Implementing TIMERS: the race against hard-to-heal wounds

Background: The TIME method of wound management is a well-researched and commonly known concept for many years. As populations change and further research undertaken, these concepts will also evolve. TIME is an acronym for Tissue, Inflammation/Infection, Moisture, and Edge. Although the concept seems simple, chronic wounds are chronic because they are difficult to heal with many patient factors and co-morbidities that complicate wound management.

The simple summary of TIME starting with tissue, refers to debridement of unhealthy tissue by multiple therapeutic options. This can also involve managing unhealthy granulation as well as the removal of dead tissues.

Inflammation/Infection is interesting since inflammation can be caused by infection, but infection does not need to be present with inflammation. Research on senescent cells, biofilm, and protease modulation, as well as improved diagnostic options for infection and matrix metalloproteases (MMPs), has added to the complexity and diagnostic capabilities of bioburden and inflammatory chronicity of managing chronic wounds.

Provision of a moist wound environment has not changed since George Winter's work in the 60s and Laura Bolton's body of work on moisture retentive dressings in the past 30+ years. What has changed is the vernacular and dressing options. Traditional gauzes and foam dressings that manage moderate to high exudate with high moisture vapor transfer rates are falling out of fashion with modern super-absorbent dressings that absorb and sequester exudate, bacteria, and MMP's. However, as exudate diminishes, clinicians should convert to moisture retentive hydrocolloids and gel sheets to prevent desiccation. Furthermore, the term ‘occlusive’ may only mean waterproof or the presence of a viral/bacterial barrier and should be avoided since there is no formal definition for the term in wound care. However, there is a dosage of ‘moisture retention’ which is ‘less than 30g/m²/hr’ as described by Laura Bolton in her 2007 JWOCN study ‘ operational definition of moist wound healing.’ Even with the evolution of regenerative products, moisture retentive dressings are needed to provide a suitable environment for healing.

The ‘edge’ in T.I.M.E. refers to the need to have a healthy, attached wound edge for epithelialization to occur. Maceration, undermining, tunnels, sinus tracts, and epibole are examples of an unhealthy edge, requiring interventions to protect and support a healthy wound edge.

T.I.M.E. + R + S = T.I.M.E.R.S.: The addition of ‘R’ for ‘repair’ draws from the the concept of a reconstruction ladder in reconstruction surgery that aims to close a wound fast and without complication with the least amount of cost and/or complexity. Some examples are primary closure, secondary closure, autografts, hyperbaric oxygen therapy, topical oxygen therapy, flaps and grafts. The explosion of cellular and tissue-based products (CTPs) has expanded options for achieving closure that can be individualized for the patient, their preferences, and their skin types. With all the options and high costs of these therapies, clinical utility and resource utilization studies are needed to ensure appropriate standard of care.

That leads us to the ‘S’ which refers to social and patient related factors. There may be patients who would prefer not to have a porcine xenograft versus a fish graft or autograft. Moreover, religious beliefs may also impact decisions on blood donations. Thus, patients should be allowed to make decisions they consider best for their wellbeing and care. This may require the enlistment of a multi-disciplinary approach to effectively communicate the patient's desires in their healthcare decision making options.