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THE 20,000 DAYS CAMPAIGN Health System Improvement Guide Emergency Care/General Surgery /TADU Collaborative The change package
SKIN INFECTION VERSION 1. DECEMBER 2013 WWW.KOAWATEA.CO.NZ THE 20,000 DAYS CAMPAIGN
What worked well for our campaign? Health systems worldwide are struggling with rising patient Alignment around a common goal demand and Middlemore Hospital, which serves a growing The campaign had a unifying goal to reduce demand and ageing population, is no exception . To meet the predicted on the hospital . This goal recognised we needed to 5 .5% increase in bed days, we needed to save 20,000 days . do things differently and all the collaborative teams Counties Manukau Health's 20,000 Days campaign aimed shared in this goal . In addition, each collaborative had to do this by returning 20,000 well and healthy days to specific aims and change ideas that would ultimately our community . contribute to the overall campaign goal . A whole-of-system approach brought together 13 Leadership and expert support for the collaborative teams collaborative teams to build on existing improvement Geraint Martin, CEO Counties Manukau Health, as work and deliver care in a different way . The 20,000 Days sponsor and Jonathon Gray, Director Ko Awatea, were campaign launched in October 2011, and in May 2012 the involved throughout the campaign to ensure that the collaborative teams came together, using the Institute for vision and milestones were met .
Healthcare Improvement's Breakthrough Series Collaborative The Ko Awatea campaign team provided support Model for Achieving Breakthrough Improvement, to test a via the campaign manager, campaign clinical lead, range of interventions .
collaborative project managers, improvement advisors and a communications co-ordinator .
By 1 July 2013 the campaign had achieved 23,060 days The campaign partnered with the Institute for saved since June 2011, which is a reflection of the difference Healthcare Improvement and Brandon Bennett, Senior between the actual bed days used and the predicted growth .
Improvement Advisor at the Ko Awatea faculty, to provide continuous learning and guidance for the Throughout our journey we also achieved many key collaborative teams . successes and learned a lot about the essential collaborative components required to contribute to successful outcomes . What the 20,000 Days campaign has built is a reusable network of skilled, passionate and committed health professionals who have the knowledge, skills and methodology to bring about sustainable change across the health sector. Professor Jonathon Gray
Director, Ko Awatea
SKIN INFECTION VERSION 1. DECEMBER 2013 WWW.KOAWATEA.CO.NZ THE 20,000 DAYS CAMPAIGN
Multi-professional teams working across the health sector Figure 1: Collaborative Model for Achieving Breakthrough Improvement1
Collaborative teams included health professionals, managers, clinical leaders, project managers, Collaborative Teams improvement advisors, data analysts and community members .
Teams worked on projects across the sector, including primary care, secondary care and in the community .
A structured series of milestones and activities The Collaborative Model for Achieving Breakthrough Improvement (Figure 1) provided an ongoing series of structured activities to support the teams in their use of the methodology and to promote collaboration between the teams . During the campaign there were a total of six days of learning sessions attended by 100–120 people . Significant expertise has been built up across the organisation in the improvement methodology .
LS – Learning session The collaborative methodology has been proven to work extremely well as a structured way to implement The Breakthrough Series: evidence-based practice, and has been enhanced by Institute for Healthcare Improvement Collaborative Model using local knowledge and skills within the Counties for Achieving Breakthrough Improvement Manukau context .
SKIN INFECTION VERSION 1. DECEMBER 2013 WWW.KOAWATEA.CO.NZ THE 20,000 DAYS CAMPAIGN
The Model for Improvement Each collaborative team applied the Model for Figure 2: Model for Improvement2 Improvement (Figure 2) . Teams then tested their theory of change through What are we trying to accomplish? Plan, Do, Study, Act (PDSA) learning cycles .
Teams tested many ideas, initially through small How will we know that tests to gain confidence in their change ideas, then a change is an improvement? with larger scale tests, before moving to implement changes across the organisation or area of work . What change can we make Change packages are captured in the health system that will result in improvement? improvement guides, to be shared with other health service providers and support improvement initiatives beyond Counties Manukau Health .
