Developing a nurse-led integrated 'red legs' service.

PROFESSIONAL

Developing a nurse-led integrated `red legs´ service Rebecca Elwell

Rebecca Elwell is Macmillan Lymphoedema Nurse Specialist, University Hospital of North Staffordshire, Stoke-on-Trent

ABSTRACT

This project was developed to set up a nurse-led service based on the needs of patients diagnosed with ‘red legs’. These patients are often wrongly admitted into hospital for treatment of cellulitis. Representatives from the specialties involved in caring for those individuals with red legs were invited to participate with patients to create a stakeholder group whose purpose was to develop integrated care pathways focused on referral criteria, diagnostics and treatment to inform a new nurse-led service. There was a commitment to utilising a number of facilitation techniques and practicedevelopment methods in the progression of the project with the support of the Foundation of Nursing Studies. Much of the prescribed care can be carried out by the patients at home and only 25% patients have required a follow-up appointment within the new service. The service has now been fully commissioned and a secondment opportunity has been developed to lead the new service. Significant savings have been demonstrated and regular revision of the integrated care pathways with all groups, including the patients, will take place.

KEY WORDS

w Cellulitis w Red legs w Practice development w Nurse-led w Innovation

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This results in a significant number of patients whose condition does not respond to the standardised treatment plan, leading to often unnecessary admissions, pressure on emergency medicine resources, extended length of hospital stay and poor patient experience. Wingfield (2009) suggests that admission to hospital can be daunting and unsettling, and highlights the risks of possible hospital-acquired infections and antibiotic resistance. CREST (2005) states that differential diagnosis of cellulitis should be carried out in all patients with bilateral symptoms. An audit by University Hospital of North Staffordshire (UHNS) revealed that many patients with bilateral redness are put directly onto a cellulitis pathway without differential diagnosis taking place. Red legs can be defined as redness throughout both legs, usually below the knee only. There can be associated warmth and tenderness but no systemic upset or malaise.

Background An retrospective audit of medical notes at UHNS in 2012 revealed that 15 out of 50 (30%) patients admitted to the trust had bilateral redness without having a true cellulitis according to the CREST guidelines. Of a further 15 sets of notes for those patients admitted on more than one occasion with cellulitis, 8 out of 15 (53%) had bilateral symptoms of redness. Firas and Cox (2009) state that some patients are referred to hospital because they are ‘not getting better’ despite antibiotic treatment and that persistent redness and/or swelling is quoted as the reason for referral. Hook et al (1996) completed a review of 50 patients with cellulitis and showed that only 26% had fever at the time of active cellulitis. Cox et al (1998) showed that 40% of patients with cellulitis admitted to hospital were apyrexial and systemically well. In an audit by Levell et al (2011) 635 patients were included, of which 425 (67%) had lower-limb cellulitis and the remaining 210 (33%) patients had 44 different other diagnoses which did not require cellulitis treatment. Of the 33%, the most common causes were eczema (118, 56%), lymphoedema (14, 7%) and lipodermatosclerosis (9, 4%), with the remaining 69 patients having over 25 other diagnoses including leg ulcers (8) and vasculitis (3). Interestingly, of the 67% with cellulitis, 28% had an underlying predisposing dermatosis, commonly eczema (10%) or tinea (9%), which, if treated, may

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ellulitis costs the NHS an estimated £96 million each year for inpatient management (UK Dermatology Clinical Trial Network’s PATCH Trial Team, 2012). This does not include the costs of antibiotics in the community or the increased number of appointments required by health-care professionals for these individuals. Cellulitis is characterised as an acute, painful and potentially serious infection of the skin and subcutaneous tissue, usually involving pathogens Staphylococcus aureus and Streptococcus pyogenes (Wingfield, 2012). Evidence suggests that the part of the body most commonly affected by cellulitis is the lower limbs (Cox et al, 1998; Halpern et al, 2008). The Clinical Resource Efficiency Support Team (CREST) (2005) guidelines for the management of cellulitis in adults very clearly states that bilateral leg cellulitis is extremely rare. In many cases the symptoms of ‘red legs’ can be attributed to gravitational eczema, infected dermatitis, tinea pedis or other chronic conditions that will not respond to intravenous (IV) antibiotics and are dermatological in nature.

