Wound management is a common practice in most veterinary surgeries and represents an aspect of veterinary medicine where registered veterinary nurses (RVNs) play a crucial role. However, determining the best approach to wound management can be challenging, and there is often a tendency to rely on just one or two treatment options. Should these options be unsuccessful, patients may face longer hospital stays and increased financial strain on their owners. This article critically evaluatesate the current techniques for managing complex wounds, assesses their effectiveness and investigates how evidence-based frameworks can guide RVNs towards improved clinical outcomes. This article is part two of a three-part series examining wound healing and management in dogs, cats and exotic species.
Frameworks for wound assessment
Wound assessment may be improved by using a structured framework (Curtis, 2022; Lux, 2022). Frameworks such as checklists or care bundles are commonly used in veterinary practices and have been shown to improve patient outcomes (Yon and Lilley, 2024). There is no validated wound assessment tool in veterinary medicine; however, there are some available in human medicine that may be adapted for veterinary use. Technology is also advancing, with applications being developed to assist with and standardise wound assessment.
TIME(S)
The acronym TIME was created over 20 years ago by an international group of experts in wound healing to improve the assessment and treatment of wounds in human medicine (Schultz et al, 2003). TIME stands for Tissue, Infection or Inflammation, Moisture and the Edge of a wound or epithelial advancement; in some publications, an S is added for surrounding skin (Curtis, 2022). A summary of each of the TIME descriptors can be found in Table 1. To follow the framework, each category should be assessed against the expected healing process to determine if interventions are needed. The normal wound healing process is described in part one of this series and is summarised in Figure 2. Leaper et al (2012) reviewed TIME to determine if it was still valid following advancements in wound care. They concluded thatthe basic principles remained the same, and therefore, TIME continued to be a useful framework to guide wound management. In 2019, TIME was reviewed again and is now embedded into a holistic approach called the TIME clinical decision support tool (CDST), summarised in Box 1 (Moore et al, 2019). In veterinary literature, TIME has been suggested as a useful tool to improve wound management (Curtis, 2022; Lux, 2022).
| Inflammation and infection: Identification and treatment of infection or a prolonged inflammatory phase. |
| Moisture: Optimisation of moisture balance |
| Edge of wound: Assessment of the progression of epithelisation and contraction |
| Surrounding skin: Assessment and protection of the skin surrounding the wound (this may be integrated into the edge of wound assessment) |
| Healing phase | Key events |
|---|---|
| Haemostasis |
|
| Inflammatory |
|
| Granulation |
|
| Maturation |
|
Stages of the CDST.
| A: Assess - includes factors that may affect wound healing such as comorbidities and location. In veterinary patients this may include patient temperament and owner factors such as cost. |
| B: Bring in multidisciplinary team - This may be referral to specialists or adjunctive therapies to promote holistic care. |
| C: Control underlying causes and barriers - Including concurrent illnesses, nutrition, pain, anxiety, lifestyle adaptations. |
| D: Decide appropriate treatment. Use the TIMES assessment framework to guide this. |
| E: Evaluate and reassess. |
Other wound assessment frameworks
While the TIME framework is widely used, other assessment models are available, such as CASE (cause, assess, select, evaluate; Figure 1) and the wound assessment triangle (WAT). The WAT considers the wound bed, wound edge and the peri-wound skin, which was overlooked in other frameworks (Dowset et al, 2015). Curtis (2022) suggests it could be better than TIME as it assesses the surrounding skin and proposes a care bundle based onthe WAT. The addition of the surrounding skin assessment to TIME considers everything the WAT does but breaks it down further, offering a more robust wound assessment. CASE was developed by BSN Medical and adopted by Wounds UK in their best practice statement for assessing chronic wounds (Wounds UK, 2018; Essity, 2025). As RVNs, both CASE and the CDST may feel familiar as they follow a pattern similar to the nursing process (assess, plan, carry out, evaluate) (Orpet, 2011). The adoption of any of the protocols discussed is likely to result in an improved level of care. Essity produces educational resources to the veterinary industry on how to use CASE, with suggestions for treatment options which may make it more accessible and appealing to the veterinary community. Both CASE and CDST use TIMES in their wound assessment phase. Therefore, TIMES will be used to guide the rest of the discussion in this article.