Measures have been defined at both the 20,000 Days campaign level as well as for each of the collaboratives . The measures were analysed and displayed monthly on dashboards . Each collaborative developed a driver diagram showing drivers of change . The driver diagram reflects the team's theories and ideas on the existing system and how it could be improved . This diagram was updated throughout the improvement journey based on lessons learned during the testing of ideas . Some of the ideas failed and were abandoned . Change ideas shown in the final driver diagram (p . 8) reflect successful ideas . These were tested using multiple PDSA cycles before implementation .
Collaborative Teams Early Delirium Identification and Management Safer Medication Outcomes on Transfer Home Enhanced Recovery After Surgery (ERAS) Hip Fracture Care Better Breathing Very High Intensity Users (VHIU) Transitions of Care For further information refer www .koawatea .co .nz SKIN INFECTION VERSION 1. DECEMBER 2013 WWW.KOAWATEA.CO.NZ WHY DID WE NEED TO DO IT?
What was the problem?Cellulitis led the top 10 diagnosis-related groups in Middlemore Hospital 2010/2011 for acute bed day utilisation . Every month, an average of 140 adults and 30 children (<  15 years) present to Emergency Care (EC) at Middlemore with this condition . On average, 92 adult patients (66% of presentations) per month are admitted as inpatients . Of these, approximately 52 are admitted to General Surgery Services, which represents 56% of admissions per month . The average number of admissions per month for children with cellulitis is 20 . In total, an average of 390 bed days is used each month for cellulitis . This equates to 4,680 bed days per annum for cellulitis patients across all specialties, including 480 bed days for children . It is a predictable and preventable condition that contributes significantly to avoidable hospitalisation and is amenable to better clinical management in the community .
SKIN INFECTION VERSION 1. DECEMBER 2013 WWW.KOAWATEA.CO.NZ WHAT WAS OUR AIM?
Initial aimsWe established a collaborative that initially aimed to develop As a consequence, a decision was taken at the beginning and implement a cellulitis pathway within the hospital to of 2013 to divide the original collaborative into two: one to reduce the variation in the way antibiotics were used to treat focus on the prevention of skin infections in primary care, cellulitis and to ensure that Primary Options for Acute Care and the other on cellulitis inpatients over 15 years of age (POAC) – a service that provides healthcare professionals and the TADU process for patients with simple abscesses . with access to investigations, care and treatment for This guide describes the project undertaken by the latter . To patients who can be safely managed in the community – reflect the new focus of our collaborative, we changed its was considered at every opportunity along the treatment name to the Skin Infection: Emergency Care (EC)/General pathway . We assumed that improved management of cellulitis Surgery/TADU Collaborative . patients in primary care could reduce the number of bed days used per year, and could reduce the number of patients presenting to Emergency Care (EC) per year by 5-10% .
We aimed to design and implement a treatment pathway for patients with cellulitis . The main purpose of the However, an audit of cellulitis patient admissions revealed pathway would be to reduce the variation in antibiotics that POAC was already being widely used in general used to treat cellulitis .
practice to avoid unnecessary presentations to EC, and that patients admitted to hospital were, in the main, appropriate We aimed to establish a clinical specialist nurse (CSN) admissions . It became clear that the potential for saving bed in EC to assess and review all cellulitis presentations . days was overstated .
Our main objective for the CSN role was to achieve a 5% reduction in the number of bed days used for patients Division of the collaborative with cellulitis by 1 July 2013 .
