A Doctors Note on Wound Bed Preparation

The concept of wound bed preparation was first established in 2000 by Dr. Vincent Falanga and Dr. Gary Sibbald and is an important mainstay in wound care today.  In 2003 the International Wound Bed Preparation Advisory Board established an algorithmic approach and developed the acronym T.I.M.E. (tissue management, Inflammation and infection control, moisture balance, and epithelial edge advancement) {1,2}.  Interestingly, this acronym has evolved into D.I.M.E with the emphasis on Debridement of Devitalized Tissue. The purpose of wound bed preparation is to identify and delineate methods in treatment stages in order to advance the wound to a normal healing state.  This is most evident with chronic wounds

In my experience, this has involved a multi-modal approach using different products and resources at key intervals tailored to the patient’s presentation as well that of the wound.  I also found addressing multiple parameters including infection control, vascular flow, the etiology of the wound, and the need for sharp debridement to be extremely paramount and thus, have served as my core in addressing hard to heal wounds.  And if there has been one consistent area of wound care that has served as my true north, it is definitely sharp debridement.  The use of labs, cultures and sensitivities, dopplers, non-invasive studies, transcutaneous oxygen measurements, x-rays, nuclear imaging, etc. have been the standard fundamentals that not only have to be addressed, but also utilized in a strategic stepwise approach along with a multi-specialty team concept.  A multi-disciplinary team approach has been a best care practice over the last twenty years, and if directed properly from the identification of the wound via the first responder to the immediate delivery of care, it can result in the preservation of the limb versus amputation by directly impacting the formation and prevention of a chronic wound. 

A Chronic Wound is a wound that fails to heal over a normal predicted timeframe and is arrested in the Inflammatory phase of wound healing. Chronic Wounds may commence as early as 2 weeks and also become well established after 3 months.  The true definition based on time varies according to the literature, but the inevitable outcome is the same. If left untreated, Chronic Wounds can progress for months and may result in a deep infection, surgical intervention and loss of limb.  The landscape of a chronic wound is composed of small colonies and aggregates of multiple bacteria which produce a protective covering known as Biofilm. Evidence has shown that Biofilm is present in over 90% of Chronic Wounds and poses as a problematic universal barrier in wound healing {3}. 

Biofilm is composed of a protective glycocalyx which is firmly attached to the wound surface.  Sharp debridement is a gold standard in treating Biofilm and is well documented.  It has been shown with weekly debridement, wounds achieve healing 83% of the time versus wounds debrided sporadically of which attain healing at 25% {4}. Sharp debridement plays a definitive and key role in Chronic Wounds by allowing disruption and separation of Biofilm from the wound bed.  When the Biofilm reforms, it is immature and more susceptible to follow on topical wound care, antibiotics, and host defenses. In short, debridement of the wound every 7 days favors wound healing 43% of the week and prepares the wound bed in preparation for topical care which doubles its efficacy to 86%! {4}. 

Chronic Wounds pose a major social economic burden:

A retrospective Medicare/Medicaid study published in 2018 consisted of an analysis of the Medicare 5% data set for 2014 in which 8.2 million Medicare beneficiaries were impacted by non-healing chronic wounds. Medicare cost projections for all wounds ranged from $28.1 to $96.8 billion!  The retrospective analysis of the 5% Medicare Limited Data Set (CY 2014) was conducted to determine the cost of chronic wound care.  This included beneficiaries in aggregate by wound type and setting, who underwent care for one or more of the following: arterial ulcers, diabetic foot ulcers, venous ulcers, pressure ulcers, surgical wounds, infection, and chronic wounds (5).  With national medical expenditures on the rise, the true cost of wound care in chronic wounds such as diabetic foot ulcers, venous ulcers and pressure ulcers remains virtually unknown for the national population of the United States (6) and has largely been ignored.  Therefore, this analysis represents the first comprehensive study of Medicare spending on wound care. The study included only Medicare beneficiaries enrolled in Medicare Part A or B.  The clinical data was collected from the US Wound Registry (USWR) which was obtained by approximately 2000 wound care clinicians and 129 hospital-based outpatient wound centers in 32 states. Three different estimates of wound care costs were studied.  The first method (low-range estimate) accounted for Medicare provider payments when the wound was the primary diagnosis excluding deductibles. The second method (midrange estimate) included total payments when the wound was the primary diagnosis and attributed payments when the wound was the secondary diagnosis in association with hospital inpatient and outpatient costs. The third method or upper bound estimate included total cost expenditures in assuming the wound was the underlying cause of the service. 

The study revealed an alarming annual cost of $28-$31.7 billion affecting nearly 15% of Medicare beneficiaries (8.2 million).  The highest costs were incurred for hospital outpatients ($9.9 – $11.4 billion) with the most expensive wounds encompassing surgical wounds (11.7-$13 billion) and diabetic foot ulcers ($6.2-$6.9 billion).  The mean spending cost per wound was $3,415-$3,859.  The most expensive wounds per beneficiaries were arterial ulcers ($9,105 – $9,418) followed by pressure ulcers ($3,696 – $4,436).  Lastly, surgical infections were the largest prevalence category (4.0%) followed by diabetic wound infections (3.4%)

As we reflect on the journey from the early foundations of wound bed preparation to its current role in healing chronic wounds, it becomes evident that this approach not only holds promise for individual patients but also offers a tangible solution for mitigating the broader economic and social challenges posed by chronic wounds. There is so much depth and information to talk about regarding wound bed preparation.  Due to that vast spectrum and literature around wound bed preparation – we will continue with ongoing content going forward with future blogs.  I hope you enjoyed the first installment of wound bed preparation.  Please check in frequently as we will be continuing our series with many more discussions still yet to come!


Dr. F. Derk

If you would like to know more about EZDebride please contact us here.

Experience the Future of Wound Care with a Guided Demo

Discover innovative solutions and witness their effectiveness in a guided demo. Revolutionize your wound care practice.