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PROFESSIONAL

Chronic oedema/lymphoedema Various risk factors have been shown to be associated with cellulitis, with lymphoedema showing the strongest association (Dupuy et al, 1999). The incidence of true cellulitis is increased in patients with chronic oedema/lymphoedema due to the protein-rich lymphatic fluid serving as an excellent medium for growth of bacteria, and the pooling of the lymphatic fluid in the limbs with associated reduced lymphatic filtration (Baddour and Bisno, 1985; Mortimer and Levick, 2004). Firas and Cox (2009) describe the relationship between cellulitis and lymphoedema as a vicious cycle, with each episode causing further damage to the lymphatic system, leading to increased swelling and thus an increased risk of cellulitis. Keeley et al (2006) concur, adding that once bacteria have gained entry to oedematous tissue, eradication proves difficult. Keeley et al (2006), in association with the British Lymphatic Society and the Lymphoedema Support Network published a consensus document for the management of cellulitis in patients with chronic oedema/lymphoedema available free to download at www.thebls.com. This document covers inpatient and treat-at-home scenarios and advocates the use of amoxycillin (in non-penicillin-sensitive patients) over flucloxacillin due to its increased absorbency into the subcutaneous tissues. Patients suffering recurrent bouts may need antibiotic prophylaxis, e.g 250 mg penicillin twice daily in patients under 75 kg, increasing to 500 mg twice daily in patients over 75 kg.The development of more effective ‘super’ antibiotics, e.g. daptomycin (IV) may become the drug of choice in problematic patients with obesity and comorbidities due to the fast action and ability to reach the skin surface efficiently (Kim et al, 2008). Chronic oedema/lymphoedema management has been shown to reduce the incidence of cellulitis from 58% to 9% (Chartered Society of Physiotherapists (CSP), 2012) and it has been estimated that, for every £1 spent on lymphoedema treatment, £100 is saved in reduced hospital admissions (Macmillan Cancer Support, 2011). Skincare is one of the key components in lymphoedema management, along with exercise and compression. Patients are advised to carry out meticulous skincare and daily washing through drying and moisturising. They are asked to observe the limb(s) for any changes and report these immediately. Certain procedures should be avoided in the

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affected limb. For example, venepuncture, injections and blood pressure readings and any breaks in the skin must be promptly treated with antiseptic and covered as appropriate. Patients and their GPs are given information about cellulitis so that they are well informed, and a copy of the consensus document is sent to the GP surgery. However, this advice relies on individuals being motivated with their self-care and/or able to facilitate this themselves, which is often not the case. Many patients are simply unable to self-care and have little or no home support. Others are reliant upon their carers to carry out their skincare. It is often these patients who suffer with red legs. A project was proposed to set up a fully commissioned, nurse-led, integrated red legs service, caring for people with a complex diagnosis/condition with causes other than acute cellulitis.

Aims and objectives The Foundation of Nursing Studies ‘Patients First’ Programme aims to support nurse-led project teams to use practice development principles to focus on people and practices, encouraging stakeholder participation in the hope that this will lead to the achievement of a sustainable improvement in health-care service. The application was successful and, as a result, a small bursary (provided by the Burdett Trust), support of an external facilitator and five development days for the project team were secured. The main aims of the project were to facilitate individual patient consultations utilising imaging and technology to support multidisciplinary input. Another aim was to raise awareness among health-care professionals of appropriate treatment for patients with red legs, leading to improved patient experience and quality of life. The objectives were to engage all relevant stakeholders in the project, correctly understand the size of the problem, develop and present a commissioning paper and ensure education and promotion of the new service along with developing a process to support the implementation of the new service.

