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Cellulitis and Abscess Management in the Era of Resistance to Antibiotics (CAMERA)

Conclusion

This report summarizes our experience in working with nine primary care practices to improve the quality of care for individuals with SSTIs. Lessons we learned from this study include:

  • SSTIs are often poorly documented in the medical record. Often it is difficult to tell if an abscess was present. Similarly, treatment, even including I&D, is poorly documented. Practices were interested in the use of the standardized patient note, although some found it difficult to incorporate into their EMR.
  • Diagnostic and treatment administrative claims data are unreliable for identifying individuals with SSTIs or the procedures that they undergo (e.g., I&D). Administrative claims databases are therefore unreliable to monitor changes in the incidence of SSTIs or to assess quality of care.
  • Among practices willing to perform I&D, the recommendation for the culture kit was perceived as helpful.
  • The rate of abscess culture was high.
  • Referral from primary care for the management of an abscess is common.
  • Most patients with an abscess are treated with an antibiotic that can provide coverage for MRSA. However, nearly half of the patients did not receive an antibiotic that would cover streptococcal infections. Some patients require subsequent change to an antibiotic that covers MRSA.
  • Rates of documented emergency department utilization or hospitalization were low after the management of a SSTI in the primary care practice setting.
  • About one in three patients had followup for a SSTI within 2 weeks of diagnosis. Follow-up rates for infections without an abscess were higher in internal medicine practices compared with pediatric practices.
  • Delivering messages about SSTIs to busy primary care physicians is complex because of the competition from information about other conditions. At the start of the project, there was great enthusiasm about improving care for MRSA infections. However, that enthusiasm rapidly decreased with the H1N1 influenza outbreak.

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Recommendations

Based on our findings, we make the following suggestions for improving care for patients with SSTIs:

  • Clear documentation facilitates adherence to clinical guidelines, and proper administrative coding can be an important adjunct to population-level surveillance. Based on our findings, practices are losing revenue due to incomplete documentation and coding. Not surprisingly, coding workshops are popular at national and local meetings.

Recommendation:

  • Develop documentation and coding presentations in partnership with national and State chapters of physician groups (e.g., American Academy of Pediatrics, American Academy of Family Physicians, American College of Physicians).
  • Integrating templates into EMRs for describing SSTIs may help improve documentation and subsequent care.

Recommendations:

  • Partner with vendors to make templates available based on the Skin and Soft Tissue Infection Action Plan developed for this project. If possible, embed the guidelines within the templates.
  • Develop coding schemes within EMRs to ensure that descriptions of SSTIs are captured in a way that allows meaningful use of the data.
  • Some primary care pediatricians lack self-efficacy in I&D due to lack of training and experience. All face significant time pressure.

Recommendations:

  • Hold workshops in the management of SSTIs, including I&D. This can be conducted in conjunction with the previously described coding workshops.
  • Work with residency training programs to ensure that the management of SSTIs in the outpatient setting is appropriately covered.
  • The CDC has developed helpful educational material regarding the management of SSTIs for primary care practices. The tools developed for this project were generally considered to be helpful. Actively engaging primary care practices in the use of the tools may help further refine them and also be a strategy to spread innovation in health care delivery.

Recommendations:

  • Provide information and tools developed through this project over the Internet (see next section).
  • Develop quality improvement projects based on this study that physicians can use as part of their activities to maintain their board certification status.
  • Most providers use antibiotic therapy that would treat MRSA for SSTIs. This could increase the pressure for the development of resistance.

Recommendations:

  • Identify primary care practices that can serve as sentinel surveillance sites for patterns of antibiotic resistance.
  • Develop guidelines for the use of strategies that can reduce MRSA colony counts (e.g., bleach baths).

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Dissemination of Findings

We have two manuscripts in development: A summary of our experience in these activities, with a more detailed quantitative evaluation of the chart audit data, and a survey of pediatricians regarding the current management of SSTIs, including barriers to recommended care. This survey was developed based on our experience in this project.

We will also make all tools listed in the appendices as well as links to the CDC material available on a University of North Carolina Web site. This Web site was not part of the original contract for this project; therefore, it will not be complete until after this project is concluded. For maximum impact, however, we recommend that the CDC partner with the organizations representing primary care physicians (e.g., American Academy of Family Physicians, American Academy of Pediatrics, American College of Physicians) to advertise the availability of the material.

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References

1. Chambers HF. The changing epidemiology of Staphylococcus aureus? Emerg Infect Dis 2001;7:178-82.

2. Benner EJ, Kayser FH. Growing clinical significance of methicillin-resistant Staphylococcus aureus. Lancet 1968;2:741-4.

3. Gorwitz RJ, Jernigan DB, Powers JH, Jernigan JA. Participants in the CDC-convened experts' meeting on management of MRSA in the community. Strategies for clinical management of MRSA in the community: Summary of an experts' meeting convened by the Centers for Disease Control and Prevention, 2006. Available at: http://www.cdc.gov/ncidod/dhqp/pdf/ar/CAMRSA_ExpMtgStrategies.pdf (Plugin Software Help). Accessed August 10, 2010

4. Mold JW, Gregory ME. Best practices research. Fam Med 2003;35:131-4.

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Page last reviewed March 2011
Internet Citation: Cellulitis and Abscess Management in the Era of Resistance to Antibiotics (CAMERA). March 2011. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/research/findings/final-reports/mrsa/nc_mrsa1a.html