Data from the audit suggested that some reduction in the average length of stay could be achieved through early We aimed to increase the number of patients transferred discharge to POAC . It also showed that a large number of to TADU both pre- and post-operatively from fewer than patients were admitted to hospital for incision and drainage five to over 25 patients per month, thereby avoiding of acute abscesses . We identified potential to reduce unnecessary inpatient admissions .
inpatient admissions by transferring these patients to the Theatre Admission & Discharge Unit (TADU) . This unit was developed to manage all acute and elective day of surgery admissions for all specialities, but was not being utilised effectively for patients with abscesses . SKIN INFECTION VERSION 1. DECEMBER 2013 WWW.KOAWATEA.CO.NZ THE DRIVERS OF CHANGE
Cellulitis Treatment Pathway to facilitate a 5% reduction in the Patient information leaflet number of bed days used for patients with cellulitis by Consistent treatment for Antibiotic discharge pack 1 July 2013 .
Electronic Primary Options for Acute Care referral care pathway for patients with simple Effective/efficient abscesses requiring Clinical specialist nurse role surgical incision and drainage .
Pre-operative inpatient number of patients General Surgical Abscess Guideline transferred to TADU both pre and post operatively from a Simplified Theatre Assessment & total of under five Discharge Unit (TADU) referral system patients to over 25 patients per month .
Use of TADU for pre-operative Use of TADU for post-operative SKIN INFECTION VERSION 1. DECEMBER 2013 WWW.KOAWATEA.CO.NZ WHAT DID WE DO?
Cellulitis Treatment Pathway Figure 3: Skin infection – Emergency Care/General Surgery Services/TADU
We developed the Cellulitis Treatment Pathway (p . 10), which change package
introduced a systematic approach to the care and treatment of cellulitis patients at Middlemore Hospital . This drew on the Greater Auckland Integrated Health Network proposals for standardisation of clinical care treatment pathways .
We also developed and implemented a parallel cellulitis pathway incorporating primary and secondary care .
Clinical specialist nurse: cellulitis and soft tissue infections We established a clinical specialist nurse (CSN) role for cellulitis and soft tissue infections (p . 11) . The CSN was based primarily in the inpatient surgical wards and Emergency Care (EC) . The main role of the CSN was to determine whether patients presenting with cellulitis could be most appropriately managed in hospital or through Primary Options for Acute General Surgical Abscess GuidelineIn conjunction with General Surgery Services, we developed an abscess guideline which streamlined the care of patients with simple abscesses requiring incision and drainage (p . 13) .
Transfer electronic discharge summaryWe developed a transfer electronic discharge summary template to facilitate the transfer of patients from EC to Theatre Admission & Discharge Unit (p . 16) .
SKIN INFECTION VERSION 1. DECEMBER 2013 WWW.KOAWATEA.CO.NZ CELLULITIS TREATMENT PATHWAY FOR ADULTS
IN EMERGENCY CARE
Figure 4: Inpatient antibiotics comparing use of
Augmentin vs. Flucloxacillin (based on monthly audit)
Why the changes were needed The things that helped We needed a treatment pathway to streamline the care of The support of EC staff, particularly the senior doctors, was patients presenting to Emergency Care (EC) with cellulitis . crucial to the successful implementation of the cellulitis Variation in the antibiotics prescribed for these patients was pathway . The pathway was also endorsed by the heads of a particular problem, with both Augmentin and Flucloxacillin General Surgery Services and Infectious Diseases .
regularly being used . We needed to standardise the antibiotic regime .
The evidence that supports what we didCampbell et al . found that patients treated in accordance with What we did differently a cellulitis guideline had similar outcomes to those treated We introduced a cellulitis pathway to achieve a reduction otherwise, but at a significantly lower cost .3 This study shows in antibiotic variation .
that efforts to encourage compliance with the guideline are We developed a patient information leaflet .
indicated . In addition, the implementation of a guideline for We introduced an antibiotic discharge pack .
the management of inpatient cellulitis and cutaneous abscess We introduced electronic referral to Primary Options leads to shorter durations of more targeted antibiotic therapy for Acute Care .
and decreased use of resources without adversely affecting clinical outcomes .4 How we know we have made a differenceVariation in antibiotic usage has reduced significantly with the increased use of Flucloxacillin, the drug recommended in the Cellulitis Treatment Pathway (Figure 4) .
