STRIDE: Strengthening Total Contact Casting for Regional Implementation and Diabetic Foot Equity

Overview

Initiative type

Service Improvement

Status

Deliver

Published

June 2025

Summary

Enhancing diabetic foot ulcer (DFU) healing by introducing instant total contact casting as a  practical offloading solution in regional North Queensland.

Key dates

1 August 2024 -

Facilities implemented: Townsville University Hospital

Aim

To improve access to gold-standard offloading for diabetes-related foot ulcers in regional  Queensland through the implementation of instant total contact casting.

Outcomes

  • 30 plantar DFUs successfully offloaded since iTCC implementation began in August 2024.
  • 44% of ulcers fully healed by the last recorded use of iTCC.
  • 60% of podiatry staff at Kirwan actively participating in iTCC application.
  • No reported adverse events or major complications.
  • Improved clinician confidence and skill in evidence based DFU  management.
  • Increased access to gold-standard offloading without referral to tertiary hospital.

Background

Diabetes-related foot ulcers (DFUs) are one of the most serious and costly complications  of diabetes, contributing to prolonged hospitalisations, lower limb amputations and reduced quality of life (McDermott et al., 2023). In Australia, diabetes management costs the health system an estimated $1.6 billion annually (AIHW, 2024).

A central component  of effective DFU treatment is pressure offloading—yet evidence-based offloading interventions remain under-utilised, particularly in regional settings (Raspovic & Landorf, 2014) National and international guidelines recommend non-removable knee-high offloading devices as the gold-standard treatment for non-ischaemic plantar DFUs, due to their superior healing outcomes and improved adherence (Lazzarini & Jarl, 2021; Bus et al., 2024).

However, data from North Queensland suggests widespread underuse. A multi-site  audit revealed that no regional Hospital and Health Service achieved more than 40% adherence to gold-standard offloading. In Townsville, the rate was just 12.5%. At Kirwan Health Campus, a community-based podiatry service in Townsville, no gold-standard offloading  had been routinely available prior to 2024. Patients requiring total contact casting were referred to the tertiary hospital, resulting in treatment delays, travel-related costs, and lower adherence. For many patients, particularly those living on fixed incomes  or without reliable transport, this created a significant barrier to timely care—widening the gap in outcomes between metropolitan and regional populations.

To address this inequity, Instant Total Contact Casting (iTCC) was introduced in July 2024. iTCC is  a modified technique that renders a removable knee-high walker irremovable using casting materials and sports tape. This approach preserves the therapeutic efficacy of traditional Total Contact Casts (TCCs) while requiring significantly less time, fewer resources,  and no specialist casting skills. These characteristics make iTCC especially well-suited for regional and rural podiatry services with limited staffing and infrastructure. Prior to implementation, a qualitative study was undertaken with ten podiatrists and  podiatry assistants at Kirwan Health Campus. Semi-structured interviews explored perceived barriers and enablers to iTCC adoption. While concerns about time constraints, sustainability, and limited high-risk foot exposure during university training were raised,  participants expressed strong motivation to upskill and improve care. Staff recognised that iTCC would reduce travel burdens, improve healing rates, and support best-practice care delivery within their local service.

The introduction of iTCC at Kirwan was  not only a response to clinical need—it also represented a strategic opportunity to strengthen the regional workforce, improve service delivery, and enhance health equity. By enabling community-based application of gold-standard DFU offloading, iTCC supports  key priorities of the Queensland Health Rural and Remote Health Service Strategy, including the reduction of avoidable hospitalisations and the promotion of value-based care. This project sought to test whether iTCC could be sustainably implemented in  regional settings.

Methods

The project began with the development of a structured Instant Total Contact Cast (iTCC)  protocol, tailored to the needs of a regional health service. This protocol included a clinician-designed manual and visual aids to ensure consistency in practice. Implementation was led by a podiatrist, with support from a senior Allied Health Research Fellow.

To assess readiness and shape implementation, semi-structured interviews were conducted with ten podiatry staff members. These interviews explored perceived barriers, enablers, and practical considerations surrounding iTCC adoption. Key concerns included time
constraints, confidence in casting skills, and the need for clinical champions. Enablers included strong motivation to deliver best-practice care, a high level of awareness of national guidelines, and team-wide enthusiasm for innovation. These findings directly  informed training strategies and sustainability planning. Staff training was delivered through hands-on workshops, peer mentoring, and shadowing opportunities, supported by a structured competency checklist. A formal rollout commenced at Kirwan Health Campus  in July 2024, aiming to embed iTCC into routine care for patients with non-ischaemic plantar diabetic foot ulcers (DFUs). The implementation approach featured staff engagement, skill development using visual workflows, team debriefs for ongoing support, and  integration of iTCC into standard practice—removing the need for tertiary referrals. Evaluation is ongoing and includes both clinical and workforce outcomes. Clinical metrics being monitored include the number of DFUs treated, healing rates, and adverse events.

