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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.

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.


For people with diabetes, regular assessment is important for determining their risk of developing a diabetic foot ulcer. Risk factors for diabetic foot ulcers include peripheral neuropathy, foot abnormalities and deformities, peripheral arterial disease, and previous ulcers or amputations.

People with an active diabetic foot ulcer should be referred to and treated immediately by health care professionals who provide specialized care (see Quality Statement 3).

For Patients

You should be assessed for your risk of developing a foot ulcer when you are diagnosed with diabetes and at least once a year after that.


For Clinicians

Assess every person with diabetes for their risk of developing a diabetic foot ulcer using a standard, validated tool. People should be assessed when they are diagnosed with diabetes and at least once a year thereafter to determine if their risk level has changed. If they have risk factors for diabetic foot ulcers, they should be reassessed more frequently.


For Health Services

Ensure that health care professionals have access to standard, validated risk-assessment tools and are knowledgeable about the frequency of diabetic foot ulcer risk assessment.

Process Indicator

Percentage of people with diabetes who have had a diabetic foot ulcer risk assessment using a standard, validated tool in the previous 12 months

  • Denominator: number of people with diabetes

  • Numerator: number of people in the denominator who have had a diabetic foot ulcer risk assessment using a standard, validated tool in the previous 12 months

  • Data source: local data collection

  • Potential stratification: risk level

Frequency of risk assessment

Assessments should be completed at least once a year but more frequently for people at higher risk: every 6 months for people with peripheral neuropathy; every 3 to 6 months for people with peripheral neuropathy plus peripheral arterial disease and/or a foot deformity; and every 1 to 3 months for people with peripheral neuropathy and a history of foot ulcers or lower-extremity amputation.


Standard validated tools

These should address the following components, at a minimum:

  • Examination of both legs and feet (including the spaces between the toes) for evidence of:

    • Neuropathy (e.g., using a 10 g monofilament)

    • Ulceration

    • Callus

    • Skin temperature (a difference of 2°C or 3–4°F between the two feet could indicate infection, issues with vascular supply, or deep trauma)

    • Structural abnormalities and deformities

    • Charcot arthropathy

    • Swelling of the calf, thigh, or ankles

    • Skin colour changes

    • Skin and nail changes

    • Range of motion, gait, and footwear

    • Palpation of foot pulses (top of foot and inner ankle)

  • Asking about previous foot ulcers and amputations

  • Ankle-brachial pressure index or toe-brachial pressure index at regular intervals to screen for peripheral arterial disease (calcified arteries may falsely elevate results in people with diabetes, so results should be interpreted carefully)

One example of a standard validated tool is Inlow’s 60-second Diabetic Foot Screen Tool.

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