Project Background - Sunderland Clinical Commissioning Group



GP Promotional PackSunderlandNon-complicated Cellulitis PathwayFor Patients aged 18 and over(Eron’s Class II)Revised Version following Improvement EventApril 2016Project BackgroundCellulitis is a common painful skin infection, usually bacterial. Patients suffering from cellulitis can be treated with oral antibiotics, although many patients suffering from cellulitis require administration of intravenous (IV) drugs and a hospital admission.The infection most commonly affects the skin of the lower leg but can infect skin in any part of the body, usually following an injury to the skin. Cellulitis can affect people of all ages, including children; rates are thought to be roughly similar in both sexes. Known risk factors for cellulitis include:Having a weakened immune systemLymphoedemaIntravenous drug misuse (injecting drugs such as heroin)The development of a primary care cellulitis pathway for Sunderland avoids the need for A&E attendances or hospital admissions for a clearly defined group of patients. As well as patients attending A&E having their follow up within or by their local practice rather than an emergency care setting. Service OutlineThis service will target all patients registered with a Sunderland GP who meet the referral criteria for treatment of non complicated cellulitis accordingly to Eron’s Class II in the community. The decision to treat the patient in the community will be made by the referring clinician either GP, GP Out of Hours, GP led WiC or ED.A team of appropriately skilled community based nurses from Community Health Services (Recovery at Home Team) will administer IV medication in patient’s homes to prevent admission to hospital. The service will be available 24 hours a day, 7 days a week.The service aims to:Reduce emergency admissionsReduce the risk of healthcare associated infectionsIncrease the level of care being delivered in the patient’s homesIncrease patient independenceIncrease partnership with patients (through them having involvement in care planning, e.g. timing of administration)Deliver cost savings, by preventing admissions to secondary careService DescriptionThe Recovery at Home Team will provide a community based service to a clearly defined group of patients who are suffering from Eron’s Class II cellulitis, in their own homes.If the patient meets the referral criteria for this service, they are referred to the Recovery at Home Team by the appropriate clinician using the identified referral documentation.Referrals to the Recovery at Home Team should be made by phone to the Recovery at Home Hub, and backed up by the relevant referral documentation, which is to be faxed to the Recovery at Home. The team will accept referrals for adults over the age of 18, the Recovery at Home team will carry out a routine risk assessment and the referring GP should alert the team of any known risk factors upon referral.The Recovery at Home Hub will take all relevant patient information during the initial telephone referral that is required for the Recovery at Home team to visit (Appendix 2). If routine bloods, swabs or investigations are required the Recovery at Home Team will carry out at time of cannulation, which are dependent upon the drug treatment. The GP will flag any anomalies with the blood or swab results for necessary action/treatment to be taken by the Recovery at Home team. During OOH periods (Friday – Sunday) the Recovery at Home team will check patient blood results and liaise with the GP OOH service as necessary to ensure seamless care 24 hours a day, 7 days a week.The GP Receptionist will fax the drug treatment card to the Recovery at Home Team, then give the treatment card to the patient to take home to share with the Recovery at Home Team when they visit. The Receptionist will make the 48hour review appointment, document this on the patient leaflet and give this to the patient (Appendix 4). If this falls on a weekend the appointment will be made with the Recovery at Home GP.Patients should be given their information leaflet and drug treatment card identifying the relevant drug prescribed for the patient; they can then share this with the Recovery at Home Team when they visit.If the referral is received from secondary care the Recovery at Home Team will visit to administer treatment. The ED/UCC or Recovery at Home Team will contact the surgery to arrange the review appointment for 48hours after commencement of treatment.The Recovery at Home Team will contact the patient within four hours of receipt of referral to confirm with the patient a suitable timescale for first contact and treatment to commence.IV drugs will be prescribed by the referring clinician and administered under an agreed drug protocol. IV Drugs will be supplied by the Recovery at Home service.While the patient is undergoing IV therapy they will remain the clinical responsibility of the referring clinician, but the drugs will be administered by the Recovery at Home Team. The drug protocols will clearly specify the responsibilities towards the patient, of each stakeholder in the service. During treatment the patient will be regularly monitored by the