Using the TIME framework to discuss current wound management techniques
T: tissue
This category focuses on evaluating the type and health of the tissue within the wound bed. It identifies viable tissue vs non-viable tissue. Removing dead tissue through debridement and promoting healthy tissue growth are primary goals in this phase.
Cleansing and lavage
Wound cleansing is performed on presentation of a traumatic wound and at dressing changes. Cochrane reviews on wound cleansing show limited evidence that it decreases infection rates or enhances healing (Fernandez and Griffiths, 2008; Svoboda et al, 2008). However, most publications still recommend cleansing and lavage to aid removal of contaminates that could become a barrier to healing (Davidson, 2015; Bell, 2021; Lux, 2022). In veterinary medicine, an isotonic solution is typically recommended for lavage as it may be less cytotoxic than tap water or saline (Buffa et al, 1997; Davidson, 2015). The use of antiseptic solutions is debated; some suggest they are cytotoxic to the cells required for healing and others argue they may improve wound healing. However, much of the research is over 20 years old (Sanchez et al, 1988; Lozier et al, 1992; Thomas et al, 2009). Suggested dilutions to prevent cell toxicity for Chlorhexidine and Povidone-Iodine are 0.05% and 0.1% respectively (Sanchez et al, 1988; Lozier et al., 1992; Davidson, 2015; Bell, 2021). The additions of Tris–ethylenediaminetetraacetic acid (EDTA) may improve the antimicrobial properties of lavage solutions (Davidson, 2015). Tris-EDTA is commonlyn found in ear flushing solutions, and a commercial Tris-EDTA and Chlorhexidine solution is available (TrizChlor, Dechra).
Debridement
Debridement, the process of removing non-viable tissue, is essential for creating an optimal healing environment. A summary of debridement methods is shown in Table 3. Wet to dry dressings, although commonly used, are no longer recommended. They disrupt normal healing by removing healthy tissue, drying the wound bed, increasing pain and potentially increasing infection risk (Fleck, 2009; Wodash, 2012; Davidson, 2015). They need to be changed daily and typically require sedation or general anaesthesia to facilitate replacement. Increased healing time and anaesthesia-associated risks can negatively affect patient outcomes and increase hospitalisation times and costs. Therefore, it is recommended that alternative techniques that promote wound bed integrity by protecting healthy tissue and reducing healing times are adopted, such as selective debridement followed by a dressing that promotes autolytic debridement or negative pressure wound therapy (NPWT).
| Type | Selective/non-selective | Details | Comments |
|---|---|---|---|
| Sharp | Selective | Uses a sharp blade to remove devitalised or unhealthy tissue | Requires sedation/local anaesthesia/GA |
| Surgical | Selective | Larger ‘chunks’ of tissue usually removed using surgical instruments | Requires sedation/local anaesthesia/GA |
| Wound irrigation | Non-selective | Flush away bacteria/debris and removes necrotic tissue | May be performed conscious in some patients |
| Adherent dressings | Non-selective | Remove necrotic tissue and debris when the dressing is removed | Painful to remove |
| Debridement pads | Non-selective | Used to wipe the wound to remove debris and necrotic tissue | Requires sedation/local anaesthesia/GA |
| Enzymatic | Non-selective | Liquifies necrotic tissue | Non-painful |
Negative pressure wound therapy
NPWT is a valuable tool in wound management, particularly for complex and chronic wounds. Within the tissue category, its primary functions are to aid in the loosening of necrotic tissue for future debridement and to facilitate the removal of infectious material (Leaper, 2012; Lux, 2022).