Description The year-long ‘Patient First’ programme consisted of five workshops during which a number of practice development methods and approaches were demonstrated and practised. These were then used to facilitate and implement the project (see Figure 1 for a summary of the project process). Initially the author had concerns regarding the applicability of the techniques within the acute trust setting and made assumptions regarding anticipated responses. That is, that members of the steering group may be too busy to bother to participate or to be receptive to working in a different way. However, the opposite was demonstrated. With the support from the Practice Development Facilitator and with a chance to practice techniques before meetings, the project leader became braver and is now proficient in introducing the techniques without fear or apprehension. The techniques are easily replicated and can be used to facilitate change in any workplace.


have prevented cellulitis. This figure is higher in a study by Morris (2004), who found 77% of 647 patients with cellulitis to have possible ports of entry for infection, 50% of which were fungal infections (mostly of the toe web). The Health and Social Care Information Centre (2009) calculated the average length of inpatient stay for cellulitis to be 7.1 days with a total of 30 524 bed days in 2007–8. Todd et al (2010) estimate that the average length of stay for patients with a diagnosis of cellulitis is approximately 10 days at a very conservative approximate cost of £2300. In the audit carried out at UHNS in 2012, the average length of stay was 10 days, but in those patients admitted for recurrent cellulitis the average length of stay was 15 days. The costs to the patient and the organisation are astronomical.



PROFESSIONAL The initial step in setting up the new service was to identify the key stakeholders. This included those clinicians who would traditionally be responsible for treating patients with red legs, namely the specialities services of dermatology, tissue viability, podiatry, infectious diseases/microbiology and vascular departments. These clinicians were brought together with accident and emergency (A&E) medics and nurses (i.e. those encountering patients at the beginning of this journey), the matron for the area, the directorate manager and patient representatives (selected from willing and interested members of the local lymphoedema support group). The first of the two face-to-face meetings held during the development of the service started with an ‘icebreaker’—a structured activity that is designed to relax the individual, introduce them to each other and energise them in what is normally an unduly formal atmosphere or situation (Forbess-Green, 1983). This was very much the case in this instance, as the meeting was held in a room in the acute trust which had a board room set up and no decoration. All members were asked to share something about themselves that the group did not know. The patient was then invited to share their story. This proved to be extremely powerful in breaking down barriers and allowing the group to focus on the task in hand. A quote from the directorate manager was particularly pertinent:

Inaugural meeting with values and beliefs exercise (Jan 2012)

‘This is very novel because the trust thinks it’s good at involving patients, but this is the first meeting I’ve been to with consultants, management, specialist nurses and patient representation!’

Writing the commissioning paper (submitted Dec 2012)


A values and beliefs exercise was completed.This technique can be used to develop a common shared vision and purpose (McCormack et al, 2013). The aim was to establish clarity of the project, ground-rules for the group and to create a mission statement. Those present were provided with Post-it notes and asked to write down their view on the following: w ‘I believe the purpose of caring for patients with red legs is...’ w Other beliefs/values of importance w ‘This purpose can be achieved by...’ w Factors that can help w Factors that can hinder Another indication of the effectiveness of using the values clarification exercise was that the project team’s aims were achieved—in this instance the ground rules and mission statement were produced. The agreement of one unified mission statement accepted by all was a phenomenal achievement and led to unification of the steering group. The mission statement of the integrated red legs service is:

‘The purpose of caring for patients with red legs is to provide an early and correct diagnosis, enabling their care pathway to be streamlined and provided by ONE integrated, multidisciplinary team.’ At the second stakeholder meeting, a ‘claims, concerns and issues’ (CCI) exercise was facilitated by the project


Application to Patient First Programme (Sept 2011) Literature search (Oct 2011) Audit of current practice (Oct 2011) Identification of stakeholders (Sept 2011)

Generation of mission statement (Jan 2012) Second and final face to face meeting with claims, concerns and issues exercise (Feb 2012) Development/Dissemination of the project newsletter (March 2012) Development of diagnostic and treatment algorithms (Ongoing Feb–Sept 2012)

Recruitment of staff and opening of 6-month pilot service (Oct 2012) Data collection (ongoing) Promotion of the service and education of frontline staff (Oct–present) Development of the patient satisfaction questionnaire and patient information (Oct 2012) Official opening of the red legs service (July 2013) Action planning and reflection have been ongoing throughout the project as well as sharing through the patient support group

Figure 1. Flow diagram to summarise the project process.

team. CCI exercises are based on Fourth Generation Evaluation (Guba and Lincoln, 1989) and aim to collect the views of individuals involved to support further progress, assess claims and to recognise achievement but, more importantly, to identify any concerns and issues. Each member present was provided with Post-it notes to write down their claims, concerns and issues (one comment on

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PROFESSIONAL

Claims

Concerns

Issues

Multidisciplinary team

Response time

How to define current need?

