Outcome-Based Pathways WOUND CARE

Outcome-Based Pathways WOUND CARE Overview, Guidelines and Glossary

Table of Contents Overview... 2 Outcome-Based Pathway Structure... 3 Guidelines for Use... 5 Outcome Terminology... 8 Pathway Stoppage Terminology... 12 Overall Pathway Outcome Terminology... 14 Exclusion Criteria Terminology... 16 Barriers to Outcome Achievement Terminology... 18 References... 21 1

Overview A series of 10 Outcome-Based Pathways have been created by a panel of CCAC wound care experts and reviewed by a panel of external subject matter experts for ten provincially-defined wound types: arterial leg ulcer; diabetic foot ulcer; maintenance wound; non-healing wound; malignant wound; pressure ulcer; pilonidal sinus; surgical wound; traumatic wound; and, venous leg ulcer. These pathways have been created in an effort to ensure: Clinical best practices are applied in the provision of wound care services in order to achieve optimal patient outcomes; Standardized reporting and outcome measurements, based in best practice, are applied provincially to evaluate sector performance in the provision of wound care services; A consistent patient experience across the province when receiving CCAC services for wound care; Provider autonomy and flexibility as the clinical expert in providing wound care treatments; A mechanism exists for CCACs to manage the progress of patients receiving wound care services which provides a framework for Care Coordinators to intervene when a patient s care trajectory is not meeting the anticipated outcomes. As implied above, the Outcome-Based Pathways are intended to be used by Care Coordinators (CC) to manage patient outcomes in conjunction with service provider staff (SPO) using clinical pathways to manage treatment goals. This distinction between the two types of pathways is further articulated in the table below: Outcome-Based Pathway (CC) Focus is on outcomes Identifies indicators to measure outcomes Case management interventions detailed Less time-specific/ sensitive activities Clinical Pathway (SPO) Focus is on clinical goals Identifies clinical tools to measure progress Clinical interventions are detailed Tends to outline multiple time-specific sequences of activities CCAC Outcome-Based Pathway content has been developed based upon best for now available evidence. 2

Outcome-Based Pathway Structure The Outcome-Based Pathways are structured in 7 sections intended to provide Care Coordinators with a framework to identify and manage patient outcomes for a particular condition/presenting problem and assist them in identifying follow-up actions or plans to address variances if they occur. Each section is described in further detail below: Interval o o Refers to key time intervals in the overall care trajectory of patients admitted with a defined condition/presenting problem. Intervals may be defined using different parameters depending upon the patient s condition/presenting problem. In the case of wound care, intervals are defined as being a period of days. Best Practice Guidelines o Hyperlinks to relevant best practice guidelines or recommendations from authoritative bodies (i.e., Registered Nurses Association of Ontario, Canadian Association of Wound Care, etc.) outlining the evidenced-based principles of care to be used and that have informed the development of the care pathway, including the identified intervals, outcomes and overall goals. The links to the best practice guidelines are intended to be used collaboratively by the Care Coordinator and SPO Clinician in the case of a variance or missed outcome to help identify possible remedial actions and the most responsible party to undertake the task. o Hyperlinks to relevant local resources (i.e., chronic disease self-management resources, etc.) or CCAC policies which support the provision of best practice patient care. Outcome o Identifies the outcomes - founded in best practices and considered to be critical to the overall pathway goals and a positive patient experience of care which are expected to be met at each interval of the care pathway by the Service Provider Organization (SPO). o Outcomes captured in the pathways are intended to identify, at a high level, key practices or outcomes, based in best practices, to be achieved by SPOs without being prescriptive as to the specific tools or processes to be utilized and to provide flexibility to SPOs as the clinical experts. o The outcomes are a combination of processes (i.e., referral initiated for long-term compression system) and clinical goals (i.e., 20 30% reduction in wound size). Reporting 3

