Pressure Injuries

Care for Patients in All Settings

Click below to see a list of brief quality statements and scroll down for more information.

Quality Statements in Brief

Quality standards are sets of concise statements designed to help health care professionals easily and quickly know what care to provide, based on the best evidence.

See below for the quality statements and click for more detail.

Quality Statement 1: Risk and Skin Assessment
People with at least one risk factor for developing a pressure injury undergo a comprehensive risk assessment, including a skin assessment, to determine their level of risk. Those at risk are reassessed on an ongoing basis.

Quality Statement 2: Patient Education and Self-Management
People who have developed or are at risk of developing a pressure injury and their families and caregivers are offered education about pressure injuries, including an overview of the condition; the importance of mobilization and repositioning for pressure redistribution; and who to contact in the event of a concerning change.

Quality Statement 3: Comprehensive Assessment
People with a pressure injury undergo a comprehensive assessment, including an evaluation of risk factors that affect healing to determine the healing potential of the wound.

Quality Statement 4: Individualized Care Plan
People who have developed or are at risk of developing a pressure injury have a mutually agreed-upon individualized care plan that identifies patient-centred concerns and is reviewed and updated regularly.

Quality Statement 5: Support Surfaces
People who have developed or are at risk of developing a pressure injury are provided with appropriate support surfaces based on their assessment.

Quality Statement 6: Repositioning
People who have developed or are at risk of developing a pressure injury receive interventions that enable repositioning at regular intervals, encouraging people to reposition themselves if they are mobile or helping them to do so if they cannot reposition themselves.

Quality Statement 7: Wound Debridement
People with a pressure injury have their wound debrided if it is determined as necessary in their assessment, and if it is not contraindicated. Debridement is carried out by a trained health care professional using an appropriate method.

Quality Statement 8: Local Infection Management
People with a pressure injury and a local infection receive appropriate treatment, including antimicrobial and non-antimicrobial interventions.

Quality Statement 9: Deep/Surrounding Tissue Infection or Systemic Infection Management
People with a pressure injury and suspected deep/surrounding tissue infection or systemic infection receive urgent assessment (within 24 hours of initiation of care) and systemic antimicrobial treatment.

Quality Statement 10: Wound Moisture Management
People with a pressure injury receive wound care that maintains the appropriate moisture balance or moisture reduction in the wound bed.

Quality Statement 11: Surgical Consultation
People who are adherent to treatment and have a stage 3 or 4 healable pressure injury that is not responding to optimal care are referred for a surgical consultation to determine their eligibility for surgical intervention.

Quality Statement 12: Health Care Provider Training and Education
People who have developed or are at risk of developing a pressure injury receive care from health care providers with training and education on the assessment and treatment of pressure injuries.

Quality Statement 13: Transitions in Care
People with a pressure injury who transition between care settings have a team or provider who is accountable for coordination and communication to ensure the effective transfer of information related to their care.

Resources Quality Statements Advisory Committee About

Summary

This quality standard focuses on care for people who have developed or are at risk of developing a pressure injury. The scope of the standard covers all settings, including primary care, home and community care, long-term care, and acute care. It also provides guidance on optimal care when a person transitions between these settings—for example, when someone is discharged from a hospital to their home or a long-term care home.

Scope of This Quality Standard

Why This Quality Standard Is Needed

Wounds represent a significant burden for patients, their caregivers and families, clinicians, and the Ontario health system, but the human and financial costs of wounds are not fully appreciated. People with pressure injuries report low levels of health-related quality of life, high rates of depression, and high rates of pain and discomfort. Pressure injuries are characterized as "damage to the skin and/or underlying soft tissue, usually over a bony prominence or related to a medical or other device." They "occur as a result of intense and/or prolonged pressure and/or shear." Pressure injuries can present as intact skin or as an open ulcer. Pressure injuries are more likely to occur in people who are older; reside in long-term or critical care settings; are acutely or seriously ill; have experienced trauma; or have a spinal cord injury, a fractured hip, a neurological condition, diabetes, impaired mobility, or nutritional deficiency. Most pressure injuries are treatable if they are detected early, but when they are left untreated, they are associated with adverse outcomes for the people who have them and high treatment costs for the health system.

