Venous Leg Ulcers

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: Screening for Peripheral Arterial Disease
People with a suspected venous leg ulcer are screened for peripheral arterial disease using the ankle-brachial pressure index (ABPI) or an alternative such as the toe-brachial pressure index (TBPI) if ABPI is not possible. Screening is conducted by a trained health care professional during the initial comprehensive assessment and at regular intervals (at least every 12 months) thereafter.

Quality Statement 2: Patient Education and Self-Management
People who have developed or are at risk of developing a venous leg ulcer, and their families or caregivers, are offered education about venous leg ulcers and who to contact for early intervention when needed.

Quality Statement 3: Comprehensive Assessment
People with a venous leg ulcer undergo a comprehensive assessment conducted by a health care professional trained in leg ulcer assessment and treatment, to determine the healing potential of the wound. This assessment informs the individualized care plan.

Quality Statement 4: Individualized Care Plan
People with a venous leg ulcer have a mutually agreed-upon individualized care plan that identifies patient-centred concerns and is reviewed and updated regularly.

Quality Statement 5: Compression Therapy
People who have developed or are at risk of developing a venous leg ulcer are offered compression therapy that is applied by a trained individual based on the results of the assessment and patient-centred goals of care.

Quality Statement 6: Wound Debridement
People with a venous leg ulcer 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 7: Local Infection Management
People with a venous leg ulcer and a local infection receive appropriate treatment, including antimicrobial and non-antimicrobial interventions.

Quality Statement 8: Deep/Surrounding Tissue Infection or Systemic Infection Management
People with a venous leg ulcer and a suspected deep/surrounding tissue infection or systemic infection receive urgent assessment (within 24 hours of initiation of care) and systemic antimicrobial treatment.

Quality Statement 9: Wound Moisture Management
People with a venous leg ulcer receive wound care that maintains the appropriate moisture balance or moisture reduction in the wound bed.

Quality Statement 10: Treatment with Pentoxifylline
People with large, slow-healing venous leg ulcers are assessed for appropriateness for pentoxifylline in combination with compression therapy.

Quality Statement 11: Referral to Specialist
People with a venous leg ulcer that is atypical, or that fails to heal and progress within 3 months despite optimal care, are referred to a specialist.

Quality Statement 12: Health Care Provider Training and Education
People who have developed or are at risk of developing a venous leg ulcer receive care from health care providers with training and education in the assessment and treatment of venous leg ulcers.

Quality Statement 13: Transitions in Care
People with a venous leg ulcer 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 venous leg ulcer. 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. Leg ulcers can cause social isolation and affect a person’s ability to work because of pain, treatment requirements, and frequent health care appointments.

Most leg ulcers are venous leg ulcers (some estimate the proportion to be 80% to 90% of all leg ulcers). Rates of venous leg ulcers in Ontario have increased over time; the average increase in hospital discharges for venous leg ulcers across the 14 local health integration networks between 2012 and 2014 was 11% (Discharge Abstract Database, IntelliHEALTH, 2016). Recurrence rates are difficult to determine, but they are high, with some studies specifying recurrence rates of 19% to 48% after 5 years.

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 venous leg ulcer. Previous efforts to improve the coordination and delivery of wound care across the province have highlighted the inconsistent application of best practice guidelines, lack of standardized documentation and 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 venous leg ulcer in Ontario. The 13 quality statements that make up this standard each 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 venous leg ulcer, 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 venous leg ulcer 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 venous leg ulcer are provided service that is 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 venous leg ulcer in a 6-month period (incidence)
Percentage of patients with a venous leg ulcer in a 6-month period (prevalence)
Percentage of patients with a closed venous leg ulcer in a 12-week period
Percentage of patients with a healed venous leg ulcer who were diagnosed with a secondary venous leg ulcer within 1 year (recurrence)
Percentage of patients with a venous leg ulcer who had a diagnosed wound infection in a 6-month period
Percentage of patients with a venous leg ulcer 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