Studies have demonstrated multiple benefits of NPWT, including increased blood flow, reduced oedema, improved granulation, faster wound closure, fewer sedations, fewer complications, reduced graft and fatty tissue necrosis, improved patient comfort and shorter hospitalisation times (Demaria et al, 2011; Stanley et al, 2013; Pitt and Stanley, 2014; Nolff et al, 2017a; 2017b; Garcia-Pertierra et al, 2019; Buote, 2022). However, once a healthy granulation bed is established, NPWT should be discontinued, as it may slow contraction and epithelialisation (Demaria et al, 2011).
The development of portable NPWT devices (Figure 5) has enabled practices of varying sizes to implement this technique, although the cost of commercial devices remains a limiting factor. For budget-conscious practices, studies suggest that hybrid NPWT setups using wall suction can produce comparable results, providing an accessible alternative for small clinics and charities (Davey et al, 2024).
I: infection or inflammation
This step assesses signs of infection or inflammation. Effective infection management is crucial, as chronic inflammation or infection can impair healing.
Biofilm
Biofilms present a significant challenge in wound management. A biofilm is a colony of microorganisms that group together and form a barrier to defend themselves. The colony can share traits and typically demonstrates a higher tolerance to the body's natural defences as well as antibiotics and biocides (Heasler et al, 2019). Colonisation begins within 2–4 hours and continues to mature over 2–4 days. Once mature, dispersal and attachment to other areas of the wound occurs. Eventually, the whole wound bed becomes covered with a biofilm that is not easily removed without specific treatment as the colony secretes an adherent substance. This substance can also adhere to non-organic surfaces such as instruments and surfaces (Bell, 2024). Effective biofilm management involves regular debridement to disrupt the biofilm structure and the use of antimicrobial agents designed to penetrate biofilms. For instance, the surfactant Prontosan (Figure 6), containing polyhexanide (PHMB), has been shown to help prevent biofilm formation and reduce bacterial load in wounds. It is available as an irrigation solution, a gel and an impregnated sponge for use with NPWT (Bell, 2021; 2024).
Detecting biofilms is challenging in veterinary settings, as standard culture and sensitivity tests often yield false negatives. Advanced electron microscopy can detect biofilms; however, it is not available to most veterinary practices. Therefore, clinical markers must be relied upon to detect potential biofilm colonisation (Heasler et al, 2019; Vestby et al, 2020; Low and Aldridge, 2022; Liu et al, 2024).
An international group of experts published an agreed list of clinical indicators for biofilm presence. They concluded that a biofilm is likely to be present if:
These indicators can help RVNs identify the possible presence of a biofilm and prompt discussion with the veterinary team on the appropriate treatment course. They can also be used retrospectively to improve practice by identifying when a biofilm was likely to have been present, which protocols were effective, which were not and how this knowledge may inform future treatment approaches.
Silver
Silver is widely used in wound management for its antimicrobial properties and is available in various forms, including ointments, gels and impregnated dressings (Boute, 2022).
Khansa et al (2019) reviewed the available evidence for the use of silver in wound care in humans. They found the evidence base to be poor but suggested that silver dressings may be useful for infected wounds and that combining silver with NPWT improved the healing of contaminated wounds.
In mice, Thammawithan et al (2021) found that anisotropic silver nanoparticle gel (ASNG) effectively treated methicillin-resistant Staphylococcus pseudintermedius (MRSP) infections, promoted collagen formation and reduced scar formation. However, iodine was equally effective against MRSP, with both the ASNG and iodine preventing purulent wounds. It should be noted that the control group healed without intervention in a similar time frame, despite initially developing purulent wounds.
Therefore, silver may, be useful when managing infected wounds, particularly in conjunction with NPWT or for preventing pus formation.
Honey
Honey has long been valued for its natural antimicrobial and anti-inflammatory properties. In wound care, it is used to help control bacterial load, reduce inflammation and promote a moist healing environment. However, its use in wound management is sometimes debated because of mixed research findings.
