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Evidence to Improve Care

Diabetic Foot Ulcers

Care for Patients in All Settings

Click below to see a list of brief quality statements and scroll down for more information.​​


Quality standards are sets of concise statements designed to help health care professionals easily and quickly know what care to provide, based on the best evidence.

See below for the quality statements and click for more detail.​


Quality Statement 1: Risk Assessment
People with diabetes are assessed for their risk of developing a diabetic foot ulcer when they are diagnosed with diabetes and at least once a year thereafter. Patients at higher risk are assessed more frequently. All risk assessments are performed using standard, validated tools.


Quality Statement 2: Patient Education and Self-Management
People with diabetes and their families or caregivers are offered education about diabetic foot care and complications, including basic foot care; how to prevent foot complications and monitor for the signs and symptoms of foot complications; and who to contact in the event of a concerning change.


Quality Statement 3: Referral to an Interprofessional Team
le with a diabetic foot ulcer are referred to an interprofessional team that delivers ongoing, coordinated, integrated care. If they have major complications, they are seen within 24 hours by a team that delivers emergency services and then referred to an interprofessional team for ongoing care.


Quality Statement 4: Comprehensive Assessment
People with a diabetic foot ulcer or foot complications undergo a comprehensive assessment that informs their individualized care plan and includes evaluation of vascular status, the presence of infection, and pressure redistribution to determine the healing potential of the wound.


Quality Statement 5: Individualized Care Plan
People with a diabetic foot ulcer or foot complications have a mutually agreed-upon individualized care plan that identifies patient-centred concerns and is reviewed and updated regularly.


Quality Statement 6: Pressure Redistribution
People with a diabetic foot ulcer or foot complications are offered pressure-redistribution devices as part of their individualized care plan.


Quality Statement 7: Wound Debridement
People with a diabetic foot ulcer have their wound debrided if it is determined as necessary in their assessment, and if it is not contraindicated. Debridement is carried out by a trained health care professional using an appropriate method.


Quality Statement 8: Local Infection Management
People with a diabetic foot ulcer and a local infection receive appropriate treatment, including antimicrobial and non-antimicrobial interventions.


Quality Statement 9: Deep/Surrounding Tissue Infection or Systemic Infection Management
People with a diabetic foot ulcer and a suspected deep/surrounding tissue infection or systemic infection receive urgent assessment (within 24 hours of initiation of care) and systemic antimicrobial treatment.


Quality Statement 10: Wound Moisture Management
People with a diabetic foot ulcer receive wound care that maintains the appropriate moisture balance or moisture reduction in the wound bed.


Quality Statement 11: Health Care Provider Training and Education
People who have developed or are at risk of developing a diabetic foot ulcer or foot complications receive care from health care providers with training and education in the assessment and management of diabetic foot ulcers and foot complications.


Quality Statement 12: Transitions in Care
People with a diabetic foot ulcer or foot complications who transition between care settings have a team or provider who is accountable for coordination and communication to ensure the effective transfer of information related to their care.

Summary

This quality standard focuses on care for people who have developed or are at risk of developing a diabetic foot ulcer. The scope of the standard covers all settings, including primary care, home and community care, long-term care, and acute care. It also provides guidance on optimal care when a person transitions between these settings—for example, when someone is discharged from a hospital to their home or a long-term care home.


Diabetes is one of the most prevalent chronic diseases, with about 1 in 10 people in Ontario currently affected. Diabetic foot ulcers are a serious and common complication of diabetes; 15% to 25% of people with diabetes will develop a diabetic foot ulcer during their lifetime. People with diabetic foot ulcers report poor overall health-related quality of life, particularly in terms of pain, discomfort, and loss of mobility. Diabetic foot ulcers are the cause of about a third of all nontraumatic below-the-knee amputations in Canada. For people with a diabetic foot ulcer and peripheral arterial disease, the probability of death after a major amputation is approximately 50% within 2 years.

Wound care represents a significant area of opportunity for quality improvement in Ontario.There are important gaps and variations in access to services and in the quality of care received by people who have developed or are at risk of developing a diabetic foot ulcer. In 2014, the amputation rate in the local health integration network (LHIN) with the highest rate was almost eight times that of the LHIN with the lowest rate (Discharge Abstract Database, IntelliHEALTH, 2016). Previous efforts to improve the coordination and delivery of wound care across the province have highlighted the inconsistent application of best practice guidelines, a lack of standardized documentation and tracking of wound outcome measures, and poor coordination of care.

