The TIME Model of Wound Bed Preparation: Frequently Asked Questions
by Martha Kelso, RN, HBOT
On July 24, 2018, I presented a webinar on the topic of the TIME (tissue management, infection or inflammation, moisture balance, and edge of wound) model of wound bed preparation as part of WoundSource's Practice Accelerator series on wound bed preparation. Preparing a wound for healing is key to ensure that chronic wounds convert to healing wounds. The TIME mnemonic for wound bed preparation assists clinicians and bedside nurses to think critically when making decisions on treatment options. During the image-driven presentation, I discussed such topics as:
- Use of the TIME mnemonic to evaluate various wound challenges
- A review of terms related to the TIME wound bed preparation model
- Visual guidance on different wound types and wound descriptors to determine appropriate next steps for wound healing
Frequently Asked Questions about Wound Bed Preparation
Attendees of the webinar were able to ask questions during our Q&A segment. Following are responses to the top-themed questions asked during the webinar related to wound bed preparation.
Do you recommend dressings that will allow for proper wound bed temperature management to allow for healing versus daily dressing changes?
As a general rule of thumb in my day-to-day practice, yes, I do encourage longer-wear dressing time to encourage proper wound bed temperature, reduction in staff time/hours required for dressing changes, increase in client comfort, and all the other positive reasons why longer-wear dressings are important. Of course, we must consider the wound and what the wound needs from us. If you are using an enzymatic debridement product that has a half-life of 24 hours, then of course the dressing must be changed daily when the wound requires an enzymatic debrider. Right patient, right wound, right time, right building, right staff, right education. There is no such thing as a cookie cutter wound.
How do you document stage 2 wounds? Fox example, the pink tissue? I chart that as granulation tissue. What is the correct term to use for this tissue?
If there is pink tissue on a true stage 2 wound, this would be epithelial tissue. If there is granulation tissue present in a pressure wound, then the correct stage would be a stage 3, per the Mega Rule updates released by the Centers for Medicare & Medicaid Services (CMS) in November 2017. A screenshot of these updates is listed in the webinar presentation.
The definition of epithelial tissue per CMS as listed in the Resident Assessment Instrument for Long Term Care is: "New skin that is light pink and shiny (even in persons with darkly pigmented skin). In Stage 2 pressure ulcers, epithelial tissue is seen in the center and edges of the ulcer."
We know a stage 2 pressure wound is only partial-thickness by definition. The CMS definition of partial-thickness and full-thickness as listed in the Mega Rule updates for November 2017 are as follows:
"Partial-thickness skin loss with exposed dermis - Partial-thickness loss of skin with exposed dermis, presenting as a shallow open ulcer. The wound bed is viable, pink or red, moist, and may also present as an intact or open/ruptured blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present."
"Full-thickness skin loss - Full-thickness loss of skin, in which subcutaneous fat may be visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible but does not obscure the depth of tissue loss. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur."
What are some combinations of synergistic debridement that you have found helpful?
Based on research studies, the most effective synergistic approach is sharp debridement followed with enzymatic debridement. I have also seen sharp debridement partnered with enzymatic debridement and autolytic debridement. Sharp debridement can be contraindicated based on blood flow, pain levels, tissue stores, blood thinners, etc., so weigh pros and cons before initiating. Keep in mind all forms of debridement can be contraindicated for one reason or another. The D.E.B.R.I.D.E. guide was referenced during the webinar. This is an excellent document to review and keep handy for practicing clinicians.
Would you please explain offloading?
Offloading is a term sometimes used to describe getting pressure off a certain area. For example, floating heels is considered "offloading the heel." It is another term used in place of saying "relieving pressure," so to speak.
What is DIME?
DIME is another mnemonic designed to assist with the systematic approach to wound documentation, assessment, and treatment options. DIME stands for devitalized tissue, infection or inflammation, moisture balance, and edge preparation.
What medication do you use to decrease hypergranulation tissue?
Silver nitrate is a form of chemical cauterization that can be used to treat hypergranulation. Please verify scope and practice along with licensure to determine whether you can use silver nitrate, whether you need a doctor's order, indications, contraindications, and who can apply this, along with what documentation is required. This may vary from state to state. Some dressings may have an indication to reduce, remove, or control hypergranulation tissue as well. Please see the cause for the hypergranulation (i.e., infection, abnormal tissue, too much moisture) in addition, as eliminating the source may eliminate the hypergranulation tissue also.
Is ultrasound appropriate to examine a deep tissue injury?
An ultrasound is generally more useful in examining organs or looking for pockets of fluid collection. When in doubt on what radiological tools or studies to order for various conditions, I would recommend calling the radiologist who presides over the radiology department in which you are considering sending the client for a study or test. He or she can generally guide you or direct you on which study would be most appropriate based on the findings you seek.
Do you have any suggestions on how to help prevent chronic deep tissue injury in an abdominal fold on a morbidly obese patient?
Often times with morbid obesity, moisture can be a factor that contributes to pressure ulcer formation, including in abdominal folds. In moist, warm, dark areas (like abdominal folds) fungus can also proliferate. I would recommend products designed to reduce moisture and wick it away (i.e., moisture wicking sheets or skin barriers). Also of importance would be products that discourage fungal growth. Consider choosing a hypochlorous acid product that has a quick kill time but also encourages appropriate pH of the skin. In addition, there are mattress overlays for morbidly obese patients that offer a microclimate to cool the body and keep moisture wicked away as well. Often, low air loss or pressure redistribution mattresses act like a warmer and encourage sweating, which in turn creates more problems. Without knowing more about this client's background, this would be where I would encourage you to start.
Could we use bromelain for enzymatic debridement in chronic wounds with eschar (as in burn treatment third degree)?
Unless you are enrolled to do clinical research in an Institutional Review Board-approved clinical research study, I always recommend that you use products based on their package insert indications and contraindications and only use Food and Drug Administration (FDA)-approved products for what the FDA indicates they are designed to be used. Off-label usage of products must be heavily considered, and the client should be fully aware that you are using products off-label or off-indication should you choose to do so, along with risks and benefits. WoundSource has a plethora of information regarding indications and contraindications on all things wound related.
About the Author
Martha Kelso is the founder and Chief Executive Officer of Wound Care Plus, LLC (WCP) and has enjoyed a career as a wound nurse in long-term care, which has given her plenty of experience to draw upon as she continues to work to educate health care professionals today.
The views and opinions expressed in this blog are solely those of the author, and do not represent the views of WoundSource, Kestrel Health Information, Inc., its affiliates, or subsidiary companies.