Heading
Leg ulceration and wound bed preparation – towards a more holistic framework
Author(s)
Jackie Stephen-Haynes
RGN, DN, DipH, BSc (Hons), ANP, PGDipR,
PGDipEd, MSc
Consultant Nurse and Senior Lecturer in Tissue
Viability
Worcestershire Primary Care Trusts and University
of Worcester, Stourport on Severn, Worcestershire.
Email: jackiesh@btopenworld.com
Contents
Abstract
Introduction
The need for an effective framework
Wound bed preparation and the TIME
framework
Frameworks in practice
A more holistic framework
Conclusion
References
Keywords: leg ulcers; chronic wounds; frameworks; acronyms; wound bed preparation; TIME;
holistic assessment.
Key Points
1. The concept of wound bed preparation and the TIME framework (Tissue management;
Inflammation and infection control; Moisture balance; Epithelial (edge) advancement) offer a
logical and systematic approach to the assessment and delivery of wound care for patients with
leg ulceration.
2. Wound bed preparation and the TIME framework must be used as part of an integrated
approach including differential diagnosis, prevention of recurrence and management of
psychosocial issues.
3. Future work needs to focus on evaluating the effectiveness of such frameworks and refining
them to best suit the clinical environment.
Heading 1
Abstract
Significant advances have been made over the past two decades in the delivery of effective
services for patients with leg ulceration. Treatment costs, however, remain high and the
development of strategies to ensure future provision of effective care is important. Recent
research into conditions at the wound bed has focused attention on the benefits of wound bed
preparation and the use of the TIME framework to underpin care. Developed as a result of
consensus meetings with key wound care opinion leaders, TIME offers a logical and systematic
approach to the assessment and management of the wound bed, guiding practitioners in linking
clinical observations and clinical outcomes. However, it is of limited value if clinicians fail to use it
as part of an holistic approach. This paper explores additional factors that need to be considered
alongside wound bed preparation and the TIME framework in order for care to be effective.
Heading 1
Introduction
The past 20 years have seen a significant shift towards the delivery of evidence-based leg ulcer
care and improved healing rates for many patients. Recent interest in chronic wound healing has
led to a clearer understanding of cellular and mollecular imbalances present in the wound bed
that may contribute to delayed healing for some patients [1] [2]. Wound bed preparation – a
concept aimed at assisting clinicians in wound bed assessment and the development of
strategies to maximise healing potential – is now recognised as an important aspect of care. The
associated development of the TIME framework (Tissue management; Inflammation and infection
control; Moisture balance; Epithelial (edge) advancement) [3] offers clinicians a practical tool for
translating wound bed preparation into practice.
The success of the wound bed preparation framework and the TIME framework in improving
patient outcomes is dependent on their value in clinical practice. A holistic approach is central to
effective care [3]. Other factors to consider alongside the wound bed include the skin, the limb,
vascular supply, pain and ulcer aetiology [4], as well as the patient’s health beliefs, level of
understanding and concordance.
Heading 1
The need for an effective framework
Leg ulceration is a common, difficult and expensive health problem, affecting 1-2% of the
population [5] [6] [7], and representing a significant challenge to the health service. A third of
patients develop their ulcer before the age of 50 [5] and 2% of those over 80 years of age is
thought to suffer with this condition [8]. Recurrence rates are high: 26% after one year and 31%
after 18 months of healing for venous ulcer patients [9]. The cost burden to the NHS has been
estimated at around £400 million per annum [10] and numerous studies have identified the
negative impact on patient quality of life [11] [12] [13]. Prevalence of leg ulceration and the
associated demands on service provision are likely to remain a challenge, due not only to these
high recurrence rates but also as a consequence of an ageing population and the rise in chronic
conditions such as obesity and diabetes.
Over recent decades service provision has become more rationalised and models of care have
been developed. In the UK, most patients with leg ulceration are treated by nurses in the primary
care setting, usually in their own homes [5]. It is important that primary care trusts (PCTs) are
responsible for modelling services around the needs and profile of their patient groups. Moffatt et
al [14] identified the benefits of leg ulcer clinics, where patients receive appropriate assessment