Workforce outcomes include the number of staff trained, confidence post-training, and service adoption. Informal feedback has also been gathered from patients to assess satisfaction with the intervention and its usability in daily life. Although full data analysis is underway, early evidence of success is emerging. Clinician uptake currently exceeds 60%, several DFUs have healed successfully using iTCC, and no major adverse events have been reported. These early results support the intervention’s feasibility, safety, and relevance in a regional health setting with resource constraints. The implementation was underpinned by principles of implementation science, specifically the Consolidated Framework for Implementation Research (CFIR). CFIR was used to guide interview  design, structure staff training, and shape the framework for post-implementation reflection and evaluation. This ensured that both contextual and behavioural factors influencing uptake were addressed throughout the process. The use of CFIR has also helped  identify lessons learned that may inform the adaptation of this model across other Hospital and Health Services in Queensland.

Discussion

The successful implementation of Instant Total Contact Casting (iTCC) at Kirwan Health  Campus was underpinned by several key enablers. Foremost among these was strong staff motivation to improve outcomes for people with diabetes-related foot ulcers (DFUs). Clinicians were eager to provide gold-standard care, and the presence of change champions  within the podiatry team helped build early momentum. Senior podiatrists and allied health assistants played critical roles in translating the intervention into routine practice, supported by strong leadership engagement across the service. Training and practical  support were central to success.

The development of a clinician-led iTCC instruction manual, combined with hands-on training, peer mentoring, and a shared competency framework, built staff confidence and consistency. Establishing a clear, shared definition  of what constitutes an iTCC was essential to reduce variation and ensure patient safety. Integrating training into existing clinical routines also helped reduce the perceived burden of change.

The project faced key challenges. Time constraints and concerns  about sustainability, particularly due to workforce turnover, were raised during early consultation. To address this, training was extended beyond a single “expert,” with all podiatry clinicians and key allied health assistants achieving competency. This distributed  capability helped embed iTCC into the team culture and reduced the risk of skill loss, improving service resilience. Initially, iTCC was perceived as time intensive. However, once integrated into workflow, clinicians reported that it did not add significant  burden. In fact, because iTCC led to faster healing and fewer clinic visits, it reduced overall service demand over time—demonstrating value beyond individual patient care. Delivering this intervention in a regional setting presented both challenges and opportunities.

Many DFU patients in North Queensland face substantial barriers accessing gold-standard care at the tertiary hospital—including travel costs and logistical challenges. Local provision of iTCC removed these barriers, improving both clinical outcomes and health  equity. Patients were more willing to engage in care when it was delivered close to home. Importantly, this model is scalable. Because iTCC uses a simplified method and standard clinical materials, it can be delivered in any Queensland Health High-Risk Foot  Clinic—even those without access to orthotic or plaster technicians. The next phase will expand implementation to rural sites within Townsville Hospital and Health Service, including Ayr, Charters Towers, Ingham, and Hughenden. Allied Health Assistants will  be trained to apply the device under podiatrist supervision using telehealth—a scalable workforce solution. A funding application has been submitted to OCAHO to support this expansion.

Lessons learned include:

  • change champions are essential to momentum
  • protocols and hands-on training must accompany new interventions
  • sustainability requires shared capability—not reliance on individuals
  • regional models must prioritise access and equity alongside clinical outcomes.

References

Australian Institute of Health and Welfare. (2024). Diabetes: Australian facts. https://www.aihw.gov.au/reports/diabetes/diabetes

Bus, S. A., Armstrong, D. G., Crews, R. T., Gooday, C., Jarl, G., Kirketerp-Moller, K., et al. (2024). IWGDF guidelines on offloading foot ulcers in persons with diabetes: 2023 update. Diabetes/Metabolism Research and Reviews, 40(3), e3647. https://doi.org/10.1002/dmrr.3647 Lazzarini, P. A., & Jarl, G. (2021). Knee-high devices are gold in closing the foot ulcer gap: A review of offloading treatments to heal diabetic foot ulcers. Medicina (Kaunas, Lithuania), 57(9), 941. https://doi.org/10.3390/medicina57090941 McDermott, K.,

Fang, M., Boulton, A. J. M., Selvin, E., & Hicks, C. W. (2023). Etiology, epidemiology, and disparities in the burden of diabetic foot ulcers. Diabetes Care, 46(1), 209–221. https://doi.org/10.2337/dci22-0043 Raspovic, A., & Landorf, K. B. (2014). A survey  of offloading practices for diabetes-related plantar neuropathic foot ulcers. Journal of Foot and Ankle Research, 7, 35. https://doi.org/10.1186/s13047-014-0035-8

Key contact

Ife Tokun

Senior Podiatrist

Townsville Hospital and Health Service

Email:  ife.tokun@health.qld.gov.au

Last updated: June 2025

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