Australian Diabetes Foot Network : management of diabetes-related foot ulceration — a clinical update

Summary Appropriate assessment and management of diabetes-related foot ulcers (DRFUs) is essential to reduce amputation risk. Management requires debridement, wound dressing, pressure off-loading, good glycaemic control and potentially antibiotic therapy and vascular intervention. As a minimum, all DRFUs should be managed by a doctor and a podiatrist and/or wound care nurse. Health professionals unable to provide appropriate care for people with DRFUs should promptly refer individuals to professionals with the requisite knowledge and skills. Indicators for immediate referral to an emergency department or multidisciplinary foot care team (MFCT) include gangrene, limb-threatening ischaemia, deep ulcers (bone, joint or tendon in the wound base), ascending cellulitis, systemic symptoms of infection and abscesses. Referral to an MFCT should occur if there is lack of wound progress after 4 weeks of appropriate treatment.

Diabetes foot disease : the Cinderella of Australian diabetes management?

Diabetes is one of the greatest public health challenges to face Australia. It is already Australia’s leading cause of kidney failure, blindness (in those under 60 years) and lower limb amputation, and causes significant cardiovascular disease. Australia’s diabetes amputation rate is one of the worst in the developed world, and appears to have significantly increased in the last decade, whereas some other diabetes complication rates appear to have decreased. This paper aims to compare the national burden of disease for the four major diabetes-related complications and the availability of government funding to combat these complications, in order to determine where diabetes foot disease ranks in Australia. Our review of relevant national literature indicates foot disease ranks second overall in burden of disease and last in evidenced-based government funding to combat these diabetes complications. This suggests public funding to address foot disease in Australia is disproportionately low when compared to funding dedicated to other diabetes complications. There is ample evidence that appropriate government funding of evidence-based care improves all diabetes complication outcomes and reduces overall costs. Numerous diverse Australian peak bodies have now recommended similar diabetes foot evidence-based strategies that have reduced diabetes amputation rates and associated costs in other developed nations. It would seem intuitive that “it’s time” to fund these evidence-based strategies for diabetes foot disease in Australia as well.

Standardising practices improves clinical diabetic foot management: the Queensland Diabetic Foot Innovation Project, 2006-09

Objective. The aim of this paper is to report the clinical practice changes resulting from strategies to standardise diabetic foot clinical management in three diverse ambulatory service sites in Queensland, Australia. Methods. Multifaceted strategies were implemented in 2008, including: multidisciplinary teams, clinical pathways, clinical training, clinical indicators, and telehealth support. Prior to the intervention, none of the aforementioned strategies were used, except one site had a basic multidisciplinary team. A retrospective audit of consecutive patient records from July 2006 to June 2007 determined baseline clinical activity (n = 101).Aclinical pathway teleform was implemented as a clinical activity analyser in 2008 (n = 327) and followed up in 2009 (n = 406). Pre- and post-implementation data were analysed using Chi-square tests with a significance level set at P < 0.05. Results. There was an improvement in surveillance of the high risk population of 34% in 2008 and 19% in 2009, and treating according to risk of 15% in 2009 (P < 0.05). The documentation of all best-practice clinical activities performed improved 13–66% (P < 0.03). Conclusion. These findings support the use of multifaceted strategies to standardise practice and improve diabetic foot complications management in diverse ambulatory services.

Is simulation training effective in increasing podiatrists' confidence in foot ulcer management?

