THE OUT-OF-HOSPITAL CELLULITIS PATHWAY

 THE OUT-OF-HOSPITAL CELLULITIS PATHWAY
Post holder responsible for Policy:
Hugh Bakere
Directorate/Department responsible for Policy:
Acute Medicine
Contact details:
Hugh Bakere, Consultant EMU, x6261
Date written:
December 2010
Date revised:
N/A
Approval route (names of committees):
Antimicrobial Subcommittee
Level of Impact Assessment
(Screening or Full – attach to policy)
Screening
Date of final approval:
March 29th 2011
Date due for revision:
March 2012
Date policy becomes live:
March 29th 2011
This document replaces:
N/A
Controlled document
This document has been created following the Royal Devon and Exeter NHS Foundation
Trust Policies, Procedures, Protocols, Guidelines and Standards Policy.
It should not be altered in any way without the express permission of
the author or their representative.
Please specify standard/criterion
numbers and tick 9 other boxes
as appropriate The Strategic Directions 2007-2012 were agreed by the Board of Directors in October 2007
to support the Trust’s vision “Respond, Deliver, Enable”. The Key Milestones below will
ensure there is a shared understanding about what needs to be delivered.
Monitoring Information Strategic Directions – Key Milestones
Patient Experience
Assurance Framework
Monitor/Finance/Performance
Waiting
Privacy and Dignity
Efficiency and Effectiveness
Delivery of Care Closer to Home
Infection Control
CQC Regulations/Outcomes:
Regulation 12 & 13
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Note: This policy has been assessed for any equality, diversity or human rights implications
The Out-of-hospital Cellulitis Pathway
th
Approved by the Antimicrobial Subcommittee: 29 March 2011
Review date: March 2012
Page 1 of 5
Sections
Page
Introduction
3
Suitability criteria at the time of assessment
3
Operational Pathway
(1) Initial assessment
(2) Out patient treatment
4
(3) On-going out patient treatment
Audit and governance
5
Associated Trust policies
5
Appendices
Appendix 1
Teicoplanin dosing and monitoring regimen
6
Appendix 2
Patient letter
7
Appendix 3
MTU initial discharge checklist
8
Appendix 4
MTU daily checklist
9
The Out-of-hospital Cellulitis Pathway
th
Approved by the Antimicrobial Subcommittee: 29 March 2011
Review date: March 2012
Page 2 of 5
The Out-of-Hospital Cellulitis Pathway
Introduction
Cellulitis is a common presentation both via ED and GP referral service and it is increasingly
accepted as appropriate for outpatient parenteral antibiotic treatment. A number of patients
currently treated as in patients in the RD&E could be currently treated as out patients. In a
study in Scotland, skin and soft tissue infections accounted for 10% of hospitalizations with a
mean stay of approximately five days1.
In this study, of the 125 patients with skin and soft tissue infections treated using an
outpatient parenteral antibiotic service, 123 were cured or improved with 2 requiring
admission for surgery. In this study, economic benefits were also realized despite use of
more expensive agents.
In another study, patients were excluded based on specific criteria2. One hundred and
twenty four patients were entered into this Australian study and in this case more patients
required admission for in-hospital treatment (19 patients – 15.3%), 105 patients were
successfully treated. Only one patient developed adverse effects to the treatment
(diarrhoea- proven to be self limiting).
The issue of the safety of parenteral therapy in the outpatient is a recurring theme though
studies, which have been validated, conclude that ‘hospital at home care’ is very safe3,4. A
pathway is therefore proposed to standardize the assessment and management of patients
with suspected cellulitis to prevent unnecessary admission of patients.
Suitability criteria at the time of assessment:
Diagnosis of cellulitis requiring intravenous antibiotics and a willingness and ability to
undergo outpatient antibiotic administration are the main requisites.
• Those unstable medically or with severe cellulitis or significant co-morbidities will not
be considered appropriate.
• Due to incidences locally of severe (PVL Staph) infection in military personnel extra
caution should be taken in considering these personnel for outpatient IV antibiotic
treatment.
• Patients with significant neutropenia or very high CRP are likely to benefit from an
initial period of inpatient care/observation.
• Frail elderly patients with multiple co-morbidities and especially those with a previous
history of Clostridium difficile are unlikely to be suitable.
