TIMERS: expanding wound care beyond the focus of the wound

Hard-to-heal wounds affect not only the patient's quality of life, but also place a significant burden on healthcare systems around the world. The incidence of hard-to-heal wounds continues to rise wherever the age of the population is increasing. Correct diagnosis and treatment at an early stage in the treatment course, therefore, holds the potential to favourably impact the outcomes of such wounds.

Once healed, clinicians cannot continue to view that their objective has been reached, because 40% of healed diabetic foot ulcers (DFUs) and up to 69% of venous leg ulcers recur within the first year (Armstrong et al, 2017).

The race to heal hard-to-heal ulcers is driven by the fact that a foot ulcer precedes 85% of lower-limb amputations in patients with diabetes (Almekinder, 2018). Once a patient with diabetes undergoes a non-traumatic lower extremity amputation their 5-year mortality rate can be as high as 70% (Hambleton, 2009). These statistics are ominous but, to look on the positive side, it is estimated that between 49% and 85% of DFU-related amputations may be preventable (Driver and de Leon, 2008).

Potential for healing is also being missed in relation to patients with venous leg ulceration. The research evidence shows that the use of compression therapy can achieve healing rates of 76% at 24 weeks, yet these figures are significantly different from real-life population data, where healing rates are as low as 47% at 12 months. Provider-related factors that have a negative impact on outcomes include:

Nearly two decades ago, wound-related articles on wound healing began describing the importance of adequate wound-bed preparation in order to positively affect the trajectory to wound closure. One of these papers, published in 2003 (Schultz et al, 2003), illustrated an approach to wound-bed preparation using the acronym TIME. This acronym represented:

However, it was soon recognised that the word ‘epidermis’ implied that non-migration was a problem of the epidermis, when, in fact, failure of the epidermis to migrate was also due to a problem with the extracellular matrix, or cells at the wound edge. Therefore, the E component of the TIME acronym was subsequently revised in 2004 so that is now represents: E for edge of wound, non-advancing or undermined (Schultz et al, 2004).

As wound care practices, infrastructure, technology and research have advanced over the past 20 years, the importance of delivering holistic patient care has been given greater emphasis. Despite this, the TIME principles have continued to focus solely on the wound, rather than the wound as part of the patient's condition. This year, the need to align the principles of TIME with current wound-care practices and technologies has been recognised with the publication of an international consensus document, where TIME has been expanded to TIMERS (Atkin et al, 2019), as follows:

Ironically, time truly is of the essence when treating hard-to-heal wounds, given the fact that the risk of complications, such as infection, hospitalisation and amputation, increases when a wound remains open for longer than 30 days, especially in the population of patients with diabetes (Lavery et al, 2006).

The standard approach to wound-bed preparation, such as the step-down step-up approach (Schultz et al, 2017) (Figure 1), incorporates the expanded recommendation; it specifies when to refer a patient to the appropriate multidisciplinary team (MDT) or advanced care setting and when to consider the use of using regenerative/reparative technologies. It also recognises often overlooked social issues and that hard-to-heal wounds can be managed more effectively with improved timely outcomes.

Pathway

The document outlines a basic 10-step management pathway required for each wound. The approach also includes how to treat palliative wounds in a maintenance fashion:

Holistic patient assessment: physical, psychological, spiritual and social needs. This must include identification of the underlying pathophysiological cause(s) and risk factor(s)

Wound assessment: measurement

Decide the desired outcome (healing or maintenance) and a care plan

Address/manage the underlying pathology or plan maintenance care

Implement wound care in accordance to local policy/wound formulary.

Follow-up, reassessment and measurement

Modify the care pathway and refer, if necessary, to specialists or MDT

Patient/family education throughout the standards of care

Discharge or transition to maintenance treatment to prevent recurrence

Record actions/outcomes at every episode of care.

In addition, the TIMERS framework provides structured approaches to managing wounds and identifies where advanced adjunctive therapies, such as dehydrated human amnion chorion membrane allografts (Tettelbach et al, 2019), should be considered when there is evidence of treatment failure with standards of care (Figure 2). The focus within the regenerative/reparative model is to encourage wound closure by:

Providing a matrix to support cell infiltration

Stimulating cell activity using signal molecules or growth factors

Delivering oxygen therapy

Using stem cells.

Another important point highlighted within the TIMERS document is bioburden, especially biofilm. It is becoming generally accepted that hard-to-heal chronic wounds contain biofilm and that treating this could be a crucial factor in pushing the wound toward a healing state.

Numerous other points highlighted in the consensus document, including the fact that the more understanding/agreement that a patient has about their care plan, the more likely they are to adhere to treatment, that the use of medical jargon should be avoided and that, ethically, it is not acceptable to withdraw or stop therapy that is recommended in best-practice statements, even if a wound has not progressed along the healing trajectory.