Cellulitis FAQs – Its all about Choice
Why this new programme? Most patients with cellulitis that requires intravenous therapy are not admitted to hospital but have intravenous antibiotics delivered in the community by the district nursing service. However, they need to attend a hospital emergency department to access this service, which is inconvenient for the patient in terms of travel and time. As low priority patients they often have lengthy waits simply to be given their first dose of treatment and discharged. This programme will provide GPs with access to the necessary medication to be able to initiate and deliver intravenous treatment for cellulitis without referral to hospital.
What will be funded under the programme? Funding will cover the cost of a 3day course the medications, cefazolin and probenecid, preparation of packs containing medication, guidelines and delivery of packs to practices. Some funding is also allocated to intravenous training for practice nurses. There is no direct funding going to practices. Any additional costs will need to be passed on to the patient.
Why can’t I prescribe these medications at present? Cefazolin is currently not funded under the PHARMAC community pharmaceutical schedule. A DHB funded supply is only available from hospital pharmacies under the PHARMAC discretionary community supply scheme. For this programme it will be supplied from Waikato Hospital Pharmacy.
Why choose this antibiotic regime? This combination allows treatment to be given just once a day. Probenecid slows renal excretion of cefazolin so that it is active over a 24 hour period, provided the probenecid is given at the same time as the cefazolin. Intravenous flucloxacillin given four times a day is equally effective to this regime, but is much less convenient and compliance is likely to be more of an issue. The cefazolin/probenecid regime is recognised best practice.
What if the patient is allergic to cephalosporins or penicillin? If the patient is allergic to cephalosporins or has anaphylaxis to penicillin, they might still be able to be managed without referral to hospital. You should contact Graham Mills, the infectious diseases specialist via Waikato Hospital switchboard, or, if he is unavailable, the emergency department specialist (not the registrar) to discuss the situation. Normally those patients would be treated with oral clindamycin, but that would require specialist endorsement in order for the prescription to be funded via a community pharmacy.
Will this communitybased treatment cost more for my patient? Patients included in this programme would previously have presented to their GP before referral to hospital, so would have been paying the cost of the first visit in any case. They will then have the choice of the district nurse delivering the second and third day doses, which will be free to the patient, or returning to their general practice for the second and third doses, where they would have to pay the usual fee. However, any charges for having the second and third dose delivered by the practice team might well be more acceptable than the cost and inconvenience of travel to an emergency department to access the treatment. It may also be more convenient for the patient to be able to choose what time to attend the practice for the second and third doses than to have the district nurse call.
What about the weekends? Will the district nurse be available? The district nursing service is available seven days a week to deliver the medication. The after hours centres in Hamilton are also available to deliver the medication over the weekend, with the usual costs to the patient. If the practice team will not be giving the second and third doses, the patient must be given the medication pack to take home so that it is available to whoever will be administering the treatment.
What if my patient needs an extended course of treatment? This will not be common as a course of oral antibiotics following intravenous therapy is usually sufficient, but may occasionally be necessary. If this is the case please indicate on the reorder form that you have used a second pack for the same patient.
What if I believe after starting this treatment, my patient would be more appropriately treated in hospital? That’s fine, please refer them. There are guidelines about the entry criteria, but there will always be circumstances where a patient doesn’t fit.
When will we find time to do this? Some GPs may feel this is an additional burden on an already busy workforce. Therefore it is important to remember this programme provides choices. The district nurses can deliver doses 2 and 3. In addition, IV certification training is being provided so practice nurses will also be able to give the antibiotic doses.
Isn’t this just about cost shifting, moving patients from ED and hospital wards to general practice? For those who still require hospitalisation, this will still occur. For those patients who don’t, this programme provides safe and convenient management options in this most appropriate place without disrupting their lives unnecessarily. This project was developed at the request of our GPs, and we know our rural GPs in particular are looking forward to it. It is important to remember that it is already being run successfully in other parts of the country. It is also important to note the DHB are funding the supply and distribution of the packs, and the district nursing service.
How will I get more packs? Can I have more packs? Each practice will automatically be sent a pack, and the bigger practices will be sent two. As you use one pack, you fill in the reorder form, and include some basic patient details, fax to Waikato Hospital Pharmacy and the replacement pack will arrive a couple of days later. Nice and easy.
Is this another project which will be pulled after a year? This is a pilot project, funded by the DHB for the next year. Outcomes such as whether there is a reduction in ED presentations for cellulitis will be measured. Therefore it is important that general practice assists by providing the small amount of information that is requested on the reorder form. It is also a case of ‘use it or lose it’. We believe this is an opportunity for general practice to demonstrate that there are services that are more appropriately delivered in the community. Se lets make this work.
If I have questions, who do I speak to? Dr Graham Mills via the hospital switchboard if you have clinical questions about a particular patient or have a patient with penicillin anaphylaxis or cephalosporin allergy. If he is not available, then the emergency department specialist (not the registrar). Otherwise Hilary GrahamSmith 07 958 8269 or Erica Amon 07 958 8281
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