TIMES ACRONYM | Wounds Africa

TIME, TIMES and TIMERS acronymns

Accurately describing a wound can be challenging for individuals who are not highly experienced in wound care. Employing a systematic approach is important when documenting medical treatments, and this principle naturally applies to wound management as well.

In 2003, a group of recognized wound care experts published an article in the Journal of Wound Repair, in which the acronym TIME was introduced. The authors argued that a standardized tool was necessary to ensure higher quality of care. The tool is straightforward and was quickly adopted by wound care professionals worldwide. Subsequently, the letter "S" was added, modifying the acronym to TIMES. The exact origin of the addition of "S" remains uncertain, but wound care literature indicates that the shift from TIME to TIMES occurred around 2010–2012.

TIMES can be applied to all wound types, including both acute and chronic wounds. It is utilized in both human and veterinary medicine.

T (Tissue):
This component addresses the appearance of the tissue within the wound bed. Useful vocabulary for describing wound tissue includes: color of the tissue (black, grey, yellow, white, red, pink), granulation tissue, hypergranulation, wet necrosis, dry necrosis, fibrin coating, yellow necrosis, black necrosis, well-perfused tissue, and pale tissue. If tendon or bone tissue is visible in the wound bed, this should also be documented. It is important to note that certain dressings can influence the perceived color of the tissue. For example, silver-containing dressings may leave a greyish residue, while iodine-based products can impart a brown or yellow discoloration to the tissue.

I (Inflammation/Infection):
This section concerns the presence of inflammation in the wound. Inflammation is most commonly observed as redness around the wound edges. It is important to remember that inflammation does not necessarily indicate infection. Many chronic wounds remain in a persistent inflammatory phase without the presence of pathogenic bacteria. Distinguishing between inflammation and infection can sometimes be challenging. A strong odor emanating from the wound may suggest an increased bacterial load, and any notable smell can be documented under “I” in the TIMES framework ( it can also be reported under "M" for moisture). It is essential to be aware that the classic signs of infection—redness, swelling, odor, and pain—may be absent, particularly in certain patient populations, such as those with diabetic foot ulcers.

This section should also include an assessment of the potential presence of biofilm. While some wound experts assert that biofilm cannot be visually identified, we disagree. In some cases, a thin, greyish coating may be visible and is strongly indicative of biofilm. If biofilm is suspected, it is appropriate to document this as "suspected biofilm present in the wound."

M (Moisture):
This refers to the volume and characteristics of exudate from the wound. The best indicator of wound exudate quantity is often the dressing just removed. It is also helpful to ask the patient about exudate levels at home; for instance, if the patient reports changing dressings three times per day, this suggests a high volume of secretion.

A decreasing amount of exudate is generally a positive indicator of wound healing, as most wounds produce less fluid as they progress toward healing. Describing exudate quantity is inherently subjective; some clinicians use terms such as "low," "moderate," or "heavy," while others may use symbols like +, ++, and +++, although these offer limited precision regarding actual volume. Notably, some patients are so focused on wound output that they weigh dressings on a kitchen scale to precisely track healing progress.

In addition to volume, exudate color and consistency should be documented. Is the exudate serous (clear or light yellow, similar to diluted urine), or is it white, yellow, green, light red, or bloody? Normal healing wounds typically produce serous fluid. Green exudate may indicate the presence of Pseudomonas aeruginosa, a bacterium known to impede healing or rapidly deteriorate wound conditions. If the exudate is bloody during dressing changes, it may suggest that the dressing is adhering to the wound bed and causing trauma upon removal. Some dressings may also alter exudate coloration: silver dressings can cause a greyish hue, iodine products may result in a brown or yellow tint, and dressings containing PHMB (Polyhexamethylene Biguanide), such as Kerlix AMD, may produce a greenish color that can be mistaken for Pseudomonas infection.

E (Edge):
This element evaluates the wound margins. Observations should include whether the edges appear healthy, necrotic, or show signs of epithelialization (new skin growth over the wound). The process of epithelialization is sometimes subtle and requires close inspection. It is essential to recognize epithelialization, as these areas should not be debrided in order to protect the fragile new tissue.

Signs of maceration (softening due to excess moisture) should also be noted here. Undermining of the wound edges also falls under this category. In patients with diabetes, it is common to observe dry, hard, and elevated wound margins, especially in plantar foot ulcers. Look for edema at the wound edges, which may indicate inflammation.

S (Surrounding Skin):
This refers to the condition of the skin a few centimeters beyond the wound margins. Is the surrounding skin inflamed? Dry? Flaky? Are there signs of eczema, such as stasis dermatitis? Has the patient been scratching the skin near the wound? Is there hyperpigmentation (hemosiderin deposits) suggestive of venous insufficiency? Are varicose veins visible beneath the skin? Is there peripheral edema?