SKIN INFECTION VERSION 1. DECEMBER 2013 WWW.KOAWATEA.CO.NZ CLINICAL SPECIALIST NURSE FOR CELLULITIS AND
SOFT TISSUE INFECTIONS
Table 1: Clinical specialist nurse – patients seen/referred/bed days saved
What we did differentlyIn November 2012, a clinical specialist nurse (CSN) for cellulitis and soft tissue infections was appointed to assist in the management of inpatients with skin infections . Based at Middlemore Hospital, the CSN collaborated with key clinical personnel as the project team developed change ideas and then promoted the changes in the clinical setting .
How we know we have made a differenceThe CSN for cellulitis and soft tissue infections soon began to have a positive impact on the number of patients either discharged to Primary Options for Acute Care or transferred to the Theatre Assessment & Discharge Unit (TADU) pre-operatively or post-operatively following incision and drainage of their abscesses (Table 1) . From November 2012 to September 2013, the CSN assisted in the management of The evidence that supports what we did care for 416 patients . She was instrumental in saving 107 bed The effectiveness of clinical specialist nurses is well days (Figure 6, p . 12) . She also identified a further 77 possible established in the literature . LaSala et al . sum it up as: bed days that could have been saved, which suggests there is potential for further savings . We anticipate that the potential The role of the clinical nurse specialist is critical to for bed day savings will increase as the CSN role becomes improving patient care and staff development and linking more established and links with the general surgical service professional practice to evidenced-based outcomes at become stronger . the patient, unit, and organizational levels . Today more than ever, the role of the clinical nurse specialist is vital to The things that helped insuring the provision of quality patient care . As a member The position of clinical specialist nurse for cellulitis and soft of the leadership team, the clinical nurse specialist is able tissue infections was funded by the 20,000 Days campaign to directly affect patient care by responding to the needs of the patient, novice clinician, and expert practitioner .5 SKIN INFECTION VERSION 1. DECEMBER 2013 WWW.KOAWATEA.CO.NZ CLINICAL SPECIALIST NURSE FOR CELLULITIS AND
SOFT TISSUE INFECTIONS
Figure 5: Number of bed days saved
by the clinical specialist nurse
Figure 6: Cumulative bed days saved
Heather Lewis, CSN for cellulitis and soft tissue infections SKIN INFECTION VERSION 1. DECEMBER 2013 WWW.KOAWATEA.CO.NZ GENERAL SURGICAL ABSCESS GUIDELINE
Why the changes were needed Patients with simple abscesses requiring incision and drainage were being admitted to hospital, primarily as a result of lack of awareness on the part of admitting doctors about the option of using the Theatre Admission & Discharge Unit .
In addition, most patients with simple abscesses were receiving systemic antibiotics, which is rarely necessary .6 This was not only an inefficient use of resources, but also contributed to the effect of over-prescribing antibiotics and increased the likelihood that patients would remain in hospital for longer . What we did differentlyWe created the General Surgical Abscess Guideline (Figure 7, p . 14) in consultation with clinicians in Emergency Care and General Surgery Services . The guideline advocated the use of TADU for patients who present with simple abscesses requiring surgical incision and drainage . The guideline also discouraged the routine prescribing of antibiotics for systemically well abscess patients . It was approved in April were displayed in areas visible to doctors . We also tested placing a copy of the guideline in patient notes to act as a further prompt, but abandoned this practice as it became The CSN for cellulitis and soft tissue infections actively evident that placement in the notes was ineffective because promoted the guideline among EC, General Surgery and the guideline was being lost among other paperwork . The theatre/recovery staff . Laminated copies of the guideline guideline has been embedded successfully in practice .