• Patients with complex diabetic soft tissue infections may not be suitable and should
be discussed with the endocrine team if necessary.
• Patients with a previous history of MRSA or C. difficile should initially be discussed
with microbiology and a decision on the outpatient regime taken in discussion with
them.
• Caution with facial cellulitis, cellulitis over joints, animal and human bite cellulitis,
IVDU.
1
Nathwani D. ‘The management of skin and soft tissue infections: outpatient therapy in the United Kingdom’.
Chemotherapy 2001;47(suppl 1):17–23.
2
M Donald, N Marlow, E Swinburn, M Wu. ‘Emergency department management of home intravenous
antibiotic therapy for cellulitis’. Emerg Med J 2005;22:715–717.
3
Caplan G, Ward J, Brennan N, et al. ‘Hospital in the home: a randomised control trial’. Med J Aust
1999;170:156–60
4
Montalto M. ‘How safe is Hospital-in-the-home care?’ Med J Aust, 199816, 168:262–3.
The Out-of-hospital Cellulitis Pathway
th
Approved by the Antimicrobial Subcommittee: 29 March 2011
Review date: March 2012
Page 3 of 5
Operational Pathway
1.
Initial Assessment:
1.1
Patients are referred to the Acute GP or the medical team, either from A&E or from
community GPs, who are diagnosed to have cellulitis.
1.2
All patients are seen in the Medical Triage Unit (10am to 10pm) and assessed by a
medical doctor. A decision is then made about either inpatient or outpatient treatment.
The patient’s vital signs, including temperature, are recorded. Investigations can
include ECG and bloods (U&E, FBC, CRP), blood cultures (if pyrexial) and wound
swab if appropriate. The cellulitis site is marked and dated with black permanent
marker (single patient use) to make clear area of initial demarcation.
1.3
The physician of the day (PoD) or the on-call/EMU SpR will review the patient for the
diagnosis to be confirmed and treatment plan implemented.
1.4
Outpatient arrangements must be discussed with the patient and the patient can
decide if they are able to attend once daily for the injections to be administered. An
appointment to re-attend the MTU must be made and documented.
2.
Outpatient Treatment:
2.1
The clerking doctor or MTU nurse organises with the patient a time next day to reattend MTU for antibiotics, usually from 9am the next day. Details are entered in the
ambulatory care patient diary in MTU for the re-attendance day.
2.2
Check allergy status: Any patient with a history of severe allergy (anaphylaxis,
angioedema, urticaria) to any beta-lactam antibiotic will need second line therapy (i.e.
avoid ceftriaxone).
2.3
Check MRSA status: Treat patients with a history of MRSA as positive unless cleared
by infection control.
2.4
The attending doctor must prescribe the antibiotic and a saline flush on a hospital
prescription chart.
1st line
Ceftriaxone 1g IV once
daily (until oral switch
possible)
Administer as
bolus dose
2nd line
(Severe betalactam allergy
or MRSA
positive)
Teicoplanin loading dose
IV once daily for three
days followed by
maintenance dose IV
once daily (if oral switch
not yet possible)
Administer as
bolus dose
See tables in
appendix for
loading and
maintenance
dosing
Switch to oral
Clindamycin
450-600mg qds
at earliest
possibility
7 to 14 days total
therapy according
to clinical
response
The Out-of-hospital Cellulitis Pathway
th
Approved by the Antimicrobial Subcommittee: 29 March 2011
Review date: March 2012
Page 4 of 5
2.5
The antibiotics can be administered through a cannula or a midline inserted under full
asepsis or using a ‘butterfly’ needle. Cannula should have a single lumen bionector
attached and the whole assembly should be covered with a tubifast bandage or
similar. Daily VIP scoring of cannulas should be undertaken and all should be
changed at day three. Most patients should be able to have IV’s through a cannula.
2.6
A letter giving clear instructions is given to the patient detailing the plan and the date
and time for re-attending.
2.7
Transport arrangements should be made; if necessary and only where there is no
alternative we may supply a taxi.
3.
On-going Outpatient Treatment.
3.1
Patient returns daily to the MTU.
3.2
IV antibiotics are given by an (appropriately trained) MTU nurse. Observations are
done, the nurse should ask for a medical review if concerned, or if it is likely the
patient could be switched to oral antibiotics. Early switch to oral antibiotics should be
considered for all patients.