Upon reviewing all of this, one may initially feel overwhelmed by the number of aspects that must be considered. However, in practice, the TIMES framework is simpler than it may seem, and we will illustrate this with several practical examples. It is perfectly acceptable to include a question mark when documenting a finding that is uncertain. For instance, if you observe a yellow coating, you may write “yellow necrosis? Fibrin?”

Example 1

T (Tissue):
The wound bed displays areas of granulation tissue, with possible very mild hypergranulation. A thicker yellow coating is present, which may represent either fibrin or yellow necrotic tissue.

I (Inflammation/Infection):
No evident signs of inflammation or infection are present.

M (Moisture):
(While exudate levels are difficult to assess from an image alone, for this exercise, we will assume that the dressing removed three days after application was approximately 50% saturated with serous exudate. This would be classified as a moderate amount of exudate, or noted as "++.")

E (Edge):
No clear evidence of epithelialization is observed, and there are no signs of edge undermining, moisture damage, or elevated wound margins.

S (Surrounding Skin):
The surrounding skin appears pink, showing no maceration or other pathological changes.

Conclusion based on the TIMES assessment:
This wound appears relatively promising. The wound margins on the right side of the image suggest that the skin is attempting to migrate over the wound bed but is impeded by the presence of a thick yellow coating, which inhibits epithelialization. Adequate debridement of this material will likely facilitate wound healing. The optimal approach would be mechanical debridement using a curette; for clinicians less comfortable with sharp debridement, gradual removal with a microfiber debridement pad or cloth may be considered during each dressing change. Given the low level of exudate, a dressing change every three days appears appropriate. Changing the current dressing type may not be necessary; the primary clinical priority is thorough and consistent debridement of the wound bed.

Example 2

T (Tissue):
Approximately two-thirds of the wound bed appears flat with a light brownish coloration, interspersed with small areas exhibiting a healthier hue. There are only sparse regions of granulation tissue. One-third of the wound is covered with a thicker yellow coating, possibly fibrin or yellow necrosis.

I (Inflammation/Infection):
Patchy irritation is observed in the peri-wound skin, possibly indicative of inflammation but likely due to excessive moisture. There are no clear signs of infection.

M (Moisture):
(Although exudate volume is difficult to assess from an image alone, for the purpose of this exercise, let us assume that the dressing, last changed the day before, was heavily saturated with serous (slightly yellow, transparent) exudate. Moisture level: +++.)

E (Edge):
Some wound edges appear slightly elevated, with localized areas showing a reddish hue. On the opposite side, the wound margins are partially covered with a coating.

S (Surrounding Skin):
Superficial erosions are present in multiple surrounding skin areas, possibly due to moisture damage from wound exudate. Eczema may also be a contributing factor.

Conclusion based on the TIMES assessment:
The yellow-coated areas should be debrided. Light curettage may also be beneficial over the other areas of the wound bed to revitalize the tissue. Alternatively, a microfiber debridement pad could gradually remove the coating during each dressing change.
Prolonged exposure to moist dressings is likely causing superficial skin damage farther from the wound. A switch to a more absorbent dressing and shortened dressing change intervals are recommended. A moisture barrier product should be applied not only near the wound but also across all areas of compromised skin in the surrounding region.

Example 3

T (Tissue):
Approximately 60% of the wound bed is granulating, with a relatively healthy pink appearance. A thin coating is present—possibly fibrin or biofilm. A triangular area of thick yellow necrosis is toward the plantar surface.

I (Inflammation/Infection):
No obvious signs of inflammation or infection are noted. However, a thin, slightly greyish coating is present on the granulating area, possibly indicative of biofilm.

M (Moisture):
(While exudate volume is difficult to assess from an image alone, for the purpose of this exercise, let us assume that the dressing, changed three days ago, was thoroughly saturated with wound fluid, suggesting moderate to heavy exudate. The surrounding skin is macerated, which further supports the presence of significant wound exudation.)

E (Edge):
The wound edges appear white, indicative of moisture damage. No signs of epithelialization are currently visible.

S (Surrounding Skin):
The surrounding skin is unremarkable, with no additional pathological findings.

Conclusion based on the TIMES assessment:
The thick yellow necrotic tissue should be debrided. Caution is required due to the anatomical location—this wound lies directly over the metatarsophalangeal (MTP) joint. The foot has a short distance between the skin and the underlying bone. The wound has a typical appearance consistent with a diabetic foot ulcer. All diabetic foot ulcers should be managed within the specialist healthcare system.