Based on the best available evidence and guided by expert consensus from health care professionals and people with lived experience, this quality standard addresses key areas with significant potential for quality improvement in the care of people who have developed or are at risk of developing a diabetic foot ulcer in Ontario. The 12 quality statements that make up this standard provide guidance on high-quality care, with accompanying indicators to help health care professionals and organizations measure their own quality of care. Each statement also includes details on how it affects people who have developed or are at risk of developing a diabetic foot ulcer, their caregivers, health care professionals, and health care services at large.

Note: in this quality standard, the term patient includes community care clients and residents of long-term care homes.

This quality standard is underpinned by the principles of respect and equity.

People who have developed or are at risk of developing a diabetic foot ulcer should receive services that are respectful of their rights and dignity and that promote self- determination.

A high-quality health system is one that provides good access, experience, and outcomes for all Ontarians, no matter where they live, what they have, or who they are.

People who have developed or are at risk of developing a diabetic foot ulcer are provided services that are respectful of their gender, sexual orientation, socioeconomic status, housing, age, background (including self-identified cultural, ethnic, and religious background), and disability.

We have set a limited number of objectives for this quality standard as a whole, and we have mapped these objectives to indicators to measure success. In addition, each quality statement within this quality standard is accompanied by one or more indicators to measure the successful implementation of the statement.

  • Percentage of patients with a new diabetic foot ulcer in a 6-month period (incidence)

  • Percentage of patients with a diabetic foot ulcer in a 6-month period (prevalence)

  • Percentage of patients with a closed diabetic foot ulcer in a 12-week period

  • Percentage of patients with a healed diabetic foot ulcer who were diagnosed with a secondary diabetic foot ulcer within 1 year (recurrence)

  • Percentage of patients with a diabetic foot ulcer who had a lower-extremity amputation in a 6-month period

  • Percentage of patients with a diabetic foot ulcer in a 12-month period who reported high satisfaction with the care provided

My mom had a foot ulcer for years before her foot had to be amputated. Although the care she needed was accessible to us, not all the professionals who provided care were knowledgeable enough to decide on the best course of action. In general, I never felt the care my mother received was patient-centered, particularly in terms of communication and respect. Our biggest barrier was not knowing why she was receiving the treatments she was given, why the treatments were not working the way they should, or what the next steps should be. After she had the amputation, I felt we had more questions than answers. And that is why I think the Quality Standards are so important.

I am very happy with the Wound Care Quality Standards. Overall, I see the quality statements as the pieces of a puzzle, allowing health care professionals to provide consistent care to patients. The standards will help patients to become more educated on issues that may affect them and to ask providers the right questions. For example, in the case of my mom, when I read the statement about individualized care plan, I thought oh my goodness, if I had known this before, things might have been different. To me, it is great that patients and caregivers will have the opportunity to be involved in their care plans and management of their wounds.

Linda O’Rourke, Wound Care Quality Standard Advisory Panel Member

Throughout my career I have worked in different sectors of the health care system, and in all of them I have seen patients suffering from chronic wounds. I think wound care needs to come up in everyone’s radar because of how troubling wounds are, how frequently they happen in the general population and how much they cost the health care system.

For organizations, I hope the Quality Standards will be the go-to document and main reference for wound care in Ontario. When you look around, there are many practice guidelines and clinical protocols for wound care. But Health Quality Ontario’s Wound Care Quality Standards are different because they clearly state how we want wound care to be delivered in Ontario. I also hope the quality standards will increase public awareness and help people become more educated and informed on what they should expect when it comes to standard of care for wounds. One other thing I like about the quality standards is that all the statements follow the same pattern as they have the same headings. We know that wound management may be different but the determination of cause, effect and assessment is standard. I think the three quality standards for wound care capture them very nicely.

Valerie Winberg, Wound Care Quality Standard Advisory Panel Member

This quality standard was completed in December 2017.

For more information, contact QualityStandards@HQOntario.ca.

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