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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.

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.


A comprehensive assessment helps identify causative and contributing factors, supports accurate diagnosis, and informs treatment and management. The results of the assessment help to determine the healability of the ulcer (ulcers may be classified as healable, maintenance, or non-healable) and inform a corresponding approach to optimal wound care and management. Healable wounds have adequate blood supply and can be healed if the underlying cause is addressed and treated. Maintenance wounds have healing potential, but barriers are present that may prevent healing (such as lack of access to appropriate treatments or poor adherence to treatment). Non-healable wounds are not likely to heal because of non-treatable causes or illnesses. The characteristics, dimensions, and healing trajectory of the ulcer should be documented at each visit. Comprehensive assessment also provides an opportunity to determine risk factors for recurrence, which is important for diabetic foot ulcers, given their high rate of recurrence. Depending on the care setting, the components of the assessment may be carried out by multiple members of an interprofessional team.

For Patients

If you have a diabetic foot ulcer or other foot problem, you should have a full assessment. Your health care team will want to learn more about your health history, concerns, and preferences. They will also examine your legs and feet, including any wounds you have.


For Clinicians

Carry out a comprehensive assessment (including evaluation of vascular status, infection status, and pressure redistribution) of people with a diabetic foot ulcer or foot complications to determine the healing potential of the wound. The results should inform their individualized care plan.


For Health Services

Ensure that tools, systems, processes, and resources are in place to help clinicians assess people with a diabetic foot ulcer or foot complications. This includes providing the time required for a full assessment and ensuring access to assessment tools.

Process Indicators

Percentage of people with a diabetic foot ulcer or foot complications who have a comprehensive assessment at first presentation that informs their individualized care plan

  • Denominator: number of people with a diabetic foot ulcer or foot complications

  • Numerator: number of people in the denominator who have a comprehensive assessment at first presentation that informs their individualized care plan

  • Data source: local data collection


Percentage of people with a diabetic foot ulcer or foot complications who have a comprehensive assessment at each transition that informs their individualized care plan

  • Denominator: number of people with a diabetic foot ulcer or foot complications

  • Numerator: number of people in the denominator who have a comprehensive assessment at each transition that informs their individualized care plan

  • Data source: local data collection


Percentage of diabetic foot assessments that include evaluation of vascular status

  • Denominator: number of diabetic foot assessments

  • Numerator: number of assessments in the denominator that include evaluation of vascular status

  • Data source: local data collection


Percentage of diabetic foot assessments that include evaluation for the presence of infection

  • Denominator: number of diabetic foot assessments

  • Numerator: number of assessments in the denominator that include evaluation for the presence of infection

  • Data source: local data collection


Percentage of diabetic foot assessments that include evaluation for pressure redistribution

  • Denominator: number of diabetic foot assessments

  • Numerator: number of assessments in the denominator that include evaluation for pressure redistribution

  • Data source: local data collection

Foot complications

These include factors that may lead to soft-tissue breakdown and ulceration, such as dry skin, callus, blister, deformities, minor fractures, and subacute Charcot arthropathy.


Comprehensive assessment

This includes the following components, at a minimum:

  • A comprehensive health history, including medical history, diabetes management and glycemic control (hemoglobin A1c), nutritional status, smoking status, allergies, medications, family history, and psychosocial history (including socioeconomic factors)
  • A physical examination of the affected limb(s), including an assessment of:
    • Vascular status
    • Motion and functioning
    • Neuropathy
    • Signs and symptoms of infection
    • Charcot changes and foot deformities
    • Pressure and ability to offload or redistribute pressure, including an examination of footwear
    • Foot and ankle anatomy and assessment of the weight-bearing foot and gait
    • Swelling (thigh, calf, and ankle)
    • Muscle pain (during exercise)
    • Palpation of foot pulses (top of foot and inner ankle)
    • Colour changes
  • Wound assessment:
    • Length, width, depth, and location
    • Presence and severity of pain
    • Exudate, odour, and condition of the tissue in the wound bed and around the wound
  • Grading and documenting the severity of the wound using a standardized system such as SINBAD (site, ischemia, neuropathy, bacterial infection, area, and depth) or the University of Texas classification system
  • Factors that may impact wound healing and activities of daily living
  • Individual concerns and preferences

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