Wound bed preparation is a well-established concept, and the TIME framework is the standard tool used to assist clinicians with the management of patients’ wounds throughout the care cycle. Recent clinical and technological breakthroughs are enhancing our understanding of this care cycle. An overview of the wound bed preparation care cycle and the TIME framework is provided here. Wound healing is a complex process that can be impacted by a variety of factors, although in general, it usually progresses through several phases, including coagulation and homeostasis, inflammation, cell proliferation and repair, and epithelization and remodeling of scar tissue.¹ The TIME framework was developed to address the pathophysiological abnormalities of wounds by optimizing conditions for healing. This is achieved by reducing edema and exudate, reducing the bacterial burden, and correcting the abnormalities that impair healing.

The TIME Model

The four components of the wound bed preparation care cycle that comprise the TIME framework are tissue management, infection or inflammation, moisture balance, and the wound edge (epithelial advancement).

1. Tissue Management: Identify viable and non-viable tissue. Look for and remove necrotic or compromised tissue to ensure a viable wound base. Debridement is generally necessary only once for acute wounds, although this treatment modality may be repeated several times with chronic wounds.²
2. Inflammation or Infection: Infection and inflammation are known to impair healing. Controlling the bioburden, or the presence and concentration of bacterial and fungal organisms, can optimize the wound bed conditions.²
3. Moisture Balance: Too much or too little moisture can hinder the healing process in several ways. Creating a balanced moisture level is instrumental in promoting re-epithelialization.²
4. Edge of Wound Advancement (Epithelial Advancement): Chronic wounds frequently do not progress sequentially through the phases of healing. Assessing a wound’s tendency to advance can guide treatment methods.² Any treatment selected should work to promote epithelialization and achieve a healthy periwound area.³

The TIME framework is not linear, however. This means that during healing, different elements within the framework may be of varying importance during each stage.² Recent developments in wound care best practices have encouraged a patient-centered focus, thus resulting in a revised TIME framework that incorporates it into the entire ABCDE care cycle described in the next section. These components should be individually addressed during each step of clinical decision making as the clinician moves through this care cycle.³

ABCDE Care Cycle

Assess Patient; Well-being, and Wound: Research has demonstrated that many patients do not receive an accurate diagnosis, and this results in the inability to treat them adequately. Assessment should identify the wound type, location, size, general wound bed conditions, presence of any inflammation or infection, patient’s level of pain, comorbidities, and any treatment efforts, including the level of patient compliance. This will help to establish an accurate diagnosis and identify appropriate support and comorbidities that may affect healing.³

Bring in a Team that Promotes Holistic Patient Care: This team may include members of multiple disciplines, such as a surgical staff, wound specialist nurses, dieticians, pain team members, vascular and diabetes team members, podiatrists, counselors, and even informal family caregivers. A multidisciplinary focus ensures that the patient is receiving all of the necessary aspects of care in a holistic and comprehensive treatment plan.³

Control or Treat Barriers to Wound Healing: This means assessing the underlying causes that may impair healing. These causes can include the following factors, among others: systemic infection, diabetes, nutritional deficiencies, edema, continence, mobility and vascular issues, pain, stress and anxiety levels, compliance with treatment, and lifestyle choices.3

Decide the Appropriate Treatment: Treatment choices can be selected based on the assessment and identification of barriers to healing. These treatment choices should address the characteristics of the wound based on the TIME framework.

Evaluate and Reassess Treatment and Wound Management Outcomes: The progression or lack of progression in the wound healing process should be recorded. If there is a failure to progress, clinicians may want to reassess all aspects of the wound and adjust the treatment plan accordingly.

Conclusion

Chronic wounds, and even complex acute wounds, are challenging to treat. They may have a multitude of issues that can impair healing. Adequate treatment can be identified only when a wound has been appropriately assessed. The long-used standard assessment tool, the TIME framework, is perhaps not as patient-centered as it could be. However, TIME is still valuable, and when it is integrated into the ABCDE wound bed preparation care cycle, proper diagnosis and treatment become much easier to identify and foster conditions that promote healing.

References

1. HSE National Wound Management Guidelines. Dublin, Ireland : The Office of Nursing and Midwifery Services, Clinical Strategy and Programmes Division; 2018.

2. Falanga V. Wound bed preparation: science applied to practice. In: Calne S, Flanagan M, Falanga V, et al., eds. Wound Bed Preparation in Practice. European Wound Management Association (EWWA). London: MEP Ltd; 2004.

3. 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.