EUROPEAN  TISSUE  REPAIR  SOCIETY

A new term relating to the treatment of chronic wounds – wound bed preparation – has emerged over the last few years. Whilst some of the components of wound bed preparation have been used in clinical practice for a long time, the novelty is that the concept looks holistically at the treatment of chronic wounds.
The term wound bed preparation appeared in the literature around 2000.^1,2 It was coined in conjunction with the use of bioengineered skin, whose use in hard to heal wounds can only be successful if the wound bed is prepared appropriately.^3,4,5 The term has since evolved taking into account the fact that chronic wounds are fundamentally different from acute wounds and that the treatment has to be adapted accordingly.
The number of publications and conference activities related to the topic indicates the great interest in this new concept.

Conference activities
The European Tissue Repair Society held the first international meeting on wound bed preparation in Oxford, in November 2000.⁶ It was the aim of this meeting to compile the current knowledge on wound bed preparation and to discuss future directions. Wound healing experts from around the world discussed questions like: is wound bed preparation a meaningful term; is there a clinical problem; what is the role of wound bed preparation in the care of chronic wounds, therapies potentially useful to prepare the wound bed, etc.
At the end of the two-day meeting there was broad agreement that wound bed preparation is a meaningful term. Several definitions were discussed and at the end it was agreed that wound bed preparation is about removing the barriers to healing and at the same time initiating the healing processes. There was also no doubt that much more work was still to be done in order to achieve a better understanding of the concept that would ultimately lead to better standards of care for patients.
Many symposia addressing the different aspects of wound bed preparation were held since, at national as well as international conferences, some of which have been published, or publication is in progress. The year after the Oxford meeting, a symposium on the clinical relevance of wound bed preparation was held at the 11th Annual Meeting of the European Tissue Repair Society in Cardiff.⁷ At this meeting, aspects like acute versus chronic wounds, the biological microenvironment of chronic wounds, infection control in wound bed preparation, cells in wound management, therapeutic tools like slow release iodine, negative pressure and enzymatic preparations were discussed.
The 4th Joint Meeting of the Wound Healing Society (WHS) and the European Tissue Repair Society (ETRS) in Baltimore⁸ saw two symposia related to the topic. The first one focussed on the scientific aspects of new concepts in wound bed preparation (publication in progress⁹). The second one highlighted the conceptual framework of wound bed preparation and demonstrated how it can be utilised to assess the local wound environment and organise wound care interventions.
The 12th Congress of the European Wound Management Association (EWMA) hosted a symposium that focussed on debridement as one important aspect of wound bed preparation.¹⁰ It was discussed from a surgeon’s as well as from a nurse’s perspective. In addition, the clinical experience of enzymatic debridement with collagenase and the role of cells in wound bed preparation were highlighted.
Another symposium held at the 6th European Pressure Ulcer Advisory Panel (EPUAP) Open Meeting in Budapest¹¹ put emphasis on the importance of bacteria in wound bed preparation, with a special focus on therapeutic means in the treatment of pressure ulcers. The papers of this symposium have been published in Ostomy Wound Management.¹²
National societies, including those from Japan, the US, Italy, Germany, France, Canada, Thailand, and others have dealt with the topic, too.

Publications
Since 2000, some twenty articles have been published which contain the term wound bed preparation either in the title or in the abstract, according to a recent literature searches. These articles describe the different aspects to wound bed preparation. Those aspects could be classified into four major categories:

• Practical wound care and education
• Measurement and classification
• Treatment, current products and new products
• Scientific aspects

Not surprisingly, most of the articles deal with the practical and educational aspects of wound bed preparation.^{2,13,14,15,16,17,18} This reflects the importance of the concept from a practical point of view. As stated above, wound bed preparation is not a totally new treatment strategy. The new paradigm focuses however on a holistic, multidisciplinary team approach, that involves doctors, nurses, the patients and their families. This is the novelty that needs to be penetrated into the health care community, in order to deliver better wound care to the patient.

The wider issue with measurement and classification of wound bed preparation is relatively new and aims to predict which therapies would be most suitable for a given wound and how to measure if a specific treatment is successful in terms of preparing the wound bed. Only two publications dealing with this could be identified,^1,19 although this topic has also been discussed at the focus meeting in Oxford in November 2000.²⁰
Most of the papers and symposia mentioned focus therapeutic interventions on debridement, managing bacterial load and managing exudate. In addition, two papers dealing specifically with this topic could be found.^21,22

Relatively little information is available on the biochemical and cellular mechanisms underlying the chronicity of wounds, and even less is known as to whether these abnormalities can be corrected with good wound bed preparation. It has become clear that, even if all therapeutic interventions currently available have been carried out, there are still some wounds that do not heal. Also, the question why wounds re-occur is yet to be answered. There is evidence that phenotypically abnormal cells contribute to a cellular burden, and that the biochemical composition of chronic wound fluid is different from acute wound fluid. More scientific investigations are needed to gain more clarity on this.