Background: Foot ulcers are a frequent reason for diabetes-related hospitalisation. Clinical training is known to have a beneficial impact on foot ulcer outcomes. Clinical training using simulation techniques has rarely been used in the management of diabetes-related foot complications or chronic wounds. Simulation can be defined as a device or environment that attempts to replicate the real world. The few non-web-based foot-related simulation courses have focused solely on training for a single skill or “part task” (for example, practicing ingrown toenail procedures on models). This pilot study aimed to primarily investigate the effect of a training program using multiple methods of simulation on participants’ clinical confidence in the management of foot ulcers. Methods: Sixteen podiatrists participated in a two-day Foot Ulcer Simulation Training (FUST) course. The course included pre-requisite web-based learning modules, practicing individual foot ulcer management part tasks (for example, debriding a model foot ulcer), and participating in replicated clinical consultation scenarios (for example, treating a standardised patient (actor) with a model foot ulcer). The primary outcome measure of the course was participants’ pre- and post completion of confidence surveys, using a five-point Likert scale (1 = Unacceptable-5 = Proficient). Participants’ knowledge, satisfaction and their perception of the relevance and fidelity (realism) of a range of course elements were also investigated. Parametric statistics were used to analyse the data. Pearson’s r was used for correlation, ANOVA for testing the differences between groups, and a paired-sample t-test to determine the significance between pre- and post-workshop scores. A minimum significance level of p < 0.05 was used. Results: An overall 42% improvement in clinical confidence was observed following completion of FUST (mean scores 3.10 compared to 4.40, p < 0.05). The lack of an overall significant change in knowledge scores reflected the participant populations’ high baseline knowledge and pre-requisite completion of web-based modules. Satisfaction, relevance and fidelity of all course elements were rated highly. Conclusions: This pilot study suggests simulation training programs can improve participants’ clinical confidence in the management of foot ulcers. The approach has the potential to enhance clinical training in diabetes-related foot complications and chronic wounds in general.

Standardising practices improves ambulatory diabetic foot management and reduces amputations : the Queensland Diabetic Foot Innovation Project, 2006 – 2009

Background Diabetic foot complications are recognised as the most common reason for diabetic related hospitalisation and lower extremity amputations. Multi-faceted strategies to reduce diabetic foot hospitalisation and amputation rates have been successful. However, most diabetic foot ulcers are managed in ambulatory settings where data availability is poor and studies limited. The project aimed to develop and evaluate strategies to improve the management of diabetic foot complications in three diverse ambulatory settings and measure the subsequent impact on ospitalisation and amputation. Methods Multifaceted strategies were implemented in 2008, including: multi-disciplinary teams, clinical pathways and training, clinical indicators, telehealth support and surveys. A retrospective audit of consecutive patient records from July 2006 – June 2007 determined baseline clinical indicators (n = 101). A clinical pathway teleform was implemented as a clinical record and clinical indicator analyser in all sites in 2008 (n = 327) and followed up in 2009 (n = 406). Results Prior to the intervention, clinical pathways were not used and multi-disciplinary teams were limited. There was an absolute improvement in treating according to risk of 15% in 2009 and surveillance of the high risk population of 34% and 19% in 2008 and 2009 respectively (p < 0.001). Improvements of 13 – 66% (p < 0.001) were recorded in 2008 for individual clinical activities to a performance > 92% in perfusion, ulcer depth, infection assessment and management, offloading and education. Hospitalisation impacts recorded reductions of up to 64% in amputation rates / 100,000 population (p < 0.001) and 24% average length of stay (p < 0.001) Conclusion These findings support the use of multi-faceted strategies in diverse ambulatory services to standardise practice, improve diabetic foot complications management and positively impact on hospitalisation outcomes. As of October 2010, these strategies had been rolled out to over 25 ambulatory sites, representing 66% of Queensland Health districts, managing 1,820 patients and 13,380 occasions of service, including 543 healed ulcer patients. It is expected that this number will rise dramatically as an incentive payment for the use of the teleform is expanded.

Mapping the dynamics of the project management field : project management in action (part 6)

This is the sixth part of a Letter from the Editor series where the results are presented of an ongoing research undertaken in order to investigate the dynamic of the evolution of the field of project management and the key trends. Dynamics of networks is a key feature in strategic diagrams analysis. The radical change in the configuration of a network between two periods, or the change at subnetwork level reflects the dynamic of science. I present here an example of subnetwork comparison over the four periods of time considered in this study. I will develop and discuss an example of subnetwork transformation in future Letter from the Editor article..

