RESIZE TEXT: Small Font Size Regular Font Size Large Font Size

Provide Organizational Support


Multi-disciplinary Team Intervention Referral Criteria Checklist

 
Identify multi-disciplinary team referrals that need to be arranged
  • Primary Care Physician
  • Advanced Wound Specialist
  • Nurse Practitioner
  • Infectious Disease Specialist
  • Vascular Surgeon
  • Dermatologist
  • Plastic surgeon
  • Internist/Endocrinologist
  • Mental Health Specialist
  • Psychologists
  • Social Work
  • Registered Dietitian
  • Pharmacist
  • Occupational Therapist
  • Physiotherapy
  • Chiropodist
  • Certified Pedorothist
  • Certified Orthotists
  • Certified Prosthetist
  • Podiatrist
  • Lymphatic Massage
  • Compression Stocking Fitter


iFUN Criteria guidelines for referral to an advanced wound specialist
i Intervention If an intervention is required (i.e. ABPI, toe pressures, debridement)
F Frequency If the frequency of dressing changes is not less than 3 x a week within 4 weeks of treatment
U Unknown If the cause of the wound or the cause of the failure to heal is unknown
N Number If the size of the wound has not decreased by 20-30% in 3-4 weeks of treatment
 

Table 11 - Professional Referral Suggestion Chart1 2

Criteria Suggestions for Referral
Presence of fixed ankle joint or impaired calf muscle pump in the presence of edema Refer to physiotherapy for ankle/calf-muscle pump training and controlled exercise.
 

RNAO Evidence Level:

Level A
If ulcer >5cm² &/or >6 months duration on admission, or not healed (100%) at 3 months. Refer to physiotherapy or other qualified health professional for therapeutic ultrasound (TU) or electrical stimulation therapy (EST).
 

RNAO Evidence Levels:

LevelsA,B
Presence of a mixed venous arterial leg ulcer with moderate to severe neuropathic pain. Refer to family physician, vascular physician or pharmacist as needed
 

RNAO Evidence Level:

Level C
If patient cannot “doff and don” compression stockings independently, and no family members are able to do so. Refer to OT for adaptive devices, Professional Compression Fitters or for PSW to assist with this ADL.
   

RNAO Evidence Level:

Level A
Medical management may include appropriate systemic antibiotic therapy for patients with bacteremia, sepsis, advancing cellulitis or osteomyelitis. Refer to family physician or Infectious Diseases Specialist for antibiotic treatment.
 

RNAO Evidence Level:

Level C
Prevent or manage pain associated with debridement. Refer to family physician or pharmacist as needed.
 

RNAO Evidence Level:

Level C
For debridement when the need is urgent (such as with advancing cellulitis or sepsis, increased pain, exudates and odour) or beyond the scope of practice/competency of the primary care providers. Refer to Wound Care Physician/Surgeon.
 

RNAO Evidence Level:

Level C
Mini Nutritional Assessment (MNA) < 24
Unable to afford or have access to nutritional food
Refer to Registered Dietitian
Refer to Social Work
 

RNAO Evidence Level:

Level B
Contact dermatitis due to suspected sensitivity to allergens Refer to dermatologist for patch testing
 

RNAO Evidence Level:

Level B
   

Patient, Caregiver and Healthcare Provider Teaching and Learning Resource

 

Discharge or Transfer Planning and Communications

Regardless of the method of providing the information (e.g. Care Connect, photocopy or Discharge Summary), it is agreed that the following information is critical in providing seamless care when individuals who have venous leg ulcers are being discharged or transferred to a different care setting:

  • Current blood work results
  • Vascular study results
  • Current and past treatment regimes
  • Any surgical interventions?
 

Waterloo Wellington Integrated Wound Care Program Evidence-Based Wound Care Venous and Mixed Venous/Arterial Clinical Pathway

 
  1. Adapted from South West Regional Wound Care Program 2014
  2. Waterloo Wellington Integrated Wound Care Program Evidence-Based Wound Care Venous and Mixed Venous/Arterial Leg Ulcers Clinical Pathway 2015

We value your feedback, and would appreciate if you took a few moments to respond to some questions.


Yes No Maybe Later