1
Table of Contents
ĂĐŬŐƌŽƵŶĚ ͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘ϱ
&ŽƌŵWƵƌƉŽƐĞ͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘ϱ
ŽƌĞ/ŶĚŝĐĂƚŽƌƐ͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘ϱ
ĐŬŶŽǁůĞĚŐŵĞŶƚƐ ͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘ϲ
YƵĞƌŝĞƐ͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘ϲ
ZĞƚƵƌŶŝŶŐƚŚĞŽŵƉůĞƚĞĚ&ŽƌŵƐ ͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘ϳ
^ĞŶĚĞƌ/ĚĞŶƚŝĨŝĐĂƚŝŽŶƐŚĞĞƚ͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘ϴ
,ŝŐŚZŝƐŬ&ŽŽƚ&Žƌŵ ͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘ ϵͲϭϮ
WĂŐĞϭ/E^dZhd/KE^;KEKd&/>>d,/^W'KhdͿ ͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘ϭϯ
'ĞŶĞƌĂů&Žƌŵ/ŶƐƚƌƵĐƚŝŽŶƐ ͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘ϭϯ
WĂƚŝĞŶƚ/ĚĞŶƚŝĨŝĐĂƚŝŽŶ ͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘ϭϯ
DĂŶƵĂůŶƚƌLJ͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘ϭϯ
&ĂĐŝůŝƚLJŽĚĞƐ ͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘ϭϰ
ĂƚĞ&ŝĞůĚƐ͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘ϭϰ
dĞdžƚŽdž&ŝĞůĚƐ ͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘ϭϰ
ŚŽŝĐĞ&ŝĞůĚƐ ͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘ϭϱ
DĂŶĚĂƚŽƌLJ&ŝĞůĚƐ ͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘ϭϱ
ŽŵƉůĞƚĞ,ŝŐŚZŝƐŬ&ŽŽƚ&ŽƌŵĂƚĂĐŚŽŶƐƵůƚ ͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘ϭϲ
hŶŝǀĞƌƐŝƚLJŽĨdĞdžĂƐůĂƐƐŝĨŝĐĂƚŝŽŶ^LJƐƚĞŵĨŽƌŝĂďĞƚŝĐtŽƵŶĚƐ͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘ϭϲ
W'Ϯ/E^dZhd/KE^͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘ϭϳ
WĂƚŝĞŶƚ/ĚĞŶƚŝĨŝĐĂƚŝŽŶ ͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘ϭϳ
^ĞdžŝĚĞŶƚŝĨŝĐĂƚŝŽŶ͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘ϭϳ
&ĂĐŝůŝƚLJ ͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘ϭϳ
sŝƐŝƚƚLJƉĞ ͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘ϭϳ
dŽĚĂLJΖƐsŝƐŝƚƚŽƚŚĞ,ŝŐŚZŝƐŬ&ŽŽƚ^ĞƌǀŝĐĞ ͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘ϭϴ
^ĞƉĂƌĂƚŝŽŶ^ƚĂƚƵƐ͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘ϭϴ
,ĞĂůƚŚWƌŽĨĞƐƐŝŽŶĂů;ƐͿƚƚĞŶĚŝŶŐ ͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘ϭϴ
ĂƚĞŽĨZĞĨĞƌƌĂůͲEĞǁůŝĞŶƚsŝƐŝƚƐKŶůLJ ͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘ϭϵ
/ŶĚŝŐĞŶŽƵƐ^ƚĂƚƵƐ͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘ϭϵ
^ƵďũĞĐƚŝǀĞͲZĞĂƐŽŶĨŽƌƚƚĞŶĚĂŶĐĞ͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘ϭϵ
DĞĚŝĐĂůĂŶĚŝĂďĞƚŝĐ&ŽŽƚ,ŝƐƚŽƌLJ ͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘ϮϬ
ŽͲŵŽƌďŝĚŝƚŝĞƐ͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘ϮϬ
ZĞĐĞŶƚ'>͛Ɛ'ƌĞĂƚĞƌƚŚĂŶϭϱŵŵŽůͬ> ͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘Ϯϭ
2
,ďϭĐZĞƐƵůƚ ͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘ϮϮ
WƌĞǀŝŽƵƐ&ŽŽƚhůĐĞƌ͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘ϮϮ
ƵƌƌĞŶƚ&ŽŽƚhůĐĞƌ ͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘ϮϮ
WƌĞǀŝŽƵƐŵƉƵƚĂƚŝŽŶ ͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘ϮϮ
ůŝŶŝĐĂůŝĂŐŶŽƐŝƐ͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘Ϯϯ
EĞƵƌŽƉĂƚŚLJ ͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘Ϯϯ
WĞƌŝƉŚĞƌĂůƌƚĞƌŝĂůŝƐĞĂƐĞ ͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘Ϯϯ
ĐƵƚĞŚĂƌĐŽƚ͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘Ϯϯ
&ŽŽƚĞĨŽƌŵŝƚLJ͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘Ϯϯ
ZŝƐŬůĂƐƐŝĨŝĐĂƚŝŽŶ ͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘Ϯϰ
hůĐĞƌͬtŽƵŶĚƐƐĞƐƐŵĞŶƚ^ƵŵŵĂƌLJ ͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘Ϯϱ
ŽŵďŝŶĞĚ^ƵƌĨĂĐĞƌĞĂ;DĞĂƐƵƌĞŵĞŶƚͿ ͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘Ϯϱ
ŽŵďŝŶĞĚ^ƵƌĨĂĐĞƌĞĂ ͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘Ϯϱ
ůŝŶŝĐĂůƐŝŐŶƐŽĨ/ŶĨĞĐƚŝŽŶ ͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘Ϯϲ
hŶŝǀĞƌƐŝƚLJŽĨdĞdžĂƐůĂƐƐŝĨŝĐĂƚŝŽŶ^LJƐƚĞŵĨŽƌŝĂďĞƚŝĐtŽƵŶĚƐ͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘Ϯϲ
DĂŶĂŐĞŵĞŶƚWĞƌĨŽƌŵĞĚ ͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘Ϯϲ
ĞďƌŝĚĞĚhůĐĞƌͬtŽƵŶĚͬĂůůƵƐ ͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘Ϯϲ
ƌĞƐƐŝŶŐKƉƚŝŵƵŵ ͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘Ϯϲ
ŶƚŝďŝŽƚŝĐZĞƋƵŝƌĞĚ ͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘Ϯϳ
KĨĨͲůŽĂĚŝŶŐKƉƚŝŵƵŵ͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘Ϯϳ
&ŽŽƚǁĞĂƌKƉƚŝŵƵŵ͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘Ϯϳ
ĚƵĐĂƚĞĚWĂƚŝĞŶƚ͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘Ϯϳ
KŶŽŵƉůĞƚŝŽŶ ͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘Ϯϴ
ZĞƚƵƌŶŝŶŐŽŵƉůĞƚĞĚ&ŽƌŵƐ͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘Ϯϴ
W'ϯ/E^dZhd/KE^͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘Ϯϵ
DĂŶĚĂƚŽƌLJ&ŽŽƚƐƐĞƐƐŵĞŶƚ ͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘Ϯϵ
ŶŬůĞƌĂĐŚŝĂůWƌĞƐƐƵƌĞ/ŶĚĞdž͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘Ϯϵ
dŽĞWƌĞƐƐƵƌĞ͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘Ϯϵ
ůĂƵĚŝĐĂƚŝŽŶĂŶĚZĞƐƚWĂŝŶ͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘Ϯϵ
DŽŶŽĨŝůĂŵĞŶƚ ͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘Ϯϵ
ĞĨŽƌŵŝƚLJĂŶĚ^ŬŝŶ>ĞƐŝŽŶƐ͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘ϯϬ
EĂŝůWĂƚŚŽůŽŐLJ ͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘ϯϬ
ĚĚŝƚŝŽŶĂůdĞƐƚƐͬKďƐĞƌǀĂƚŝŽŶƐ ͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘ϯϬ
hůĐĞƌtŽƵŶĚƐƐĞƐƐŵĞŶƚ ͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘ϯϬ
