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Provide Organizational Support

Multi-disciplinary Team Referral Checklist

Multi-disciplinary referrals are needed for adjunctive therapy. Please note that these are suggestions based on the available evidence-based literature and the interpretation and availability of these services will depend on individual agency policy.

Checklist coming soon1

Client/Patient Teaching and Learning Resources

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 are at risk of or have developed a Pressure Ulcer are being discharged or transferred to a different care setting:

  • Current Pressure Ulcer Risk Score and Sub-scale scores
  • Current blood work results
  • Vascular study results (if lower leg ulcer)
  • History of pressure ulcer occurrence
  • Current and past treatment regimes
  • Any surgical interventions?
  • Pressure redistribution surfaces in use
  • Any turning schedule established by OT/PT

Pressure Ulcer Interventions Algorithm

Pressure ulcer interventions algorithm

OACCAC Pressure Ulcer Outcome-Based Pathway (OBP) Outcomes

Aligning with the Ministry of Health and Long Term Care’s Ontario’s Action Plan for Health Care (2012), the Ontario Association of Community Care Access Centres’ (OACCACs’) evidence-based Outcome-Based Pathways were created to act as outcome management tools to help effect outcome-based reimbursement and continue to improve value and quality of care for Ontarians served by CCACs. Click here to download the OACCAC Pressure Ulcer Outcome-Based Pathway as a PDF. An in-depth analysis of the implementation of OBP from the proof-of-concept sites continues at this time, and the decision about the timing of a provincial roll-out is still to be determined. In preparation for this “Go-Live” event, we have reviewed our document to ensure that by implementing the synthesized evidence-based or “best” practices contained therein, service providers in the community sector have the resources to help them meet the set of reportable outcomes that will be required.

The following intervals are from the October 2013 release:

Interval 1 (7 days)

  • Length_______ x Width______ x Depth______ cm
  • Holistic client and wound assessment completed
  • Correct outcome-based pathway confirmed
  • Pressure redistribution measures initiated
  • Wound therapy initiated
  • D/C planning initiated for client independence & prevention

Interval 2 (28 days)

  • Length_______ x Width______ x Depth______ cm
    (should be 20-30% reduction)
  • Chronic disease self-management plan initiated

Interval 3 (84 days)

  • Length_______ x Width______ x Depth______ cm
    (should be 70-80% healed)

Interval 4 (126 days)

  • Length_______ x Width______ x Depth______ cm
    (should be healed: 0 x 0 x 0)

Day X = 189 days (if client not healed at Interval 3)

  • Length_______ x Width______ x Depth______ cm

  1. Registered Nurses’ Association of Ontario (2005). Risk assessment and prevention of pressure ulcers. (Revised). Toronto, Canada: Registered Nurses’ Association of Ontario. Updated 2011.

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