Diabetic Foot Ulcer Outcome-Based Pathway
Pathway Identification
Pathway Name
Presenting Issue or
Condition Defined
Exclusion Criteria
Overall Pathway Outcome
Reason for Stoppage
Diabetic Foot Ulcer
Diabetic foot ulceration is a full-thickness penetration of the dermis of the foot in
1
a person with diabetes. Ulceration is a complication of either Type I or Type II
diabetes which can cause neuropathy resulting in sensory loss of protective
sensation, skin changes, foot deformity, and limited joint mobility. As a result,
2
pressure from footwear, cuts, bruises or other injury may go unnoticed. Risk
for ulceration is exacerbated by peripheral arterial disease, poor glucose control,
3
obesity, self-care deficit and improper footwear.
o Acute Charcot foot
o Gangrene (tissue ischemia)
4
o Known osteomyelitis or upon initial assessment, ability to probe to bone
o Intact skin (without visible injury or opening e.g. cellulitis)
o Wound closed
o Wound Closed
o Acute Charcot Foot
o Osteomyelitis
o Supervening event:
o Transfer to other CCAC
o Admission to hospital >14 days
o Admission to a LTCH
o Death
o Vacation away from home >14 days
o Patient refuses care
o Moved to a different pathway
o List reason:
o New pathway:
o Other:
1
Hunt D. Diabetes: foot ulcers and amputations. BMJ Clinical Evidence 2011;08:602. 1.
http://clinicalevidence.bmj.com/x/pdf/clinical-evidence/en-gb/systematic-review/0602.pdf
2
DermNet NZ. http://dermnetnz.org/systemic/diabetic-foot.html
3
Adapted from Registered Nurses’ Association of Ontario, Assessment and Management of Foot Ulcers for People
with Diabetes (RNAO Nursing Best Practice Guideline, Mar 2005) 19. http://rnao.ca/sites/rnaoca/files/Assessment_and_Management_of_Foot_Ulcers_for_People_with_Diabetes.pdf
4
Registered Nurses’ Association of Ontario, Assessment and Management of Foot Ulcers for People with Diabetes
(RNAO Nursing Best Practice Guideline, Mar 2005) 27. http://rnao.ca/sites/rnaoca/files/Assessment_and_Management_of_Foot_Ulcers_for_People_with_Diabetes.pdf
1v5 – 20130925
© Community Care Access Centre/Centre d’accès aux soins communautaires and Ontario Association of Community Care Access
Centres/Association des Centres d’accès aux soins communautaires de l’Ontario, 2013. All rights reserved. Unauthorized
distribution and duplication strictly prohibited.
Page 1 of 6
Diabetic Foot Ulcer Outcome-Based Pathway
Pathway Evaluation
Date Created
Date Reviewed
(Subject Matter Experts)
Subject Matter Experts
December 7, 2011
January 10, 2012 – February 21, 2012
o
o
o
o
o
o
o
o
o
o
Date of Endorsement by
Provincial Patient Services
Committee
Frequency of Review
Next Review Date
What triggers a special
condition review of
pathway
Ontario Home Care Association & Ontario Community Support Association
(OHCA-OCSA), Nursing Practice Council (NPC)
OHCA-OCSA, Therapy Advisory Group (TAG)
Catherine Harley, Canadian Association of Enterostomal Therapy (CAET)
Executive Director
Dr. Gary Sibbald, Women’s College Hospital (WCH), Director of Wound
Healing Clinic, Director of Medical Education
Dr. Kevin Woo, Advanced Wound Consultant, West Park Health Centre
Heather McConnell, Registered Nurses Association of Ontario (RNAO),
International Affairs & Best Practice Guidelines (IABPG) Associate Director
Mariam Botros, WCH, Chiropody
Patricia Coutts, WCH, Wound Healing Centre
Peggy Ahearn, Canadian Association of Wound Care (CAWC), Executive
Director
Rhona McGlasson, Sunnybrook Health Sciences Centre, Executive Director
June 29, 2012
TBD based on RNAO and CAWC guidelines
May 2014
o Criteria for special condition review will be determined based upon results
obtained from the OBP/OBR pilot.
1v5 – 20130925
© Community Care Access Centre/Centre d’accès aux soins communautaires and Ontario Association of Community Care Access
Centres/Association des Centres d’accès aux soins communautaires de l’Ontario, 2013. All rights reserved. Unauthorized
distribution and duplication strictly prohibited.
Page 2 of 6
Diabetic Foot Ulcer Outcome-Based Pathway
Best Practice
Guideline
Interval
Outcome
o
0 to 7 Days
RNAO BPG Foot Ulcer
for People with
Diabetes
Holistic patient
and wound
assessment
completed
Outcome
Evaluation
Reporting
o
SPO
o
Outcome
not met
Barriers to Outcome
Achievement
o
o
o
o
CAWC BPG Diabetic
Foot Ulcer
Lower limb
assessment
completed
o
SPO
o
Outcome
not met
o
o
o
o
CAWC 60s Screening
Tool
Correct outcomebased pathway
confirmed
o
SPO
o
Outcome
not met
o
o
o
o
o
Pressure
redistribution
measures initiated
o
SPO
o
Outcome
not met
o
o
o
Follow up Actions
Resource barriers
o Patient
o SPO
o CCAC
o System
Patient declined
Other:
o
Resource barriers
o Patient
o SPO
o CCAC
o System
Patient declined
Other:
Inaccurate diagnosis on
referral
Incomplete SPO report
Unknown etiology
Other:
o
Resource barriers
o Patient
o SPO
o CCAC
o System
Patient declined
Other:
o
o
o
o
o
o
o
o
o
o
o
o
CC system navigation to
address resource
barriers
Contact patient /
caregiver re: rationale
Other:
CC system navigation to
address resource
barriers
Contact patient /
caregiver re: rationale
Other:
Follow-up with SPO for
report completion
Discontinue pathway
Other:
Inter-professional
referrals (e.g. OT,
Chiropodist, foot care)
based on offloading
needs
CC system navigation to
address resource
barriers
Contact patient /
caregiver re: rationale
Other:
1v5 – 20130913
© Community Care Access Centre/Centre d’accès aux soins communautaires and Ontario Association of Community Care Access Centres/Association des Centres d’accès aux soins
communautaires de l’Ontario, 2013. All rights reserved. Unauthorized distribution and duplication strictly prohibited.