>ŽĐĂƚŝŽŶ͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘ϯϬ
3
ŚĂŶŐĞ ͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘ϯϭ
dLJƉĞ͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘ϯϭ
^ŝnjĞ ͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘ϯϮ
tŽƵŶĚĞĚ ͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘ϯϮ
^ƵƌƌŽƵŶĚŝŶŐ^ŬŝŶ͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘ϯϯ
tŽƵŶĚĚŐĞ͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘ϯϯ
KĚŽƵƌ ͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘ϯϯ
džƵĚĂƚĞ>ĞǀĞů ͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘ϯϰ
džƵĚĂƚĞŚĂƌĂĐƚĞƌŝƐƚŝĐƐ͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘ϯϰ
^ŝŶƵƐ ͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘ϯϰ
WƌŽďĞƚŽŽŶĞ ͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘ϯϰ
hŶŝǀĞƌƐŝƚLJŽĨdĞdžĂƐůĂƐƐŝĨŝĐĂƚŝŽŶ^LJƐƚĞŵĨŽƌŝĂďĞƚŝĐtŽƵŶĚƐ͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘ϯϰ
dƌĞĂƚŵĞŶƚŐŽĂů͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘ϯϱ
ƌĞƐƐŝŶŐZĞŐŝŵĞ͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘ϯϱ
ĚĚWŚŽƚŽͬdƌĂĐĞ͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘ϯϱ
W'ϰ/E^dZhd/KE^͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘ϯϲ
/ŶĨĞĐƚŝŽŶ ͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘ϯϲ
ŶƚŝďŝŽƚŝĐƐZĞƋƵŝƌĞĚ͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘ϯϲ
ŝĂďĞƚŝĐ&ŽŽƚ/ŶĨĞĐƚŝŽŶƐ;d'ʹŶƚŝďŝŽŝƚĐƐϮϬϭϬͿ͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘ ϯϲͲϯϳ
ĞůůƵůŝƚŝƐ͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘ϯϴ
>ĞǀĞůŽĨ/ŶĨĞĐƚŝŽŶ͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘ϯϴ
KĨĨͲůŽĂĚŝŶŐĞĨŽƌŵŝƚLJ͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘ϯϵ
&ŽŽƚǁĞĂƌKƉƚŝŵƵŵ͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘ϰϬ
ĚĚŝƚŝŽŶĂůŽŵŵĞŶƚƐ ͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘ϰϬ
WĂƚŝĞŶƚĚƵĐĂƚŝŽŶ͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘ϰϬ
dƌĞĂƚŵĞŶƚWůĂŶ ͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘ϰϭ
^ĞƌǀŝĐĞ'ŽĂů͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘ϰϮ
ZĞǀŝĞǁĂŶĚZĞĨĞƌƌĂůƐ ͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘ ϰϮͬϰϯ
^ŝŐŶŝŶŐKĨĨ͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘ϰϰ
ƉƉƉĞŶĚŝdž ͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘ ϰϱͬϰϲ
ZĞĨĞƌĞŶĐĞƐ ͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘ϰϳ
4
Background
The diabetic foot innovation project (DFIP), 2007-2009 showed that the
implementation of evidence based clinical pathways and data systems into
clinical practice resulted in a significant reduction in diabetic related bed days
and amputation(s).
The high risk foot form (HRFF) has been developed for use in high risk foot
clinics, to facilitate and support best practice and improved patient outcomes.
The aim of the HRFF is to:
• Utilise evidence-based multi-disciplinary pathways to manage patients
(including those patients with diabetes), who are at risk of developing foot
complications.
• Encourage early identification and effective management of the high risk
foot.
• To reduce diabetic foot hospital admissions, decrease overall length of
inpatient stay, and minimise the incidence of ulceration and amputation.
Form Purpose
The aim of the HRFF is to:
• Provide an evidence-based assessment and management pathway for all
at risk / high risk foot complications.
• Facilitate the capture of high risk foot clinical indicators and best practice
core clinical activities that improve patient outcome and reduce
hospitalisation and amputation.
• Encourage and prompt effective management of the at risk / high risk foot.
Core Indicators
The High Risk Foot Form captures the following 5 core indicators.
Process Indicators
Outcome Measures
Patients with diabetic foot ulcers are
seen by the multidisciplinary foot care
team within 2 weeks from referral
date.
All patient visits have wound
assessments completed and
documented.
Patients with diabetic foot ulcers have
access to high risk foot services
Patient visits with foot ulcers
appropriately off-loaded and
documented
Median total foot ulcer healing time
reduced
Foot ulcer severity is graded on basis
of wound depth, presence of infection
and presence of peripheral arterial
disease.
Pressure reduction management
plans are in place.
As recommended by NHMRC
‘Diabetic Foot’ Guidelines (2010).
Total foot ulcer healed
5
Reduced incidence of patients with
new foot ulceration who have had
previous foot ulceration.
Reduction of re-ulceration or new foot
ulceration
Acknowledgments
Thank you for all those involved especially the following groups:
• Statewide Diabetic Foot Working Group
• Statewide Diabetic Clinical Network
• Statewide Podiatry Network
• Centre for Health Care Improvement.
Queries
If you require further assistance please contact:
Mr Ewan Kinnear
District Director of Podiatry - Metro North Health Service District
Chair/ Professional Lead - Statewide Podiatry Network
Chair - Statewide Diabetic Foot Working Group (DFWG)
E-mail - [email protected]
6
Returning the Completed Forms
On document completion
• Carefully separate pages 1 and 2 from pages 3 and 4.
• Photocopy page 2
• Sign and date photocopy and retain in clinical records.
• Keep pages 3 and 4 in the patient’s clinical records.