Wound care represents a significant area of opportunity for quality improvement in Ontario. There are important gaps and variations in access to services and in the quality of care received by people who have developed or are at risk of developing a pressure injury. For example, rates of new pressure injuries in home care varied two-fold across community care access centres in 2013/2014 (Home Care Database, 2014). Previous efforts to improve the coordination and delivery of wound care across the province have highlighted the inconsistent application of best practice guidelines, a lack of standardized documentation, tracking of wound outcome measures, and poor coordination of care.

Based on the best available evidence and guided by expert consensus from health care professionals and people with lived experience, this quality standard addresses key areas with significant potential for quality improvement in the care of people who have developed or are at risk of developing a pressure injury in Ontario. The 13 quality statements that make up this standard provide guidance on high-quality care, with accompanying indicators to help health care professionals and organizations measure their own quality of care. Each statement also includes details on how it affects people who have developed or are at risk of developing a pressure injury, their caregivers, health care professionals, and health care services at large.

Note: In this quality standard, the term patient includes community care clients and residents of long-term care homes.

Principles Underpinning This Quality Standard

This quality standard is underpinned by the principles of respect and equity.

People who have developed or are at risk of developing a pressure injury should receive services that are respectful of their rights and dignity and that promote self-determination.

A high-quality health system is one that provides good access, experience, and outcomes for all Ontarians, no matter where they live, what they have, or who they are.

People who have developed or are at risk of developing a pressure injury are provided services that are respectful of their gender, sexual orientation, socioeconomic status, housing, age, background (including self-identified cultural, ethnic, and religious background), and disability.

How To Measure Success

We have set a limited number of objectives for this quality standard as a whole, and we have mapped these objectives to indicators to measure its success. In addition, each quality statement within this quality standard is accompanied by one or more indicators to measure the successful implementation of the statement.

Percentage of patients with a new pressure injury in a 6-month period (incidence)
Percentage of patients with a pressure injury in a 6-month period (prevalence)
Percentage of patients with a closed pressure injury in a 12-week period
Percentage of patients with a healed pressure injury who were diagnosed with a secondary pressure injury within 1 year (recurrence)
Percentage of patients with a pressure injury who had a diagnosed wound infection in a 6-month period
Percentage of patients with a pressure injury in a 12-month period who reported high satisfaction with the care provided

What Does It Mean for Patients and Caregivers?

« My mom had a foot ulcer for years before her foot had to be amputated. Although the care she needed was accessible to us, not all the professionals who provided care were knowledgeable enough to decide on the best course of action. In general, I never felt the care my mother received was patient-centered, particularly in terms of communication and respect. Our biggest barrier was not knowing why she was receiving the treatments she was given, why the treatments were not working the way they should, or what the next steps should be. After she had the amputation, I felt we had more questions than answers. And that is why I think the Quality Standards are so important.

I am very happy with the Wound Care Quality Standards. Overall, I see the quality statements as the pieces of a puzzle, allowing health care professionals to provide consistent care to patients. The standards will help patients to become more educated on issues that may affect them and to ask providers the right questions. For example, in the case of my mom, when I read the statement about individualized care plan, I thought oh my goodness, if I had known this before, things might have been different. To me, it is great that patients and caregivers will have the opportunity to be involved in their care plans and management of their wounds. »

- Linda O’Rourke, Wound Care Quality Standard Advisory Panel Member

What Does It Mean for Providers?

« Throughout my career I have worked in different sectors of the health care system, and in all of them I have seen patients suffering from chronic wounds. I think wound care needs to come up in everyone’s radar because of how troubling wounds are, how frequently they happen in the general population and how much they cost the health care system.

For organizations, I hope the Quality Standards will be the go-to document and main reference for wound care in Ontario. When you look around, there are many practice guidelines and clinical protocols for wound care. But Health Quality Ontario’s Wound Care Quality Standards are different because they clearly state how we want wound care to be delivered in Ontario. I also hope the quality standards will increase public awareness and help people become more educated and informed on what they should expect when it comes to standard of care for wounds. One other thing I like about the quality standards is that all the statements follow the same pattern as they have the same headings. We know that wound management may be different but the determination of cause, effect and assessment is standard. I think the three quality standards for wound care capture them very nicely. »

- Valerie Winberg, Wound Care Quality Standard Advisory Panel Member

Timeline for this Quality Standard

This quality standard was completed in December 2017.

For more information, contact QualityStandards@HQOntario.ca.

Evidence to Improve Care