Gap Analysis
Assessment & Management of Stage I to IV Pressure Ulcers,
Revised 2007
Work Sheet
This guideline can be downloaded for free at:
http://rnao.ca/bpg/guidelines/assessment-and-management-stage-i-iv-pressure-ulcers
The RNAO Toolkit: Implementation of Best Practice Guidelines, Second Edition is also available at:
http://rnao.ca/bpg/resources/toolkit-implementation-best-practice-guidelines-second-edition
What is a Gap Analysis?
Uses of a Gap Analysis
A process comparing your organization’s current
practice with evidence-based best practice
recommendations to determine:
 Existing practices and processes that are currently
implemented and supported by best practices. This
information is useful to reinforce practice strengths.
 Recommendations that are currently partially
implemented in practice. These would be good first
targets for change efforts.
 Recommendations that are not currently being met.
 Recommendations that are not applicable to your
practice setting.
 Contributes to annual evaluation by allowing you to
compare practice from year to year and choose
which areas to focus on changing within the year.
 Focuses on needed practice change which prevents
a total overhaul of practice and builds on
established practices and processes.
 Informs next steps such as development of
infrastructure to support implementation,
stakeholder engagement, identification of barriers
and facilitators, resource requirements, selection of
implementation strategies and evaluation
approaches.
 Leads to sustained practice change by informing
plans related to process, staff and organization and
reinforces current evidence based practices.
Conducting a Gap Analysis
Engage the team, and internal and external stakeholders as needed in gathering information for the gap analysis.
Collect information on:
 Current practice – is it known and is it consistent?
 Are there any barriers to implementation? These
(met, unmet, partially met)
may include staffing, skill mix, budget, workload
issues, etc.
 Partially met recommendations may only be
implemented in some parts of the home, or you
 What are the time frames in relation to specific
may feel it is only half done.
actions and people or departments who can
support the change effort?
 Are there some recommendations that must be
implemented before others?
 Are there links with other practices and programs in
the LTC home?
 Can any recommendations be implemented
quickly? These are easy wins and build confidence
 Are there existing resources and education that
in the change.
your LTC home can access?
 Are there recommendations based on higher levels
 Are there any must-do recommendations that are
of evidence than others?
crucial to resident and staff safety?
Next Steps
What do Levels of Evidence mean?
1. Celebrate the recommendations you are
meeting.
2. Prioritize the areas you want to work on. Start
with practice changes that can be made easily
or are crucial to resident and staff safety. Start
by reinforcing success and focusing on quick
wins.
3. These priority areas become the foundation for
planning your program or implementing
practice change.
4. For more information on taking your gap
analysis to the next level see the RNAO Toolkit:
Implementation of Best Practice Guidelines
(Second edition).
After each guideline recommendation you will notice a
level of evidence. Levels of evidence is a ranking
system used to describe the strength of results
measured in clinical trials and other types of research
studies.
Ia: Evidence obtained from meta-analysis of
randomized controlled trials.
Ib: Evidence obtained from at least one randomized
controlled trial.
IIa: Evidence obtained from at least one welldesigned controlled study without randomization
IIb: Evidence obtained from at least one other type of
well-designed quasi-experimental study, without
randomization
III: Evidence obtained from well-designed nonexperimental descriptive studies, such as
comparative studies, correlation studies and case
studies.
IV: Evidence obtained from expert committee reports
or opinions and/or clinical experiences of
respected authorities
Long-Term Care Homes:
Contact your Long-Term Care Best Practice
Co-ordinator to assist you in completing a gap
analysis. Visit RNAO.ca/ltc.
Gap Analysis – Updated September 2013
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Gap Analysis: Assessment & Management of Stage I to IV Pressure Ulcers, Revised 2007
Date Completed:
Team Members participating in the Gap Analysis:
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Unmet
Partially
Met
RNAO Best Practice Guideline
Recommendations
Met
Completion of this gap analysis allows for the annual comparison of your current practice to evidence-based practices
as regulated by the MOHLTC. See Appendix A for this and other regulations that apply to a skin and wound care
program in your home.
