CLINICAL REVIEW
Understanding wound bed
preparation and wound debridement
Karen Ousey and Caroline McIntosh
Karen Ousey is Principal lecturer/Divisional Head Acute and Critical Care Nursing, Department of Nursing and Health
Studies, School of Human and Health Sciences, The University of Huddersfield and Caroline McIntosh is Head of Podiatry at
the National University of Ireland, Galway 
O ver 90% of all patient contact within the NHS
takes place outside the hospital setting predomi-
nantly with primary care staff in general practice
surgeries, pharmacies or dental surgeries and with nurses,
health visitors, allied health professionals and healthcare sci-
entists working in community health services (Department
of Health (DH), 2008).
In partnership with the NHS Institute, the DH are roll-
ing out the ‘productive community hospitals programme’
and developing a ‘productive community services’ pro-
gramme. These programmes will review the evidence
base for care pathways, initially focusing on wound care,
continence services and stroke services, to enable more
time for direct patient care, and improve quality and
patient outcomes. This initiative will inevitably lead to
the further development of the community nurse role as
greater emphasis will be placed on the need for an evi-
dence-based understanding and a widening skills set. The
DH (2008) identified wound care as being one of the key
areas where a review of the evidence base for interventions
was required, and integral to this will be effective wound
assessment and management strategies. The cost of wound
care to the NHS has been estimated to be approximately
£2.3 billion to £3.1 billion a year (2005–2006 prices)
(Posnett and Franks, 2007).White (2008), however, believes
that the trend in current NHS spending indicates that
2008 expenditure on wound care was approximately £100
billion. There is a need to review the current evidence
base in the field of wound care to ensure quality and high
standards of care are met, while also ensuring interventions
are clinically and cost effective.
Abstract
Wound 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 WORDS
w Wound Healing w Wound bed preparation w Debridement
S22
Email: k.j.ousey@hud.ac.uk
Wound bed preparation and debridement are key compo-
nents of modern wound care. It is therefore important that
community nurses are aware of the evidence base in this area
so that they can deliver high quality care for patients and
make clinical decisions underpinned by current literature.
This paper provides an overview of current evidence for the
principles of wound bed preparation and wound debride-
ment techniques.
Wound healing
To appreciate the importance of wound bed preparation
it is important to review the physiological components of
wound healing. The process of wound healing can generally
be divided into four phases:
w vascular response or homeostasis
w inflammation
w proliferation
w aturation.
A hard-to-heal wound can be defined as one that fails to
heal with ‘standard therapy’ in an orderly and timely manner
(Troxler et al, 2006) with a chronic wound being ‘stuck’ in
the inflammatory stage of the healing continuum. Chronic
wounds have been conceptualized as the sequence of neglect,
incompetence, misdiagnosis or inappropriate treatment strate-
gies (Enoch and Price, 2004). All patients with wounds require
a comprehensive assessment to identify the cause, underlying
aetiology, the type of wound, size of wound and the stage of
healing to allow the practitioner to identify and address poten-
tial barriers to healing (Dowsett and Ayello, 2004).Wound bed
assessment and optimum local wound care are essential to
facilitate the wound healing process. The presence of devital-
ized tissue, for instance, necrotic tissue or slough, is common in
hard-to-heal wounds and acts as a barrier to healing.
Assessing the wound bed
Wound bed preparation is a systematic approach to removing
the barriers to natural healing and enhancing the effects of
advanced therapies (Schultz et al, 2003). The TIME frame-
work was developed as a systematic approach to implement-
ing wound bed preparation by the International Advisory
Board for Wound Bed Preparation (Schultz et al, 2003) and is
a useful approach to wound assessment, focusing specifically
on the wound bed (Dowsett and Newton, 2005).
Sibbald et al (2000) defined wound bed preparation
(WBP) as:
Wound Care, March 2010
CLINICAL REVIEW
‘A changing paradigm that links treatment to the
cause and focuses on three components of local
wound care: debridement, wound-friendly moist
interactive dressings and bacterial balance’.
