barriers to wound healing. Throughout our health care careers, we have seen it over and over again: the collective emphasis on standards of care, evidence-based practice, and cost-effectiveness in order to achieve positive outcomes for our patients.The wound bed preparation model supports all of these aspects of care delivery. Wound bed preparation is not only the basis for clinicians to be successful in treatment, but more importantly, to achieve faster and better results for our patients afflicted by wounds. Achieving better wound healing results for our patients is the number one reason why we must continue to educate ourselves and our wound team members in order to be successful in this field. Believe me when I say, it takes a village to a heal a wound.

What is Wound Bed Preparation?

By definition, wound bed preparation is "the management of a wound in order to accelerate endogenous healing or to facilitate the effectiveness of other therapeutic measures." ^{1, 2} It allows clinicians to provide wound management by identifying barriers that affect the patient with the wound, and not just the wound itself.

The Principles of TIME

To facilitate wound bed preparation, a group of wound care experts developed the mnemonic TIME. The concept was created in 2002 and since then has been providing wound care clinicians with the tools needed to promote wound bed preparation in a simpler way. Following is explanation of the TIME framework:

T – (tissue)

Is the tissue non-viable or deficient in the wound? If there is a presence of non-viable tissue, necrosis, slough or eschar, then the next step is to determine the best type of debridement that would be the most appropriate for this patient (enzymatic, autolytic, sharps, surgical, mechanical, etc.). If all tissue is viable, then choose a dressing that maintains optimal moisture conducive for wound healing, and address the presence of dead space, undermining and tunneling of the wound as those areas would require to be loosely packed or filled to prevent further complications or development of new barriers.

I – (infection / inflammation)

Are there any visible signs or symptoms of infection? Does the wound appear "angry"? The presence of infection, whether local or systemic, creates a barrier to healing. Presence of edema to the wound bed and or periwound also creates a barrier. With infection, the host has been overwhelmed by microorganisms that have surpassed their stay. Infection has to go through several stages in order to achieve total control of host and cause a systemic infection. Microorganisms tend to interact with chronic wounds at different levels. There is wound contamination, colonization, critical colonization and ultimately, infection. At this point, systemic antibiotics will assist greatly once the organism has been identified, and using local antimicrobials will assist at the local level as well. With edema at the periwound, how do we manage it? Is compression adequate? Does the patient have enough circulation? Venous or arterial? Answering these questions can help determine the correct amount of compression and type of dressing needed to provide a moist wound environment.

M – (moisture balance)

Does the wound appear too dry or too wet? Dr. George Winters' research in the early 1960s came to the conclusion that moisture balance is essential for positive outcomes in wound healing, resulting in the practice of what we now call moist wound healing. So, if the wound is too dry or desiccated, add moisture. If the wound is too moist or macerated—as evidenced by presence of maceration to wound edges and periwound—then choose dressings that are designed for moderate to heavy drainage.

E – (edge of wound)

Are the wound edges non-advancing or undermined? As we evaluate all aspects of local and systemic barriers, identifying the progress, or lack thereof, of wound edges is another critical point in wound management. When healthy, wound edges appear attached, open, and migrating or contracting. When wounds are improperly dressed, typically in cases with tunneling and undermining, other barriers such as epibole, undermined, or rolled edges will arise. By properly filling in those dead spaces, with the use of wound fillers, packing strips, or any other appropriate product of choice, the wound edges will then migrate and contract without complications.

Key Ending Points on Wound Bed Preparation

There is a popular saying that "practice makes perfect." A martial arts instructor once told me that is not correct, but in fact, "proper practice makes perfect." I agree with the latter. Wound bed preparation is the "proper practice" we clinicians should be doing with every dressing change because doing so will allow us to perfect our assessment skills of wounds. Additionally, wound progress should be noted within two weeks of consistently using initial advanced wound care products recommended by the SWAT (skin, wound assessment team, term coined by Dr. Joyce Black, University of Nebraska). The SWAT (if not alone, then in conjunction with wound bed preparation) should be able to modify treatment and meet the current needs of the wound.

So, at the end of the day, we must make sure that the TIME principles are being addressed for wound bed preparation, the patient and facility are in compliance, and we are supplying the correct tools for our patients and their families to be successful. Lastly, as we are practicing wound management; comorbid conditions should be assessed and addressed, as well as local and systemic factors. Keep healing, my friends!

References

1. Falanga V. Classifications for wound bed preparation and stimulation of chronic wounds. Wound Repair Regen, 2000; 8(5): 347-52.

2. Schultz, G. S., Sibbald, R. G., Falanga, V., Ayello, E. A., Dowsett, C., Harding, K., Romanelli, M., Stacey, M. C., Teot, L. and Vanscheidt, W. (2003), Wound bed preparation: a systematic approach to wound management. Wound Repair Regen, 11: S1–S28. doi:10.1046/j.1524-475X.11.s2.1.x

About the Author

Martin Vera is a certified wound specialist with over 19 years of nursing experience, with a passion for wound management and patient-centered care.