Identifies who is responsible for the outcome report. Within the Wound Care OBPs this will be the SPO. Electronic interval reporting must occur in accordance to intervals identified on the relevant Outcome-Based Pathway. In instances where patients achieve the desired outcomes sooner than anticipated in the typical care trajectory, electronic interval reporting is available to be completed at that time. Outcome Evaluation o Identifies variances or alternative states in the event an outcome is not achieved: Outcome Not Met o A variance is a difference between what is expected and what actually occurs. i o Unmet outcomes will usually require follow-up by the Care Coordinator. Barriers to Outcome Achievement o Contributing factors that would potentially result in outcomes not being met are identified in order to assist with appropriate follow-up planning. Follow-up Actions o Provides recommendations regarding possible actions the Care Coordinator should take to address the identified barrier impeding outcome achievement and ensure a positive overall patient outcome and experience. o This list is not intended to be exhaustive or prescriptive Care Coordinators will need to use their professional judgment to determine the appropriate course of action to follow-up on missed outcomes. 4

Guidelines for Use As previously noted, the care pathways have been created to serve a number of purposes. In fulfilling these functions they will provide a platform for discussion between the CCACs and SPOs when a patients care trajectory is not meeting the expected outcomes. Review of patient outcomes as reported by the SPO and compared against the anticipated outcomes as defined by the care pathways will result in action on two levels: The individual Care Coordinator/Clinician/Patient level o The outcomes in the pathways should be met in the majority of circumstances. However, in the event they are not, the Care Coordinator, in conjunction with the SPO Clinician and Patient will review variances in expected outcomes or missed best practices and, subsequently, identify actions which can be undertaken by the most responsible party to address stalled or missed outcomes The organizational CCAC/OACCAC/SPO level o To review overall SPO performance in the provision of services or care to identify areas for organizational improvement or review o While this is occurring at broader, organizational levels, it is an important activity for Care Coordinators, SPO Clinicians and other frontline staff to be aware of what will support ongoing improvements to service delivery and care provided to patients Assessment pathway In addition to the 10 outcome-based wound care pathways that have been developed, an eleventh Assessment pathway has also been created in order to: Support practices or business processes in CCACs which choose to admit all wound care patients as having undifferentiated or unclassified wounds pending assessment and confirmation of wound etiology by the assigned SPO; and/or Assist Care Coordinators to initiate outcome-based wound care services when it is unclear on the initial referral or not possible upon the Care Coordinator s assessment to determine the etiology of the wound and a comprehensive wound assessment is required to determine the underlying cause The assessment pathway is brief in nature with only two outcomes. It is purely intended to enable the initiation of outcome-based wound care services to determine the etiology of the wound and assign the appropriate outcome-based care pathway. Once etiology of the wound has been established by the SPO, there are two possible courses of action: The wound is determined to be appropriate for one of the outcome-based wound care pathways. The SPO Clinician should initiate best practice treatment of the wound and report on the outcomes for the corresponding Outcome-Based Pathway. Upon receipt of the SPO s 5