and management and where a robust referral system to a member of the multi-professional team
is in place. Clinics afford the adoption of leg ulcer guidelines and the opportunity to develop ‘onestop’ assessment centres that incorporate investigations such as Duplex scanning and access to
vascular surgeons [15]. The Lindsay Leg Club Model [12] recognises the importance of holistic
care for patients with or at risk of leg ulceration and is based on a social model of ‘leg health’.
Services are delivered in a non-medical setting with an emphasis on ‘drop-in’, social interaction,
participation, empathy and peer support.
The quest for effective frameworks of care continues. Service delivery and choice of setting
varies across the UK and even within individual PCTs. Factors that may influence future
developments include the increase in the number of older people as the population ages, as well
as growing financial constraints within the health service. It is important that directors within
health service organisations engage with the needs of patients with leg ulceration, and that
clinicians are well educated, utilise local and national guidelines and continue to network in the
quest for delivery of a high-quality, systematic and effective approach to care.
Heading 1
Wound bed preparation and the TIME framework
Wound bed preparation is a rapidly emerging concept [16] that has recently gained popularity
among practitioners. It represents a model of care for the management of chronic wounds based
on the observation that cellular and molecular imbalances at the wound bed may contribute to
delayed healing [3]. The TIME acronym – inspired by Falanga’s original work and further
developed by EWMA (European Wound Management Association) following consensus meetings
with key opinion leaders [3] – comprises the four components of wound bed preparation and
offers a logical and systematic framework (see Table 1). It guides clinicians to consider each of
these key clinical areas in monitoring the wound, decision making and use of targeted
interventions.
Table 1: The TIME Acronym.
The TIME acronym, as originally developed by the International Wound Bed Preparation
Advisory Board [3]:
T = Tissue, non-viable or deficient
I = Infection or inflammation
M = Moisture imbalance
E = Edge of wound, non-advancing or undermined.
Terms proposed by the EWMA Wound Bed Preparation Editorial Advisory Board in order to
maximise its value across different disciplines and languages [3]:
T = Tissue management
I = Inflammation and infection control
M = Moisture balance
E = Epithelial (edge) advancement.
It has always been stressed that the original concept of wound bed preparation must
be part of an ongoing, holistic wound management strategy [3]. It could, however, be
argued that in some areas of practice clinicians focus mainly on the wound and less
attention is paid to assessment, underlying aetiology and the management of
psycosocial issues.
Heading 1
Frameworks in practice
The success of any framework is largely dependent on the way individual practitioners interpret
and integrate it in practice. While frameworks cannot replace good clinical judgement or make up
for poor clinical skills, they offer an aide-mémoire [17] [18]. They also present clinicians with a
useful means of providing evidence of care and of ensuring assessments are standardised
between practitioners. Future research needs to focus on evaluating the uptake of wound bed
preparation and the TIME framework in clinical practice and its effect on patient care. Evaluation
of similar frameworks such as pressure ulcer risk assessment tools suggest that they are widely
used and valued in clinical practice and that their limitations are not necessarily problematic in the
clinical environment [18].
A possible limitation of the TIME framework is that it might encourage an emphasis on the wound
bed to the detriment of wider issues such as ulcer aetiology and the patient’s psychosocial wellbeing. While attempts have been made to include the TIME framework within the context of total
patient care (see Figures 1 and 2) there are some key elements of assessment and management
that may not receive an equal focus.
Figure 1 to be inserted here with caption as follows:
Figure 1 – A pathway showing how wound bed preparation is applied to practice.
Reproduced from Falanga V. (2002) [3].
Figure 2 to go here with heading as follows:
Figure 2 – Using wound bed preparation and TIME in context.
Reproduced from Dowsett C. (2004) [17]
Heading 1
A more holistic framework
Leg ulceration is recognised as a multi-faceted problem requiring a holistic approach (see Table
2). Early diagnosis and implementation of therapies required for healing and wound bed
preparation are essential.
Table 2: The main components of leg ulcer treatment.

