Breaking the Cycle of Recurrent Diabetic Foot Ulceration: A Novel and Sustainable Offloading Modality to Treat Diabetic Foot Ulceration and Prevent Recurrence.

INTRODUCTION: Delayed healing and recurrence of diabetic foot ulcerations (DFUs) is often related to excessive pressure. Offloading, a mainstay of treatment, can be achieved through a variety of methods. Although pressure mitigation should be continued after wound resolution to prevent recurrence, many offloading modalities are discontinued at that point, with providers instead relying on patient self-directed use of appropriate inserts and shoe gear. Use of a novel offloading modality continued upon wound healing may help break the cycle of recurrent DFUs. CASE REPORT: A patient presented with a 2-year history of recurrent DFU to the right fourth metatarsal head following amputation of the fourth digit. Recurrence continued despite self-reported compliance with therapeutic footwear use. Use of a novel offloading modality that incorporates intermittent pneumatic compression, smart technology for monitoring of patient compliance with use, and the ability to continue therapeutic shoe gear use upon wound resolution was initiated. Wound resolution was achieved, allowing for reconstructive surgery to further mitigate the potential for recurrence. The patient remains free of DFU recurrence for 3 years with continued use of the device's shoe gear. CONCLUSIONS: Implementation of a novel offloading device, which facilitates enhanced perfusion, monitors patient compliance with use, and can be continued upon wound resolution, was able to break the cycle of a recurrent DFU.

Optimizing nursing time in a day care unit: Quality improvement using Lean Six Sigma methodology.

OBJECTIVE: This study applies Lean Six Sigma (LSS) to improve the efficiency of a private hospital day care unit and generate a positive impact on optimizing nursing time and improving personalized patient care and staff satisfaction. DESIGN: A prospective interventional study using pre- and post-evaluation. SETTING: A day care unit at a private hospital. PARTICIPANTS: Nurses and patients from the day unit. INTERVENTION(S): Define, Measure, Analyze, Improve and Control was used as an overarching problem-solving framework. All front line staff, clinical leaders and managers were supported as active change agents in the quality improvement (QI) initiative. Multiple interventions were adopted across the service that aimed to de-implement non-value added activities and enhance processes with activities that added value. MAIN OUTCOME MEASURES: Patient turnaround times (PTTs), nursing time, nurse-patient ratio, nurse and patient survey. RESULTS: A post-implementation evaluation highlighted significant improvements in service performance and patient and staff satisfaction. Significant added value includes a reduction in PTTs, an increase in nursing care time and improvement in the nurse-patient ratio. CONCLUSION: This project identified that utilizing LSS that relies on collaborative team effort is effective in creating a positive organizational culture for improvement and change. The Six Sigma tools and techniques provide evidence-based approaches that support QI in practice.

Guidelines for the management of the foot health problems associated with rheumatoid arthritis.

BACKGROUND: Rheumatoid arthritis (RA) as a chronic systemic disease, commonly affects the feet, impacting negatively on patients' quality of life. Specialist podiatrists have a prime role to play in the assessment and management of foot and ankle problems within this patient group. However, it has been identified that in many areas there is no specialist podiatry service, with many patients being managed by non-specialist podiatrists. Therefore, the North West Clinical Effectiveness Group for the Foot in Rheumatic Diseases (NWCEG) identified the need to develop 'practitioner facing' guidelines for the management of specific foot health problems associated with RA. METHODS: Members of a guideline development group from the NWCEG each reviewed the evidence for specific aspects of the assessment and management of foot problems. Where evidence was lacking, 'expert opinion' was obtained from the members of the NWCEG and added as a consensus on current and best practice. An iterative approach was employed, with the results being reviewed and revised by all members of the group and external reviewers before the final guideline document was produced. RESULTS: The management of specific foot problems (callus, nail pathology, ulceration) and the use of specific interventions (foot orthoses, footwear, patient education, steroid injection therapy) are detailed and standards in relation to each are provided. A diagrammatic screening pathway is presented, with the aim of guiding non-specialist podiatrists through the complexity of assessing and managing those patients with problems requiring input from a specialist podiatrist and other members of the rheumatology multidisciplinary team. CONCLUSION: This pragmatic approach ensured that the guidelines were relevant and applicable to current practice as 'best practice', based on the available evidence from the literature and consensus expert opinion. These guidelines provide both specialist and non-specialist podiatrists with the essential and 'gold standard' aspects of managing people with RA-related foot problems.