3.3
At day three of treatment and at the end of treatment, there should be a formal review
(albeit maybe brief if all is well) by the MTU medical doctor (MTU nurses to liaise with
EMU medical staff to organize) and documented in the notes. Early switch to oral
antibiotics should be considered for all patients. Most patients with uncomplicated
soft tissue infections may be safely switched to oral antibiotics after 3-4 days.
3.4
Repeat blood tests may be appropriate. If there are any concerns the SpR and/or
Physician of the day should be asked to review.
3.5
IV antibiotics can be changed to suitable oral alternative as soon as there is
acceptable improvement in the patient’s condition and inflammatory markers.
Microbiology can be contacted for advice in the normal way if needed.
3.6
Once the patient is established on oral antibiotics treatment only, they can be referred
to their own GP for follow up; or if necessary EMU clinic follow up can be arranged.
Audit and Governance
Audit of outcomes including readmissions, treatment failure and patient satisfaction will be
conducted. Adverse incidents will be recorded. The patients will be the clinical
responsibility of the EMU consultants.
Associated Trust Policies
Guidelines for Intravenous to Oral Switch of Antimicrobial Treatment
The Out-of-hospital Cellulitis Pathway
th
Approved by the Antimicrobial Subcommittee: 29 March 2011
Review date: March 2012
Page 5 of 5
TEICOPLANIN DOSING REGIMEN
Instructions:
1. Calculate the patient’s creatinine clearance (CrCl) using the Cockcroft-Gault equation
below:
CrCl = (140 – age in years) x weight (kg) x F
Serum creatinine (μmol/L)
F = 1.03 for women and 1.23 for men.
2. Prescribe initial loading regimen of teicoplanin, based on the patient’s ideal body weight (or
total body weight if lower) using Table 1. Doses to be given 24 hourly for the first 3 days.
IBW = T + (2.3 x each inch over 5ft)
T = 45 for women and 50 for men.
Table 1. LOADING REGIMEN (DAYS 1-3) #
Creatinine clearance* Ideal body weight (kg) or total body weight if lower
(CrCl)
40-59
60-79
>80
<60mL/min
600mg
800mg
1000mg
>60mL/min
800mg
800mg
1000mg
*Where CrCl is measured using the Cockcroft-Gault equation above (using total body weight).
# Doses to be given 24 hourly for the first 3 days.
3. On day four, if IV therapy still required, switch to teicoplanin maintenance dosing using
Table 2. (continue dosing 24 hourly):
Table 2. MAINTENANCE REGIMEN (DAY 4 ONWARDS) #
Creatinine clearance*
<25
25-40
41-54
(CrCl)
Daily dose#
100mg
200mg
300mg
55-89
≥90
400mg
500mg
*Where CrCl is measured using the Cockcroft-Gault equation above (using total body weight).
# Doses to be given 24 hourly from day 4 onwards. If renal function changes during treatment, doses should be modified
according to renal function (and teicoplanin concentration measurements if treatment prolonged).
4. If IV teicoplanin is still indicated at day seven check levels; serum teicoplanin levels should
be taken ≤60 minutes before a dose is given (i.e. trough levels). Do NOT withhold the
administration of further doses while waiting for the results, unless toxicity is suspected
when Microbiology should be contacted for advice.
Notes:
• When a teicoplanin level assay has been performed, the result should be checked and acted on within
2 days. Levels are sent to Bristol and will be reported on the Pathology system.
• Send a clotted blood sample (brown top tube) for serum teicoplanin levels to microbiology. Write the
time of the last teicoplanin dose and the time that the blood sample was taken on the request form.
• Monitor baseline and ongoing LFTs, U&Es, Cr, FBC and CRP as clinically indicated.
o Neutropenia or thrombocytopenia can occur after prolonged therapy.
• Contact microbiology or pharmacy for advice about dose adjustments in response to levels. Usual
target range for cellulitis: 10-20mg/L.
• Refer to Medusa for further information on administration.
• In keeping with good clinical pharmaceutical practice reconstituted vials of teicoplanin should be used
immediately and any unused portion discarded. On the few occasions when changing circumstances
make this impractical reconstituted solutions should be kept at 2-8oC and discarded within 24 hours.