Mapping the dynamics of the project management field : project management in action (part 5)

This is the fifth part of a Letter From the Editor series where the results are presented of an ongoing research undertaken in order to investigate the dynamic of the evolution of the field of project management and the key trends. I present some general findings and the strategic diagrams generated for each of the time periods introduced herein and discuss what we can learn from them on a general standpoint. I will develop and discuss some detailed findings in future Letter From the Editor articles...

Striving to achieve best practice in heart failure disease management

Based on a national audit of chronic heart failure (CHF) management programmes (CHF-MPs) conducted in 2006, Driscoll et al identified a disproportionate distribution ranging from 0 to 4.2 programmes/million population in the various states of Australia with many programmes not following best practice.1 We welcome their proposal to develop national benchmarks for CHF management and acknowledge the contributions of the Heart Foundation and health professionals in finalising these recommendations.2 We would like to share the Queensland experience in striving towards best practice with the number of CHF-MPs increasing from four (at the time of the 2006 survey) to 23, equating to 5.0 programmes/million population. Queensland now has a state-wide heart failure service steering committee with a focus on the development of CHF-MPs supported by a central coordinator...

Investigating the deployment of project management : a new perspective based on the concept of certification

Purpose – The purpose of this paper is to provide a summary description of the doctoral thesis investigating the field of project management (PM) deployment. Researchers will be informed of the current contributions within this topic and of the possible further investigations and researches. The decision makers and practitioners will be aware of a set of tools addressing the PM deployment with new perspectives. Design/methodology/approach – Research undertaken with the thesis is based on quantitative methods using time series statistics (time distance analysis) and comparative and correlation analysis aimed to better define and understand the PM deployment within and between countries or groups. Findings – The results suggest a project management deployment index (PMDI) to objectively measure the PM deployment based on the concept of certification. A proposed framework to empirically benchmark the PM deployment between countries by integrating the PMDI time series with the two dimensional comparative analysis of Sicherl. The correlation analysis within Hoftsede cultural framework shows the impact of the national culture dimensions on the PM deployment. The forecasting model shows a general continual growth trend of the PM deployment, with continual increase in the time distance between the countries. Research limitations/implications – The PM researchers are offered an empirical quantification on which they can construct further investigations and understanding of this phenomenon. The number of possible units that can be studied offers wide possibilities to replicate the thesis work. New researches can be undertaken to investigate further the contribution of other social or economical indicators, or to refine and enrich the definition of the PMDI indicator. Practical implications – These results have important implications on the PM deployment approaches. The PMDI measurements and time series comparisons facilitate considerably the measurement and benchmarking between the units (e.g. countries) and against targets, while the readiness setting of the studied unit (in terms of development and cultural levels) impacts the PM deployment within this country. Originality/value – This paper provides a summary of cutting-edge research work in the studied field of PM deployment and a link to the published works that researchers can use to help them understand the thesis research as well as how it can be extended.