Page 3 of 6
Diabetic Foot Ulcer Outcome-Based Pathway
Best Practice
Guideline
Interval
Outcome
o
0 to 7 Days
Wound therapy
initiated
Outcome
Evaluation
Reporting
o
SPO
o
Outcome
not met
Barriers to Outcome
Achievement
o
o
o
o
Patient contraindication
Resource barriers
o Patient
o SPO
o CCAC
o System
Patient declined
Other:
Follow up Actions
o
o
o
o
Inter-professional
referrals to address
contraindications
CC system navigation to
address resource
barriers
Contact patient /
caregiver re: rationale
Other:
o
o
Patient discharge
planning initiated
for patient
independence and
prevention
SPO
o
Outcome
not met
o
o
o
Non-adherence to BPG
o Patient
o SPO
o CCAC
Patient declined
Other:
o
o
o
o
o
21 to 28 days
o
RNAO BPG Foot Ulcer
for People with
Diabetes
20-30% reduction
in wound size
o
SPO
o
Outcome
not met
o
o
o
Causative factors
o Internal
o External
Non-adherence to BPG
o Patient
o SPO
o CCAC
Other:
CAWC BPG Diabetic
Foot Ulcer
o
o
o
o
o
Consult with SPO / ET /
Wound Care Specialist
Inter-professional
referrals as required
CC system navigation
as required
Contact
patient/caregiver re:
rationale
Other:
Consult with SPO ET /
Wound Care Specialist
and review / update
care plan as required
Validate use of BPG
Inter-professional
referrals as required
Consider transfer to
another pathway
Other:
1v5 – 20130913
© Community Care Access Centre/Centre d’accès aux soins communautaires and Ontario Association of Community Care Access Centres/Association des Centres d’accès aux soins
communautaires de l’Ontario, 2013. All rights reserved. Unauthorized distribution and duplication strictly prohibited.
Page 4 of 6
Diabetic Foot Ulcer Outcome-Based Pathway
Best Practice
Guideline
Interval
Outcome
o
21 to 28 days
CAWC 60s Screening
Tool
Chronic disease
self-management
plan initiated
Outcome
Evaluation
Reporting
o
SPO
o
Outcome
not met
Barriers to Outcome
Achievement
o
o
o
o
o
Stanford SelfManagement
Program
o
Referral initiated
for long-term
pressure
redistribution
system
o
SPO
o
Outcome
not met
o
o
o
o
Follow up Actions
Non-adherence to BPG
o Patient
o SPO
o CCAC
Patient / caregiver
appropriateness for selfmanagement
Already linked with
resource
Patient declined
Other:
o
o
o
Patient readiness for
long-term pressure
redistribution system
o Psychological
o Physiological
Prescription not
obtained
Resource barriers
o Patient
o SPO
o CCAC
o System
Other:
o
o
o
o
o
o
o
o
Validate use of BPG
Consult with SPO
Inter-professional
referrals as required
CC system navigation
as required
Contact patient /
caregiver re: rationale
Other:
Psychological readiness
- Contact
patient/caregiver
Physiological readiness
– re-evaluate in
consultation with SPO /
Consult with SPO
ET/Wound Care
Specialist
Consult with SPO
and/or physician
CC system navigation
as required
Other:
1v5 – 20130913
© Community Care Access Centre/Centre d’accès aux soins communautaires and Ontario Association of Community Care Access Centres/Association des Centres d’accès aux soins
communautaires de l’Ontario, 2013. All rights reserved. Unauthorized distribution and duplication strictly prohibited.
Page 5 of 6
Diabetic Foot Ulcer Outcome-Based Pathway
Best Practice
Guideline
Interval
77 to 84 days
Or upon
discharge
Outcome
o
Wound is closed
by 12 weeks
Outcome
Evaluation
Reporting
o
SPO
o
Outcome
not met
Barriers to Outcome
Achievement
o
o
RNAO BPG Foot Ulcer
for People with
Diabetes
o
Causative factors
o Internal
o External
Non-adherence to BPG
o Patient
o SPO
o CCAC
Other:
o
o
o
o
o
CAWC BPG Diabetic
Foot Ulcer
CAWC 60s Screening
Tool
Follow up Actions
o
Patient has
obtained and is
adhering to
pressure
redistribution
system
o
SPO
o
Outcome
not met
o
o
o
Patient/caregiver
capacity
Resource barriers
o Patient
o SPO
o CCAC
o System
Other:
o
o
o
o
Consult with SPO / ET /
Wound Care Specialist
and review / update
care as required
Validate use of BPG
Inter-professional
referrals as required
Consider transfer to
another pathway
Other:
CC system navigation
as required
Contact
patient/caregiver
Inter-professional
referrals as required
Other:
1v5 – 20130913
© Community Care Access Centre/Centre d’accès aux soins communautaires and Ontario Association of Community Care Access Centres/Association des Centres d’accès aux soins
communautaires de l’Ontario, 2013. All rights reserved. Unauthorized distribution and duplication strictly prohibited.
Page 6 of 6