Medical Triage Unit (MTU)
Royal Devon and Exeter Hospital
Area C, Level 1
Barrack Road
Exeter EX2 5DW
01392 404614 (10-8pm)
01392 402831 / 406123 (24hrs)
Dear Mr. / Mrs.
Date: ________________
Outpatient treatment for cellulitis ID Number: ________________________
We have arranged for you to have your soft tissue infection (cellulitis) treated on an
outpatient basis. We hope you will find this more convenient then having to stay in hospital.
Please report back to Medical Triage Unit at the following times
Time
Date
Please also:
• Call us at any time if you are feeling unwell or having problems with your cannula
and ask to speak to the nurse in charge
• If you feel very unwell call an ambulance or go to the Emergency Department in the
usual way.
Cannula care
Your cannula sits in a blood vessel for up to 72 hours, following which it will be removed
and changed if necessary. There is no needle present but it is important you look after it.
• Keep your cannula dry and covered with the dressing provided.
• Ensure it does not become caught in clothing or dislodged.
• If your cannula does come out apply pressure with a clean dressing. A new cannula
will be inserted the next day.
• Sometimes the cannula site becomes infected. If skin around the cannula becomes
red or painful call the above number for advice.
If you are concerned in anyway feel free to call the nurse in charge on the above numbers.
Yours sincerely
Hugh Bakere
Consultant EMU
The Out-of-Hospital Cellulitis Pathway
Check list for MTU prior to Initial Discharge
(Please circle as appropriate)
Attendance with diagnosis of Cellulitis
Yes
No
Suitable for outpatient cellulitis service (See criteria in policy)
Yes
No
Mark cellulitic area with indelible pen.
Yes
No
Patient given information letter
Yes
No
Ensure cellulitic area clearly marked
Yes
No
Give second dose of antibiotics if appropriate
Yes
No
Single lumen bionector attached to cannula
Yes
No
Cannula secure and flushed with saline
Yes
No
Insertion date is present and VIP score completed
Yes
No
Identifying first return point and time
(09.00 next day as default) hh/mm
Discharge letter
Yes
No
Yes
No
Book patient into MTU ambulatory care book
Yes
No
Book patient into MTU ambulatory care book
Yes
No
1. Medical and nursing notes
Yes
No
2. Observation chart
Yes
No
3. Drug chart
Yes
No
Complete discharge checklist below:
(Please circle as appropriate)
Signature:………………………………………
Print Name:…………………………………….
Date: dd/mm/yyyy
The Out-of-Hospital Cellulitis Pathway
Approved by: Records Management Committee Jan 2011
Review date: December 2013
Health Records:
Charts & Special Sheets
Page 1 of 1
Cellulitis Daily Checklist
Start date: DD/MM/YYYY
Any Grey boxes ticked require ACTION : Inform medical doctor
DAY 1
Assess Patient
Systemic symptoms
• Better
YES
NO
DAY 2
YES
DAY 3 NO
YES
NO
Effect of antibiotics
• GI Upset
• Rash
Cellulitic area-ensure mark visible
• Better
• Unchanged on two visits-Dr r/v
Cannula - Date inserted
(Use attached care plan)
HH/MM
HH/MM
HH/MM
Check Observations
• Normal (EWS 0)?
If abnormal must be discussed with doctor
Bloods repeat at 72 hours
• Normal?
If abnormal must be discussed with doctor
Antibiotics administration
• Check identity of patient
• Check for allergy
• Check microbiology results
3.7
Duration of treatment
• Has the cellulitis improved?
• Apyrexial for 48hours?
• Blood tests normal or better?
Nurse Signature:
Print Name:
Date:
DAY 1
DAY 2
DAY 3
Signature
Signature
Signature
Print Name
Print Name
Print Name
DD/MM/YYYY
DD/MM/YYYY
DD/MM/YYYY
ON FINAL DISCHARGE (signature)
Cannula removed
Follow up with GP/EMU
clinic booked
TTO’s provided
Discharged on:
DD/MM/YYYY
The Out-of-Hospital Cellulitis Pathway
Approved by Records Management Committee Jan 2011
Review date: December 2013
Health Records:
Charts & Special Sheets Page 1 of 1