Achievable

What if further investigations are needed?

Development of robust screening tools

Improving patient experience

Inappropriate referrals

Streamlining service

Agreement for funding

Timely, correct diagnosis and treatment

Sustainability of service and workforce

Central point of contact Robust referral pathways Commissioned service Educating health-care professionals

Table 2. Concerns and issues and how they were resolved Question/issue

Resolution

What if further investigations are needed?

These had to be factored into the commissioning document

How to define current need?

This was done via the audit and best guesstimates

How to ensure the sustainability of service and workforce?

Key stakeholders and commissioning paper

How to stop inappropriate referrals?

Referral criteria

How to get agreement for funding?

Involvement at board level initially and then commissioning paper

What will the response time be?

One week

How will robust screening tools be developed?

The development of algorithms with the key clinical areas and photography as backup

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each note). They were then invited to stick these onto flipchart paper stuck to the wall with the appropriate title (e.g. ‘claims’). The mission statement was revisited as the purpose for the existence of the group and the shared aim. This was then also examined for CCI. The results can be seen in Table 1. All group members participated and described the techniques as ‘different and fun’. The project team felt that the CCI exercise was viewed positively and was successful in affirming the importance of the views and perspectives of each steering group member. Once the exercise was completed, the claims were discussed. This proved a very positive experience and reaffirmed the group’s purpose. Any concerns and issues were quickly turned into questions by the key stakeholders, facilitated by the project team (Table 2). McCormack et al (2013) state that CCI exercises highlight the need to reflect the complexity and multiple realities of the key stakeholders. They suggest that CCI generates and values evidence from those involved. The discussion also leads to clarification of the roles of each stakeholder and their required contribution to the project. A newsletter was developed to keep the steering group fully informed with the progress of the project and to maintain momentum and enthusiasm. This visual aid included images of the project team and the steering group as well as colourful sections with regular headings. A secondary aim was to publicise the project and its development to a wider group than the steering group, namely, the director of nursing for the acute trust, the finance department (who were responsible for the appropriate use of the bursary for the project) and the patient lymphoedema support group. The newsletter was kept to one side of A4 paper to ensure it stayed focused and was not too onerous. Costs were kept to a minimum by distributing by email.

Commissioning Writing the commissioning paper was the biggest challenge of setting up the new service as it was difficult to merge two camps with very different priorities. As a clinician, the project leader was focused on improving the patient journey, being able to see as many patients as possible and providing highquality clinical care. The directorate manager was focused on finances and sustainability of the service. It was evident that the planning that had gone into the project with the identification of the key stakeholders to include management led to a real shared aim. Furthermore, returning many times to the mission statement to reiterate the reason for the commissioning paper helped both sides to stay focused. The commissioning document was developed by the project leader writing the background and clinical information and the directorate manager compiling the figures and costings, along with making the strategic arguments. The paper was reviewed by the patient stakeholders who had been present at each stage and the report was circulated at the lymphoedema patient support group for comment.