• Send original page 2 to MRAT (Measurement, Redesign & Analysis
Team) in batches with a completed ‘sender identification sheet’. (Refer to
page 8.)
Please send batches of completed page 2 HRFF’s to MRAT a minimum
of once a month. If large batches sent twice monthly to;
Collections Officer
Measurement, Redesign & Analysis Team (MRAT)
Patient Safety & Quality Improvement services
RBWH Block 7 level 13
Herston QLD 4029
Registered mail
To order additional registered mail labels, (no more than 2 per month) please
contact the data collections officer on 36369780.
For further information on completing a data collection form please contact
Measurement, Redesign & Analysis Team (MRAT) at:
[email protected]
7
8
9
10
11
12
PAGE 1 INSTRUCTIONS for completingTeleform
(Page 2)
ͳ
General Form Instructions
•
•
•
•
•
Use only original printed forms.
Use a Black Pen only to complete the form – do not
use pencil, other pen colours or white out (Liquid
Paper).
Indicate responses by filling in the circle or inserting
numbers or letters completely within the boxes.
Dates should always be Day Month Year (e.g.
01/04/2008)
All ‘Yes/No’ questions must be completed – do not
leave blank.
Patient Identification
•
•
Affix patient identification label
within the box at the top right corner
of the form.
Ensure label does not cover corner
marker on the form.
Manual Entry: (If no labels supplied)
•
•
•
•
These fields, Sex, UR number, and Date of Birth, are used to identify and
track the patient’s records through our database.
This information is mandatory and should be completed for every form
sent to PSQ (Patient Safety and Quality Improvement Service).
Examples include Sex (M, F, I), Date of Birth (01/01/2011) URN 1234567,
F345656, 023556.
Please include leading zeros and characters in UR numbers
eg.
13
Facility Codes
•
•
Facility (Hospital, Facility Code, Referral Site)
These fields are used to capture the facility in which the form was
completed. Put the name or the code of the facility in the space provided.
eg. Royal Brisbane Hospital or 00201
OR
Date Fields
Date fields are used to capture various dates in the format of dd/mm/yyyy.
Dates such as 03/05/2011 should include leading zeros when entering the
date and month.
Other dates fields may also have times attached therefore the format will be
dd/mm/yyyy hh:mm
03/05/2011 15:00 (Time is not applicable for the HRFF)
eg.
Text Box Fields
Text box fields are alphanumeric by default meaning they can hold both alpha
characters, or numeric characters. Typically data collection forms are
designed to only accept either numeric or alpha not both for each text box.
Exceptions - The University of Texas classification system for diabetic wounds
(UTWCS) grading score requires a mixed character and numerical character.
Therefore it is important when completing these types of fields that the correct
data format is used.
For instance ‘Age’ requires numerical values such as 23, 45, 32 and ‘Ward
requires alpha values such as ICU.
Text box fields with a decimal place built in box allow data such as height or
some measure to be entered. Text boxes with no decimal do not allow users
to enter their own decimal place and will reject the data when scanning.
eg.
Choice
Fields
Choice
Fields let you choose one or more
14
options within a select group of options available. There are two formal rules
for choice fields: Single Choice or Multiple Choice.
Single Choice Fields: only choose one option out of the one or more
available. Single choice fields may be indicated with a (Single Choice) next to
the field.
eg.
Multiple Choice Fields: you can select more than one option out of all
options available. Multiple Choice fields may be indicated with a (Multiple
Choice) next to the title of the field.
eg.
Mandatory Fields
When mandatory fields cannot be completed please fill in the circle or box
next to N/A. This indicates that the field has not been overlooked and has
been completed although data not available or applicable.
Do not write over the top or add comments over the pre-printed text or boxes.
Add comments to space provided if single choice answer options are not
applicable.
eg.
Mr. X has a foot wound on his
left foot from stepping on
some sharp glass. The Type
of ulcer/wound is “Trauma”
Yes
or
No
15
Complete High Risk Foot Form at each Consult
To ensure best practice the HRFF must be completed at every visit, on
every patient consultation.
However, the Data Collection form (page 2) is only required to be filled in and
submitted once per week per patient.
For example, if the patient was seen multiple times in the same week for a
foot ulcer, clinicians would use the entire form once in that week. The data
collection form is then submitted with the monthly batches.
For the other visits in that week the clinician should simply fill in page 3 and 4
and discard page 2.
UTWCS (University of Texas Classification System for
Diabetic Wounds)
THE UTWSC assess the ulcer for three main components
1. Wound depth
2. Presence of infection
3. Presence of arterial disease
For multiple ulcers choose the highest score.
16
PAGE 2 – INSTRUCTIONS
Patient Identification
•
•
•
Affix patient information sticker to the top right hand side all 4 pages of the
HRFF.
Ensure that the label does not cover the ‘label corner here’ marker on the
form.
Handwritten patients details can be used but manual reading is required
and thus patient information labels are encouraged.
Sex Identification - Single choice answer
M - Male
F - Female
I - Indeterminate or intersex.
Facility
The facility is the site of consultation.
These fields are used to capture the facility in which the form was completed.
Put the name or the code of the facility in the space provided. For example
Royal Brisbane Hospital or 00201.
or code
Visit Type - Single choice answer
New Client Visit - This is a new patient who has not been treated at this
facility, or was discharged and now has a new referral.
Review Client Visit - This is an existing client who has already been referred
to the clinic and is receiving ongoing treatment.
Did Not Attend - This is a patient who failed to attend the clinic on the day of
his/her appointment. Please complete Today’s Visit to High Risk Foot Service
section using the date of the patient’s appointment.
eg. Mr. X is a new patient, he has never been to the clinic.
17
Today’s Visit to HRFS (High Risk Foot Service)
•
•
•
This is the date of the patient’s appointment or the date that the patient
was booked into the clinic.
Please include Today’s visit date when completing the separation status or
if the patient did not attend the clinic.
Please use date format xx/xx/xxxx.
eg. Today’s visit 12/05/2011 or patient did
not attend clinic on the 12/05/2011
Separation Status - Single choice answer
Leave blank if not applicable.
Ensure that you complete Today’s visit to the high risk foot service as the date
the form was completed.
Discharged - Patient has been discharged from the high risk foot service.
Transferred - Patient transferred to another high risk foot service or
alternative care.
Deceased - Patient is deceased.
eg. Patient transferred.
Health Professional(s) Attending - Multiple choice answer
Please select all health professionals involved in the care of the patients foot
complications this week.
eg. Mr. X was seen by a podiatrist,
endocrinologist, (Physician) and a nurse
educator this week.
Select all three options.
18
New Client Visits Only (or Client Previously
Discharged with New Referral)
Date of Referral
This is the date the referral was made. Leave blank if not applicable.
For example the date the Patient referred him/her self to the clinic or the date
of the referral letter.
