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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 Chart?? 1 ?? ?? 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 spinal cord stimulation or Intermittent Pneumatic Leg Compression3
Patient requiring assistance to quit smoking Refer patient to smoking cessation program, pharmacist, social worker, physician and/or counsellor
 

RNAO Evidence Level:

Level A (Smoking Cessation)
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 Refer to family physician, pain and symptom management team or pharmacist as needed
 

RNAO Evidence Level:

Level C
Patient is not a surgical candidate or wound does not heal despite revascularization surgery Refer to Hyperbaric Oxygen Therapist4
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
Mobility Issues Refer to physiotherapy or occupational therapist for mobility or gait aids
 

RNAO Evidence Level:

Level B
Need for spinal stimulation Refer to physiotherapy for this adjunctive therapy5
Unable to complete lower leg assessment and/or ABPI Refer to wound care specialist, trained nurse or vascular lab
 

RNAO Evidence Level:

Level B
ABPI 0.5 to 0.8
TBPI 0.64 to 0.7
Suggest Transcutaneous Oxygen Pressure(TcPO&sub2;), Laser Doppler Flowmetry, Doppler Arterial Waveforms or Segmental Doppler Pressure studies be performed and vascular surgeon consult obtained
 

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 arterial leg ulcers are being discharged or transferred to a different care setting:

  • Lower leg assessment
  • Need to reassess ABPI/TBPI in 6 months
  • Recent vascular study results (eg. ABPI, TPBI, Transcutaneous Oxygen Pressure(TcPO2), Laser Doppler Flowmetry, Doppler Arterial Waveforms or Segmental Doppler Pressure studies)
  • Relevant consultation notes
  • Diagnostic results
  • Current treatment plan
 

Waterloo Wellington Integrated Wound Care Program Evidence-Based Wound Care Arterial Clinical Pathway

 
 
  1. ?
  2. ?
  3. Weir G.R, Hiske S, Marle J.V, Cronje F.J, Sibbald R.G. Arterial Disease Ulcers, Part 2: Treatment. Advances in Skin and Wound Care: September 2014.
  4. Kranke P, Bennett M.H, Martyn-St James M, Schnabel A, Debus S.E. Hyperbaric Oxygen Therapy for Chronic Wounds. Cochrane Database Syst Review 2012;(4):CD004123.
  5. Weir G.R, Hiske S, Marle J.V, Cronje F.J, Sibbald R.G. Arterial Disease Ulcers, Part 2: Treatment. Advances in Skin and Wound Care: September 2014.

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