Recovery at Home Team. If RAH are unable to recannulate in community setting the member of staff is to refer to Pallion UCC and only if the patient is house bound to refer to NEAS. The team will liaise with the referring clinician, highlighting if the patient is not responding to treatment; or if the patient has responded and needs to be transferred to oral antibiotics. The decision to move from IV to oral antibiotics will be made by the patient’s referring clinician in liaison with the Recovery at Home Team.Please see the detailed pathway described in Figure 1 overleaf.Figure 1Emergency Care DirectorateGP/GP Led UCC/OOHsExclusionsDiagnose cellulitis Eron’s Class IIConsider sepsis sepsis pathwayPrescribe drugs on hospital drug chartIV cannula administer first doseDischarge patient to care of RAH TeamDischarge include drugs/drug chartIn hours, review appointment at GP Practice to be made by ED Staff; OOH’s, arrange review appointment with RAHInformation leaflet including time of RAH visitDiagnose cellulitis Eron’s Class IIConsider sepsis admit to EDIdentify suitability for community IV ABx (see exclusion criteria)Discuss community pathway with patientTelephone RAH Team with relevant patient information or to discuss pathwayComplete Drug Treatment RecordArrange 48 Hr review appointmentGive patient information leafletExclusion criteria;IVDUFacial cellulitisPregnancy / breastfeedingKnown or suspected MRSA colonizationUnder 18 years of ageIf bilateral symptoms reconsider diagnosis of cellulitis288099412160474676012192028743273102928573627230705434604067160369413274671603694288988566103531565852002790NOArrange hospital admission using standard admissions proforma0NOArrange hospital admission using standard admissions proforma-57152002790YESReceptionist/GP fax Drug Treatment Record to RAH Team00YESReceptionist/GP fax Drug Treatment Record to RAH Team-5715993140RAH Team co-ordinator ensures referral meets criteria for acceptanceRAH Team co-ordinator ensures referral meets criteria for acceptance-5715173990Telephone RAH Team Co-ordinator0Telephone RAH Team Co-ordinator57359551403352286041910RAH Team contact patient within 4 hours of receipt of referral to discuss time of visit. RAH Nurse will obtain IV antibiotics from stock.00RAH Team contact patient within 4 hours of receipt of referral to discuss time of visit. RAH Nurse will obtain IV antibiotics from stock.2483167111132286047625First Visit by RAH TeamDiscuss care to gain consentCannulateAdminister drugsProvide patient information leaflet with contact detailsSchedule next visit00First Visit by RAH TeamDiscuss care to gain consentCannulateAdminister drugsProvide patient information leaflet with contact detailsSchedule next visit57353201549405734685125730424402210382324431621038236334121133483547110160020Deterioration * Discuss with referrer if appropriate or admit directly to hospital.CONSIDER ambulatory care between 7.30am and 10pm weekdays and 7.30am to 8pm weekends00Deterioration * Discuss with referrer if appropriate or admit directly to hospital.CONSIDER ambulatory care between 7.30am and 10pm weekdays and 7.30am to 8pm weekends1765935160020Ongoing review * Planned and unplanned according to patient’s needs00Ongoing review * Planned and unplanned according to patient’s needs22860151130Responsiveness to treatment *Referrer will review after 48 hrs or if over a weekend RAH GP will review. RAH Team to discuss progress.If no improvement after 48 hrs CONSIDER discussion with microbiologyIf no improvement after 72 hrs MUST liaise with microbiologist0Responsiveness to treatment *Referrer will review after 48 hrs or if over a weekend RAH GP will review. RAH Team to discuss progress.If no improvement after 48 hrs CONSIDER discussion with microbiologyIf no improvement after 72 hrs MUST liaise with microbiologist57340509144035471102762885Patients who RAH unable to cannulate:Housebound patient -contact NEAS (ANP). 00Patients who RAH unable to cannulate:Housebound patient -contact NEAS (ANP). 5380355934085573246274834816046452383790228602763520Discharge00Discharge Diagnosis of CellulitisGP or medical practitioner will carry out clinical assessment; including risk factors and full patient history to establish diagnosis and Erons classification II cellulitis. Eron’s classification system can be found in Appendix 1.Clinical features of cellulitis are3:Acute and progressive onset of red, painful, hot, swollen and tender skin with possible blister or bullae formation, usually unilateralFever, malaise, shivering and rigors may precede or accompany the skin changesSpreading lymphangitis in severe casesCause usually identifiable (such as laceration, burn, bite, leg ulceration, eczema). Differential diagnosis are identified in table one.Table OneCommonRareVaricose eczemaDVTAcute goutGangreneCarcinomaErisipeloidesNecrotising fasciitisAcute lipopsclerosisVasculitisPyoderma gangrenosum4409440673100012268204127500358521012700Bilateral Varicose Eczema00Bilateral Varicose Eczema51816012700Typical CellulitisTypical CellulitisPatient assessment to include the following, erythematous edges should be marked with indelible ink pen to allow subsequent clinical assessment of progress by the Recovery at