report, the Care Coordinator will ensure that the assessment pathway is ended in CHRIS, the appropriate Outcome-Based Pathway has been assigned and follow-up with the SPO and patient as indicated to support the achievement of the outcomes defined in the pathway and to address any other patient related needs or concerns as per routine practices. It is not anticipated that additional payment will flow from the CCAC to the SPO for the assessment pathway as reimbursement for these activities will occur once the appropriate outcome-based wound care pathway has been assigned and is considered part of the first interval of the correctly assigned pathway OR The wound is determined not to be appropriate for one of the outcome-based wound care pathways. This may occur, for example, in the case of wounds with an atypical etiology such as pyoderma gangrenosum, etc. In this instance the SPO Clinician should initiate best practice treatment of the wound and report back to the Care Coordinator on the etiology and status of the wound. The Care Coordinator will end the assessment pathway in CHRIS, transfer the patient to fee-for-service wound care and establish a service plan and visit frequency in collaboration with the SPO Clinician, including authorization for the number of visits completed by the SPO Clinician to complete the assessment pathway. The Care Coordinator and SPO Clinician should also collaboratively identify any outcomes or goals which could be established based on the unique wound characteristics and patient situation (i.e., self-management) in these instances the SPO and the Care Coordinator should continue to follow-up to support the achievement of these goals or to address any other patient related needs or concerns as per routine practices. Recurring Pathways Even with the use of best practices on the part of CCACs and SPOs, it is recognized that not all wounds will heal within the expected timeframes. These variances may be the result of issues relating to patient comorbid conditions, broader healthcare or social service sector barriers outside the control of the CCAC or SPO or other contributing factors. In order to address these situations, criteria have been developed to assist Care Coordinators in transitioning patients from a healable Outcome-Based Pathway to either the Maintenance or Non-Healable Outcome-Based Pathway. A Maintenance wound is a wound that is healable, but either the patient is making choices not consistent with optimal wound healing or the system is unable to support the optimal treatment for this patient at this time. ii Patient factors may include refusing a treatment/condition resistant to treatment that addresses the cause (i.e. not wear compression therapy or not using a specialty seating cushion) A health system error or barrier may include waitlists for service, lack of required medical care or lack of affordable supplies/equipment which are not covered by OHIP. A Non-Healable wound is a wound in which the patient does not have the physical capacity to heal. iii For example, in the case of end-of-life patients. 6

If a wound has not healed by the expected pathway end-date, the following process is recommended: The Care Coordinator and SPO Clinician should review the patient s situation and current status of the wound, including progress to date and any unresolved clinical or psychosocial barriers which may be impeding wound healing and determine a follow-up plan if applicable If the wound is not closed by Day X, the current Outcome-Based Pathway should be ended and either a Maintenance or Non-Healable pathway assigned based upon the SPO Clinicians updated assessment of the healability status. This process does not preclude the possibility of a Maintenance or Non- Healable pathway being assigned upon a patient s admission to services or at any earlier point in time during the patients care based upon the assessment by the SPO Clinician but can be done on a case-bycase basis (i.e. a recurring patient known to the CC/SPO relating to wound care). *For further details regarding specific business process, please refer to the OBP/OBR Business Process Guidelines Document 7

Outcome Terminology Holistic patient & wound assessment completed A patient and wound assessment completed according to SPO, CNO, RNAO Best Practice Guidelines and clinicians judgment. As above, with additional lower limb assessment completed. Holistic patient & wound assessment completed, including lower limb assessment The RNAO Best Practice Guideline, Assessment and Management of Venous Leg Ulcers, identifies that assessments and investigations for lower leg ulcers should be under taken by a healthcare professional trained and experienced in leg ulcer management. iv Holistic patient & wound assessment completed; root cause of trauma identified and addressed As above with additional assessments completed to identify and address any patient safety or wellbeing issues which resulted in the wound. For example, assessment of mobility/balance, home environment, patient personal safety, etc. and consultation with the Care Coordinator to ensure appropriate supports and resources are identified and in place to mitigate risk and address patient concerns and needs. Correct Outcome-Based Pathway confirmed Verification is received from the SPO that the Outcome-Based Pathway assigned upon the patient s admission to CCAC services is accurate based upon their assessment of the etiology of the wound. Wound therapy initiated Wound care treatments have been initiated based upon the SPO clinicians assessment and Best Practice Guidelines. Compression therapy initiated Pressure redistribution measures initiated Compression therapy has been initiated after completion of the appropriate assessments (i.e., lower limb assessment, ABPI) in accordance with Best Practice Guidelines. Compression therapy is identified as being the gold standard of care for the treatment of venous leg ulcers in the absence of arterial disease. v Appropriate countermeasures have been initiated to address pressure redistribution needs. The National Pressure Ulcer Advisory Panel (NPUAP) defines pressure redistribution as being: The ability of a support surface 8

