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CLINICAL REVIEW

Oer 90% of ll ptient contct within the NHS

tkes plce outside the hospitl setting predomi-

nntly with primry cre stff in generl prctice

surgeries, phrmcies or dentl surgeries nd with nurses,

helth isitors, llied helth professionls nd helthcre sci-

entists working in community helth serices (Deprtment

of Helth (DH), 2008).In prtnership with the NHS Institute, the DH re roll-

ing out the ‘productie community hospitls progrmme’

nd deeloping ‘productie community serices’ pro-

grmme. These progrmmes will reiew the eidence

bse for cre pthwys, initilly focusing on wound cre,

continence serices nd stroke serices, to enble more

time for direct ptient cre, nd improe qulity nd

ptient outcomes. This inititie will ineitbly led to

the further deelopment of the community nurse role s

greter emphsis will be plced on the need for n ei-

dence-bsed understnding nd widening skills set. The

DH (2008) identified wound cre s being one of the key

res where reiew of the eidence bse for interentions

ws required, nd integrl to this will be effectie wound

ssessment nd mngement strtegies. The cost of wound

cre to the NHS hs been estimted to be pproximtely

£2.3 billion to £3.1 billion yer (2005–2006 prices)

(Posnett nd Frnks, 2007). White (2008), howeer, beliees

tht the trend in current NHS spending indictes tht

2008 expenditure on wound cre ws pproximtely £100

billion. There is need to reiew the current eidence

bse in the field of wound cre to ensure qulity nd high

stndrds of cre re met, while lso ensuring interentions

re cliniclly nd cost effectie.

Wound bed preprtion nd debridement re key compo-

nents of modern wound cre. It is therefore importnt tht

community nurses re wre of the eidence bse in this re

so tht they cn delier high qulity cre for ptients nd

mke clinicl decisions underpinned by current literture.

This pper proides n oeriew of current eidence for the

principles of wound bed preprtion nd wound debride-ment techniques.

Wound healingTo pprecite the importnce of wound bed preprtion

it is importnt to reiew the physiologicl components of

wound heling. The process of wound heling cn generlly

be diided into four phses:

w vsculr response or homeostsis

w Inflmmtion

w Prolifertion

w aturtion.

a hrd-to-hel wound cn be defined s one tht fils to

hel with ‘stndrd therpy’ in n orderly nd timely mnner

(Troxler et l, 2006) with chronic wound being ‘stuck’ in

the inflmmtory stge of the heling continuum. Chronic

wounds he been conceptulized s the sequence of neglect,

incompetence, misdignosis or inpproprite tretment strte-

gies (Enoch nd Price, 2004). all ptients with wounds require

comprehensie ssessment to identify the cuse, underlying

etiology, the type of wound, size of wound nd the stge of

heling to llow the prctitioner to identify nd ddress poten-

til brriers to heling (Dowsett nd ayello, 2004). Wound bed

ssessment nd optimum locl wound cre re essentil to

fcilitte the wound heling process. The presence of deitl-

ized tissue, for instnce, necrotic tissue or slough, is common inhrd-to-hel wounds nd cts s brrier to heling.

Aeing he wound edWound bed preprtion is systemtic pproch to remoing

the brriers to nturl heling nd enhncing the effects of

dnced therpies (Schultz et l, 2003). The TIME frme-

work ws deeloped s systemtic pproch to implement-

ing wound bed preprtion by the Interntionl adisory

Bord for Wound Bed Preprtion (Schultz et l, 2003) nd is

useful pproch to wound ssessment, focusing specificlly

on the wound bed (Dowsett nd Newton, 2005).

Sibbld et l (2000) defined wound bed preprtion

(WBP) s:

Understanding wound bedpreparation and wound debridement

Karen Ousey and Caroline McIntoshKaren Ousey is Principal lecturer/Divisional Head Acute and Critical Care Nursing, Department of Nursing and HealthStudies, School of Human and Health Sciences, The University of Huddersfield and Caroline McIntosh is Head of Podiatry at the National University of Ireland, Galway Email: [email protected]

AbstrActWound bed assessment and optimum local wound care are essential to

facilitate the wound healing process. The presence of devitalized tissue, for

instance necrotic tissue or slough, is common in hard-to-heal wounds and

acts as a barrier to healing. There are several debridement options available to

the practitioner with the choice of wound debridement technique being made

following a holistic assessment of the patient and the wound. The method of

debridement should be discussed with the patient and family where appropriate

and consent to treatment obtained prior to the procedure being undertaken.