This does not preclude debridement in primary care; if the general practitioner feels confident and competent, debridement may be performed. However, the patient must still be referred for specialist evaluation. The most critical intervention in this case is offloading. Additionally, frequent dressing changes are warranted, and a more absorbent dressing should be combined with a barrier product applied to the wound edges.

Advantages of Using a Systematic Tool for Wound Assessment

The TIMES framework simplifies the wound assessment by providing a structured and standardized approach.

By working through each component of TIMES step by step, clinicians reduce the risk of overlooking important clinical features of the wound.

TIMES facilitates interdisciplinary communication between general practitioners, community nurses, and specialist wound care teams, including outpatient wound clinics.

Each element of the acronym—tissue, Inflammation/Infection, Moisture, Edge, and Surrounding Skin—helps guide targeted clinical interventions, such as debridement, infection management, or appropriate dressing selection.

The acronym is easy to remember and widely used in both academic literature and educational settings, making it an effective pedagogical tool for healthcare professionals and students alike.

TIMES is aligned with current clinical guidelines and best practices in wound care and wound bed preparation.

Regular use of the TIMES framework provides a strong foundation for monitoring wound progression. It helps identify when a wound is no longer healing, prompting timely reassessment or referral when needed.

How Widespread Is the Use of TIMES in Wound Documentation today?

In the past five years, there has been a noticeable increase in the use of the TIMES framework globally, particularly among wound clinics and community nurses who have completed advanced training in wound care.

However, the TIMES framework is strikingly absent in wound documentation performed by physicians. This is perhaps unsurprising—many physicians have only a vague familiarity with TIMES and have likely received little to no formal education on the tool.

Orthopedic surgeon Bodo Günther, one of the editors of WoundsAfrica, once expressed skepticism about the value of TIMES, stating that he did not find wound description particularly challenging. However, after realizing how significantly TIMES can simplify wound assessment—especially for those with less experience in wound care—he underwent a complete change in perspective. He is now a strong advocate for using TIMES in all wound documentation. When teaching other physicians about the benefits of TIMES, he often draws an analogy to interpreting a chest X-ray—another clinical scenario where a systematic approach is essential for accurate description and diagnosis. (See the image below for a textual illustration of this concept.)

When physicians are asked to describe a chest X-ray, many struggle to do so in a systematic manner. Therefore, the ABCDE framework is often recommended:

A = Airways: In this case, the trachea appears normal and centrally located.
B = Breathing: The lung parenchyma appears unremarkable.
C = Circulation: The heart appears slender and within normal limits.
D = Diaphragm: The diaphragm has a normal contour.
E = Elsewhere: This includes an assessment of the ribs and other visible bones.

This example serves to clearly illustrate to physicians the value of using a structured tool for describing what is seen. It makes it easier for them to appreciate that the TIMES framework serves exactly the same purpose in wound assessment.

What About the TIMERS Acronym That Has Emerged in Recent Years?

One of the challenges in academia is the continual push by authors to revise or “improve” existing frameworks in order to claim credit for new ideas. In our view, this does not always lead to better outcomes.

In 2012, a group of authors introduced the acronym TIMERS in an article published in the International Wound Journal. We believe that TIMERS only adds confusion and undermines efforts to establish a unified framework for wound assessment. It does not introduce any revolutionary changes.

TIMERS builds upon the same principles as TIMES but expands slightly on the recommended clinical actions associated with each letter. It also introduces an additional letter:R = Regeneration/Repair

Here is a breakdown of TIMERS:

T (Tissue): Removal of non-viable tissue (debridement)
I (Inflammation/Infection): Control of bacterial load and inflammatory processes
M (Moisture): Maintaining moisture balance—not too wet, not too dry
E (Edge): Assessment of stagnant or undermined wound edges
R (Regeneration/Repair): Implementation of therapies that promote tissue regeneration; consider advanced treatment modalities
S (Surrounding Skin): Protection and repair of the periwound skin

As demonstrated, TIMERS does not provide any substantial improvements over the original model. We strongly recommend continued use of the standard TIMES tool.

References:

Schultz GS, Sibbald RG, Falanga V, Ayello EA, Dowsett C, Harding K, Romanelli M, Stacey MC, Teot L, Vanscheidt W.
"Wound bed preparation: a systematic approach to wound management."
Wound Repair and Regeneration. 2003;11 Suppl 1:S1–S28.

Leaper DJ, Schultz G, Carville K, Fletcher J, Swanson T, Drake R.
"Extending the TIME concept: what have we learned in the past 10 years?"
International Wound Journal. 2012;9(Suppl 2):1–19.