SKIN INFECTION VERSION 1. DECEMBER 2013 WWW.KOAWATEA.CO.NZ GENERAL SURGICAL ABSCESS GUIDELINE
Figure 7: General Surgical Abscess Guideline
Patient arrives in Emergency Care General Surgical
Abscess Guideline – Adults
Patient self refers Seen by EC doctor or CNS Seen by specialty doctor approved by Mr . A Bloods and IV Luer Antibiotics if systematically unwell or wound with surrounding erythema Book on Acute Theatre List Mon–Fri 7am–8pm, Sat/Sun and Public hols 7 .30am–6pm Signs of haemodynamic instability Extreme or worsening pain Circulation is compromised Systematically well Unstable co-morbidities e .g heart failure, diabetes, renal failure Mobilising adequately Suitable for TADU? Animal or human bite Glycaemia control management plan documented Discuss with SMO RE: Theatre list – If not meeting admission criteria above and whether the patient will be able to have surgery on the day of presentation Stat dose of IV antibiotics if indicated Provide a script for oral antibiotics and Book on acute operating list analgesia if required Book onto acute operating list for SEND DIRECTLY TO TADU
Ask to return to TADU at 0700hrs the following morning and advise to be NBM POST OP & DISCHARGE PLAN
Print out two EC to TADU transfer Make decision in OT if the patient is suitable for sheets – give one to patient and put one transfer to TADU then home following recovery – this can happen irrespective of having a ward bed Please retain this form in Registrar/operating surgeon to complete discharge the patients notes SKIN INFECTION VERSION 1. DECEMBER 2013 WWW.KOAWATEA.CO.NZ GENERAL SURGICAL ABSCESS GUIDELINE
Figure 8: Number of incision and drainage patients entering
Figure 9: Percentage of incision and drainage patients entering
operating theatres via TADU or directly from EC
operating theatres via TADU or directly from EC
How we know we have made a difference The evidence that supports what we did The guideline was introduced in July 2013 . There has been a Loftus and and Watkin established a day case service for significant increase in the number of patients with abscesses surgical treatment of superficial abscesses which was found to being admitted to theatre via EC or TADU from July 2013 be efficient and safe .7 The study concluded that day surgery onwards (Figures 8 and 9) .
had important implications for the management of abscesses . SKIN INFECTION VERSION 1. DECEMBER 2013 WWW.KOAWATEA.CO.NZ TRANSFER ELECTRONIC DISCHARGE SUMMARY
Why the changes were needed Figure 9: Total number of patients with
One of the obstacles we had to overcome in increasing abscesses through TADU per month
the utilisation of TADU was the need to complete a full electronic discharge summary (EDS) in Emergency Care prior to the patient being sent home, only to return to TADU for treatment the following day . This template has been so successful that other specialties have now begun using it to document the patient journey from EC presentation to TADU for surgery .
The evidence that supports what we did Operating theatre reception area The potential for timely, appropriate and consistent electronic information transfer processes to improve healthcare delivery, What we did differently support patient care and strengthen the link between acute We streamlined the discharge process by replacing the EDS and primary care is acknowledged in the literature .8,  9 with a transfer EDS template, which is a simple one page McKenna identifies a gap that often exists between the electronic document summarising the patient's diagnosis and evidence needed to support the best informed care decisions treatment plan . This is a more efficient option for doctors and the information available to the clinician at the time than completing a full EDS .
and place those decisions need to be made . He argues that improving information ‘liquidity' through systems that How we know we have made a difference facilitate the flow of information is a prerequisite for person- Following the introduction of the transfer template and centred healthcare: ‘This flow of information can then follow the CSN for cellulitis and soft tissue infections, there was patients from care setting to care setting along the patient a significant rise in the number of patients with abscesses care pathway, supporting a shared decision-making process presenting to TADU (Figure 9) .
that involves patients, clinicians and care teams .'8 SKIN INFECTION VERSION 1. DECEMBER 2013 WWW.KOAWATEA.CO.NZ TRANSFER ELECTRONIC DISCHARGE SUMMARY
Figure 10: EC to TADU transfer EDS – quick guide*
*Patient details used in this figure are fictitious .
SKIN INFECTION VERSION 1. DECEMBER 2013 WWW.KOAWATEA.CO.NZ

EXPERIENCES AND LEARNING
Data needs to be accurate and requires ongoing clinical input to validate .