Table 1. Results of the CCI exercise



PROFESSIONAL A local commissioner was contacted to assist with the process and inform the next steps, the project was very much in line with new clinical commissioning group guidance (NHS England, 2012) which highlights planning the optimum services which meet national and local standards, ensuring that patients and the public are involved in the planning of, and changes to, health services, alongside other key stakeholders and the range of health professionals who contribute to patient care (collective involvement). The red legs service was successfully commissioned in full and was commended for its innovation and commitment to avoidance of admission, reduced length of stay, reduced misdiagnosis, reduced antibiotic (especially IV) therapy, and thus reduced risk of hospital-acquired infection. The ‘one stop shop’ approach, with use of photography to enable other disciplines to be involved in the patients’ care also sought to reduce outpatient appointments and inconvenience to the patient. During the development of the commissioning paper, diagnostic and treatment algorithms were being developed with the relevant clinicians, with patient representatives. These were to be used to assist in the differential diagnosis of each patient attending the new service with red legs and to develop the appropriate treatment plan. The algorithms included varicose eczema, contact dermatitis, infected leg ulcer(s), thrombophlebitis and lymphoedema. These tools will be subject to annual revision so that any updates can be made. Clinical photography is used for atypical patients, with the appropriate consent, and the relevant clinician is emailed with a brief outline of the reason for their involvement. The photographs are viewed through an online photography system within the trust and feedback is given to the red leg service and then communicated to the patient. This process usually takes one working week.


Results The red legs service at UHNS officially opened on 1 July 2013, after a 6-month pilot. The pilot occurred as the project met the requirements of the acute trust’s unscheduled care improvement plan (UCIP). The aim of the UCIP was to ensure the throughput at the hospital enabled the A&E targets to be met. As the director of nursing had been kept informed via the newsletter, the new service was ‘on the radar’ and this support enabled the early start date and undoubtedly contributed to the successful setup. This did put added pressure on the project team to ensure that the launch would go smoothly. The pilot was very successful and led by a band 7 member of the lymphoedema team. The commissioned service comprised funding for a clinic one day a week (7.5 hours) with a band 5/6 nurse 0.2 work-time equvalent (WTE), a band 4 0.2 WTE associate practitioner to administer prescribed care and administrative support form a band 2 0.2 WTE. It was agreed that a secondment position would be developed as a training initiative and to continue raising awareness of the service via the emergency portals. The successful applicant has a substantive post in A&E and has been instrumental in the promotion of the service among her colleagues.


Evaluation and analysis It was agreed that constant evaluation was important to assess progress, but was also important as a marker of success. Action plans were used throughout the project, providing motivation as each step was achieved and to maintain focus. As each stage in the process was so new, there was a desire for realistic timeframes along with clarity and transparency of the process. Using the framework for reflection in action adapted from Gibbs (1988), the project team have reflected on each event as the project has developed and these discussions have resulted in evaluation and analysis, which have in turn driven the action planning. During the pilot, a spreadsheet was developed to record the number of referrals received, where they originated and whether they were appropriate. A patient information leaflet was also written, along with a patient satisfaction questionnaire to be given to all patients on discharge from the service. This questionnaire could collect information about the patients’ experiences of the red leg service and also their previous experiences. This would be used as evidence for the need for continuation of the red legs service. Keeping patients at the heart of this project was key, and was innovative for this acute trust. To maintain the involvement of patients at all stages, regular discussion took place at the lymphoedema patient support group monthly meetings. This kept a wider group of patients informed about the project’s progress and served to include the views of as many patients as possible in an informal setting, which led to ease of expression of views. Comments received from the support group included the following:

‘Wish the service had been in place when I was sent to A&E!’ ‘Really good to be a part of something developing.’ Practice development aims to improve patient or service-user experiences and patient satisfaction questionnaires to date support the existence of this improvement in care (see Table 3). General comments received were as follows:

‘The service I received was excellent’ ‘I feel much better. The red legs service has taken a deeper interest in me.’ ‘I now feel at ease as everything was explained to me so well.’ ‘I was very concerned about my legs but I am very grateful for the help and I’m relieved.’ ‘I feel relieved to know what the problem is; I can’t keep going to the doctor’s. I can never get in and I don’t want to keep taking antibiotics.’

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PROFESSIONAL

Question

Results

How long have you had red legs?

Range from 2 days to 28 years

Have you been in hospital before for red legs?

21% (no. = 6) said yes

What did you think when you heard of the red leg service?

39% (no. = 11) Pleased, happy, great, very good, good idea

46% (no. = 13) had had red legs for more than 12 months

29% (no. = 8) Relieved, finally get sorted, I’d do anything, so glad 14% (no. = 4) Never heard of it before 11% (no. = 3) Worried, didn’t want to come 7% (no. = 2) No opinion, would just go and find out

Were you happy with the level of care?