Correct the underlying cause of the ulcer, for example to improve the underlying venous or
arterial flow

Create an optimal local environment for wound healing

Improve the wider intrinsic and extrinsic factors that may delay healing, such as poor
mobility, malnutrition and psychosocial issues

Prevent avoidable complications, such as infection, dermatitis and bandage trauma

Maintain healed ulcers.
Reproduced from Morrison et al [18]
The development of an additional framework that addresses other key elements of care, used
alongside the original TIME framework may help encourage a more holistic approach to leg
ulcer management. This might include:
Heading 2
Quality of life
The concept of quality of life reflects an individual’s level of satisfaction with various aspects of
daily life, including housing, environment, recreation, health and well-being [19]. Leg ulceration
can impact significantly on a person’s quality of life, affecting physical and social functioning as
well as psychological well-being [19]. Patients report increased pain, restrictions around what
they can wear, limitations to their social lives, low self-esteem, depression and social stigma
[12].
Heading 2
Concordance
An understanding of the impact of the ulcer on quality of life and the development of realistic
patient-focused outcomes is important if concordance is to be achieved [12] [13]. Poor regard
for patient concerns may be particularly difficult where healing is not a realistic outcome and the
focus is on chronic disease management. Negotiation may be required to find a treatment that
is both comfortable and effective [20].
Heading 2
Education
Patient education and active participation in treatment are important aspects of care and may
improve concordance [21] [22].
Heading 2
Pain
Pain and discomfort are frequently associated with leg ulceration regardless of aetiology and
may be linked to poor concordance [20] [23] [24] [25]. Ongoing, systematic pain assessment
and management, as well as timely referral for specialist input where required [26] [27], are
integral to holistic care and should be adequately documented [28]. An individual’s experience
of pain is unique, complex and influenced by many factors, although ability to effectively
communicate these details may vary considerably between patients. Practitioners should
assume that all wounds are painful or can become painful over time, that the surrounding skin
may be sensitive, and that even the lightest touch may be intensely painful [26] [27]. The World
Union of Wound Healing Societies (WUWHS) and EWMA consensus documents on woundrelated pain provide invaluable guidance to clinicians [26] [27]. Hollinworth [29] offers a practical
template for assessment of procedural pain, as well as strategies to minimise pain at dressing
changes, including:
(Bullet points please)

Use of warm cleansing solutions

Careful removal of dressings and their residue or encouraging patients to remove their own
dressings

Use of ‘time out’

Use of atraumatic dressings

Correct application of dressings and bandages

Changing the frequency of dressing changes.
Heading 2
Aetiology
Successful leg ulcer management is dependent on accurate diagnosis of the underlying
pathophysiology (ulcer aetiology) and subsequent targeted interventions. Venous hypertension
and arterial insufficiency are widely accepted as the most common causes [30], with many
patients experiencing mixed venous/arterial ulceration [1] [31]. Less common causes include,
among others, rheumatoid arthritis (9%), diabetes (2.5 %) [32], pyoderma gangrenosum,
necrobiosis lipoidica, vasculitis, erythema induratum, cellulitis, bullous pemphigoid and skin
cancer [33].
Clinical intervention at the wound bed without adequate measures to understand and manage the
ulcer aetiology represents an ineffective and potentially detrimental approach to care. Clinicians
should be aware of skin and lower limb changes that may indicate the underlying aetiology, as
well as associated risk factors. Where diagnosis is difficult, prompt referral to a specialist is
required. A holistic framework is important in establishing ulcer aetiology and national Royal
College of Nursing (RCN) and Scottish Intercollegiate Guidelines Network (SIGN) guidelines offer
documentation that can be used to inform diagnosis [31] [34]. Clinicians should be familiar with
local, national and international guidelines and referral pathways.
Effective care should be targeted at managing the underlying aetiology as well as the wound bed.
The International Leg Ulcer Advisory Board’s recommended treatment pathway provides clear
guidance on treatment choices and referral pathways according to the ulcer aetiology [35].
Heading 2
Co-morbidities
Measures to manage any co-existing medical conditions that may delay healing are integral to an
effective framework of care. Margolis examined co-existing medical conditions in patients with
venous disease and found asthma, congestive heart failure, diabetes, deep vein thrombosis,
lower limb cellulitis, lower limb oedema, osteoarthritis, rheumatoid arthritis and peripheral
vascular disease [36].
Heading 2
Nutrition
Although malnutrition is frequently linked to delayed healing [37] clinicians tend to be poor at
assessing patients’ nutritional status [38] [39]. A balanced diet that includes protein,
carbohydrates, fats, vitamins and minerals is important in effective wound bed preparation [40],
while obesity is linked to increased risk of venous hypertension, arteriosclerosis, atherosclerosis
and diabetes. The MUST tool (Malnutrition Universal Screening Tool) and the NICE nutrition
guidelines provide useful frameworks for assessment and should be used to guide practice [38]
[39].
Heading 2
Evaluation of care
Nurses are responsible for continually evaluating and recording the care they give [28] and for
altering the treatment where appropriate. An effective framework of care should include clear
treatment aims, including well-defined entry and exit points in order to avoid long-term use of
ineffective therapies. Appropriate measures should be chosen to evaluate care, such as reduction
in wound size, ability to tolerate compression or a reduction in limb circumference. Time frames
for evaluation should be clearly identified and rationalised.
Heading 1
Conclusion
Important advances in leg ulcer management have been made in the past two decades in relation
to leg ulceration, including provision of national and international guidelines [26] [31] [34] [41] [42]
[43] [44], education, the availability of compression bandaging on UK prescription and an
emerging understanding of wound bed preparation. Wound bed preparation and the TIME
framework offers an important and systematic tool to aid chronic wound management. This must
be used alongside an holistic approach, as stressed by Falanga [3]. Future work needs to focus
on evaluating the effectiveness of frameworks, such as the wound bed preparation and the TIME
framework.
Heading 1
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ends