Cellulitis can be categorised as simple or complex . There are not many bed days to be saved in the complex cellulitis group and most simple cellulitis is effectively managed in the community using Primary Options for Acute Care .
There is an opportunity to improve the utilisation of TADU for general surgery patients with simple abscesses requiring surgical incision and drainage .
SKIN INFECTION VERSION 1. DECEMBER 2013 WWW.KOAWATEA.CO.NZ THE COLLABORATIVE TEAM
Clinical Lead: Vanessa Thornton Clinical Head, Emergency Care (EC) Clinical Nurse Coordinator, Lymphoedema Service Alex Boersma Service Manager, EC Jodie Reynolds Lymphoedema Physiotherapist, Home Health Care Clinical Specialist Nurse for Cellulitis and Soft Tissue Infections Anna Lee Clinical Analyst, Decision Support Deanna Williams Service Manager, Primary Options for Acute Care Mary McManaway Nurse Manager, EC Debbie Hailstone Facilitator – Quality Improvement, EC Helen Thomas Patient Flow Coordinator, Surgical Services Associate Clinical Nurse Manager, Theatre Assessment & Discharge Unit Ian Hutchby Improvement Advisor, 20,000 Days Adrienne Batterton Clinical Specialist Nurse – Quality, Surgical and Ambulatory Care Project Manager, 20,000 Days Nurse Educator, Maaori Responsiveness Programme Project Manager, 20,000 Days SKIN INFECTION VERSION 1. DECEMBER 2013 1 . Institute for Healthcare Improvement . The breakthrough 6 . Stevens DL, Bisno AL, Chambers HF, Everett ED, Dellinger series: IHI's collaborative model for achieving breakthrough P, Goldstein EJ, et al . Practice guidelines for the diagnosis improvement . IHI Innovation Series white paper . Boston: and management of skin and soft-tissue infections . Clin The Institute; 2003 .
Infect Dis . 2005 Nov 15;41(10):1373-406 .
2 . Langley GL, Nolan KM, Nolan TW, Norman CL, Provost LP . 7 . Loftus IM, Watkin DF . Provision of a day case abscess The improvement guide: A practical approach to enhancing service . Ann R Coll Surg Engl . 1997 Jul;79(4):289-290 .
organizational performance . 2nd ed . San Francisco: Jossey-Bass; 2009 .
8 . McKenna R . Using information and communications technology to enable the exchange of information between 3 . Campbell S, Burton-MacLeod R, Howlett T . A cellulitis New Zealand clinicians and health providers . N Z Med J guideline at a community hospital – we can reduce costs by [Internet] . 2010 May 14 [cited 2012 Apr 9];123(1314):92- standardizing care . Australasian Journal of Paramedicine 104 . Available from: http://journal .nzma .org .nz/ [Internet] . 2009 [cited 2012 Mar 2];7(1) . Available from: http://ro .ecu .edu .au/jephc/vol7/iss1/2/ 9 . Okoniewska BM, Santana MJ, Holroyd-Leduc J, Flemons 4 . Jenkins TC, Knepper BC, Sabel AL, Sarcone EE, Long JA, W, O'Beirne M, White D, et al . The seamless transfer-of- Haukoos JS, et al . Decreased antibiotic utilization after care protocol: A randomized controlled trial assessing the implementation of a guideline for cellulitis and cutaneous efficacy of an electronic transfer-of-care communication abscess . Arch Intern Med . 2011 Jun 27;171(12):1072-9 . tool . BMC Health Serv Res . 2012;12:414 . doi: 10 .1186/1472-6963-12-414 5 . LaSala CA, Connors RM, Pedro JT, Phipps M . The role of the clinical nurse specialist in promoting evidence-based practice and effecting positive patient outcomes . J Contin Educ Nurs . 2007;38(6):262-270 .
SKIN INFECTION VERSION 1. DECEMBER 2013 WWW.KOAWATEA.CO.NZ

Source: http://improvementmethodology.govt.nz/system/files/documents/pages/ko_awatea_-_20000_days_-_how_to_guide_-_skin_infection.pdf