The most recent review, written by a group of leading experts in the field, has just been published in Wound Repair and Regeneration.²³ It provides an overview of the current status, role, and key elements of wound bed preparation.

Summary and outlook
Wound bed preparation is a new clinical concept that combines existing treatment strategies and looks at chronic wounds in a holistic manner. Much progress has been made in the field. This can be seen from recent conference activities, which have collated the current knowledge. Also many publications, which describe and disseminate the current knowledge, have been undertaken in the last few years. There is much more effort needed to elucidate the mechanisms underlying the chronicity of wounds and to develop better treatments for good wound bed preparation, in order to improve the patient’s lives.
Good wound bed preparation is required for the successful use of advanced treatments, which are expensive and must be used in the most effective way.

Dr Willi Jung, Wound Management Division
Smith & Nephew, PO Box 18, Hessle Road, Hull, UK

References

1. V Falanga: Classification for Wound Bed Preparation and Stimulation of Chronic Wounds, Wound Repair and Regeneration 8 (5), 347–352, 2000 (Editorial).
2. R G Sibbald, D Williamson, H L Orstedt, et al.: Preparing the Wound Bed – Debridement, Bacterial Balance, and Moisture Balance, OstomyWound Management, 46 (11), 14–35, 2000.
3. H Brem, J Balledux, T Bloom, et al.: Optimal Wound Bed preparation for the successful use of bioengineered skin in Venous Ulcers, 10th Annual Meeting of the WHS, Toronto, Canada, June 4–6, 2000. Wound Repair and Renegeration 8 (4), 322–345, 2000.
4. Y M Bello, A F Fallabella, W H Eaglestein, et al.: Tissue-engineered skin. Current Status in Wound Healing. Am. J. Clin. Dermatol 3(7), 305–313, 2001.
5. D H Keast: Preparing the Wound Bed before Dermagraft Use, Can. J. Plast. Surg 10, Suppl. A, 2002.
6. G W Cherry, K G Harding, T J Ryan (eds.): Wound Bed Preparation, The Royal Society of Medicine, International Congress and Symposium Series 250, 2001.
7. V Falanga, K Harding (eds.): The Clinical Relevance of Wound Bed Preparation, Springer Verlag, 2002.
8. Joint Conference of the WHS and the ETRS, Baltimore, 28 May – 1 June, 2002.
9. V Falanga, G Sibbald (chair): New Concepts in Wound Bed Preparation (in preparation by Springer Verlag).
10. K Harding (chair): Wound Bed Preparation – A Focus on Debridement, 12th Congress of the European Wound Management Association, Granada, 23–25 May, 2002.
11. The 6th European Pressure Ulcer Advisory Panel Open Meeting, Budapest, 18–21 September, 2002.
12. G Sibbald (ed): Bacteria & Pressure Ulcers: The role of silver versus traditional antimicrobials. Supplement to OstomyWound Management, May 2003.
13. C Dowsett: The Role of the Nurse in Wound Bed Preparation, Nursing Standard 16, 44, 69–76, 2002.
14. D Krasner: How to Prepare the Wound Bed, OstomyWound Management 47 (4), 59–61, 2001.
15. K Vowden, P Vowden: Wound Bed Preparation, World Wide Wounds, http://www.worldwidewounds.com/2002/april/Vowden/Wound-Bed-Preparation.html
16. M Romanelli, D Mastronicola: The Role of Wound Bed Preparation in Managing Chronic Pressure Ulcers, Journal of Wound Care 11 (8), 2002.
17. M Collier: Wound-Bed Preparation, NT Plus 98 (2), 2002.
18. R Pudner: Wound Bed Preparation, J of Community Nursing 16 (5), 2002.
19. M Romanelli, G Gaggio, M Coluggia, et al.: Technological Advances in Wound Bed Measurements, Wounds 14 (2), 58–66, 2002.
20. R Mani: ‘Is Wound Bed Preparation Assessable non-invasively?’ In: G W Cherry, K G Harding, T J Ryan (eds.): Wound Bed Preparation, The Royal Society of Medicine, International Congress and Symposium Series 250, 2001.
21. V Falanga: New Therapeutic Approaches in Wound Healing (Commentary), Wounds 14(2), 45–46, 2002.
22. V Falanga: Wound Bed Preparation and the Role of Enzymes: A case for Multiple Actions of Therapeutic Agents, Wounds 14 (2), 47–57, 2002.
23. G S Schultz, R G Sibbald, V Falanga, et al.: Wound Bed Preparation: A Systematic Approach to Wound Management. Wound Repair and Regeneration, March-April 2003, Vol. 11, Number 2 Supplement.