KEY WOrDswWound Healing wWound bed preparation w Debridement

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CLINICAL REVIEW

‘A changing paradigm that links treatment to thecause and focuses on three components of localwound care: debridement, wound-friendly moist interactive dressings and bacterial balance’.

The cronym TIME ws deeloped to ssist the prcti-

tioner when considering the min components of woundbed preprtion, s identified by Sibbld, with the dded

component of epithelil dncement of the wound edges:

tissue managemenIt is importnt to mke n ccurte description of tissue

stte during wound ssessment. Where tissue is non-ible or

deficient, wound heling is delyed. It lso proides focus

for infection, prolongs the inflmmtory response, mechni-

clly obstructs contrction nd impedes re-epitheliliztion

(Bhrestni, 1999). The presence of necrotic or compro-

mized tissue is common in chronic non-heling wounds, nd

its remol is beneficil; non-sculrized tissue, bcteri nd

cells tht impede the heling process (cellulr burden) reremoed, proiding n enironment tht stimultes the pro-

lifertion of helthy tissue (Flng, 2004).

Infecion — conrol of infecion andinflammaionInflmmtion is prt of the norml heling process, how-

eer, prolonged/persistent inflmmtion cn dely wound

heling. Chronic wounds frequently pper to be stuck

in the inflmmtory stge of heling (Sibbld et l, 2003)

nd such inflmmtion cn be confused with infection. It

is therefore importnt tht community nurses re ble to

distinguish between signs of inflmmtion nd infection s

the required mngement strtegies will be significntly dif-

ferent. Infection in wound cuses pin nd discomfort for

the ptient, delyed wound heling, nd cn be life threten-

ing. Furthermore infections, s well s hing serious conse-

quences for the ptient, cn significntly increse the oerll

cost of cre s length of sty my be incresed (Dowsett nd

Newton, 2005).

Moisure balanceCreting moisture blnce t the wound interfce is essen-

til if wound heling is to be chieed. Exudte is produced s

prt of the body’s response to tissue dmge nd the mount

of exudte produced is dependnt on the pressure grdientwithin the tissues (Trudgin, 2005). a wound tht progresses

through the norml wound heling cycle produces enough

moisture to promote cell prolifertion nd supports the

remol of deitlized tissue through utolysis. If, howeer,

the wound becomes inflmed nd/or stuck in the inflm-

mtory phse of heling, exudte production increses s the

blood essels dilte (Trudgin, 2005).

Edge — advancemen of he epihelialedge of he woundEffectie heling requires the re-estblishment of n intct

epithelium nd restortion of skin function (Flng, 2004).

The finl stge of wound heling is epitheliliztion, which

is the ctie diision, migrtion, nd mturtion of epiderml

cells from the wound mrgin cross the open wound (Dodds

nd Hynes, 2004).

Wound debridement is considered to be n essentil prt

of wound bed preprtion nd is mjor component of the

oerll mngement of the wound nd the ptient (Stephen-Hynes nd Thompson, 2007).

Wha is debridemen?Debridement is defined s ‘the remol of foreign mtter or

deitlized, injured, infected tissue from wound until the

surrounding helthy tissue is exposed’ (Ble nd Jones, 2000)

nd is essentil for optimizing wound heling (Leper, 2002).

Until wound or ulcer hs been debrided of necrotic tissue

full wound ssessment cnnot be undertken, mking it

difficult to pln wound cre, nd slowing the heling proc-

ess. One of the key principles of wound bed preprtion is

to reduce the bcteril burden; excess exudte, slough nd

necrotic tissue proide reseroir for bcteri, extend theinflmmtory phse nd impir epitheliliztion

There re seerl debridement options ilble to the

prctitioner, howeer, there is no eidence to support one

method oer nother (Leper, 2002). Selection should

be mde following holistic ssessment of the ptient

nd the wound. The method of debridement should be

discussed with the ptient nd fmily where pproprite

nd consent to tretment obtined prior to the procedure

being undertken.

types of debridemen echniquesThere re rious types of debridement techniques

ilble to the prctitioner; utolytic; shrp; surgicl;

biologicl (lrl); enzymtic; mechnicl; nd chemicl.