Use date format xx/xx/xxxx. (Refer to section 3, page 1.)
eg. Mr. X or his local doctor referred to the
High Risk Foot Clinic the date of his
referral or referral received was 12th of
June 2011.
Indigenous Status - Single choice answer
Please indicate the patient’s status by allowing the patient to identify their
status.
Aboriginal - An Aboriginal person, is a person of Aboriginal descent who
identifies as an Aboriginal person and is accepted as such by the community
in which he or she lives.
Torres Strait Islander - A Torres Strait Islander person, is a person of Torres
Strait Islander descent who identifies as a Torres Strait Islander and is
accepted as such by the community in which he or she lives.
Both - Refers to an Aboriginal and Torres Strait Islander person of Aboriginal
and Torres Strait Islander descent who identifies as both Aboriginal and
Torres Strait Islander and is accepted as such by the community in which he
or she lives.
eg. John identifies as
an Aboriginal and
Torres Strait Islander.
Subjective - Reason for Attendance
Please write in the patient’s own words his/her reason for attending the clinic
today.
eg. When asked, Mr. X stated that he came to the clinic because his doctor
told him to “come in and get his foot wound looked at”
19
Medical and Diabetic Foot History
Medical History - Single choice answer
•
Non-Diabetes - Patients who do not have Diabetes
•
Type 1 Diabetes - Patients who have been diagnosed with Type 1
Diabetes.
•
Type 2 Diabetes - Patients who have been diagnosed with Type 2
Diabetes.
Year diagnosed - If the patient has diabetes please include the year the
patient was diagnosed in the format xxxx.
Patient self estimate is acceptable.
If the patient is not able to estimate then leave blank.
eg. Mr. X is a 64 year old man who was diagnosed with Type 2 Diabetes who
is now on insulin. Mr. X was diagnosed in 1980.
Co-morbidities - Multiple choice answer
Categories
Neuropathy
PAD (peripheral arterial disease)
Definitions
Neuropathy is defined as damage to
nerves of the peripheral nervous
system causing loss of feeling.
Having loss of protective sensation on
two or three sites on the plantar
aspect of the foot using the 10g
monofilament and absence of 128Hz
tuning fork.
Other neurological tests may be
indicated.
No - No symptoms or signs of
ischaemia, palpable pedal pulses,
ABI 0.9-1.1
Yes – Restriction in blood supply,
Signs and symptoms of intermittent
claudication, rest pain or ABI <0.9
with toe pressure <70mmHg.
20
Hypertension (mild hypertension)
Smoker
Dyslipidaemia
CKD (chronic kidney disease)
CVD (cardio vascular disease)
ESRF (end stage renal failure)
Adult blood pressure of >140 mm Hg
systolic and >90 mm Hg diastolic.
Patient self report of hypertension is
acceptable.
Smokes tobacco regularly or has
smoked in the last 4 weeks.
LDL-C >2.5 mmols/L
Triglycerides >2.0mmol/L
Cholesterol >6.2mmol/l
Patient self report of dyslipidaemia is
acceptable.
Estimate Glomerular filtration rate
(eGFR) less than or equal to 90mL/min.
Patient self report of CKD is
acceptable.
This definition covers all diseases and
conditions of the heart and blood
vessels, including atherosclerosis,
myocardial infarction, angina or
stroke.
Patient self report of CVD is
acceptable.
Loss of kidney function > 3 months
Glomerular filtration rate (GFR) less
than or equal to 15 mL/min or
on dialysis or kidney transplantation.
Patient self report of ESRF is
acceptable.
eg. Mr X has a history of Type 2 Diabetes, ESRF, CVD, hypertension and
Chronic Obstructive Airways Disease. Mr X has given up smoking 5 days ago.
Recent BGL’s Greater than 15mmol/L? - Single choice answer
Yes - Blood glucose levels have been greater than 15mmmol/L in the last
week.
or
No - Blood glucose levels less than 15mmol/L, Leave boxes empty if
unknown.
21
HbA1c Result
Indicate the patient’s recent HbA1c result by filling in the boxes below.
Patient’s self report is acceptable. Leave boxes empty if unknown.
eg. Mr. Z has had recent blood
glucose levels of 18mmol/L. His last
HbA1c was 10.4.
Previous Foot Ulcer - Single choice answer
Yes - History of previous foot ulcer
or
No - No history of foot ulcer
eg. Mr. X has a healed foot ulcer
on the apex of his hallux.
Current Foot Ulcer - Single choice answer
Does the patient have a foot ulcer today?
Yes - Foot ulcer present today. (This includes any existing or totally new
ulcers)
or
No - No Foot ulcer present today.
If yes, a new foot ulcer is defined as having developed since the previous
consultation and presenting at today’s visit.
.
eg. Mr. X has a 2 week old ulcer on his PMA 1, which was not present at his
last visit.
Previous Amputation - Single choice answer
The patient has had a partial or full amputation of the lower limb.
Yes - History of amputation
or
No - No history of amputation
eg. Mr. X has had a forefoot
amputation.
22
Clinical Diagnosis
Neuropathy - Single choice answer
Neuropathy is defined as having loss of protective sensation on two or three
sites on the plantar aspect of the foot using the 10g monofilament. Other
neurological tests such as the 128Hz vibration tuning fork may be indicated.
eg. Mr. X has no sensation using the 10g monofilament on Plantar Metatarsal
Area 1 and on the apex of the Hallux, but has sensation on the Plantar
Metatarsal Area 5.
Peripheral Arterial Disease (PAD) - single choice answer
Grade
Nil
Moderate
Critical
Description
No symptoms or signs of ischaemia,
palpable pedal pulses, ABI >0.9, or
toe pressure of greater than 70mmHg
ABI 0.4-0.7 or Toe pressure 3070mmHg
Absent pulses + ABI <0.4, Toe
pressure <30mmHg
Location
Please write on line in space provided.
This is the area where the patient experiences claudication.
eg. Left Calf
Acute Charcot - single choice answer
Yes - Acute Charcot present
or
No - No presence of acute Charcot
Location
Please write in space provided.
This is the area with the active Charcot
eg. Right mid foot
Foot Deformity
Yes - If the patient has a foot deformity score of 3 or above on the 6 point
scale.
or
No - If the patient has a foot point deformity score of 2 or less.
23
NHMRC Foot Deformity 6 Point Scale
6 point scale (1 point for each
characteristic) – Score of 3 or above
indicates foot deformity.
Small muscle wasting
Charcot foot deformity
Bony prominence
Prominent metatarsal heads
Hammer or claw toes
Limited joint mobility
Total out of 6
Score
Risk Classification - Single choice answer
Risk Classification
Acute
Definition
People with –
High Risk
• Current foot ulceration +/- infection and/or,
• Acute Charcot Arthropathy, and /or
Necrosis / Acute Ischaemia
People with –
Previous history of foot ulcer / amputation
and / or two or more of these risk factors
•
•
•
At Risk ( Intermediate)
Neuropathy
Peripheral Arterial Disease (PAD)
Foot deformity
People with –
NO previous history of foot ulcer / amputation
and one of these risk factors
• Neuropathy
• Peripheral Arterial Disease (PAD)
• Foot Deformity
Low Risk
People with –
NO risk factors and no history of foot ulcer /
Amputation
24
Ulcer/Wound Assessment Summary - Single choice answer.
