Who’s got the TIME for wound care?

If you work in an acute setting, you will see these wounds, but perhaps not often enough to develop expertise in treatment options.  Nurses in the community, wound clinics, Wound CNC’s and even Stomal Therapist are exposed to these types of wounds on a regularly basis so naturally are a fabulous resource in planning treatment and dressing regimes.

The TIME acronym (tissue, infection/inflammation, moisture balance and edge of wound) was first developed more than 10 years ago, by an international group of wound healing experts, to provide a framework for a structured approach to wound bed preparation; a basis for optimising the management of open chronic wounds healing by secondary intention¹.

It’s important to understand that wound bed preparation is not static: it’s dynamic and rapidly evolving.  Wound bed preparation is a concept that emphases holistic and systematic approach to evaluate and remove barriers to the healing process².

The overall goal of wound bed preparation is to create an optimal wound healing environment by producing a well-vascularised, stable wound bed with little or no exudates^3,4.  The wound bed preparation is particularly applied to address chronic wounds that fail to progress through the normal healing process. It is performed via removing senescent or abnormal cells, reducing the bacterial load, decreasing the level of wound exudates and increasing the formation of healthy granulation tissue. When these goals are met, the final phase of wound healing will occur.

In 2003, the International Wound Bed Preparation Advisory Board established an algorithmic approach to this process with the development of the ‘T.I.M.E.’ acronym^5,6.

There are four components of wound bed preparation, which address the different pathophysiological abnormalities underlying chronic wounds:

1. Tissue management


2. Inflammation and infection control


3. Moisture balance


4. Epithelial (edge) advancement.

 

For the purposes of this blog, I will provide a brief outline of each of the four components.

Tissue Management

Tissue management is the process of removing necrotic or devitalized tissue, bacteria and cells that impede the healing process to reduce wound contamination and tissue destruction. The aim is to restore a viable wound base with a functional extracellular matrix. Chronic wounds are converted into acute wounds with the removal of the necrotic burden of senescent cells, the extracellular matrix, inflammatory enzymes and biofilms that contain bacterial colonies^7,8.

Inflammation and infection control

Chronic wound beds are often colonised by various species of bacteria or fungal organisms due to the prolonged opening of the wound, poor blood flow and underlying disease process. The bacterial balance is achieved by controlling the bacterial burden in terms of its density and pathogenicity⁷.

The critically colonised wound should be treated with topical antimicrobial dressings. Sustained-release silver dressings have gained in popularity due to their efficacy, low resistance and broad-spectrum antimicrobial actions, especially when pseudomonas or MRSA infection is a concern. The wound should be cleansed with low toxicity topical antiseptic solutions, e.g. normal saline or chlorhexidine solution, instead of cytotoxic solutions such as povidone-iodine. Topical antiseptics have the advantages of a broad spectrum of bacterial coverage and delivery in high concentrations directly to the wound bed. Wound debridement is an important adjunct as it directly reduces the bacterial burden, including the biofilms.

An important point to make here is that most chronic wounds will be devoid of constitutional symptoms. Chronic wound infection is recognized by an increasing ulcer size, increasing exudate production and friable unhealthy granulation tissue. These are wound more than 3 months old that are less likely to have advancing inflammation and constitutional symptoms⁹.

Moisture balance

The benefit of maintaining a moist wound environment is acceleration of re-epithelisation while minimising infection rate¹.  Achieving moisture balance involves the creation and maintenance of a warm, moist wound bed and the stimulation of components in the moisture that have a positive impact on wound healing, such as growth factors. Excessive wound fluids can break down or damage essential healing tissue. On the other hand, inadequate moisture may inhibit cellular activities and promote eschar formation¹⁰. Thus, moisture balance is a delicate process of maintaining a moist healing environment that is optimal for healing. 

Exudates can be managed directly via the use of a number of dressing materials, depending on the moisture status of the wound bed. For example, in a highly exudative wound, an absorptive dressing such as foam will be appropriate, whereas in a dry wound eschar, an occlusive or semi-occlusive dressing such as a hydrocolloid will be suitable to achieve the appropriate moisture balance. Negative pressure wound therapy is an important device that can be used to manage a heavily exudating wound. 

Epithelial advancement

The progression of the wound edge in terms of epidermal cell/keratinocyte migration and wound contraction is one of the key indicators of a healing wound. If there is an arrest of these processes,  clinicians should consider the earlier elements discussed (T.I.M.E.), including cellular dysfunction and biochemical imbalances-discussed below, as possible reasons for the failure of wound healing.

Every wound is unique and therefore should be assessed and treated individually, principally correcting the underlying cause(s) and systematically going through each of the T.I.M.E. components of wound bed preparation. An advanced knowledge of wound bed preparation has definitely improved treatment outcomes.

References

1. Schultz GS, Sibbald RG, Falanga V, Ayello EA, Dowsett C, Harding K, Romanelli M, Stacey MC, Teot L, Vanscheidt W. Wound bed preparation: a systematic approach to wound management. Wound Repair Regen 2003;11:1–28.


2. Falanga V. Wound Bed Preparation in Practice. EWMA Position Document. London: Medical Education Partnership Ltd; 2004. Wound bed preparation: Science applied to practice; pp. 2–5. [Google Scholar]


3.  Falanga V. Classifications for wound bed preparation and stimulation of chronic wounds. Wound Repair Regen. 2000;8:347–52. [PubMed] [Google Scholar]


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6. Schultz GS, Sibbald RG, Falanga V, Ayello EA, Dowsett C, Harding K, et al. Wound bed preparation: A systematic approach to wound management. Wound Repair Regen. 2003;11(Suppl 1):S1–28. [PubMed] [Google Scholar]


7. Sibbald RG, Orsted HL, Coutts PM, Keast DH. Best practice recommendations for preparing the wound bed: Update 2006. Adv Skin Wound Care. 2007;20:390–405. [PubMed] [Google Scholar]


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Venous Leg Ulcers, Diabetic Foot Ulcers, Surgical Site Infections, Dehisced Wounds, Pressure Injuries Ð is it possible to get these wounds healed? Absolutely! Wound care is a complex process, often compromised by budget restraints, patient non-compliance and co-morbidities, but how life changing is it for a patient with a chronic wound to have their skin integrity return?