The concept of wound bed preparation has been utilized and accepted for over two decades. Wound bed preparation techniques can only be accurately employed after a thorough and complete assessment of the wound. Poor assessments result in a negative impact of needless costs and truancy of appropriate treatments and outcomes. The goal of wound bed preparation is to provide an optimal wound healing environment. Up-to-date research in molecular science has helped evolve new technology and advanced therapies that include growth factors, growing cells in vitro, and developing bioengineered tissue.¹ Researchers now know that the healing process involves an array of elements that require monitoring and attentiveness. Clinicians have used the mnemonic TIME since it was born in 2003; since then, updates have been made to the mnemonic to encourage a more patient-centered focus.² TIME is a systematic approach integrating four clinical areas.

Components of TIME

TIME includes the following intervention recommendations^1,2:

Tissue Management

Identifying and removing non-viable or devitalized tissue by utilizing one or more of the five methods of debridement, as appropriate, comprises the first step in the TIME concept of wound bed preparation. There are five types of debridement: biological, enzymatic, autolytic, mechanical, and surgical. Sharp or surgical debridement is indicated only if there is an adequate arterial blood supply. Healthy and viable tissue is the intended wound outcome. Wound bed preparation will restore the wound bed base and functional extracellular matrix proteins. Identifying tissue types can help clinicians determine next steps for wound management, such as identifying exposed bone or muscle and making appropriate decisions from there.

Infection or Inflammation

Wound bed preparation will help control and manage infection, bioburden, and biofilm and reduce inflammation. High bacteria counts slow healing, increase exudate amounts, and can lead to the development of clinical infection. Always consider inflammatory diseases, such as autoimmune diseases. Utilize bioactive, antimicrobial, antiseptic, or antibiotic-type dressings and therapies as indicated.

Moisture Balance

Provide an optimal moisture balance in both the wound bed and the periwound. Utilize appropriate advanced wound care dressings to control and manage edema. Maceration or desiccation slows epithelial cell migration. Compress edematous limbs as indicated. Donate moisture with dressings such as hydrogel, or petrolatum as indicated. Wick away moisture with absorbent dressings such as alginates, hydrofibers, foams, and super absorbents. The effect of wound bed preparation will help restore epithelial cell migration and balance moisture levels.

Edge of Wound Advancement (Epithelial Advancement)

Edges of the wound will improve with proper wound bed preparation. Epibole, undermining, and non-advancing wound edges warrant other treatment modalities such as debridement, skin grafts, biological agents, and/or adjunctive therapies as indicated. Wound bed preparation will stimulate migrating keratinocytes and responsive wound cells and will restore appropriate proteases.

TIME Clinical Decision Support Tool

The TIME principles are key in enhancing assessment and management of wounds. However, we now know that there are also biological imbalances from a cellular standpoint in the more complex wound. TIME has been re-evaluated and expanded through the years. In 2018, the TIME Clinical Decision Support Tool (CDST) was developed.² Strong evidence-based research, clinical judgment, and expertise are influencing elements in the expansion of TIME CDST. TIME CDST uses an A, B, C, D, E approach.^1,2

• Assess: Implement an effective wound management strategy, to provide accurate ongoing patient and wound assessment and diagnosis. A thorough patient and wound assessment is imperative in moving toward successful wound healing outcomes. Attempting to treat the wound without first identifying comorbidities or underlying risk factors can lead to stalled healing progress and increased costs both for the facility and the patient.
• Bring: Utilize a multidisciplinary team to assist in providing holistic care (wound specialist, surgeon, physical therapist, physician specialist, diabetes educator, pain clinic team, family, and caregiver). A diverse team can provide different perspectives and contributions to wound healing. For example, a nutritionist may be able to identify areas in the patient’s diet that are lacking and causing delayed healing, while a pain management team may be able to provide insight on modified routines that can help encourage compliance.
• Control: Identify and treat underlying causes and barriers that impede wound healing while communicating among multidisciplinary team members. Educate patients to minimize non-adherence (offloading, nutrition, compression).
• Decide: Select appropriate treatment by tissue types, wound edges, infection or inflammation, bioburden, and moisture levels. Select advanced wound care dressings and treatment modalities that pinpoint each element to ensure healing progress.
• Evaluate: Monitor and evaluate treatment and effectiveness weekly. The wound bed and periwound should both be evaluated. Reassess if no wound healing progression. Restart A, B, and C. Change the treatment where indicated.

Conclusion

As clinicians, we need to remember that a small break in the skin or any wound will heal in the same way. Wounds need to be assessed individually along with the whole patient. TIME provides a shell for wound bed preparation while the expansion of the CDST encourages holistic wound assessment, ascertaining underlying associated etiologies, and meeting the patient’s psychosocial needs. Application of TIME and CDST will only enhance wound healing outcomes. The wound management specialty will continue to grow, along with algorithms and comprehensive studies.

References

1. European Wound Management Association (EWMA). EWMA position document: wound bed preparation in practice. 2004. https://ewma.org/fileadmin/user_upload/EWMA.org/Position_documents_2002…. Accessed June 13, 2019.

2. Moore Z, Dowsett C, Smith G, et al. TIME CDST: an updated tool to address the current challenges in wound care. J Wound Care. 2019;28(3):154-161.