20,000 Days Campaign
Learning Session 3
11-12 March 2013
Cellulitis and Skin Infections Team
Dr Vanessa Thornton
Dr Adrian Trenholme
Sarah Hyder (POAC)
Debbie Hailstone
Karla Rika-Heke
Jodie Reynolds
Dr Andrew Connolly
Alex Boersma
Dr Jennifer Njenga (GP)
Olivia Woodman
Kate Moodebe (Localities)
Maika Kinahoi-Veikune
Project Manager:
Improvement Advisor:
Monique Davies
Ian Hutchby
Dr David Holland
Heather Lewis
Louise McCarthy (GAIHN)
Adrienne Batterton
Peggy Williams
Anna Lee
Aim & Direction
Initial Aim:
•
Reduce the number of bed days used for patients with cellulitis by 5-10%
•
Primary care prevention to prevent patients developing cellulitis
•
Treating as many patients early in the community as possible
•
Streamline the care of patients admitted to hospital with cellulitis to reduce variation
•
Reduce the length of stay in hospital using POAC to facilitate early discharge
•
Streamline the care and treatment of patients presenting with abscesses
From our work over the past 8 months, the group has re-focused its direction into three
key work streams
1.
2.
3.
Clinical Nurse Specialist support for inpatients with serious skin infections
EC TADU and POAC working together with the CNS to manage non complex cellulitis and
abscess
Prevention and management of serious skin infections in the community (20,000 Days
Campaign Application for Phase 2 )
Driver Diagram
primary
Secondary
Concept
Patient
knowledge of
Cellulitis/abscess
Patient information leaflet
Patient Education
Prevention
intervention
Patient
compliance to
treatment
Raise community awareness
of causes and treatment
Improve health literacy of at
risk patients/families
Identification of
high risk families
Access to GPs
Provision of POAC for treatment
Early treatment in
the community
Reduce the
number of bed
days used for
patients with
cellulitis and
abscesses by
10% by 1 July
2013. By
reducing
presentations and
average length of
stay
Electronic referral to POAC
Ease of access to
POAC
POAC option in EDS
Consistent
treatment
Standardisation
End to end cellulitis pathway
(primary -> secondary -> primary)
End to end Paediatric cellulitis
pathway
Effective/efficient
hospital Care
Pre-operative inpatient stay
(abscess)
Identification of
recurrent
Management of
recurrent
Cellulitis
Use of TADU for pre-operative
abscess patients
POAC report identifying frequent
attenders
ID Outpatient clinic
Treatment of
recurrent
Simple referral process to ID Clinic
Change Concepts
Change Concept 1: Manage Variation
Standardisation of care (create standardised process for patients with simple cellulitis )
Provision of oral antibiotics to assist with compliance issues
Adherence to clinical pathways and involvement in the development of the regional cellulitis and
skin infection clinical pathway (completed December 2012)
Change Concept 2: Improve Workflow
Worked with Pharmacy to develop patient take home oral antibiotics packs
Patients followed up in the community utilising POAC
Reduce the length of stay in hospital using POAC to facilitate early discharge
Facilitated simplified POAC referral process for staff to encourage referrals to community care
Change Concept 3: Use of a Co-ordinator
CNS appointed for soft tissue infections in Surgery (General Surgery, Plastics, Ortho)
Enhance the relationship between carer and patient to:
Improve understanding of cellulitis and the required treatment regime
Focus on the outcomes for patients to reduce re-admissions and earlier treatment of
recurrent cellulitis
Facilitating early discharge
Nurse led follow up
Change Packages
Secondary
Drivers
Standardisation of
care
Change Ideas Tested




Improving Workflow
Evidence of
Improvement
(Run Charts)
creating a standardised process for patients with
simple cellulitis
provision of oral antibiotics to assist with compliance
issues
involvement in the development of the regional
cellulitis and skin infection clinical pathway
(completed December 2012)
adherence to clinical pathways
EC TADU and POAC working together with the
support of the CNS to manage patients with non
complex cellulitis and abscess
Number of patients sent to POAC or TADU by
CNS
4
3
2
1
28/01/2013
21/01/2013
14/01/2013
07/01/2013
31/12/2012
24/12/2012
17/12/2012
10/12/2012
03/12/2012
26/11/2012
0
Week Commencing
Number of patients seen per week by CNS
18
16
14
12
10
8
6
4
2
Week Commencing
28/01/2013
21/01/2013
14/01/2013
07/01/2013
24/12/2012
17/12/2012
10/12/2012
03/12/2012
0
26/11/2012
•improve understanding of cellulitis and the required treatment
regime
•focus on the outcomes for patients to reduce re-admissions
•earlier treatment of recurrent cellulitis and referral to ID
Outpatient Clinic
•Facilitating early discharge using POAC if appropriate
•SWITCH programme (IV antibiotics to oral antibiotics)
19/11/2012
Use of a Coordinator
Most Successful PDSA Cycles?
