The ‘TIME’ concept (tissue debridement, infection or inflammation, moisture balance and edge effect) as a tool to aid wound assessment was mentioned in part 1 of this series (Jones, 2019). It was first introduced by the European Wound Management Association (EWMA) in 2004 (EWMA, 2004). Some 15 years on from that historic document, Atkin et al (2019) recommended that TIME should be updated to include other factors that have an impact on wound healing outcomes. They added ‘R’ for repair/regeneration and ‘S’ for social factors. Thus, ‘TIME’ has changed to ‘TIMERS’.
This section 5 of the document looks in more depth at the six factors that make up the TIMERS framework.
Section 5. Advanced and adjunctive product use: when and how?
Section 5 of the document explains that TIMERS is a general framework to guide care at all competency levels in all settings. The authors explain that although the framework is relevant to all care settings, the details of wound management would vary according to each setting and to each individual healthcare professional/provider's competencies (Atkin et al, 2019:S27).
T: Tissue
During a wound assessment, the healthcare provider should look at the characteristics of the tissue within the wound bed. Any non-viable tissue/devitalised tissue can lead to delayed healing and should be removed (Atkin et al, 2019:S28).
The terms ‘non-viable’ or ‘devitalised’ tissue are used to describe tissue that has lost normal cellular structure and the physical properties required of living tissue. Unless it is removed, devitalised tissue can lead to infection and delayed healing (Atkin et al, 2019:S28).
The recommended treatment is to debride the wound and the document goes on to explain that before the choice of wound debridement is selected, the health professional's competency should be considered. The patient's general condition should also be considered, for example, sharp debridement may not be appropriate for a patient on anticoagulants. Other factors that can compromise the patient's ability to heal, such as ischaemia, are also highlighted as a possible contraindication to debridement (Atkin et al, 2019:S28).
I: Inflammation and infection
The document explains that the focus of this component of TIMERS is on bioburden management and in particular the biofilm pathway, which was referred to in Section 4 of the document.
M: Moisture balance
Exudate is an essential component of wound healing. It bathes the wound bed with a serous fluid that is mainly made up of water that contains electrolytes, nutrients, proteins, growth factors, white blood cells and matrix metalloproteins (MMPs) (Jones, 2014). However, too much or too little exudate can be detrimental to wound healing and also to the surrounding skin. In this section 5, the document discusses the importance of a moist wound bed and also the importance of managing the peri-wound skin. It also looks at the quality of life factors, that can occur when exudate is not managed properly, for example, exudate leakage can lead to soiling of the patient's clothing and bedding. This in turn can be distressing and a source of embarrassment for the patient.
The document states that exudate management is an important part of an effective standard of care and that the patient should also be included in the planning of their own care. The document states: ‘There is no situation where moisture should not be managed and balanced in a wound’ (Atkin et al, 2019:S33).
E: Edge
This section starts by explaining that in full-thickness and larger wounds, epithelial migration takes place from the wound margins and that in order to provide the appropriate care, it is essential to observe the wound margins. However, other factors considered in TIMERS, such as level of exudate production, underlying pathology and infection, must first be addressed (Atkin et al, 2019:S34) (see Photo 2).
A wound that requires debridement. In this case, sharp debridement would probably be the debridement method of choice. See Table 1.
shows maceration of surrounding skin; observe the unhealthy condition of the wound margin, which will need to be addressed in order to encourage epithelialisation from the wound margins. Also, over 50% of the wound is covered with devitalised tissue, which will require debridement.
Advanced therapies
The last part of this section looks at some of the more advanced wound therapies that may be considered in order to reduce the size of the wound. These may include tissueequivalent or living-skin-equivalent products. However, the need to prepare the wound margins for healing, for example, the use of debridement, is recommended before the use of any advanced products. All aspects of TIMERS should first be applied and only when the wound is not responding to standard of care (SoC), should advanced therapy be applied.
The document states that some authorities will only allow the use of advanced wound therapies when the wounds have responded to SoC by less than 50% at four weeks (Atkin et al, 2019:S35).
Key points about TIMERS
Source: Atkin et al, 2019.
Advanced therapy options for wound repair
There are several different options of advanced therapy available for chronic, hard-to-heal wounds. However, the treatment option should be selected depending on the suitability of the technology for an individual patient and their wound. Advanced therapy is numerous and complex, and examples are listed in Table 5.