Notes
(Examples of what to include: is this a priority to our home,
information on current practice, possible overlap with
other programs or partners)
Practice Recommendations - Assessment
1.1 Conduct a history and focused physical
assessment. (Level IV Evidence)
1.2 Conduct a psychosocial assessment to determine
the client’s goals and motivation to comprehend
and adhere to the treatment plan of care
options
(Level IV Evidence)
1.3 Assess quality of life from the clients’
perspective (Level IV Evidence)
1.4 Ensure adequate dietary intake to prevent
malnutrition or replace existing deficiencies to
that extent that this is compatible with the
individual’s wishes (Level III Evidence)
1.5 Prevent clinical nutrient deficiencies by ensuring
that the patient is provided with optimal
nutritional support (Level Ia-IV Evidence)
1.6 Assess all patients for pain related to the
pressure ulcer or its treatment (Level IV
Evidence)
1.7 Assess location, frequency and intensity of pain
to determine the presence of underlying
disease, the exposure of nerve endings, efficacy
of local wound care & psychological need
(Level IIb Evidence)
1.8 Assess all patients with EXISTING PRESSURE
ULCERS to determine their risk for developing
pressure ulcers using the “Braden Scale for
Predicting Pressure Sore Risk
(Level IV Evidence)
1.9 If the patient remains at risk for other pressure
ulcers, a high specification foam mattress
instead of a standard hospital mattress should
be used to prevent pressure ulcers in moderate
to high risk patients (Level Ia Evidence)
1.10 Vascular assessment (e.g., clinical assessment,
Gap Analysis – Updated September 2013
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Unmet
Partially
Met
Met
Gap Analysis: Assessment & Management of Stage I to IV Pressure Ulcers, Revised 2007
Notes
RNAO Best Practice Guideline
(Examples of what to include: is this a priority to our home,
information on current practice, possible overlap with
Recommendations
other programs or partners)
palpable pedal pulses, capillary refill,
ankle/brachial pressure index and toe pressure)
is recommended for ulcers in lower extremities
to rule out vascular compromise
(Level IV Evidence)
Practice Recommendations – Management of causative/contributing factors
2.1 Choose the support surface which best fits with
the overall care plan for the client considering
the goals of treatment, client bed mobility,
transfers, caregiver impacts, ease of use,
cost/benefit etc. Ensure ongoing monitoring and
evaluation to ensure the support surface
continues to meet the clients’ needs and that
the surface is used appropriately and is properly
maintained. If the wound is not healing consider
the total care plan for the client before replacing
the surface
(Level IV Evidence)
2.2 Pressure management of heels while in bed
should be considered independently of the
support surface (Level III Evidence)
2.3 Use pressure management for clients in the
operating room to reduce the incidence of
pressure ulcers post operatively
(Level Ia Evidence)
2.4 Obtain a seating assessment if a client has a
pressure ulcer on a sitting surface
(Level IV Evidence)
2.5 Refer patients at RISK to appropriate
interdisciplinary team members (Occupational
Therapist, Physiotherapist, Enterostomal
Therapist etc.). (Level IV Evidence)
2.6 A client with a pressure ulcer on the buttocks
and/or trochanter should optimize mobilization.
If pressure on the ulcer can be managed,
encourage sitting as tolerated
(Level IV Evidence)
Practice Recommendations – Local Wound Care: Assessment
3.1a To plan treatment and evaluate its
effectiveness, assess the pressure ulcer initially
for:
 stage/depth; location;
 surface area (length x width) (mm3, cm2)
 odour; sinus tracts, undermining, tunneling
 exudate; appearance of the wound bed; and
 condition of the surrounding skin (periwound)
& wound edges
(Level IV Evidence)
Gap Analysis – Updated September 2013
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Unmet
Partially
Met
Met
Gap Analysis: Assessment & Management of Stage I to IV Pressure Ulcers, Revised 2007
Notes
RNAO Best Practice Guideline
(Examples of what to include: is this a priority to our home,
information on current practice, possible overlap with
Recommendations
other programs or partners)
3.1b Conduct a comprehensive reassessment weekly
to determine wound progress and the
effectiveness of the treatment plan. Monitor for
variances from assessment with each dressing
change. Identification of variances indicates
need for reassessment.