For mny wounds, wound bed preprtion will require

the use of more thn one debridement technique either

within the initil phse of debridement or for minte-

nnce debridement (vowden nd vowden, 2002). The

choice of debridement technique will depend on

riety of fctors including the findings of the wound

ssessment; the ptient’s ttitude to debridement; the

ilbility of resources; nd the skills of the prctitioners.

It should be remembered tht shrp debridement must

only be undertken by suitbly qulified prctitioner

educted nd trined in shrp debridement skills; this myinclude the tissue ibility specilist, poditrists or medi-

cl prctitioners, mong others.

Auolyicautolytic debridement is considered to be the sfest

method of debr idement ilble s only deitlized tis-

sue is remoed (Gwynne nd Newton, 2006). autolysis

cn be ctiely ssisted by the use of moist wound dress-

ings, such s hydrocolloid or semi-permeble dressings

with or without hydrogels. This pproch moistens the

necrotic tissue enbling the body’s own enzymes to

loosen nd liquefy the deitlized tissue (vowden nd

vowden, 1999).

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CLINICAL REVIEW

sharpShrp debridement is consertie method tht fre-

quently lees thin mrgin of necrotic tissue within

wound; in contrst surgicl debridement is more extensie

nd usully requires nesthesi; the ltter ims to conert

chronic wound to n cute wound by complete exci-sion (vowden nd vowden, 2002). Gwynne nd Newton

(2006) emphsize the importnce tht skilled registered

prctitioner with recognized eductionl qulifiction in

shrp debridement, who hs completed recognized study

course, should undertke the procedure (Tissue vibility

Nurses’ assocition, 2005). The prctitioner should be

prepred to stop the procedure nd seek pproprite help

if the tsk becomes beyond their skills nd they must he

n wreness of ntomicl structures or prosthetic deices

lying beneth the deitlized tissue.

surgial

Surgicl debridement is the term used when extensie deb-ridement, necessitting generl nesthesi, is undertken. It

is normlly crried out by surgeons nd inoles the remol

of deitlized nd helthy tissue leing ible tissue bed

(Gwynne nd Newton, 2006). Shrp or surgicl debridement

should be oided when there is ischemi due to rteril

insufficiency unless steps re lso tken to correct this. Where

there is underlying mlignncy the risks of shrp or surgicl

debridement include hemorrhge nd prolifertion of the

tumour. There my be underlying structures close to the

wound, including prosthetic grfts, dilysis fistul, prosthesis

or blood essels, ll of which mke the procedure more

difficult. Furthermore ptients who re on nticogultion

therpy should he stble clotting prior to shrp debride-

ment (Gwynne nd Newton, 2006).

biologial (larval)The free-rnge sterile lre of the common greenbottle

fly Lucilia sericata (LrE, Zoobiotic, Bridgend) re pplied

directly to the wound nd seek out res of slough or

necrotic tissue. They re conceled in net dressing or simi-

lr. Free-rnge lre cn be left for up to 3 dys fter which

the wound should be ressessed. LrE BioFOaM dressings

consist of mggots tht re enclosed in net pouches. The

dressings contin pieces of hydrophilic polyurethne fom

nd this proides fourble enironment for the lre,nd encourges ctiity. The BioFOaM dressings cn be left

for up to 5 dys fter which the wound should be ressessed

(Zoobiotics, 2009). Bexfield et l (2004) demonstrted the

bility of mggots to combt MRSa in-itro while Kotb et

l (2002) described tht mggot therpy hd preented the

need for mputtions.

EnzymaiEnzymtic debridement relies on the ddition of proteolytic

nd other exogenous enzymes to the wound surfce. These

enzymes brek down necrotic tissue nd cn be effectiely

combined with moist wound heling. Enzymtic gents my

be used s the primry technique for debridement in certin

cses, especilly when lterntie methods such s surgicl

or consertie shrp wound debridement (CSWD) re

not fesible owing to bleeding disorders or other consider-

tions (Rmundo nd Gry, 2008). Enzymtic debridement

relies on the ddition of proteolytic nd other exogenous

enzymes to the wound surfce. These enzymes brek downnecrotic tissue nd cn be effectiely combined with moist

wound heling. Enzymtic gents my be used s the pri-

mry technique for debridement in certin cses, especilly

when lterntie methods such s surgicl or CSWD re not

fesible owing to bleeding disorders or other considertions

(Rmundo nd Gry, 2008).