82% (no. = 23) Extremely satisfied

Were you happy with wait time?

89% (no. = 25) Excellent

Are you still concerned having been seen?

100% (no. = 28) No

18% (no. = 5) Very satisfied

11% (no. = 3) Acceptable

Discussion The promotion of the red legs service and the education of relevant health-care professionals also required innovation. Study leave and opportunities for training are very limited within health care, and are often quickly forgotten due to infrequency of use and/or time pressures (Andrews, 2005). The author decided to use a visual image which would hopefully be lasting and achieve the goal of ensuring correct diagnosis and prompt onward referral.

KEY POINTS

w Cellulitis costs the NHS an estimated £96 million each year with the average length of inpatient stay of 7.1 days w Bilateral leg cellulitis is extremely rare and differential diagnosis should be carried out in all patients with bilateral symptoms w Various risk factors have been shown to be associated with cellulitis, with lymphoedema showing the strongest association (Dupuy et al, 1999) w Practice development techniques are designed to focus on people and practices, in the hope that this will lead to the achievement of a sustainable improvement in health-care service w Many patients diagnosed with cellulitis have an untreated, underlying skin condition which highlights the importance of the role of the health-care professional in early identification of conditions and prompt treatment to prevent primary cellulitis or recurrence

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Posters were displayed in all emergency portals where it was hoped patients would be identified (for example, A&E, and doctors’ out-of-hours services) and a section was created on the Trust intranet). A newsletter from the acute trust is sent to all GPs on a regular basis and the red leg service information was included. Training was required for the secondment nurse on how to use the algorithms and some of the treatment modalities required more input than others. For example, the secondee had not used compression hosiery with patients previously. Another educational requirement was a change in the Trust medical guidelines to reflect CREST (2005).The current guidelines did not highlight the use of differential diagnosis in atypical patients and the rareness of bilateral cellulitis. The red leg service could also be promoted in this document. Due to the high incidence of patients having an untreated, underlying skin condition which can precipitate a cellulitis, a red leg study day is planned for community nurses to highlight the importance of early identification and prompt treatment of conditions such as tinea pedis. There is often an uninterested response from patients as the conditions often seem trivial or have been present for some time. However, the role of the health-care professional in ensuring vigilance and compliance with prevention and treatment is essential. Often there is a lack of understanding of the risks of cellulitis and how serious this condition can be.

Savings Using the data from the audit conducted at UHNS in 2012, an annual saving of £232 890 was calculated based on an expected admission avoidance of 90%. The remaining 10% of patients would require admission due to another medical issue or comorbidity. However, they would be referred onto the red legs service upon discharge due to being identified by the inpatient screening tool. At the time of going to print, 77 referrals have been received and the same number of patients have been seen in the red leg service. A total of 19 (25%) have required a follow-up appointment and 58 (75%) were discharged. This demonstrates a current saving of approximately £100 000 but does not take into account the savings both economic and personal to the patient. Levell et al (2011) demonstrated savings of £818 000 over 40 months in bed days alone; however, this did not take into account savings of IV antibiotics or costs to the 210 patients who did not have cellulitis and may otherwise have been treated inappropriately. More importantly, the underlying skin disease of this group of patients was treated and thus their risk of developing cellulitis, which can lead to leg ulceration and lymphoedema, were significantly reduced.

Conclusion Throughout the process, the positivity and feedback has been astounding, and there has been a willingness to change due to the patient-centred nature of the project and the way it has fitted into the larger strategic picture. By educating health-care professionals about the need for differential diagnosis in patients with cellulitis, the patient