(Level IV Evidence)
Practice Recommendations – Local Wound Care: Debridement
3.2a Lower extremity ulcers or wounds in patients
who are gravely palliative with dry eschar need
not be debrided if they do not have edema,
erythema, fluctuance or drainage. Assess these
wounds daily to monitor for pressure ulcer
complications that would require debridement
(Level IV Evidence)
3.2b Prior to debridement on ulcers on the lower
extremities, complete a vascular assessment
(e.g., clinical assessment, palpable pedal pulses,
capillary refill, ankle/brachial pressure index and
toe pressure) to rule out vascular compromise
(Level IV Evidence)
3.2c Determine if debridement is appropriate for the
patient and the wound (Level IV Evidence)
3.2d If debridement is indicated, select the
appropriate method of debridement
considering:
 type, quantity and location of necrotic tissue
 the depth and amount of drainage, and
 availability of resources
(Level IV Evidence)
3.2e Sharp debridement should be selected when
the need is urgent, such as with advancing
cellulitus or sepsis, increased pain, exudates and
odour. Sharp debridement must be conducted
by a qualified person
(Level IV Evidence)
3.2f Use sterile instruments to debride pressure
ulcers (Level IV Evidence)
3.2g Prevent or manage pain associated with
debridement.
(Level IV Evidence)
Practice Recommendations – Local Wound Care: Control Bacteria/Infection
3.3a The treatment of infection is managed by
wound cleansing, systematic antibiotics and
debridement, as needed (Level Ib Evidence)
3.3b Protect pressure ulcers from sources of
contamination e.g., fecal matter
(Level IIa Evidence)
3.3c Follow body substance precautions (BSP) or an
equivalent protocol appropriate for the
healthcare setting and the client’s condition
Gap Analysis – Updated September 2013
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Unmet
Partially
Met
Met
Gap Analysis: Assessment & Management of Stage I to IV Pressure Ulcers, Revised 2007
Notes
RNAO Best Practice Guideline
(Examples of what to include: is this a priority to our home,
information on current practice, possible overlap with
Recommendations
other programs or partners)
when treating pressure ulcers (Level IV
Evidence)
3.3d Medical management may include initiating a
two-week trial of topical antibiotics for clean
pressure ulcers that are not healing or are
continuing to produce exudates after two to
four weeks of optimal patient care. The
antibiotic should be effective against gramnegative, gram- positive and anaerobic
organisms
(Level Ib Evidence)
3.3e Medical management may include appropriate
systematic antibiotic therapy for patients with
bacteremia, sepsis, advancing cellulitus or
osteomyelitis (Level Ib Evidence)
3.3f To obtain a wound culture cleanse wound with
normal saline first. Swab wound bed, not eschar,
slough exudates or edges (Level IV Evidence)
3.3g The use of cytotoxic antiseptics to reduce
bacteria in wound tissue is not usually
recommended
(Level IIb Evidence)
Practice Recommendations – Local Wound Care: Wound Cleansing
3.4a Do not use skin cleansers or antiseptic agents to
clean ulcer wounds (Level III Evidence)
3.4b Use normal saline, Ringers Lactate, sterile
water or non-cytotoxic wound cleansers for
wound cleansers (Level IV Evidence)
3.4c Fluid used for cleansing should be warmed to at
least room temperature (Level III Evidence)
3.4d Cleanse wounds at each dressing change
(Level IV Evidence)
3.4e To reduce surface bacteria and tissue trauma,
the wound should be irrigated with 100 to 150
millilitres of solution
(Level IV Evidence)
3.4f Use enough irrigation pressure to enhance
wound cleansing without causing trauma to the
wound bed. (Level IIa Evidence)
Practice Recommendations – Local Wound Care: Management Approaches
3.5a For comprehensive wound management
consider:
 Etiology of the wound;
 Client’s general health status, preference,
goals of care and environment;
 Lifestyle;
 Quality of life;
 Location of the wound;
Gap Analysis – Updated September 2013
Page 6 of 11
Unmet
Partially
Met
Met
Gap Analysis: Assessment & Management of Stage I to IV Pressure Ulcers, Revised 2007
Notes
RNAO Best Practice Guideline
(Examples of what to include: is this a priority to our home,
information on current practice, possible overlap with
Recommendations
other programs or partners)
 Size of the wound, including depth and





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




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undermining;
Pain;
A dressing that will loosely fill wound cavity;
Exudate: type and amount;
Risk of infection;
Risk of recurrence;
Type of tissue involved;
Phase of the wound healing process;
Frequency of the dressing change;
Comfort and cosmetic appearance;
Where and by whom the dressing will be
changed;
Product availability; and
Adjunctive therapies.