The acronym TIME was developed to assist the practi-
tioner when considering the main components of wound
bed preparation, as identified by Sibbald, with the added
component of epithelial advancement of the wound edges:
Tissue management
It is important to make an accurate description of tissue
state during wound assessment.Where tissue is non-viable or
deficient, wound healing is delayed. It also provides a focus
for infection, prolongs the inflammatory response, mechani-
cally obstructs contraction and impedes re-epithelialization
(Baharestani, 1999). The presence of necrotic or compro-
mized tissue is common in chronic non-healing wounds, and
its removal is beneficial; non-vascularized tissue, bacteria and
cells that impede the healing process (cellular burden) are
removed, providing an environment that stimulates the pro-
liferation of healthy tissue (Falanga, 2004).
Infection — control of infection and
inflammation
Inflammation is a part of the normal healing process, how-
ever, prolonged/persistent inflammation can delay wound
healing. Chronic wounds frequently appear to be stuck
in the inflammatory stage of healing (Sibbald et al, 2003)
and such inflammation can be confused with infection. It
is therefore important that community nurses are able to
distinguish between signs of inflammation and infection as
the required management strategies will be significantly dif-
ferent. Infection in a wound causes pain and discomfort for
the patient, delayed wound healing, and can be life threaten-
ing. Furthermore infections, as well as having serious conse-
quences for the patient, can significantly increase the overall
cost of care as length of stay may be increased (Dowsett and
Newton, 2005).
Moisture balance
Creating a moisture balance at the wound interface is essen-
tial if wound healing is to be achieved. Exudate is produced as
part of the body’s response to tissue damage and the amount
of exudate produced is dependant on the pressure gradient
within the tissues (Trudgian, 2005). A wound that progresses
through the normal wound healing cycle produces enough
moisture to promote cell proliferation and supports the
removal of devitalized tissue through autolysis. If, however,
the wound becomes inflamed and/or stuck in the inflam-
matory phase of healing, exudate production increases as the
blood vessels dilate (Trudgian, 2005).
Edge — advancement of the epithelial
edge of the wound
Effective healing requires the re-establishment of an intact
epithelium and restoration of skin function (Falanga, 2004).
The final stage of wound healing is epithelialization, which
S24
is the active division, migration, and maturation of epidermal
cells from the wound margin across the open wound (Dodds
and Haynes, 2004).
Wound debridement is considered to be an essential part
of wound bed preparation and is a major component of the
overall management of the wound and the patient (Stephen-
Haynes and Thompson, 2007).
What is debridement?
Debridement is defined as ‘the removal of foreign matter or
devitalized, injured, infected tissue from a wound until the
surrounding healthy tissue is exposed’ (Bale and Jones, 2000)
and is essential for optimizing wound healing (Leaper, 2002).
Until a wound or ulcer has been debrided of necrotic tissue
a full wound assessment cannot be undertaken, making it
difficult to plan wound care, and slowing the healing proc-
ess. One of the key principles of wound bed preparation is
to reduce the bacterial burden; excess exudate, slough and
necrotic tissue provide a reservoir for bacteria, extend the
inflammatory phase and impair epithelialization
There are several debridement options available to the
practitioner, however, there is no evidence to support one
method over another (Leaper, 2002). Selection should
be 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.
Types of debridement techniques
There are various types of debridement techniques
available to the practitioner; autolytic; sharp; surgical;
biological (larval); enzymatic; mechanical; and chemical.
For many wounds, wound bed preparation will require
the use of more than one debridement technique either
within the initial phase of debridement or for mainte-
nance debridement (Vowden and Vowden, 2002). The
choice of debridement technique will depend on a
variety of factors including the findings of the wound
assessment; the patient’s attitude to debridement; the
availability of resources; and the skills of the practitioners.