Please choose the category that is the dominant cause of the ulceration.
Categories
Neuropathic
Ischaemic
Neuro-Ischaemic
Post Surgical
Definition
Loss of protective sensation
Absence of pedal pulses,
signs of intermittent claudication, or
ABPI <0.9 or toe pressure <70mmHg
A combination of both neuropathic
and ischaemic pathology
Wounds with surgical origin
Exceptions – for example TRAUMA, please do not choose the above options,
but add comments in the space provided next to Type.
Combined Surface Area
(measurement)
Estimate the surface area in mm2 using the
formula below.
Surface area
= length of ulcer in mm X width of ulcer in mm
Wound 1.
= 7.5mm X 5.0mm
= 37.5mm2
Wound 2.
= 5.0mm X 5.0mm
=25.0mm2
Combined Surface area = Wound 1 + 2
=37.5mm2 + 25mm2
=62.5mm2
Combined Surface Area - Single choice answer
Total surface area or all foot wounds/ulceration.
Healed - Healed
No Change - No change to ulcer size
Smaller - Ulcer size smaller
Larger – Ulcer size larger
25
Clinical Signs of Infection - Single choice answer.
Nil - No infection
Mild - Erythema <2cm from wound border
Moderate - Erythema > 2cm from wound border
Systemic Symptoms- spreading infection with systemic involvement, and/or
suspected or confirmed osteomyelitis.
UTWCS (University of Texas Classification System for
Diabetic Wounds)
The UTWSC assess the ulcer for three main components
1. Wound depth
2. Presence of infection
3. Presence of arterial disease
For multiple ulcers choose the highest score.
eg. Mr. X has two foot ulcers with
the UTWCS grading B3 and B1.
Management Performed
This section refers to management/treatment provided today.
Debrided Ulcer/Wound/Callus - Single choice answer
Yes – Ulcer debridement performed today
No – No ulcer debridement performed
N/A – Not applicable
Dressing Optimum - Single choice answer
Yes - Dressing optimised today
No - Dressing not optimal.
Please give brief explanation why optimal dressing could not be used. eg.
Allergy.
N/A - Not applicable
Health care professionals should use wound dressings that best match clinical
presentation, the site of the wound and consider the cost of the dressings.
26
Dressings are optimum if it promotes a moist wound healing environment
unless clinically contraindicated.
Ischaemic Ulcers
Promote a dry environment when in the presence of dry eschar with
insufficient blood flow.
Promote dry environment in palliative wound management when
healing is not a realistic goal and eschar protects underlying vascular
structures against bleeding or infection
Antibiotics Required - Single choice answer.
Management performed today
Yes - Medical practitioner contacted or antibiotic therapy commenced
No - No antibiotics required
N/A - Not applicable
For additional information on recommended antibiotic treatment refer to
Appendix A.
Off-loading Optimum - Single choice answer
Yes - Off-loading optimum today
No - Off-loading not optimum
Please give brief explanation as to why off-loading is not optimum. eg. Falls
Risk due to poor patient balance.
N/A - Not applicable
Pressure is a causal factor for neuropathic foot ulcers.
Therefore the removal or relief from pressure should facilitate healing of the
foot ulcer.
Plantar ulceration
For plantar ulceration, evidence suggests that off-loading is optimal if
the device is a total contact cast, however a removable cast walker
which has been rendered non-removable has been shown by research
to be as effective as the total contact cast.
If off-loading not optimum please state why in the space provided in the
comments area.
Footwear Optimum - Single choice answer
Yes - Footwear is optimum if it prevents injury, allows appropriate offloading if
required and encourages safe mobility.
No - Footwear is not suitable.
N/A - Not applicable
27
Educated Patient - Single choice answer
Management performed today
Yes - Patient/Carer education given
No - No patient/carer education given
N/A - Not applicable
On completion
Please sign and date the management performed in the area defined.
eg. Jill Anderson is the podiatrist who completed the form and performed the
assessment on the 6th of June 2011.
Returning the Completed Forms
On document completion
• Carefully separate pages 1 and 2 from pages 3 and 4.
• Photocopy page 2
• Sign and date photocopy and retain in clinical records.
• Keep pages 3 and 4 in the patient’s clinical records.
• Send original page 2 to MRAT (Measurement, Redesign & Analysis
Team) in batches with a completed ‘sender identification sheet’. (Refer to
page 8.)
Please send batches of completed page 2 HRFF’s to MRAT a minimum
of once a month. If large batches sent twice monthly to;
Collections Officer
Measurement, Redesign & Analysis Team (MRAT)
Patient Safety & Quality Improvement services
RBWH Block 7 level 13
Herston QLD 4029
Registered mail
To order additional registered mail labels, (no more than 2 per month) please
contact the data collections officer on 36369780.
For further information on completing a data collection form please contact
Measurement, Redesign & Analysis Team (MRAT) at:
[email protected]
28
PAGE 3 INSTRUCTIONS
Mandatory Foot Assessment - Must be completed every 6
months
Pulse – Single choice answer, tick box that best describes pulse.
Pulse grading
0
+
++
+++
Pulse sensation
Absent
Faint or weak
Normal
Bounding
Ankle Brachial Pressure Index (ABPI)
Measure the ankle brachial pressure index using the formula below and write
results in the space provided.
Toe Pressure
Measure the toe pressure and write in the space provided
Claudication or Rest Pain - single choice answer
Present - Patient complains of claudication
Absent – Nil complaints of claudication
Distance before onset - Write distance if known, in space provided.
Monofilament 10g
Please indicate multiple answers by ticking the box.
• Hallux (apex if available)
• PMA 1 (Plantar metatarsal area 1)
• PMA 5 (Plantar metatarsal area 5)
Yes - Tick
No - Cross
Blank - Not tested
If the area is not available due to amputation or ulceration please test closest
area possible or leave blank.
eg. Mr. X has absent sensation using the monofilament on the apex of his
hallux. He has normal sensation on the 1st plantar metatarsal area. His 5th
metatarsal area is unavailable due to amputation.
29
Deformity and Skin Lesions - Multiple choice answer
Area of deformity or skin lesion location can be indicated by circling or
marking the foot illustration.
If other category is indicated please write details in other or additional
tests/observations space provided above.
Nail Pathology - Single choice answer
Nail pathology is any abnormal nail shape or presentation.