(Level IV Evidence)
3.5b Moisture-retentive dressings optimize the local
wound environment and promote healing
(Level Ia Evidence)
3.5c Consider caregiver time when selecting a
dressing (Level Ib Evidence)
3.5d Consider the following criteria when selecting
an interactive dressing:
 provides thermal insulation and wound
temperature stability
 maintains its integrity and does not leave
fibres or foreign substances with the wound
 client preference
 is simple to handle and is economical in cost
and time
(Level Ia-IV Evidence)
3.5e Monitor dressings applied near the anus, since
they are difficult to keep intact. Consider use of
special sacral-shaped dressings.
(Level Ib Evidence)
Practice Recommendations – Local Wound Care: Adjunctive Therapies
3.6a Refer to physiotherapy for a course of
treatment with electrotherapy. Electrical
stimulation may also be useful (Level Ib
Evidence)
3.6b Chronic pressure ulcers may be treated by:
 electrical stimulation
 ultraviolet light
 warming therapy
 growth factors
 skin equivalents
Gap Analysis – Updated September 2013
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Unmet
Partially
Met
Met
Gap Analysis: Assessment & Management of Stage I to IV Pressure Ulcers, Revised 2007
Notes
RNAO Best Practice Guideline
(Examples of what to include: is this a priority to our home,
information on current practice, possible overlap with
Recommendations
other programs or partners)
 negative pressure wound therapy
 hyperbaric oxygen
(Level IIa-IV Evidence)
Practice Recommendations – Local Wound Care: Surgical Intervention
3.7 Possible candidates for operative repair are
medically stable, adequately nourished and are
able to tolerate operative blood loss and
postoperative immobility. (Level IV Evidence)
Practice Recommendations – Discharge/Transfer of Care Arrangements
4.1 Clients moving between care settings should
have the following information provided:
 risk factors identified
 details of pressure points & skin condition
prior to transfer
 need for pressure management/mobility
equipment (e.g., support surfaces, seating,
special transfer equipment, heel boots)
 details of healed ulcers
 stage, site and size of existing ulcers
 history of ulcers, previous treatments &
dressings (generic) used
 frequency & type of dressing change currently
used and any allergies to dressing products
 need for ongoing nutritional support
(Level IV Evidence)
4.2 Use the RNAO Best Practice Guideline Risk
Assessment and Prevention of Pressure Ulcers
(Revised) (2005)
(Level IV Evidence)
Practice Recommendations – Patient Education
5.1 Involve the patient and caregiver, when possible,
in pressure ulcer treatment and prevention
strategies and options. Include information on
pain, discomfort, possible outcomes and
duration of treatment, if known. Other areas of
education may include patient information
regarding appropriate surface supports, as well
as roles of various health professionals.