to redistribute load over the contact areas of the human body. This term replaces prior terminology of pressure reduction and pressure relief surfaces. A support surface is defined as: A specialized device for pressure redistribution designed for management of tissue loads, microclimate, and/or other therapeutic functions. vi Referral for vascular assessment initiated/completed Upon identification of an arterial leg ulcer, a referral is requested (or a referral/assessment is confirmed has having been completed) for an assessment by a vascular surgeon to determine potential for surgical correction of compromised or inadequate blood flow. 20 30% reduction in wound size The benchmark for wound healing is 20 30% within four weeks (based on the FUN criteria). vii Percentage healing is determined by calculating the area of the wound by length x width x depth (cm). Patient discharge planning initiated for patient independence (and prevention) Discharge planning should be initiated upon admission to services and should be assessed on a case-by-case basis dependent on the individual patients clinical and psychosocial needs. Any issues or barriers to discharge which are identified should be escalated by the SPO Clinician to the Care Coordinator in a timely manner to ensure follow-up and prevent avoidable delays in discharge. Chronic disease self-management plan initiated Self-management support is defined as the systematic provision of education and supportive interventions by health care staff to increase patients skills and confidence in managing their health problems, including regular assessment of progress and problems, goal setting and problem-solving support. Reference: Institute of Medicine, 2004 Referral initiated for long-term pressure redistribution system Referral initiated for long-term The appropriate clinician has completed their assessment and referral to the appropriate vendor for the required long-term pressure redistribution system to facilitate wound healing and reduce the risk of wound recurrence. The appropriate clinician has completed their assessment and referral to the appropriate vendor for the required long-term 9

compression system compression system to facilitate wound healing and reduce the risk of wound recurrence. 70 80% reduction in initial wound size Percentage healing is determined by calculating the area of the wound by length x width x depth (cm). Wound has 100% re-epithelialized, but lacks tensile strength. Wound is closed The clinical milestone is that the wound has closed. It will not be considered to be healed for two years during which time epithelium will continue to be laid down (though will only reach a maximum tensile strength of 80%). Patient has obtained and is adhering to pressure redistribution system The patient has obtained the long-term pressure redistribution as recommended/prescribed by the appropriate clinician, is using the system as directed and is independent in its use or has appropriate caregiver support. Patient has obtained and is independent with compression system The patient has obtained the long-term compression system recommended/prescribed by the appropriate clinician, is using the system as directed and is independent in its use or has appropriate caregiver support. Wound related symptoms managed Malignant wounds only Pain, odour and other symptoms related to the wound are managed and patient-centred concerns around quality of life are addressed. Maintenance & Non-healable wounds only No change in Wound The size and condition of the wound remains unchanged from the previous assessment/report. Any change in wound size should result in a reassessment of the wound and current treatment protocol to ensure appropriateness. Any decrease in wound size should result in a reassessment of the healability status. Assessment and identification of Resource/System barriers - intervention initiated (CM In the event a wound is categorized as Maintenance due to resource or system barriers (i.e., patient ability to afford compression stockings, lack of necessary medical services such as 10

Outcome) chiropody, etc.), an assessment and investigation is undertaken by the CCAC to explore options to address the identified barriers. Resource/System Barriers Addressed (CM Outcome) Health related Quality of Life issues addressed In the case of Maintenance wounds, measures have been successfully undertaken by the CCAC to resolve the identified resource or system barriers which were impeding wound healing. Examples may include: accessing alternative resources, such as funding supports, or advocating with existing system partners. When resource or system barriers have been addressed (which had previously been identified as being the primary impediment to wound healing), healability of the wound should be reassessed by the SPO Clinician. Malignant wounds only Quality of life is defined as an individual's perception of their position in life in the context of the culture and value systems in which they live and in relation to their goals, expectations, standards and concerns. It is a broad ranging concept affected in a complex way by the person's physical health, psychological state, level of independence, social relationships, and their relationships to salient features of their environment. viii Health-related quality of life domains include physical, functional, psychological, emotional and social components. ix 11