Appointment of Soft Tissue Nurse
Heather Lewis has been working in this 20,000 Days funded role since November 2012
and is working within surgical wards managing the care for patients with complex cellulitis
and with emergency care staff to ensure that patients with simple cellulitis are more
appropriately managed in the community
Cellulitis Brochure
Development of our brochure (tested prior to use with families in emergency
Care waiting room) and following completion of the final version, a subsequent request
from the Auckland regional group for the brochure to be used with the regional clinical
pathway for cellulitis and skin infection
Take Home Packs of Oral Antiobiotics
Healthy Skin packs including information and take home oral antibiotics for patients
meeting defined criteria with simple cellulitis
Measures Summary
Implementation
Implementation
Areas
Changes to Support
Implementation
PDSA cycles
Ensure compliance with pathway in secondary
care
Group’s involvement in the development of the
regional Cellulitis and Skin Infections Pathway
Debbie’s work?
EC Guidelines developed and followed ?audited
Development of patient information brochures
for abscess and cellulitis
Audit
Surveyed EC patients re: draft brochures,
suggested improvements incorporated
Increasing compliance of staff to EC Cellulitis
guidelines
Knowledge and compliance with Hospital
pathway
Collection of EC cellulitis data by month –
Debbie Hailstone
Measurement
Continued monthly analysis of EC patients with
cellulitis
Continued data collection
Resourcing
Appointment of CNS – Soft Tissue
Provision of oral antibiotics and skin kits in take
home packs to improve compliance
Identification of patients and their families with
recurrent cellulitis and referral to ID Outpatients
Identification of lymphodema patients and
referral to lymphodema service
TADU use for simple abscess
Use in wards and EC
Standardisation
Documentation
Training
Pathway development (but not had final
sign off by GAIHN for implementation)
Data collected regarding referrals
Data collected regarding referrals
Adapted from “The Improvement Guide. A Practical Approach to Enhancing Organizational Performance” Gerald Langley et al., 2009, p180.
Highlights and Lowlights
Lowlights
Recognition that there were not the bed savings to be made from inpatients with cellulitis
Patients admitted with cellulitis were often complex and very sick and the focus needs to
be with education and prevention of serious skin infections in the community
Highlights
Commissioning of a report by Louise McCarthy from GAIHN
Reducing the Burden of Skin Infections in Counties Manukau District Health Board
(Potential interventions for education and prevention of skin infections in community
and primary care settings) – application being considered for 20,000 Days Campaign
Phase 2
Collaborative team members involved in development of the regional clinical pathway
for cellulitis and skin infections
Achievements to date
What has changed and what difference have the changes made?
From our work over the past 8 months, the group has re-focused its direction into three
key work streams after identifying ….
1. Clinical Nurse Specialist support for inpatients with serious skin infections
2. EC TADU and POAC working together to manage non complex cellulitis and abscess
3. Prevention and management of serious skin infections in the community (Phase 2 20,000
Days Campaign Application)
Our change package
The report on reducing hospitalisation rates for skin infections focuses on the prevention and
management of skin infections in the community provides specific objectives moving into the second
phase (if our application is successful).
The report
•
provides an overview of the problem of serious skin infections in CMDHB
•
describes the determinants of skin infections and to outline current issues with regard to defining
skin infections
•
describes key findings arising from the literature and key informant interviews
•
provides recommendations for interventions relating to education and prevention in community
and primary care settings