Collaborate with patient, family and caregivers
to design and implement a plan for pressure
ulcer prevention and treatment. (Level of
Evidence IV)
Education Recommendations
6.1 Design, develop and implement educational
programs that reflect a continuum of care. The
program should begin with a structure,
comprehensive and organized approach to
prevention and should culminate in effective
Gap Analysis – Updated September 2013
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Unmet
Partially
Met
Met
Gap Analysis: Assessment & Management of Stage I to IV Pressure Ulcers, Revised 2007
Notes
RNAO Best Practice Guideline
(Examples of what to include: is this a priority to our home,
information on current practice, possible overlap with
Recommendations
other programs or partners)
treatment protocols that promote healing as
well as prevent recurrence (Level IV Evidence)
6.2 Develop educational programs that target
appropriate healthcare providers patients family
member and caregivers. Present information at
an appropriate level for the target audience, in
order to maximize retention and facilitate
translation into practice (Level IV Evidence)
6.3 Include the following information when
developing an educational program on the
treatment of pressure ulcers:
 role of the interdisciplinary team
 etiology and pathology
 risk factors
 individualized program of skin care, quality of
life & pain management
 uniform terminology for stages of tissue
damage based on specific classifications
 need for accurate consistent and uniform
assessment, description & documentation of
the extent of tissue damage
 principles of wound healing, cleansing
debridement, infection control
 principles of nutritional support with regard to
tissue integrity
 product selection (i.e., support surfaces,
dressings, topical antibiotics, antimicrobials)
 post operative principles (positioning and
support surfaces)
 principles of pressure management
 mechanisms for accurate documentation and
monitoring of pertinent data (treatment
interventions and healing progress)
 principles of patient education related to
prevention to reduce recurrence
(Level IV Evidence)
6.4 Update knowledge and skills related to the
assessment and management of pressure ulcers
on an ongoing basis. Organizations should
provide opportunities for professional
development related to the best practice
guideline and support its use in daily practice
(Level IV Evidence)
Organization & Policy Recommendations
7.1 Guidelines are likely to be effective if they take
into account local circumstances and are
disseminated by an active ongoing training and
Gap Analysis – Updated September 2013
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Unmet
Partially
Met
Met
Gap Analysis: Assessment & Management of Stage I to IV Pressure Ulcers, Revised 2007
Notes
RNAO Best Practice Guideline
(Examples of what to include: is this a priority to our home,
information on current practice, possible overlap with
Recommendations
other programs or partners)
educational program (Level IV Evidence)
7.2 Practice settings need a policy with respect to
providing and requesting advance notice when
transferring or admitting clients between
practice settings when special resources (e.g.,
surfaces) are required (Level IV Evidence)
7.3Practice settings must ensure that resources are
available to clients and staff, (e.g., appropriate
moisturizers, barriers, dressings, documentation
systems, access to equipment and clinical
experts, etc.) (Level IV Evidence)
7.4 Practice settings need a policy that requires
product vendors to be registered as regulated
healthcare professionals if they provide
assessment and/or recommendations on any
aspect of pressure ulcer related practice
(Level IV Evidence)
7.5 Practice settings need an interdisciplinary team
of interested and knowledgeable persons to
address quality improvement in pressure ulcer
management. This team requires representation
across departments and programs
(Level IV Evidence)
7.6 Nursing best practice guidelines can be
successfully implemented only where there are
adequate planning, organizational, resources,
and administrative support, as well as the
appropriate facilitation. Organizations may wish
to develop a plan for implementation that
includes:
 An assessment of organizational readiness and
barriers to implementation.
 Involvement of all members (whether in a
direct or indirect supportive function) who will
contribute to the implementation process.
 Dedication of a qualified individual to provide
the support needed for the education and
implementation process.
 Ongoing opportunities for discussion and
education to reinforce the importance of best
practices.