MehanialMechnicl debridement is the lest common form of debri-

dement in the UK. It inoles the use of non-discrimintory

physicl force to remoe necrotic tissue nd debris from the

wound surfce (vowden nd vowden, 2002). In its simplest

form, mechnicl debridement inoles the use of wet-to-dry dressings tht unselectiely remoe tissue, both helthy

nd necrotic, t dressing chnges. It is known to be pinful,

cn dmge helthy tissue nd my led to wound desicc-

tion (Jeffrey, 1995; Gwynne nd Newton, 2006).

chemialChemicl debridement includes the use of siler-, honey-

nd iodine-bsed products, which re used to debride nd

tret wound infections, either lone or in conjunction with

systemic ntibiotics. Their use should be limited to wounds

with proen bcteril infection nd oeruse should be

oided to minimize the risks of resistnce (Cooper, 2004)

nd toxicity.

Advaned modaliie for woundderidemenadnced technologicl interentions, for instnce topicl

negtie pressure (TNP) therpy nd hydro-debridement,

re incresingly being used in clinicl prctice to ssist in

wound bed preprtion, wound debridement nd encour-

ge heling.

tNP herapyTNP hs been described by Mendonc et l (2006) s tech-

nique to remoe chronic oedem fluid, leding to decresein the fter lod to blood flow, resulting in incresed loclized

tissue perfusion nd the resultnt formtion of grnultion

tissue. The concept of using negtie pressure is to crete

suction force, enbling the dringe of surgicl wounds in

order to promote wound heling (Fox nd Golden, 1976;

Fy, 1987).

TNP therpy is incresingly used in prctice prticulrly

in the mngement of hrd-to-hel wounds. There is n

incresingly strong eidence bse, bsed on the findings of

clinicl trils, tht demonstrtes the positie ttributes of TNP

in ccelerting wound heling (armstrong nd Lery, 2005;

Blume et l, 2008). Gustfsson et l (2007) specificlly stte

tht TNP will:

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CLINICAL REVIEW

w Increse locl blood flow

w Reduce oedem

w Stimulte formtion of grnultion tissue

w Stimulte cell prolifertion

w Remoe soluble heling inhibitors from the wound

wReduce bcteril lod

w Drw the wound edges closer together.

Furthermore Schwein et l (2005) undertook lrge study

(n=2228) tht compred hospitliztion rtes in ptients

receiing TNP with mtched control group treted with

stndrd cre. Schwein nd ssocites found tht hospitliz-

tion rtes were significntly lower in those receiing TNP. It

is incresingly common prctice for ptients to receie TNP

in community settings nd therefore the community nurse

will often be piotl in ssessing the ptient’s suitbility for

TNP, commencing tretment nd monitoring outcomes.

Hydro-debridement

versjet®, mnufctured by Smith & Nephew, is reltielynew hydrosurgery system tht uses pressurized strems of

sterile fluid to debride ded nd deitlized tissue from

wounds. Essentilly this system llows high-pressure wter jet

dissection of the wound surfce which Bowling et l (2009)

suggest my possibly sere to reduce biofilm (communities of

bcteri ttched to the wound surfce) prelence nd locl

bcteril burden, thereby stimulting the heling process.

