20,000 Days Campaign Learning Session March 2013 Cellulitis and Skin Infections Team Dr Vanessa ThorntonDr Andrew Connolly Dr David Holland Dr Adrian TrenholmeAlex BoersmaHeather Lewis Sarah Hyder (POAC)Dr Jennifer Njenga (GP)Louise McCarthy (GAIHN) Debbie HailstoneOlivia WoodmanAdrienne Batterton Karla Rika-HekeKate Moodebe (Localities) Peggy Williams Jodie ReynoldsMaika Kinahoi-VeikuneAnna Lee Project Manager:Monique Davies Improvement Advisor:Ian Hutchby

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.Clinical Nurse Specialist support for inpatients with serious skin infections 2.EC TADU and POAC working together with the CNS to manage non complex cellulitis and abscess 3.Prevention and management of serious skin infections in the community (20,000 Days Campaign Application for Phase 2 )

Driver Diagram

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 Change Ideas TestedEvidence of Improvement (Run Charts) Standardisation of care  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 Improving Workflow EC TADU and POAC working together with the support of the CNS to manage patients with non complex cellulitis and abscess Use of a Coordinator 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)

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 Standardisation Ensure compliance with pathway in secondary care Group’s involvement in the development of the regional Cellulitis and Skin Infections Pathway Debbie’s work? Pathway development (but not had final sign off by GAIHN for implementation) Documentation 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 Training 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 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