Wound Bed Assessment: Understanding and Using TIMERS

Every wound tells a story, and the first chapter begins with wound bed assessment. The TIMERS model goes beyond the basics, addressing a variety of factors that influence healing.

Whether you’re a seasoned professional or are new to the field, you’ve likely encountered the acronym TIME or, more recently, TIMERS. These terms relate to clinical categories of comprehensive assessment, management, and wound bed preparation for hard-to-heal wounds, according to Donald Wollheim, MD, FAPWCA, WCC, DWC, a board-certified surgeon and clinical instructor for WCEI.

Let’s explore how the TIME and TIMERS frameworks guide the delivery of effective treatment strategies. Whether you’re aiming to refresh your knowledge or build a stronger foundation in wound bed preparation, this tool can support your clinical decision-making and patient outcomes.

Understanding the TIME acronym

The TIME acronym was developed in 2002 by a group of 10 wound care clinicians. Their goal was to create a framework to improve healing for chronic wounds, which was outlined in the International Journal of Tissue Repair and Regeneration in 2003.

Each letter in TIME stands for a key component of wound bed preparation:

• T: Tissue management
• I: Inflammation and infection control
• M: Moisture balance
• E: Epithelial edge advancement

“Essentially, TIME and TIMERS provide a checklist for clinicians,” explained Wollheim. “Each letter stands for a specific aspect of wound assessment and management regarding wound bed preparation.”

From TIME to TIMERS

In 2018, a new consensus panel of wound care experts revisited the TIME model. Recognizing the need for a more holistic approach to chronic wounds, they proposed two new elements:

• R: Regeneration and repair of tissue
• S: Social factors

These updates transformed the TIME framework into TIMERS.

“The consensus panel felt two components were missing from the current wound management framework,” Wollheim said. “By adding two more categories to their clinical checklist, it could capture other factors that also contribute to delayed healing.”

The revised model was introduced in the 2019 article “Implementing TIMERS: The race against hard-to-heal wounds” published in the Journal of Wound Care.

TIMERS and how it helps wound bed assessment

Learning more about the use of each category in TIMERS can provide a useful and structured approach to wound bed preparation and wound management that helps patients, Wollheim said.

“The goal for wound care clinicians is to heal a wound as quickly and painlessly as possible,” he said.

To better understand this framework, let’s break down each component of TIMERS and how it contributes to wound bed assessment and supports healing.

Tissue management

Effective healing begins with removing nonviable tissue using the appropriate method of debridement. The choice of method should align with the wound type, healing goals, and patient condition.

“First, you need to get rid of what is slowing or delaying healing of the wound,” explained Wollheim. “Second, you want to help stimulate the wound to heal.”

Inflammation and infection

Understanding inflammation and infection is a critical step for effective wound bed assessment. This means asking the right questions, including:

• Is there an infection present?
• If so, what type of organisms — bacterial, fungal, or both?
• Is biofilm present?
• What local or systemic treatment is indicated?

Moisture balance

Maintaining moisture balance promotes healing, so consider these components:

• Is the wound too dry? If so, you’ll want to add moisture.
• Is the wound too moist? If there’s too much moisture, you’ll need to control it and decrease any excess moisture and exudate.

Epithelial edge

Evaluating the wound edge helps determine healing potential. When conducting the assessment, consider these details:

• Is the edge advancing or static?
• Are keratosis or epibole present?
• What interventions can support edge migration?

Regeneration and repair

This category focuses on stimulating tissue regeneration. As a wound care clinician, you’ll want to influence and improve the trajectory of wound closure, so ask these questions during this part of the process:

• How can you reduce the effects of proinflammatory cytokines?
• What can be done to encourage regeneration and/or repair?

Advanced modalities should be tailored to the patient’s wound type and overall condition. Some examples may include stem cells, growth factors, and oxygen.

Social factors

This often-overlooked category can make or break treatment adherence and outcomes.

Patients and their caregivers may not understand their disease process. So, it’s important to assess their level of health literacy and then provide education using appropriate methods that facilitate the learning process.

In addition to health literacy, these are some other important social factors to assess:

• Depression
• Cognitive impairment
• Geographical location
• Transportation barriers
• Financial limitations
• Availability of caregiving support

Final thoughts on TIMERS and wound bed assessment

By integrating the TIMERS framework into your practice, you can approach each wound with a comprehensive, patient-centered mindset that accounts for both clinical and social complexities. This model not only enhances wound bed assessment and treatment but also helps clinicians anticipate potential barriers to healing.