Earned value management insights using inferential statistics

Purpose – The purpose of this paper is to summarise a successfully defended doctoral thesis. The main purpose of this paper is to provide a summary of the scope, and main issues raised in the thesis so that readers undertaking studies in the same or connected areas may be aware of current contributions to the topic. The secondary aims are to frame the completed thesis in the context of doctoral-level research in project management as well as offer ideas for further investigation which would serve to extend scientific knowledge on the topic. Design/methodology/approach – Research reported in this paper is based on a quantitative study using inferential statistics aimed at better understanding the actual and potential usage of earned value management (EVM) as applied to external projects under contract. Theories uncovered during the literature review were hypothesized and tested using experiential data collected from 145 EVM practitioners with direct experience on one or more external projects under contract that applied the methodology. Findings – The results of this research suggest that EVM is an effective project management methodology. The principles of EVM were shown to be significant positive predictors of project success on contracted efforts and to be a relatively greater positive predictor of project success when using fixed-price versus cost-plus (CP) type contracts. Moreover, EVM's work-breakdown structure (WBS) utility was shown to positively contribute to the formation of project contracts. The contribution was not significantly different between fixed-price and CP contracted projects, with exceptions in the areas of schedule planning and payment planning. EVM's “S” curve benefited the administration of project contracts. The contribution of the S-curve was not significantly different between fixed-price and CP contracted projects. Furthermore, EVM metrics were shown to also be important contributors to the administration of project contracts. The relative contribution of EVM metrics to projects under fixed-price versus CP contracts was not significantly different, with one exception in the area of evaluating and processing payment requests. Practical implications – These results have important implications for project practitioners, EVM advocates, as well as corporate and governmental policy makers. EVM should be considered for all projects – not only for its positive contribution to project contract development and administration, for its contribution to project success as well, regardless of contract type. Contract type should not be the sole determining factor in the decision whether or not to use EVM. More particularly, the more fixed the contracted project cost, the more the principles of EVM explain the success of the project. The use of EVM mechanics should also be used in all projects regardless of contract type. Payment planning using a WBS should be emphasized in fixed-price contracts using EVM in order to help mitigate performance risk. Schedule planning using a WBS should be emphasized in CP contracts using EVM in order to help mitigate financial risk. Similarly, EVM metrics should be emphasized in fixed-price contracts in evaluating and processing payment requests. Originality/value – This paper provides a summary of cutting-edge research work and a link to the published thesis that researchers can use to help them understand how the research methodology was applied as well as how it can be extended.

Exercise, appetite and weight management: understanding the compensatory responses in eating behaviour and how they contribute to variability in exercise-induced weight loss

Does exercise promote weight loss? One of the key problems with studies assessing the efficacy of exercise as a method of weight management and obesityis that mean data are presented and the individual variability in response is overlooked. Recent data have highlighted the need to demonstrate and characterise the individual variability in response to exercise. Do people who exercise compensate for the increase in energy expenditure via compensatory increases in hunger and food intake? The authors address the physiological, psychological and behavioural factors potentially involved in the relationship between exercise and appetite, and identify the research questions that remain unanswered. A negative consequence of the phenomena of individual variability and compensatory responses has been the focus on those who lose little weight in response to exercise; this has been used unreasonably as evidence to suggest that exercise is a futile method of controlling weight and managing obesity. Most of the evidence suggests that exercise is useful for improving body composition and health. For example, when exercise-induced mean weight loss is <1.0 kg, significant improvements in aerobic capacity (+6.3 ml/kg/min), systolic (−6.00 mm Hg) and diastolic (−3.9 mm Hg) blood pressure, waist circumference (−3.7 cm) and positive mood still occur. However, people will vary in their responses to exercise; understanding and characterising this variability will help tailor weight loss strategies to suit individuals.

Advances and future directions for management of trauma patients with musculoskeletal injuries

Musculoskeletal injuries are the most common reason for operative procedures in severely injured patients and are major determinants of functional outcomes. In this paper, we summarise advances and future directions for management of multiply injured patients with major musculoskeletal trauma. Improved understanding of fracture healing has created new possibilities for management of particularly challenging problems, such as delayed union and non union of fractures and large bone defects. Optimum timing of major orthopaedic interventions is guided by increased knowledge about the immune response after injury. Individual treatment should be guided by trading off the benefits of early definitive skeletal stabilisation, and the potentially life-threatening risks of systemic complications such as fat embolism, acute lung injury, and multiple organ failure. New methods for measurement of fracture healing and function and quality of life outcomes pave the way for landmark trials that will guide the future management of musculoskeletal injuries.