Pathway Stoppage Terminology Wound closed Wound has 100% re-epithelialized, but lacks tensile strength. The clinical milestone is that the wound has closed. It will not be considered to be healed for two years during which time epithelium will continue to be laid down (though will only reach a maximum tensile strength of 80%). Moved to a different pathway Upon assessment or reassessment of the wound, transfer to another pathway is indicated due to: Incorrect pathway assignment upon admission to CCAC Change in healability status of the wound Change in wound etiology (i.e., amputation) In these instances it is important for both the SPO Clinician and CCAC Care Coordinator to document the reason why the current pathway is being discontinued and the new pathway that has been initiated for the patient if they are continuing to receive wound care services. Admitted to hospital The patient has been admitted to a hospital for >14 days and has been discharged from CCAC services as per MIS guidelines. Deceased The patient has died, either while receiving services in the community or during an admission to hospital. Arterial only Inoperable arterial disease Surgical correction of the arterial blockage is not an option for treatment and the patient should be transferred to the Maintenance pathway. Patients admitted to service with confirmed inoperable arterial disease should be immediately assigned to the Maintenance pathway. Awaiting surgical intervention Arterial only Patients waiting surgical intervention to correct the arterial blockage should be transferred to the Maintenance pathway. 12

Healability/pathway assignment should be reassessed after the patient has undergone surgery. Diabetic Foot Ulcer only Acute Charcot Foot There are two phases in the development of Charcot s foot. The acute Charcot foot is hot, swollen and red. Chronic Charcot foot refers to the constellation of foot deformities that may include cocked up toes, herniated metatarsal fat pads, fractures and rocker bottom sole. The chronic Charcot foot may result from previous acute changes or from longstanding motor neuropathy. x Other The pathway has been stopped for a reason not otherwise specified in the Reasons for Stoppage. Ensure to indicate the exact reason why if selecting this option. Admission to a LTCH Patient has been admitted to a Long-Term Care Home. Transfer to other CCAC Patient is moving to a geographical area that is outside of the current CCAC boundaries. 13

Overall Pathway Outcome Terminology Wound has 100% re-epithelialized, but lacks tensile strength. Wound closure The clinical milestone is that the wound has closed. It will not be considered to be healed for two years during which time epithelium will continue to be laid down (though will only reach a maximum tensile strength of 80%) Excludes Malignant and Maintenance Prevention of wound deterioration Maintenance only The goal is to maintain the current wound condition and prevent further deterioration and infection. Move to another pathway if underlying cause treated/resolved Maintenance only In the event any intrinsic or extrinsic factors impeding the healing of a Maintenance wound are reversed, transfer to another pathway should be considered upon reassessment of the wound. Move to another pathway if system barriers removed Maintenance only In the event a wound has been classified as being Maintenance due to system barriers, transfer to another pathway should be considered once the appropriate corrective measures have been taken and healability of the wound has been reassessed. Active involvement by patient and/or caregiver with wound care Malignant only The patient and/or caregiver participate, to the maximum of their ability, in wound care related activities. Wound related symptoms controlled Malignant only Pain, odour and other symptoms related to the wound are managed and patient-centred concerns around quality of life are addressed. 14

Malignant only Comfort measures and quality of life issues addressed Quality of life is defined as an individual's perception of their position in life in the context of the culture and value systems in which they live and in relation to their goals, expectations, standards and concerns. It is a broad ranging concept affected in a complex way by the person's physical health, psychological state, level of independence, social relationships, and their relationships to salient features of their environment. xi Health-related quality of life domains include physical, functional, psychological, emotional and social components. xii 15