 Opportunities for reflection on personal and
organizational experience in implementing
guidelines
(Level IV Evidence)
Gap Analysis – Updated September 2013
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Gap Analysis: Assessment & Management of Stage I to IV Pressure Ulcers, Revised 2007
Appendix A
Applicable Ministry of Health and Long-Term Care Regulations for Skin and Wound Care
Required programs
48. (1) Every licensee of a long-term care home shall ensure that the following interdisciplinary programs are
developed and implemented in the home:
2. A skin and wound care program to promote skin integrity, prevent the development of wounds and pressure
ulcers, and provide effective skin and wound care interventions.
(2) Each program must, in addition to meeting the requirements set out in section 30,
(a) provide for screening protocols; and
(b) provide for assessment and reassessment instruments. O. Reg. 79/10, s. 48 (2).
Section 30
30. (1) Every licensee of a long-term care home shall ensure that the following is complied with in respect of each of
the organized programs required under sections 8 to 16 of the Act and each of the interdisciplinary programs
required under section 48 of this Regulation:
1. There must be a written description of the program that includes its goals and objectives and relevant policies,
procedures and protocols and provides for methods to reduce risk and monitor outcomes, including protocols
for the referral of residents to specialized resources where required.
2. Where, under the program, staff use any equipment, supplies, devices, assistive aids or positioning aids with
respect to a resident, the equipment, supplies, devices or aids are appropriate for the resident based on the
resident’s condition.
3. The program must be evaluated and updated at least annually in accordance with evidence-based practices and, if
there are none, in accordance with prevailing practices.
4. The licensee shall keep a written record relating to each evaluation under paragraph 3 that includes the date of
the evaluation, the names of the persons who participated in the evaluation, a summary of the changes made
and the date that those changes were implemented. O. Reg. 79/10, s. 30 (1).
(2) The licensee shall ensure that any actions taken with respect to a resident under a program, including
assessments, reassessments, interventions and the resident’s responses to interventions are documented. O. Reg.
79/10, s. 30 (2).
Skin and wound care
50. (1) The skin and wound care program must, at a minimum, provide for the following:
1. The provision of routine skin care to maintain skin integrity and prevent wounds.
2. Strategies to promote resident comfort and mobility and promote the prevention of infection, including the
monitoring of residents.
3. Strategies to transfer and position residents to reduce and prevent skin breakdown and reduce and relieve
pressure, including the use of equipment, supplies, devices and positioning aids.
4. Treatments and interventions, including physiotherapy and nutrition care. O. Reg. 79/10, s. 50 (1).
(2) Every licensee of a long-term care home shall ensure that,
(a) a resident at risk of altered skin integrity receives a skin assessment by a member of the registered nursing staff,
(i) within 24 hours of the resident’s admission,
(ii) upon any return of the resident from hospital, and
(iii) upon any return of the resident from an absence of greater than 24 hours;
(b) a resident exhibiting altered skin integrity, including skin breakdown, pressure ulcers, skin tears or wounds,
(i) receives a skin assessment by a member of the registered nursing staff, using a clinically appropriate
assessment instrument that is specifically designed for skin and wound assessment,
(ii) receives immediate treatment and interventions to reduce or relieve pain, promote healing, and prevent
infection, as required,
(iii) is assessed by a registered dietitian who is a member of the staff of the home, and any changes made to the
resident’s plan of care relating to nutrition and hydration are implemented, and
(iv) is reassessed at least weekly by a member of the registered nursing staff, if clinically indicated;
(c) the equipment, supplies, devices and positioning aids referred to in subsection (1) are readily available at the home
as required to relieve pressure, treat pressure ulcers, skin tears or wounds and promote healing; and
(d) any resident who is dependent on staff for repositioning is repositioned every two hours or more frequently as
required depending upon the resident’s condition and tolerance of tissue load, except that a resident shall only be
repositioned while asleep if clinically indicated. O. Reg. 79/10, s. 50 (2).
(3) In this section,
“altered skin integrity” means potential or actual disruption of epidermal or dermal tissue. O. Reg. 79/10, s. 50 (3).
Gap Analysis – Updated September 2013
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