Yes - Nail pathology present
or
No - No nail pathology
eg. Mr X has an ulcer on PMA 1, a heel fissure, subungal onychomycosis on
his hallux and a scar to the plantar aspect of his foot.
Additional Tests/Observations
Please write additional tests or observations in the space provided.
eg. Mr X has pitted odema. The skin temperature test shows the left foot is
TC˚36.6 and the right is TC˚39. He has absent sensation on his left foot.
Ulcer Wound Assessment
Location
Describe anatomical location of ulcer in space provided
There is space provided for 3 separate areas of ulceration/wounds
If additional space is required please use the High Risk Foot Form – Ulcer add
on - FAMMIS 10236554
30
eg. Mr X has 3 foot ulcers;
1. Left dorsal interphalangeal joint ulcer on the 2nd digit.
2. Left lateral calcaneal ulcer.
3. Right plantar metatarsal 1 ulcer.
Change - Multiple choice answer
Indicate if there is a change in the ulcer
Change
Healed
No Change
Infected
Smaller
Larger
Definition
Ulcer totally epithelialised.
Overlying epidermis is intact.
No change to ulcer characteristics.
Infection is suspected if there is an
inflammatory response.
There is a decrease in ulcer size/
including depth.
There is an increase in ulcer size/
including depth.
eg. Mr. X has a plantar metatarsal ulcer that has increased in size and the
area is red and swollen. There is an increase in wound exudate. Infection is
suspected.
Type - Single choice answer
Choose dominant reason for ulceration.
Categories
Neuropathic
Ischaemic Ulcers
Neuro-Ishaemic Ulcers
Post Surgical Ulcers
Other - write in space beside
Signs and symptoms
Absence of monofilament sensation
Absence of pedal pulses or
Signs and symptoms of intermittent
claudication, or
ABPI <0.9
or
Toe pressure <70mmHg.
A combination of both neuropathic
and ischaemic pathology.
Surgical wounds.
eg. Wounds from mechanical trauma.
31
eg. Mr. X has peripheral neuropathy. He has a planar ulcer that was caused
from a stone in his shoe.
Size
Give a 3 dimensional description of the ulcer.
W - Width measure widest area of the ulcer
L - Length measure longest area of the ulcer
D - Depth measure deepest area of the ulcer gently with sterile probe
SA - Surface area is the total area of each wound.
Wound Bed - Multiple choice answer
Estimate percentage of each characteristics identified in the wound bed.
Total percentage should add to 100%
Category
Necrotic
Granulating
Epithelialising
Sloughy
Pale
Hypergranulating
Bone
Description
Black non viable tissue.
Pink and clean granulating tissue.
Clean pink wound with evidence of
epithelial growth on the wound
surface.
Soft yellow or creamy slough. Slough
is an accumulation of dead cells
within the exudating wound.
Grey dusky colour, associated with
arterial disease.
Abnormal gelatinous, red moist
tissue.
Bone exposed, full thickness ulcer.
eg. Mr. X has a large plantar heel ulcer. It is 10% Necrotic, 40%
Epithelialising, 50% Sloughy.
32
Surrounding Skin - Multiple choice answer
Choose categories that best describe the surrounding skin of the wound.
Category
Macerated
Hyperkeratotic
Indurated
Normal Healthy
Fragile
Erythema
Oedema
Dry/scaly
Description
Softening and whitening of skin that is
kept constantly moist
Thick hard callus
Sclerosis or hardening of the skin
Normal healthy
Atrophic, thin and soft skin
Redness of the skin caused by
hyperaemia in the lower layers of the
skin
Abnormal amount of fluid
accumulated beneath the skin
Flakes of skin visible on skin surface
Wound Edge - Multiple choice answer
Choose category that best fits wound edge description
• Regular - shape edge normal and uniform
• Irregular - Shape edge uneven and undefined
• Undermined - Area of tissue destruction extending under wound edges.
• Rolling - rolled or everted edges raises the suspicion of malignancy
Odour - Single choice answer
•
•
Nil - Nil odour present
Offensive - odour present
33
Exudate Level - Single choice answer
Please indicate level of exudate by indicating single answer
• Nil - no exudate
• Low - low exudate
• Moderate - moderate exudate
• High - high exudate
Exudate Characteristic - Single choice answer
•
•
•
Serous - Clear straw coloured fluid
Purulent- containing pus often yellow or milky in colour
Haemoserous - slight blood stained serous fluid
Sinus - Single choice answer
No - No sinus present
or
Yes - Sinus present
Measure depth in mm with sterile blunt instrument. GENTLY probe sinus, do
not cause tissue damage.
Probe to Bone - Single choice answer
Yes - Probes to hard base, Bone
or
No - Probes to soft base, tissue
UTWCS Grade
(University of Texas classification system for diabetic
wounds)
Assess the ulcer for 3 main components
1. Wound depth
2. Presence of infection
3. Presence of arterial disease
Using the grading grid above insert results into the boxes provided.
For multiple ulcers choose the highest score and write score on page 2.
34
Treatment Goal - Multiple choice answer
•
•
•
•
•
•
•
•
Debridement
Control exudates
Decrease bacterial load
Protect
Rehydration
Control odour
Increase granulation
Manage pain
eg. Mr. X has a foot ulcer. His treatment today includes sharp debridement.
He has a localised infection and his dressing is a silver aquacel to help absorb
exudate and decrease bacterial load.
Dressing Regime - Multiple choice answer
•
•
•
•
•
•
•
Dry Dressing eg. Melolite
Alginate eg. Sorbsan
Hydrofibre eg. Aquacel
Antimicrobial - please indicate dressing type/name eg. Acticoat
Hydrogel eg. Intrasite gel
Foam eg. Allevyn
Other
Add Photo/Trace - Single choice answer
Yes – Trace/photo added
or
No – No trace/Photo added
•
•
•
•
•
•
Ensure Patient consent form completed and signed.
Attach on separate piece of paper with clearly labelled photo or tracing of
the patient’s wound.
Ensure date and time is written on photo or tracing, 1600hrs 01/01/2011
Please ensure that Infection control procedures are implemented
Please ensure that Patient identification label is attached if available
Include wound location for example – plantar metatarsal area 1
35
Page 4 - Instructions
Infection
Infection - Single choice answer
Yes - Infection
No - No infection
N/A - Not applicable, unable to determine.
Antibiotics required - Single choice answer
Patients with non-healing or progressive ulcers with clinical signs of active
infection (redness, pain, swelling, or discharge) should receive therapy.
Yes - antibiotics required
No - no antibiotics required
N/A - Not applicable
Diabetic Foot Infections; Therapeutic Guidelines Australia Antibiotics
2010.
Diabetic foot infections are often worse than they appear and should always
be regarded as serious.
Acute infections in patients who have not recently received antimicrobials are
usually due to Staphylococcus aureus and streptococci. Chronic infections are
often polymicrobial, including Gram-positive and Gram-negative aerobes and
anaerobes.