conlusionThe DH (2008) promised to trnsform community ser-

ices with the dent of the ‘productie community hospitls

progrmme’ nd through the deelopment of ‘productie

community serices’. The primry im of this inititie is to

chiee nd sustin the highest possible qulity. One key re

included within this scheme is wound cre. It is recognized

tht hrd-to-hel wounds pose significnt personl costs

for those ffected, s well s substntil monetry costs to

the NHS. In community settings nd within the specilty

of wound cre the community nurse is prmount in the

implementtion of eidence-bsed cre nd best prctice to

promote qulity nd positie outcomes. Wound bed prep-

rtion nd wound debridement re importnt tretment

strtegies for hrd-to-hel wounds tht require n in-depth

knowledge bse nd skills set tht will ensure interentions

re sfe nd qulity of cre is mintined.The community nurse plys n importnt role in the selec-

tion of the most pproprite method of debridement, ensur-

ing tht ptients receie the best possible eidence-bsed cre

tht is both cliniclly nd cost effectie. BJCN

armstrong DG, Lery La (2005) Negtie pressure wound therpy fter prtil

dibetic foot mputtion: multicentre, rndomised controlled tril. The Lancet

366: 1704–10

Bhrestni M (1999) ‘The clinicl relence of debridement.’ In: Bhrestni M et l,

(eds).The Clinical Relevance of Debridement. Springer-verlg, Berlin

Ble S, Jones v (2000) Wound Care nursing. A patient centred approach. Blliere Tindll,

London

Bexfield a, Nigm Y, Thoms S, Rtcliffe Na (2004) Detection nd prtil chr-

cteristion of two ntibcteril fctors from the excretions/secretions of the

medicinl mggot Lucili serict nd their ctiity ginst methicillin-resistnt

Stphylococcus ureus (MRSa). Microbes Infect 6(14)

:1297-304

Blume Pa, Wlters J, Pyne W, ayl J, Lntis J (2008) Comprison of negtie pressure

wound therpy using cuum-ssisted closure with dnced moist wound therpy

in the tretment of dibetic foot ulcers: multicenter rndomized controlled tril.

Diabetes Care 31(4): 631–6

Bowling FL, Stickings DS, Edwrd-Jones v et l (2009) Hydro-debridement of

wounds: effectieness in reducing wound bcteril contmintion nd potentil

for ir bcteril contmintion. J of Foot Ankle Res 8(2) (online) http://tinyurl.

com/ygtfzux (accessed 25 Februry 2010)Cooper R (2004) a reiew of the eidence for the use of topicl ntimicrobil gents

in wound cre. ailble: www.worldwidewounds.com/2004/februry/Cooper/

Topicl-antimicrobil-agents.html (ccessed 17/10/09)

Deprtment of Helth (2008) NHS Next Stge Reiew Our ision for primry nd

community cre. http://tinyurl.com/yfr8m93 (accessed 20 Februry 2010)

Dodds S, Hynes S (2004) The wound edge, epitheliliztion nd monitoring wound

heling. British Journal of Community Nursing 9(9): 23-6

Dowsett C, ayello E (2004) TIME principles of chronic wound bed preprtion nd

tretment.Br J Nurs 13(Suppl 15): S16–S23

Dowsett C, Newton H (2005) Wound bed preprtion: TIME in prctice. Wounds

UK 1(3): 58–70

Enoch S, Price P (2004) Cellular, molecular and biochemical differences in the pathophysiology

of healing between acute wounds, chronic wounds and wounds in the aged. http://www.

worldwidewounds.com/2004/ugust/Enoch/Pthophysiology-Of-Heling.html

ccessed 17/10/09

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Management Association (EWMA). Position Document: Wound Bed Preparation in

Practice . MEP Ltd, LondonFy ME (1987) Dringe systems: their role in wound heling. AORN J 46: 442-55

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Am J Surg 132: 673-4

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debridement. Br J Nurs 15(19): S4–10

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Therapy, European Wound Management Association (EWMA) Position Document. Topical

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Kotb MM, Tntwi TI, Gohr YM, Beshr FMS, Ftthll SSa (2002) The medicinl

use of mggots in the mngement of enous stsis ulcers nd dibetic foot ulcers.

Bulletin of Alexandria Faculty of Medicine 37(2): 205–1

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com/2002/December/Leper/Shrp-Debridement.html

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snpshot of the eidence International Wound Journal 3: 261–71 http://tinyurl.

com/yc6osx6 (accessed 25 Februry 2010)Posnett J, Frnks PJ (2007) The costs of skin breakdown and ulceration in the UK. The silent

epidemic . The Smith & Nephew Foundtion 2007

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and Continence Nursing: 35(3): 273-80

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pproch to wound mngement. Wound Repair Regeneration 11:(Supplement 1):

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