Preparing the Wound Bed 2003: Focus on Infection and Inflammation

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Author(s): 
R. Gary Sibbald, MD; Heather Orsted, RN, ET; Gregory S. Schultz, PhD; Patricia Coutts, RN; and David Keast, MD, for the International Wound Bed Preparation Advisory Board and the Canadian Chronic Wound Advisory Board

The Preparing the Wound Bed Concept

Wound bed preparation was first described in 2000 by Sibbald et al1 and Falanga.2 This approach to wound management stresses that successful diagnosis and treatment of patients with chronic wounds requires holistic care and a team approach. The whole patient, the underlying cause, and patient-centered concerns must be considered before looking at the wound itself (see Figure 1).

This article updates the wound bed preparation model and examines the evidence base and expert opinion regarding infection. Three components of wound bed preparation are relevant in this respect: Tissue debridement, infection/inflammation, and moisture balance. Even when these factors have been corrected, some wounds do not heal and have an abrupt or steep epidermal edge, with no migration of epidermal cells across the wound surface. These four components of wound bed preparation can easily be remembered using the mnemonic TIME - tissue, infection/inflammation, moisture, and edge effect.

To date, expert opinion has provided recommendations for preparing the wound bed. It remains the best guide because the evidence base is still weak (see Appendix 1). A template for wound bed preparation, revised since 2000, is presented in Table 1.

Scope of Review

This review examines the management of infection and inflammation in all types of chronic wounds (pressure ulcers, diabetic foot ulcers, venous and arterial leg ulcers, and inflammatory ulcers), and does not include burns, surgical, and other acute wounds. Wounds that have a suspected diagnosis of pyoderma gangrenosum or vasculitis are also included.

A number of systematic reviews have been conducted regarding the management of infection in chronic wounds. Although little of the work published in this area passes the rigorous assessment criteria set by the reviewers to direct clinicians to the most appropriate interventions, readers may be interested in noting the study conclusions. The sources below were searched for reviews on wound management within the scope of this review. All the systematic reviews listed are based on searches of the major databases, individual inquiries to non-indexed journals, searches of meetings abstracts, and personal interviews with researchers in order to identify unpublished material.

   * DARE (the Database of Abstracts of Reviews of Effects). Available at www.nhscrd.york.ac.uk. A database of systematic reviews, assembled by staff at the University of York, including reviews in the Cochrane Library and elsewhere

   * The Cochrane Library, free to UK users through www.nelh.nhs.uk

   * TRIP (Turning Research Into Practice) through www.tripdatabase.com. It includes a wide range of UK and US clinical effectiveness resources and evidence-based guidelines

   * Health Technology Assessments (HTA reviews).

In the absence of evidence that matches the gold standard of the double-blinded, randomized, controlled trial, clinicians have to rely on expert opinion and evidence available from controlled and uncontrolled studies. This review presents a consensus from two expert groups: the International Wound Bed Preparation Advisory Board and the Canadian Chronic Wound Advisory Board.

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