Home Intermediate Care Team.:TemperatureBlood pressureHeart RateRespiration RateOxygen Saturation on airPatient weight if availableInvestigations to include the following, initial investigations will be carried out by the Recovery at Home Intermediate Care Team at the patient’s first home visit:FBC/U&E/LFT/CRP/Glucose/INR (if applicable) and routine swab if skin is broken or blistering this is dependent upon patient needs and GP clinical judgementPatients suitable and unsuitable for the pathway are identified in table two. Table TwoSuitableUnsuitableAdults with uncomplicated cellulitis (Eron’s Class II)Any patient who, on assessment, can be safely treated at homeIV drug usersFacial/ periorbital cellulitisPregnancy/breastfeedingKnown or suspected colonisation/infection with MRSAWhether to prescribe oral or intravenous antibiotics will be a matter of clinical judgement. IV antibiotics should be considered for patients with:Marked cellulitis (more than mild localised but not extensive)Mild systemic - features (e.g. Flu-like symptoms, malaise) but not unwellStable co-morbidity such as peripheral vascular disease, chronic venous insufficiency or morbid obesity which may complicate or delay resolution of their infectionCellulitis not improved on oral therapyTreatmentFollowing diagnosis of Class II cellulitis according to Eron’s classification, patients suitable for the pathway should be referred to the Recovery at Home Team for treatment in the community. The three options of recommended IV treatments depending upon patient risk are outlined in Table 3.Table 3No particular risk of C.difficile infectionCDI within past 12 months or living in nursing home or otherwise deemed at high risk by the prescriberNo allergies or other contra- indicationsCeftriaxone IV*1-2g once dailyUnder 80kg 1g, over 80kg 2g per dayReview the morning after the second dose or next working day to decide whether to orally switch or continueOral switch after 48/72 hours to Flucloxacillin (Complete 7 day course)Flucloxacillin IV*1-2g 6 hourlyReview with the 7th or 8th dose to decide whether to orally switch or continueOral switch after 48/72 hours to Flucloxacillin (Complete 7 day course )Allergic to cephalosporins or anaphylactic to penicillinsClindamycin IV*600mg 6 hourlyReview with the 7th or 8th dose or the next working day to decide whether to orally switch or continue.Oral switch to Clindamycin 300mg qds (Complete 5 day course)Not suitable for the pathway** Doses may need to be modified in light of renal function, liver function or extremes of body weightDrug cards can be found as Appendix 3.Intravenous to oral switch; patients should be reviewed at 48 hours or the next working day if at a weekend and if possible switch to oral preparations, suggested criteria are:Pyrexia settlingErythema settlingFalling inflammatory markers if availableAny co-morbidities stabilizedIf the patient has not improved at the time of review hospital referral should be consideredManagement of Healthcare Associated InfectionsThe list below outlines advice for GP and Recovery at Home Team to minimise the risk of C.difficile in the community:Nurse and GP to liaise following patients first symptoms of diarrhoeaTest for C difficile and treat according to local guidelines if positiveReview all antibiotic treatment if applicableReview and stop gastric acid suppressant therapy if applicableDo not prescribe antimotility medicationEvaluation of PathwayThe following monitoring arrangements will be put in place to ensure the pathway is operating as planned:Cellulitis activity data will be collected and monitored quarterly at the Project Group Meetings to inform the key metrics below:Number of referrals and from Sunderland GP’s to CHS A&ENumber of admissions from Sunderland GP’s to CHSNumber of referrals to Recovery at Home TeamNumber of inappropriate referrals to Recovery at Home Team ie. Class I,111 & IVNumber of patients switched to oral medication within 72 hoursNumber of referrals from CHS A&E department to Recovery at Home TeamAny evidence of patients on the pathway who have developed C difficileNumber and range of antibiotics prescribedIdentify the number of practices operating the pathway ContactsIf you have any queries or require any information relating to this project please don’t hesitate to contact:NameDesignationContact DetailsNatalie McClarySunderland CCG0191 5128456Natalie.mcclary@Dr Tracey LucasSunderland CCG0191 5128456tlucas@Appendix 1Eron’s Severity Classification SystemEron LJ (2000) 4devised this classification system of skin and soft tissue infections to aid the GP/Nurse diagnosis, treatment and admission decisions. Once a diagnosis of lower limb cellulitis has been made a decision should be made as to admission/treatment options according to the following classification system. Please see Figure 2:Class IPatients have no signs of systemic toxicity, have no uncontrolled co-morbidities and can usually be managed with oral antimicrobials.Class IIPatients are either systemically ill or systemically well but with a co-morbidity such as peripheral vascular disease, chronic venous insufficiency or morbid obesity whichmay complicate or delay resolution of their infection.Class