Emergency treatment for people with serious skin conditions

Early recognition of serious skin conditions in the emergency department is vital

Early recognition of serious skin conditions in the emergency department is vital

Serious skin infections, also known as acute bacterial skin and skin structure infections (ABSSSI), include conditions such as cellulitis or erysipelas, wound infections and abscesses. Cellulitis alone accounts for 8% of emergency hospital admissions (NHS England 2014).

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Treatment can be given in an outpatient parenteral antimicrobial therapy (OPAT) setting, so hospital admission can be avoided. However, this service is not suitable for all patients.

Oral antibiotics can also be an option but patient adherence is low and can carry a significant pill burden (sometimes up to 20 tablets per day) resulting in poor clinical outcomes (Eells et al 2016).

Some presentations can be particularly challenging for nursing and clinical staff in emergency departments (EDs):

  • Older people and the frail who attend hospital daily for IV therapy and therefore have to be admitted.
  • People with dementia experiencing confusion, unpredictable behaviours, with a risk of falls, or decline in their health status make admittance high-risk.
  • Some intravenous drug users can be problematic.
  • Homeless people who are excluded from the OPAT service due to having no fixed address and therefore have to be admitted.
  • Obese people who have mobility issues and require high doses of treatment.

Effective and early treatment of serious skin infections is critical in optimising patient recovery, as sub-optimal treatment can lead to the patient requiring extended periods of hospitalisation. Of the 104,598 recorded cases in the UK of cellulitis, nearly 70,000 were hospital admissions that resulted in a mean and median bed stay of 6.2 and three days respectively (NHS Digital 2018), costing an average of £2,480 and £1,200 per patient – based on the cost of a one-day hospital stay being around £500 (Laing 2018).

And with long waiting times and the availability of bed space continuing to be a problem for UK hospitals and likely to worsen during the winter months, nursing resource is at a premium (Ewbank et al 2017).

Therefore, when assessing how to treat these challenging and unpredictable patients, nurses need to look at minimising the risk to their staff, the patient and the amount of time spent in hospital.

Treatment with the lowest level of intervention and involving the least number of infusions is preferable, as it reduces the risk to patients and staff. This is something echoed by the Health and Safety Executive’s (HSE) own guidance on sharp instruments in healthcare (HSE 2013).

Reassessing safety

When managing unpredictable patients that present a significant risk to themselves and staff, is it time to reassess the health and safety policies in your hospital to align with new treatment options?

Treatment options available to nurses and clinicians include:

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  • IV antibiotics that can be given every two to three days.
  • IV antibiotics given once daily for several days until infection has resolved (this could be up to 14 days or more).
  • IV antibiotics followed by oral antibiotics.
  • A single IV antibiotic which allows the patient to be treated and discharged the same day.
  • Related: Maintaining skin health in older people 

Cost-saving treatments

Recent data from Aberdeen Royal Infirmary presented at the European Congress of Clinical Microbiology and Infectious Diseases (ECCMID) in April 2018 showed that a number of hospital admissions were avoided by using a different treatment approach.

There were 17 patients included in the data who would be expected to require a total of 119 hospital days; this was reduced to 13 by using different treatment options, representing a possible saving of £53,000 (Laing 2018).

Included in the data presented at ECCMID were a number of challenging patients, some of who were intravenous drug users and obese patients. 



About the author

Sharon Falconer is a specialist outpatient parenteral antimicrobial therapy nurse at Aberdeen Royal Infirmary

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