Culture of tissue specimens obtained by biopsy or aspiration may guide
therapy.
For uninfected ulcers, cultures are unnecessary and antibiotic therapy
should be avoided.
Assess vascular supply and consider underlying osteomyelitis or septic
arthritis. Surgical debridement is often necessary and antibiotic therapy
should be effective against the mixed aerobic and anaerobic organisms
frequently responsible.
For mild to moderate infection with no evidence of osteomyelitis or septic
arthritis, use:
amoxycillin+clavulanate 875+125 mg orally, 12-hourly
OR
cephalexin 500 mg orally, 6-hourly
PLUS
metronidazole 400 mg orally, 12-hourly.
36
For patients with penicillin hypersensitivity (see Table 2.2), use:
ciprofloxacin 500 mg orally, 12-hourly
PLUS
clindamycin 600 mg orally, 8-hourly.
Continue antibiotic therapy for at least 5 days.
For severe limb- or life-threatening infection (systemic toxicity/septic
shock, bacteraemia, marked necrosis/gangrene, ulceration to deep tissues,
severe cellulitis, presence of osteomyelitis), use initially:
piperacillin+tazobactam 4+0.5 g IV, 8-hourly
OR
ticarcillin+clavulanate 3+0.1 g IV, 6-hourly.
For patients with penicillin hypersensitivity (see Table 2.2), use initially:
ciprofloxacin 400 mg IV, 12-hourly
or ciprofloxacin 750 mg orally, 12-hourly
PLUS EITHER
clindamycin 900 mg IV, 8-hourly (slow infusion required)
OR
clincomycin 900 mg IV, 8-hourly (slow infusion required).
Depending on the organisms subsequently isolated from deep tissue
specimens, other antibiotic combinations may be indicated. The duration of IV
treatment will depend on the response. Change to oral therapy as for mild to
moderate diabetic foot infection after substantial improvement. Continue
antibiotic therapy until there is evidence that the infection has resolved, but
not necessarily until the wound has healed. For patients with evidence of
osteomyelitis or septic arthritis, a longer duration of therapy is required
Antibiotic therapy can be ceased 2 to 5 days after amputation if the entire
infected bone is removed.
For further information on the management of diabetes see Diabetes:
diagnosis and principles of management, or for wound care see Leg ulcers
and wound healing.
37
Cellulitis - Single choice answer.
Cellulitis is defined as inflammation of the soft tissue and is characterised by
redness, heat swelling and pain.
No - No cellulitis.
or
Yes - cellulitis present.
If Yes, Measure the width of erythema from the ulcer edge to the thickest
border.
Please continue to next section; level of infection
Level of infection; Mild, moderate, systemic symptoms, or
MRSA
Classification
Signs and Symptoms
Mild
<2cm cellulitis
•
Moderate
>2cm cellulitis
•
•
•
•
Referred for medical review <24
hours
Amoxycillin/Clavulanate 875/125
oral BD
If there is non-severe penicillin
allergy or other contra-indication
Cephalexin 500mg Oral QID and
Metronidazole 400mg Oral BD
Other (Please write antibiotic
intervention, if known)
Systemic symptoms
Spreading cellulitis or suspect
osteomyelitis
(Probe to Bone)
•
Refer for potential admission
and/or parenteral antibiotics.
Refer: TGA antibiotic version
2010.
MRSA/ VRE or severe Penicillin
allergy
•
Patient has had positive wound
swabs that show MRSA/ VRE
OR
• Patient has severe Penicillin
allergy
CONTACT INFECTIOUS DISEASES
IMMEDIATELY for CONSULTATION
38
Off - loading Deformity
Off - loading Deformity (wound) - Single choice answer
Pressure is a causal factor for neuropathic foot ulcers.
Therefore the removal or relief from pressure should facilitate healing of foot
ulcers.
The removal of pressure on affected feet or joints can be achieved by
avoidance of weight bearing, known as off-loading.
Achieving effective off-loading of pressure on the foot while the patient
remains ambulant remains a challenge.
Yes - Off-loading of deformity required
No - No off-loading of deformity required
N/A - Not applicable or unable to assess
eg. Mr. X has a Charcot foot deformity and requires pressure off-loading.
Off-loading Deformity - Multiple choice answer
Please indicate off-loading intervention at time of visit and if further comments
please add to comments space provided.
Off-loading type
Total contact cast
Removable cast walker
Post-op shoe/foot
Insole/orthotics
Custom footwear
Depth/width footwear
Off/shelf footwear
Padding
Surgical repair
Definition
Plaster or fibreglass cast, midfoot to
knee contact cast
Full or ½ rocker sole boot such as an
aircast.
Half shoe such as the Darco
Custom or modified off the shelf
orthotic
Specific purpose custom made
footwear made to fit the patient’s foot
and accommodate deformities
Over the counter medical grade
footwear such as Propet, Drew.
Over the counter enclosed shoes or
sandals such as sports shoes
Semi compressed felt or poron
Surgical intervention such as
arthroplasty for bony prominence.
39
Comments
Extra space available for comments on off-loading or footwear
eg. Mr. X wears a total contact cast on his right foot and a custom shoe with
orthoses on his left foot
Footwear Optimum - Single choice answer
Footwear is optimum if it prevents injury, allows appropriate offloading if
required and encourages safe mobility.
Yes - Footwear optimum
No - Footwear not optimum
eg. Mr. X presents to the clinic wearing his sandals.
Additional Comments
This area is provided if there is any further intervention required or planned.
eg. Mr. X is complaining of having difficulty controlling his blood glucose
levels. He tells me that he has been having hypoglycaemic events during the
night.
Patient Education - Multiple choice answer.
Yes - Education given
No - No education give
N/A - Not available, unable to give education or determine
Please indicate topic of education given.
40
Foot Risk Status - Patient/carer given education on his/her risk status.
Blood Glucose Control - Patient/carer given education on maintaining blood
glucose control and/or referred to diabetes nurse educator or endocrinologist.
Daily Foot Checks - Patient/carer encouraged to check feet daily
Appropriate Footwear - Patient/carer educated about appropriate footwear
Ulcer Management - Patient/carer educated on ulcer management
Other - Patient/carer given education on other topic. Write extra information
comments box right of patient education.
Comments
Please add additional comments for example patient understanding or
response to education session or other topics of education.
For example: Mr. X has been given education today on his high risk status
and ulcer management. His carer has been advised to check his feet daily.
Treatment Plan
Write brief statement on short term and long term treatment goals.
Short Term
Short term goals are patient outcomes that are considered to be for a period
of less than 3 months.
Write a brief description of patients short term goals in the space provided and
additional information can be added to comments space provided.
Long Term
These long term goals are patient outcomes that are considered to be for
greater than 3 months.
Write a brief description of patients long term goals in the space provided and
additional information can be added to comments space provided.