It should be remembered that sharp debridement must
only be undertaken by a suitably qualified practitioner
educated and trained in sharp debridement skills; this may
include the tissue viability specialist, podiatrists or medi-
cal practitioners, among others.
Autolytic
Autolytic debridement is considered to be the safest
method of debridement available as only devitalized tis-
sue is removed (Gwynne and Newton, 2006). Autolysis
can be actively assisted by the use of moist wound dress-
ings, such as hydrocolloid or semi-permeable dressings
with or without hydrogels. This approach moistens the
necrotic tissue enabling the body’s own enzymes to
loosen and liquefy the devitalized tissue (Vowden and
Vowden, 1999).
Wound Care, March 2010
CLINICAL REVIEW
Sharp
Sharp debridement is a conservative method that fre-
quently leaves a thin margin of necrotic tissue within a
wound; in contrast surgical debridement is more extensive
and usually requires anaesthesia; the latter aims to convert
a chronic wound to an acute wound by complete exci-
sion (Vowden and Vowden, 2002). Gwynne and Newton
(2006) emphasize the importance that a skilled registered
practitioner with a recognized educational qualification in
sharp debridement, who has completed a recognized study
course, should undertake the procedure (Tissue Viability
Nurses’ Association, 2005). The practitioner should be
prepared to stop the procedure and seek appropriate help
if the task becomes beyond their skills and they must have
an awareness of anatomical structures or prosthetic devices
lying beneath the devitalized tissue.
Surgical
Surgical debridement is the term used when extensive deb-
ridement, necessitating general anaesthesia, is undertaken. It
is normally carried out by surgeons and involves the removal
of devitalized and healthy tissue leaving a viable tissue bed
(Gwynne and Newton, 2006). Sharp or surgical debridement
should be avoided when there is ischaemia due to arterial
insufficiency unless steps are also taken to correct this.Where
there is underlying malignancy the risks of sharp or surgical
debridement include haemorrhage and proliferation of the
tumour. There may be underlying structures close to the
wound, including prosthetic grafts, dialysis fistula, prosthesis
or blood vessels, all of which make the procedure more
difficult. Furthermore patients who are on anticoagulation
therapy should have stable clotting prior to sharp debride-
ment (Gwynne and Newton, 2006).
Biological (larval)
The free-range sterile larvae of the common greenbottle
fly Lucilia sericata (LarvE, Zoobiotic, Bridgend) are applied
directly to the wound and seek out areas of slough or
necrotic tissue. They are concealed in a net dressing or simi-
lar. Free-range larvae can be left for up to 3 days after which
the wound should be reassessed. LarvE BioFOAM dressings
consist of maggots that are enclosed in net pouches. The
dressings contain pieces of hydrophilic polyurethane foam
and this provides a favourable environment for the larvae,
and encourages activity. The BioFOAM dressings can be left
for up to 5 days after which the wound should be reassessed
(Zoobiotics, 2009). Bexfield et al (2004) demonstrated the
ability of maggots to combat MRSA in-vitro while Kotb et
al (2002) described that maggot therapy had prevented the
need for amputations.
Enzymatic
Enzymatic debridement relies on the addition of proteolytic
and other exogenous enzymes to the wound surface. These
enzymes break down necrotic tissue and can be effectively
combined with moist wound healing. Enzymatic agents may
be used as the primary technique for debridement in certain
S26
cases, especially when alternative methods such as surgical
or conservative sharp wound debridement (CSWD) are
not feasible owing to bleeding disorders or other considera-
tions (Ramundo and Gray, 2008). Enzymatic debridement
relies on the addition of proteolytic and other exogenous
enzymes to the wound surface. These enzymes break down
necrotic tissue and can be effectively combined with moist
wound healing. Enzymatic agents may be used as the pri-
mary technique for debridement in certain cases, especially
when alternative methods such as surgical or CSWD are not
feasible owing to bleeding disorders or other considerations
(Ramundo and Gray, 2008).