Talk and web searching in an early years classroom

Recent Australian early childhood policy and curriculum guidelines promoting the use of technologies invite investigations of young children’s practices in classrooms. This study examined the practices of one preparatory year classroom, to show teacher and child interactions as they engaged in Web searching. The study investigated the in situ practices of the teacher and children to show how they accomplished the Web search. The data corpus consists of eight hours of videorecorded interactions over three days where children and teachers engaged in Web searching. One episode was selected that showed a teacher and two children undertaking a Web search. The episode is shown to consist of four phases: deciding on a new search subject, inputting the search query, considering the result options, and exploring the selected result. The sociological perspectives of ethnomethodology and conversation analysis were employed as the conceptual and methodological frameworks of the study, to analyse the video-recorded teacher and child interactions as they co-constructed a Web search. Ethnomethodology is concerned with how people make ‘sense’ in everyday interactions, and conversation analysis focuses on the sequential features of interaction to show how the interaction unfolds moment by moment. This extended single case analysis showed how the Web search was accomplished over multiple turns, and how the children and teacher collaboratively engaged in talk. There are four main findings. The first was that Web searching featured sustained teacher-child interaction, requiring a particular sort of classroom organisation to enable the teacher to work in this sustained way. The second finding was that the teacher’s actions recognised the children’s interactional competence in situ, orchestrating an interactional climate where everyone was heard. The third finding was that the teacher drew upon a range of interactional resources designed to progress the activity at hand, that of accomplishing the Web search. The teacher drew upon the interactional resources of interrogatives, discourse markers, and multi-unit turns during the Web search, and these assisted the teacher and children to co-construct their discussion, decide upon and co-ordinate their future actions, and accomplish the Web search in a timely way. The fourth finding explicates how particular social and pedagogic orders are accomplished through talk, where children collaborated with each other and with the teacher to complete the Web search. The study makes three key recommendations for the field of early childhood education. The study’s first recommendation is that fine-grained transcription and analysis of interaction aids in understanding interactional practices of Web searching. This study offers material for use in professional development, such as using transcribed and videorecorded interactions to highlight how teachers strategically engage with children, that is, how talk works in classroom settings. Another strategy is to focus on the social interactions of members engaging in Web searches, which is likely to be of interest to teachers as they work to engage with children in an increasingly online environment. The second recommendation involves classroom organisation; how teachers consider and plan for extended periods of time for Web searching, and how teachers accommodate children’s prior knowledge of Web searching in their classrooms. The third recommendation is in relation to future empirical research, with suggested possible topics focusing on the social interactions of children as they engage with peers as they Web search, as well as investigations of techno-literacy skills as children use the Internet in the early years.

Improvement of the statutory framework for construction and demolition waste management exemplified in Germany and Australia

Construction and demolition (C&D) waste occupies the largest share of overall waste generation in many countries. However, waste management practices and outcomes may differ between countries. For instance, in Australia, C&D waste recovery is continuously improving during the last years but the amount of C&D waste increases every year, as there has been little improvement in waste avoidance and minimization. In contrast, in Germany, waste generation remains constant over many years despite the continuous economic growth. The waste recycling rate in Germany is one of the highest in the world. However, most waste recycled is from demolition work rather than from waste generated during new construction. In addition, specific laws need to be developed to further reduce landfill of non-recycled waste. Despite of the differences, C&D waste generation and recovery in both countries depend on the effectiveness of the statutory framework, which regulates their waste management practices. This is an issue in other parts of the world as well. Therefore countries can learn from each other to improve their current statutory framework for C&D waste management. By taking Germany and Australia as an example, possible measures to improve current practices of C&D waste management through better statutory tools are identified in this paper. After providing an overview of the statutory framework of both countries and their status in waste generation and recovery, a SWOT analysis is conducted to identify strengths, weaknesses, opportunities and threats of the statutory tools. Recommendations to improve the current statutory frameworks, in order to achieve less waste generation and more waste recovery in the construction industry are provided for the German and Australian government and they can also be transferred to other countries.