very pleased to be contributing
to these Henry Stewart
talks on wound healing.
And my topic is wound bed
preparation with the acronym TIME.
I'm Professor David Leaper, Emeritus
Professor of Surgery at Newcastle
upon Tyne, and Visiting Professor
at Imperial College, London.
And that's me in the
bottom left-hand corner.
The TIME acronym
was originally aimed
to describe the observable
culturistics of chronic wounds
within the framework of
wound bed preparation.
It was developed by an
international advisory board
just over 10 years ago.
The concept of wound bed preparation
has been taken from plastic surgery
where a wound is prepared to
be optimal for a skin graft.
But in this context,
in chronic wounds,
wound bed preparation is a
preparation of a chronic wound
to allow successful healing
by secondary intention.
The TIME acronym, which I'll
describe throughout the lecture,
is based on T for
making the wound as
clean as possible.
Controlling infection and bioburden
and inflammation, that's the I. M
is for moisture balance.
Wounds heal optimally
when they are optimally
moist-- not too much
moisture, not too dry.
And finally, E for
the epithelial edge,
ensuring the healthiest epithelial
edge at the healing edge.
And also looking after the
periwound skin and making sure
it doesn't become too macerated.
This is a very busy slide and
summarises the concepts first
published in 2003 on the principles
for wound bed preparation.
And again, we can see
on the left-hand side
the acronym for tissue
cleaning, managing infection
and inflammation, managing moisture
and looking after the wound edge.
The proposed physiology and the
background for undertaking this
is given, and the clinical
actions and their effects.
And finally, the concepts of
the vast clinical outcomes.
Now, I shall be going
through this in the lecture
in the next few slides.
This slide shows the background of
wound bed preparation that might be
seen through the eyes
of a plastic surgeon.
This is a leg ulcer.
This has had a split thickness skin
graft put on it with poor wound bed
preparation, and as you can see,
the skin graft has not taken well.
Almost certainly, there is excessive
inflammation and moisture here.
However, the bottom
of this slide, you
can see that the split
thickness skin graft has largely
been salvaged using time principles
by getting on top of the bioburden
and infection and making sure
that any necrotic tissue has been
removed, and also looking after
moisture and the wound edge.
Over the last few years, the
concept of evidence-based medicine
has become a very powerful
tool in deciding on treatments.
David Sackett of Canada
can be considered
to be one of the leading
exponents of this.
And his comment was that
evidence-based medicine should be
conscientious, explicit, and
judicious use of current best
evidence in making decisions
about care of individual patients,
and integrating each clinician's
individual expertise with the best
external evidence from
So this just isn't
looking at the best
evidence that's been published.
But it also takes in the
expertise of the practitioner
and should also include the
patient's choice and maybe even
their carer's input to that,
together with the health economics
of this rather austere time
we're living in in health care.
David Sackett's concepts
of evidence-based medicine
have been added to enormously
by the recommendations
of the Cochrane Collaboration.
But in some ways, the myth of
the randomized control trial
has overtaken managing patients.
Really, the Cochrane Collaboration
looks only at systematic reviews
and meta-analyses, and randomized
controlled double blind studies
for the best evidence.
Of course, this is laudable.
But in the studies of
wound care, very little
of this kind of trial work exists.
So we really do have to look on
evidence that may not be in RCT.
We have to look to the expertise
of international groups of experts,
and to take in the
patient choice and health
economics of the current day.
The concern about the
is that grading
evidence could be seen
as being hierarchical
or even anarchy by some.
And to denigrate guidelines
that are based on expert opinion
Clearly both are
correct, and I think
that if we could bring together the
Cochrane Collaboration with those
of us who are working in the wound
field to produce guidelines based
on the best published evidence and
expert opinion, then people working
at the coalface would
have the best support.