Mechanical
Mechanical debridement is the least common form of debri-
dement in the UK. It involves the use of non-discriminatory
physical force to remove necrotic tissue and debris from the
wound surface (Vowden and Vowden, 2002). In its simplest
form, mechanical debridement involves the use of wet-to-
dry dressings that unselectively remove tissue, both healthy
and necrotic, at dressing changes. It is known to be painful,
can damage healthy tissue and may lead to wound desicca-
tion (Jeffrey, 1995; Gwynne and Newton, 2006).
Chemical
Chemical debridement includes the use of silver-, honey-
and iodine-based products, which are used to debride and
treat wound infections, either alone or in conjunction with
systemic antibiotics. Their use should be limited to wounds
with a proven bacterial infection and overuse should be
avoided to minimize the risks of resistance (Cooper, 2004)
and toxicity.
Advanced modalities for wound
debridement
Advanced technological interventions, for instance topical
negative pressure (TNP) therapy and hydro-debridement,
are increasingly being used in clinical practice to assist in
wound bed preparation, wound debridement and encour-
age healing.
TNP therapy
TNP has been described by Mendonca et al (2006) as a tech-
nique to remove chronic oedema fluid, leading to a decrease
in the after load to blood flow, resulting in increased localized
tissue perfusion and the resultant formation of granulation
tissue. The concept of using negative pressure is to create a
suction force, enabling the drainage of surgical wounds in
order to promote wound healing (Fox and Golden, 1976;
Fay, 1987).
TNP therapy is increasingly used in practice particularly
in the management of hard-to-heal wounds. There is an
increasingly strong evidence base, based on the findings of
clinical trials, that demonstrates the positive attributes of TNP
in accelerating wound healing (Armstrong and Lavery, 2005;
Blume et al, 2008). Gustafsson et al (2007) specifically state
that TNP will:
Wound Care, March 2010
CLINICAL REVIEW
w increase local blood flow
w reduce oedema
w stimulate formation of granulation tissue
w stimulate cell proliferation
w remove soluble healing inhibitors from the wound
w reduce bacterial load
w draw the wound edges closer together.
Furthermore Schwein et al (2005) undertook a large study
(n=2228) that compared hospitalization rates in patients
receiving TNP with a matched control group treated with
standard care. Schwein and associates found that hospitaliza-
tion rates were significantly lower in those receiving TNP. It
is increasingly common practice for patients to receive TNP
in community settings and therefore the community nurse
will often be pivotal in assessing the patient’s suitability for
TNP, commencing treatment and monitoring outcomes.
Hydro-debridement
Versajet®, manufactured by Smith & Nephew, is a relatively
new hydrosurgery system that uses pressurized streams of
sterile fluid to debride dead and devitalized tissue from
wounds. Essentially this system allows high-pressure water jet
dissection of the wound surface which Bowling et al (2009)
suggest may possibly serve to reduce biofilm (communities of
bacteria attached to the wound surface) prevalence and local
bacterial burden, thereby stimulating the healing process.
Conclusion
The DH (2008) promised to transform community serv-
ices with the advent of the ‘productive community hospitals
programme’ and through the development of a ‘productive
community services’. The primary aim of this initiative is to
achieve and sustain the highest possible quality. One key area
included within this scheme is wound care. It is recognized
that hard-to-heal wounds pose significant personal costs
for those affected, as well as substantial monetary costs to
the NHS. In community settings and within the specialty
of wound care the community nurse is paramount in the
implementation of evidence-based care and best practice to
promote quality and positive outcomes. Wound bed prepa-
ration and wound debridement are important treatment
strategies for hard-to-heal wounds that require an in-depth
knowledge base and skills set that will ensure interventions
are safe and quality of care is maintained.
The community nurse plays an important role in the selec-
tion of the most appropriate method of debridement, ensur-
ing that patients receive the best possible evidence-based care
that is both clinically and cost effective.  BJCN
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