Exclusion Criteria Terminology Palliative Patients who are end-of-life (SRC 95) Acute Charcot Foot Diabetic Foot Ulcer only There are two phases in the development of Charcot s foot. The acute Charcot foot is hot, swollen and red. Chronic Charcot foot refers to the constellation of foot deformities that may include cocked up toes, herniated metatarsal fat pads, fractures and rocker bottom sole. The chronic Charcot foot may result from previous acute changes or from longstanding motor neuropathy. xiii Arterial only Inoperable arterial disease Surgical correction of the arterial blockage is not an option for treatment and the patient should be transferred to the Maintenance pathway. Patients admitted to service with confirmed inoperable arterial disease should be immediately assigned to the Maintenance pathway. Gangrene (tissue ischemia) Death and decay of body tissue, often occurring in a limb, caused by insufficient blood supply and usually following injury or disease. xiv Arterial & Diabetic foot ulcer Mixed ulcer etiology Mixed ulcers have the features of a venous ulcer in combination with signs of arterial impairment. ABI is between 0.5 and 0.8. Arterial only Stage I ulcer Pressure only 16

Intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area. xv Pressure Ulcer only Suspected Deep Tissue Injury Purple or maroon localized area of discoloured intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. Deep tissue injury may be difficult to detect in individuals with dark skin tones. Skin grafts/donor Sites Closed surgical wound with or without a drain Surgical only Surgically attached skin (grafting) sites or surgical sites where skin was removed to be used for a graft. Surgical only A wound which is closed by primary intention (i.e., through the use of staples, sutures or adhesive strips). Intact skin (without visible injury or opening e.g. cellulitis) Intact skin (without visible injury or opening e.g. cellulitis) New referrals unless classified as Maintenance for a reason of system barrier (i.e. awaiting surgery) New referrals unless classified as Maintenance for a reason of system barrier (i.e. awaiting surgery) 17

Barriers to Outcome Achievement Terminology Refers to a lack of resources required to achieve the identified outcome. Resource barriers could be encountered by the Patient, SPO, CCAC or broader healthcare/social services system. For example: Resource Barriers Patient financial limitations preventing the purchase of non- OHIP covered medical supplies, lack of access to transportation to attend a clinic setting for care, etc. SPO staff availability or lack of staff with the appropriate training, knowledge or expertise to perform certain assessments or interventions (i.e., ABPI, compression therapy). CCAC availability of medical supplies or delays in the involvement of other contracted services (i.e., waitlists). System lack of appropriate medical resources or social services, waitlists for specialist physician follow-up, etc. Patient Declined The patient or caregiver refused to participate in activities to support the achievement of the outcome. This may be due to choice (i.e., living at risk), lack of understanding of the necessity or benefit of participation or other influencing factors. In these instances it is important for the Case Manager/Care Coordinator to review with the patient their reasons for nonparticipation and ensure that the patient is provided with the appropriate education, encouragement and support to promote participation yet still respecting the patients choice. Inaccurate diagnosis on referral The etiology of the wound was misdiagnosed on the original referral to CCAC resulting in the wrong Outcome-Based Pathway being assigned. Patient contraindications The patient has a condition or situation (i.e., comorbid medical condition) which prohibits activities required for achievement of the outcome. For example, the presence of CHF preventing the use of compression bandaging or hosiery to treat a venous leg ulcer. 18

Refers to a lack of adherence to recognized Best Practice Guidelines in the treatment of the presenting disease/condition/problem. Non-adherence could occur on the part of the: Non-adherence to BPG (Best Practice Guidelines) Patient i.e., non-compliance with the prescribed treatment SPO/physician i.e., staff do not adhere to established best practice guidelines when providing/prescribing treatment/care CCAC i.e., services required to address the patients needs are not coordinated Factors which are impeding achievement of the outcome, including: Causative Factors Internal intrinsic factors related to the patients health, such as comorbid conditions, the presence of infection, etc. External factors related to the patients environment, diet, medication, etc. Refers to issues relating to the patients capacity to undertake activities to support achievement of the outcome. These issues could include Patient/caregiver capacity Physical capacity i.e., inability to bend over to don or doff compression hosiery, self-care deficits, etc. Cognitive capacity i.e., memory deficit impeding the patients ability to learn and understand new information or direct their own care, etc. Patient / caregiver appropriateness for selfmanagement The patient and/or caregiver not appropriate to participate in self-management activities due to factors such as cognitive issues, etc. Already linked with resource The patient/caregiver is already linked with appropriate community resources. The patient is not ready to be fitted for a long-term compression system as a result of the following reasons: 19