While honey may aid healing in infected wounds, reviews by Brennan and Belshaw (2020) and Vogt et al (2021) found limited evidence to support its use in companion animals. More recent studies suggest that honey can improve tissue perfusion, reduce oedema and enhance epithelialisation, though its impact on overall healing speed remains inconclusive (Repellin et al, 2021; Chatzimisios et al, 2023). Medical-grade honey has been shown to be more bactericidal than other honey types (Neo et al, 2024).
Cost and the potential presence of Clostridium botulinum spores in non-medical-grade honey also limit its use. Despite these factors, honey may be valuable for specific wound types, particularly those with signs of infection, oedema or delayed healing.
M: moisture
The aim of this section is to maintain a balanced moisture environment to support healing. Moisture management strategies include selecting appropriate dressings.
Maintaining proper moisture levels in a wound is essential to promote healing and prevent tissue damage. Insufficient moisture can cause the wound bed to dry out, slowing healing and increasing pain, while excessive moisture can lead to maceration of the surrounding skin (Figure 4). To manage this balance, dressings should be selected based on the wound's current moisture needs, with regular reassessment as healing progresses.
NPWT is highly effective for managing moisture in large or exuding wounds, as it actively removes excess fluid while maintaining a moist wound environment. For smaller wounds, various dressings can help maintain the ideal level of hydration, such as hydrogels for dry wounds and foams for highly exudative wounds (Davidson, 2015; Lux, 2022).
Veterinary nurses play a vital role in monitoring moisture levels, as dressings should be checked frequently for signs of strike-through or dryness.
E: edge of wound
This category involves assessing the wound edges to determine if they are progressing toward closure. Non-advancing edges may indicate underlying issues and may require interventions to encourage epithelialisation.
Wound measurement applications
Taking wound measurements is a valuable method for tracking wound contraction. Although simple ruler measurements are commonly used, they tend to overestimate wound area by approximately 40%, making them less reliable for precise tracking (Rogers et al, 2010). A more accurate option is planimetry, which involves tracing the wound edges and calculating surface area either manually or using digital software. While effective, planimetry can be time-consuming, costly and may require specialised equipment that is not available in most practices (Chang et al, 2011).
Recent advancements in smartphone technology have made wound measurement more accessible. Digital planimetry apps offer reliable alternatives that are easier to use, require no special equipment and allow for consistent tracking over time. Studies indicate that these apps can provide results comparable to traditional planimetry, saving time and improving accuracy (Foltynski, 2018; Nair, 2018; Biagioni et al, 2021; Bodea et al, 2021).
S: surrounding skin
This section focuses on monitoring the surrounding skin and maintaining skin integrity to prevent secondary issues and preserve a barrier against infection.
The health of the peri-wound skin is crucial to successful wound healing, as damage to the surrounding area can lead to complications and delay recovery. Regular assessment helps detect early signs of issues such as maceration, dryness, erythema or dermatitis, which may result from excessive moisture, friction or irritation caused by dressings (Curtis, 2022).
To protect peri-wound skin, barrier creams and sprays can be applied to create a protective layer, preventing exudate from causing maceration or irritation. Additionally, selecting non-adherent dressings, using gentle adhesives and applying adhesive removal sprays can help reduce the risk of skin trauma during dressing changes (Figure 5).
By proactively managing peri-wound skin health, RVNs can help prevent secondary issues, support faster healing and improve overall patient comfort.
Conclusions
Reviewing current research in wound management practices has highlighted how frameworks such as CDST and CASE can offer a structured, holistic approach to wound assessment. These frameworks support decision-making and enhance the quality and effectiveness of wound care in veterinary practice. Emerging technologies such as NPWT, biofilm management solutions and smartphone applications are advancing standards of care. However, the suitability of each technique depends on factors such as cost, ease of use and patient needs. Adopting and adapting these techniques with a critical, evidence-based approach is likely to lead to improved healing outcomes, reduced hospitalisation times and better overall patient care.