Extreme long-term and non-responsive wounds
Despite the best care, some wounds fail to progress to healing. For these patients, the document explains that, ethically, it is not acceptable to either withdraw or stop treatment, which is recommended in best-practice statements. The document explains that treatment should continue in order to prevent any deterioration in the wound-healing progress.
Management pathway required for each wound
A 10-step approach in the management pathway required for each wound is outlined in Section 4. This also includes how to treat palliative wounds in a maintenance fashion:
Source: Atkin et al, 2019.
“In order for the patient to understand the reason for their personal prescribed treatment, it is important that they are involved, where possible, in the planning of their care. The expectation of the treatment should also be explained to them and any questions they have answered as clearly and honestly as possible”
It goes on to state that both the patient's and health professionals' expectations should be managed accordingly and this may include prioritising patient factors.
Section 6. management of patient-related factors
This is the last but by no means the least important section of the document and covers the ‘S’ of TIMERS.
S: Social and patient-related
This section of the document refers back to the importance of a holistic assessment and the identification of all the risk factors that need to be addressed in order to provide the optimal environment for wound healing. However, the holistic assessment should also identify non-clinical risk factors that will need to be addressed (Atkin et al, 2019:S38).
Psychological factors
In order for the patient to understand the reason for their personal prescribed treatment, it is important that they are involved, where possible, in the planning of their care. The expectation of the treatment should also be explained to them and any questions they might have answered as clearly and honestly as possible.
Factors that affect adherence
A factor that may affect adherence is the differing goals of the patient and the healthcare professional. In order for the patient to adhere to the care plan, efforts should be made to ensure that past problems are explored. For example, the patient may have had compression in the past and been unable to wear their shoes and therefore unable to feel confident enough to socialise and as a result had become housebound.
Changing the compression from bandages to hosiery may be a realistic option and thus allowing the patient to wear their shoes, which enables them to be able to go out.
TIMERS framework for managing hard-to-heal wounds (Atkin et al, 2019)
Physical and comorbidity factors
The majority of patients with chronic wounds are elderly and with age come factors that can affect their ability to self-care. For example, a patient who is diabetic may also have diabetic retinopathy, which affects their vision, which in turn affects their ability to observe the wound themselves and report any visible problems.
Extrinsic factors
Methods of debridement that can be used to remove non-viable tissue include the following:
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(Adapted from Atkin et al, 2019).
Extrinsic factors may be difficult for the healthcare provider to be able to control, for example, where the patient lives, which may be far from a clinical setting; they may also have difficulty accessing public transport and therefore attending clinics at specific times (adapted from Atkin et al, 2019:S39).
Management of patient-related factors
Psychosocial factors
Check that the patient understands their plan of care and note any issues that they may have. This documentation in turn will help in the formulation of a plan that aligns with their comments and wishes (Atkin et al, 2019:S39).
Physical and comorbidity factors
Where possible, the treatment prescribed should fit in with the patient's physical ability. Empowering the patient is important; however, if their eyesight is poor, there is no point asking them to check a wound or dressing etc.
Extrinsic factors
If the patient needs to attend a clinic and has transport difficulties, effort should be made to look for volunteer services that can transport the patient etc.
“Despite the best care, some wounds fail to progress to healing. For these patients, ethically, it is not acceptable to either withdraw or stop treatment, which is recommended in best-practice statements. Treatment should continue, in order to prevent any deterioration in the wound-healing progress”
Like all the sections in this series of the consensus document, Implementing TIMERS: the race against hard-to-heal wounds, sections 5 and 6 are meant to provide a summary of the corresponding sections in the document.
The document has more in-depth information and it is recommended that if you are involved in wound care that you read the complete document.
“A factor that may affect adherence is the differing goals of the patient and the healthcare professional. In order for the patient to adhere to the care plan, efforts should be made to ensure that past problems are explored”
Advanced therapy options for controlling inflammation and bioburden
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(Adapted from Atkin et al, 2019:S31).
Advanced and other therapy options for managing moisture
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(Adapted from Atkin et al, 2019:S34).
Considerations for wound edge management
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Topical interventions
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For more in-depth information on the above-listed treatments, it is advisable to read the Consensus Document (Atkin et al, 2019:S35–37) https://www.magonlinelibrary.com/doi/pdf/10.12968/jowc.2019.28.Sup3a.S1