IIIPatients may have a significant systemic upset such as acute confusion,tachycardia, tachypnoea and hypotension or may have unstable co-morbidities that may interfere with a response to therapy or have a limb threatening infection due to vascular compromise.Class IVPatients have sepsis syndrome or severe life threatening infection such as necrotizing fasciitis.Clinical findings alone are usually adequate for diagnosing cellulitis, particularly in non-toxic immunocompetent patients.Figure 2Treatment in the communityHospital AdmissionsEron’s Class I Oral FlucloxacillinEron’s Class IIIV antibioticsEron’s Class IIIEron’s Class IVAppendix 2Telephone Referral InformationPatient DemographicsName:Address:Telephone Number:D.O.B.GP Practice DetailsName of Referrer:GP Practice:Telephone Number:Reason for ReferralErons classificationBPTempHeart RateRespiratory RateOxygen Sats on airPast Medical HistoryAllergiesRoutine Investigations requiredAppendix 3Drug Therapy Record – Community Nursing RecordPatient Name:GPDate of BirthNHS Number:Address:GP Address:Patient Telephone NumberHome:GP Telephone Number:Work:MobileOther cards in use:AllergiesAll drugs and changes of drug therapy to be recorded before administration by nursing staffRegular PrescriptionsDateDrug Name, Strength and PreparationDoseRouteFrequencyAdditional instructionsPrescriber’s Name (PRINT) and SignatureDate DiscontinuedCeftriaxone injection1gIV bolusOnce dailyReconstitute the vial with 10ml water for injection according to the IV guide and administer as bolus over 2-4 minutesCeftriaxone injection2gIV infusionOnce dailyReconstitute the vial with 40ml sodium chloride 0.9% and infuse over 30 minutesClindamycin injection600mgIV infusionEvery 6 hrsPrepare the clinidamycin infusion according to the IV guide and administer Infusion over 20-30 minutes foreach 600mg of clindamycinFlucloxacillin injection1gIVEvery 6 hrsReconstitute the vial according to the IV guide and administer as bolus over 2-4 minutesSodium chloride 0.9%5mlIVBefore and after antibioticFlush the line with 5ml sodium chloride 0.9% before and after administration of antibioticAppendix 4Cellulitis and Intravenous Antibiotics: Having your Treatment at HomeYou have been given this leaflet because your doctor/practitioner has seen you and diagnosed cellulitis. The doctor/practitioner has prescribed intravenous antibiotic treatment for you to be given at home. The doctor has referred you to the Recovery at Home Team who will contact you at your home within 4 hours to arrange to visit. Their telephone number is 5616666 fax number 5536928What is cellulitis?Cellulitis is an infection of the deep layer of skin [dermis] and the layer of fat and tissues just under the skin [the subcutaneous tissues]. It is generally caused by a break in the skin that has allowed bacteria [germs] to get into and under the skin. Various types of bacteria can cause cellulitis.What is the treatment for cellulitis?A course of antibiotic tablets will often clear cellulitis but sometimes, as in this case, more is needed and intravenous antibiotic treatment is needed. This is where the antibiotic is injected into a vein.You will be contacted by the Recovery at Home Team who will visit you at your home. They will bring the intravenous antibiotics with them to administer at each visit. The Recovery at Home Team will visit twice daily to monitor condition and administer your medications.Your doctor will review you after 48 hours of treatment. This has been arranged for you on-------------------------------------- at ----------------------------------You should contact the Recovery at Home Team (or your doctor) sooner however if the area of infection continues to spread or you become worse after you start your antibiotic treatment.The nurse from the Recovery at Home Team will provide you with a full information leaflet so that you can monitor your symptoms and treatment but things you need to know about now are:some patients may develop diarrhoea; this can occur up to 2-3 weeks after finishing treatment, you should tell the Recovery at Home Team nurse or contact your doctor if you develop diarrhoeaelevating (raising) the affected body part uses gravity to help prevent excess swelling, which may also ease painpainkillers such as paracetamol or ibuprofen can ease pain and reduce fever and make you feel generally more comfortableusing a moisturiser cream and soap substitute on the affected area of skin until it heals to help prevent the skin from becoming dry and damageddrinking plenty of fluids helps prevent dehydration and can make you feelgenerally more comfortableyou may need a tetanus booster vaccination / human tetanus immunoglobulin if you have had dirty cut or wound and your tetanus injections are not up-to-dateYou should contact your nurse or doctor for advice immediately if you notice any of these symptoms.Pain 'out of proportion' to the look of the skin changesFeeling unwell and becoming ill 'out of proportion' to the look of the skinSymptoms that get worse rapidly - either skin symptoms, or how you feel generallyAffected skin that goes dusky, purple or blistering ................
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