Wound bed preparation and TIME

Published on October 7, 2014   66 min
0:00
I'm 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.
0:23
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 tissue debridement, 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.
1:37
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.
2:20
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.
3:05
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 systematic research. 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.
4:03
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 Cochrane Collaboration 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 is difficult. 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.
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Wound bed preparation and TIME

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