Comments
Space provided for additional comments on short or long term goals.
41
Service Goal
Discuss short and long term treatment goals with the patient and/or carer.
Get the patient/carer to select the box that he/she does or does not agree and
understand the treatment plan.
Get the patient/carer to sign and date the service goal in the space provided in
the beginning of his/her treatment.
eg. Mr. X has a plantar ulcer on his PMA 1. His short term goal is for the ulcer
to heal and for him to be free from infection. His long term goal is to prevent
further re-ulceration. This is achieved though off-loading and patient
education.
Review and referrals
Write review period in the space provided
Write review appointment date in the box provided.
Request for specialist medical referrals should be directed through the
patient’s medical officer.
eg. Mr. X is returning to the clinic in 1 week. He is being reviewed on the 6th of
June 2011.
Hyperglycaemia - Single choice answer
If blood glucose levels are greater than 15mmols or HbA1c greater than 8%
then refer for education and further intervention to
Diabetes Educator - Nurse educator
GP - General practitioner
Endocrinologist - Specialist or physician
eg. Mr. X’s HbA1c is 10%. He has been referred to his endocrinologist
42
PAD/Ischaemia - Single choice answer
If patient was classified as having moderate or critical PAD indicate which
intervention was given.
Vascular surgeon
• Critical PAD
• Absent pulses + claudication/rest pain or ulcer.
• Toe pressure <30mmHg or ABI <0.4
HRFS
• Moderate PAD
• Toe pressure 30-70mmHg or ABI 0.4-0.7
eg. Mr. X has absent pulses and his toe pressure is 25mmHg.
He has been referred to the vascular surgeon
Painful Neuropathy - Optional choice answer
If the patient complains of neuropathic foot pain refer to the medical officer for
a medical pain review.
Yes - Tick box if patient requires a medication pain review
Other Referrals - Multiple choice answer
Orthopaedic surgeon
Infectious disease consultant
Other - Write additional comments in space provided
eg. Mr. X has a Charcot foot deformity with a plantar ulceration. The wound
swab shows MRSA. He has been referred to an orthopaedic surgeon and the
infectious disease consultant for a review. Mr. X has ESRF (end stage renal
failure) and needs to see a renal specialist also.
Other referrals
x
Orthopaedic Surgeon
x Infectious disease consultant x Nephrologist
Tests - Multiple choice answer
•
•
•
•
X-ray
Bloods
Swab/pathology
Other
43
Signing Off
•
•
•
•
•
Print clinicians name.
Designation of clinician eg. Podiatrist
Assessor sign in the box provided.
Write date patient is being assessed for example today’s date.
Retain this form in clinical records.
eg. Jill Anderson is the podiatrist assessing Mr. X on the 6th of June 2011.
44
Appendix A Diabetic Foot Infections; Therapeutic Guidelines Australia
Antibiotics 2010.
Diabetic foot infections are often worse than they appear and should always
be regarded as serious.
Acute infections in patients who have not recently received antimicrobials are
usually due to Staphylococcus aureus and streptococci. Chronic infections are
often polymicrobial, including Gram-positive and Gram-negative aerobes and
anaerobes.
Culture of tissue specimens obtained by biopsy or aspiration may guide
therapy.
For uninfected ulcers, cultures are unnecessary and antibiotic therapy
should be avoided.
Assess vascular supply and consider underlying osteomyelitis or septic
arthritis. Surgical debridement is often necessary and antibiotic therapy
should be effective against the mixed aerobic and anaerobic organisms
frequently responsible.
For mild to moderate infection with no evidence of osteomyelitis or septic
arthritis, use:
amoxycillin+clavulanate 875+125 mg orally, 12-hourly
OR
cephalexin 500 mg orally, 6-hourly
PLUS
metronidazole 400 mg orally, 12-hourly.
For patients with penicillin hypersensitivity (see Table 2.2), use:
ciprofloxacin 500 mg orally, 12-hourly
PLUS
clindamycin 600 mg orally, 8-hourly.
Continue antibiotic therapy for at least 5 days.
For severe limb- or life-threatening infection (systemic toxicity/septic
shock, bacteraemia, marked necrosis/gangrene, ulceration to deep tissues,
severe cellulitis, presence of osteomyelitis), use initially:
piperacillin+tazobactam 4+0.5 g IV, 8-hourly
OR
ticarcillin+clavulanate 3+0.1 g IV, 6-hourly.
For patients with penicillin hypersensitivity (see Table 2.2), use initially:
ciprofloxacin 400 mg IV, 12-hourly
or ciprofloxacin 750 mg orally, 12-hourly
45
PLUS EITHER
clindamycin 900 mg IV, 8-hourly (slow infusion required)
OR
clincomycin 900 mg IV, 8-hourly (slow infusion required).
Depending on the organisms subsequently isolated from deep tissue
specimens, other antibiotic combinations may be indicated. The duration of IV
treatment will depend on the response. Change to oral therapy as for mild to
moderate diabetic foot infection after substantial improvement. Continue
antibiotic therapy until there is evidence that the infection has resolved, but
not necessarily until the wound has healed. For patients with evidence of
osteomyelitis or septic arthritis, a longer duration of therapy is required
Antibiotic therapy can be ceased 2 to 5 days after amputation if the entire
infected bone is removed.
For further information on the management of diabetes see Diabetes:
diagnosis and principles of management, or for wound care see Leg ulcers
and wound healing.
46
References
Aboriginal and Torres Strait Islander definitions
www.health.qld.gov.au/atsihealth
Australian Wound Management Australia
http://www.awma.com.au
Baker IDI Heart and Diabetes Institute, Draft guidelines for secondary prevention of
vascular disease in type 2 diabetes. 13 May 2011
Http: //t2dgr.bakeridi.edu.au
Baker IDI Heart and Diabetes Institute, Type 2 complications guideline and technical
report approved by NHMRC, 6th April 2011.
http: //t2dgr.bakeridi.edu.au
Carville K, 2007, Wound Care Manual, 5th Edition, Silver Chain Foundation, Australia.
Centre for Healthcare Improvement, MRAT – Templates for Measurement for
Improvement Indicator Development, Version 2.0.
Diabetes Australia
www.diabetesasutralia.com.au
Grey at al. 2006, ABC of wound healing wound assessment, BMJ, 332(7536): 285.
www.bmj.com/content/332/7536/285.full.pdf
International Working Group on the Diabetic Foot
www.iwgdr.org/
Inter-Society Consensus for the Management of PAD (TASC II) guidelines. Published
January 2007
www.tasc-2-pad.org
National Heart foundation
www.heartfoundation.org.au
NHS - National Institute for Health and Clinical Excellence, Diabetic Foot Problems.
www.nice.org.uk
Therapeutic Guidelines Australia: Antibiotics version 14, 2010
https://online-tg-org-au.ckn.dotsec.com/lp/
47