Table 3. Results from patient satisfaction questionnaires



PROFESSIONAL experience has been significantly improved. An integrated red leg service is an innovative approach, not only giving treatment at the acute phase of care but also using education at the initial assessment in order to provide the user with preventative strategies for future care. The project has a broad, multi-agency scope which has involved a significant amount of coordination. Developments have been measured constantly and evaluated with a project newsletter as the main way of communicating. There has been a commitment to utilising a number of facilitation techniques and practice development methods in the progression of the project, with the patient at the centre at all times. BJCN Andrews S (2005) Time for study. Paediatric Care 17(7): 42–4 Baddour LM, Bisno AL (1985) Non-group A beta-haemolytic streptococcal cellulitis: association with venous and lymphatic compromise. Am J Med 79(2): 155–9 Chartered Society of Physiotherapists (2012) Physiotherapy works. http://tinyurl. com/o32cqop (accessed 12 December 2013) Clinical Resource Efficiency Support Team (CREST) (2005) Guidelines on the management of cellulitis in adults. http://tinyurl.com/obx26x9 (accessed 12 December 2013) Cox NH, Colver GB, Paterson WD (1998) Management and morbidity of cellulitis of the leg. J Royal Soc Med 91(12): 634–7 Health and Social Care Information Centre (2009) Hospital episode statistics: primary diagnosis. Department of Health, London. http://tinyurl.com/nzj7pxo (accessed 12 December 2013) Dupuy A, Benchikhi H, Roujeau JC et al (1999) Risk factors for erysipelas of the leg (cellulitis): case-control study. Br Med J 318(7198): 1591–4 Firas A, Cox N (2009) Cellulitis and lymphoedema: a vicious cycle. J Lymphoedema 4(2): 38–42 Forbess-Greene S (1983) The Encyclopedia of Icebreakers: Structured Activities that

Warm-up, Motivate, Challenge, Acquaint and Energize.Jossey Bass/Wiley, New York Gibbs G (1988) Learning by Doing: A Guide to Teaching and Learning Methods. Further Education Unit, Oxford Guba E, Lincoln Y (1989) Fourth Generation Evaluation. Sage, Texas Halpern J, Holder R, Langford NJ (2008) Ethnicity and other risk factors for acute lower limb cellulitis: a UK-based prospective case-control study. Br J Dermatol 158(6): 1288–92 Hook EW 3rd, Hooton TM, Horton CA, Coyle MB, Ramsey PG,Turck M (1986) Microbiologic evaluation of cutaneous cellulitis in adults. Arch Intern Med 146: 295–7 Keeley V, Mortimer PS, Welsh J et al (2006) Consensus Document on the Management of Cellulitis in Lymphoedema. British Lymphology Society, Cheltenham. http:// tinyurl.com/nj4k3sj (accessed 12 December 2013) Kim A, Suecof L, Sutherland C, Gao L, Kuti J, Nicolau D (2008) In vivo microdyalisis study of the penetration of daptomycin into soft tissues in diabetic versus healthy volunteers. Antimicrob Agents Chemother 52(11): 3941–6 Levell N,Wingfield C, Garlock J (2011) Severe lower limb cellulitis is best diagnosed by dermatologists and managed with shared care between primary and secondary care. Br J Dermatol 164(6): 1326–8 Macmillan Cancer Support (2011) Specialist lymphoedema services: an evidence review. http://tinyurl.com/mfwf785 (accessed 12 December 2013) McCormack B, Manley K, Titchen A (2013) Practice Development in Nursing and Healthcare, 2nd edn. Wiley, New York Morris A (2004) Cellulitis and erysipelas. Clin Evid 12: 2271–7 Mortimer P, Levick R (2004) Chronic peripheral oedema: the critical role of the lymphatic system. Clin Med 4: 448–53 NHS England (2012) Clinical Commissioning Group Authorisation: Draft Guide for Applicants. http://tinyurl.com/nzzeadk (accessed 12 December 2013) Todd J, Harding J, Green T (2010) Helping patients self-manage their lymphoedema. J Lymphoedema 5(1): 91–6 UK Dermatology Clinical Trials Network’s PATCH Trial Team (2012) Br J Dermatol 166(1): 169–78. doi: 10.1111/j.1365-2133.2011.10586.x Wingfield C (2009) Lower limb cellulitis: a dermatological perspective. J Lymphoedema 5(2): 26–36 Wingfield C. (2012) Diagnosing and Managing Lower Limb Cellulitis. Nursing Times 108 (27): 18-21

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