Patient readiness for compression fitting Psychological related to body image issues, perception by others, lifestyle, etc. Physiological such as lack of optimal edema control (achieved through the use of compression bandaging) prior to fitting, etc. Prescription not obtained The prescription from the appropriate prescriber required to achieve the outcome has not been secured. The patient is not ready for a long-term pressure redistribution system as a result of the following reasons: Patient readiness for long-term pressure redistribution system Psychological related to body image issues, perception by others, lifestyle, etc. Physiological due to the location of the wound, status of wound, etc. Other Other barriers not otherwise identified. 20

References i The Free Dictionary. http://www.thefreedictionary.com/variance ii Norton, L., Coutts, P. & Sibbald, G.R. (2011). Choosing between a healable, non-healable and maintenance wound. Wound Care: www.rehabmaganzine.ca, Fall 2011. iii Norton, L., Coutts, P. & Sibbald, G.R. (2011). Choosing between a healable, non-healable and maintenance wound. Wound Care: www.rehabmaganzine.ca, Fall 2011. iv Registered Nurses Association of Ontario, Assessment and Management of Venous Leg Ulcers, Guideline Supplement (RNAO Nursing Best Practice Guideline, 2007) 3. http://rnao.ca/sites/rnaoca/files/storage/related/2469_rnao_venous_leg_ulcer_supplement.pdf v Canadian Association of Wound Care, Best Practice Recommendations for the Prevention and Treatment of Venous Leg Ulcers; update 2006 (Wound Care Canada, Vol. 4, No. 1, 2006) 49. http://cawc.net/images/uploads/wcc/4-1-vol4no1-bp-vlu.pdf vi National Pressure Ulcer Advisory Panel, Terms and Definitions Related to Support Surfaces (NPUAP Support Surface Standards Initiative, Ver. 01/29/2007) 1. http://www.npuap.org/npuap_s3i_td.pdf vii Orridge C, Purbhoo D. Wound Care: A Guiding Framework: A Joint CCAC Initiative in Collaboration With Their Service Partners. Toronto, Ontario: Wound Review Project, Toronto CCAC; 2004. viii World Health Organization, WHOQOL: Measuring Quality of Life (WHO Division of Mental Health and Prevention of Substance Abuse, 1997) 1. http://www.who.int/mental_health/media/68.pdf ix Hayward Group Ltd., What is quality of life? What is? Series. May 2009 (2). http://www.medicine.ox.ac.uk/bandolier/painres/download/whatis/whatisqol.pdf x Registered Nurses Association of Ontario, Reducing Foot Complications for People with Diabetes (RNAO Nursing Best Practice Guideline, Mar 2004 rev 2011) 53. http://rnao.ca/sites/rnaoca/files/reducing_foot_complications_for_people_with_diabetes.pdf xi World Health Organization, WHOQOL: Measuring Quality of Life (WHO Division of Mental Health and Prevention of Substance Abuse, 1997) 1. http://www.who.int/mental_health/media/68.pdf xii Hayward Group Ltd., What is quality of life? What is? Series. May 2009 (2). http://www.medicine.ox.ac.uk/bandolier/painres/download/whatis/whatisqol.pdf xiii Registered Nurses Association of Ontario, Reducing Foot Complications for People with Diabetes (RNAO Nursing Best Practice Guideline, Mar 2004 rev 2011) 53. http://rnao.ca/sites/rnaoca/files/reducing_foot_complications_for_people_with_diabetes.pdf xiv The Free Dictionary. http://www.thefreedictionary.com/gangrene xv National Pressure Ulcer Advisory Panel. http://www.npuap.org/pr2.htm 21