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INFORMATION MANUAL - Manaia Health PHO

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1. Mild Severe Admit to hospital Hydrate Assess dehydration with oral Moderate 6 9 Significant thirst Oliguira Sunken eyes Dry mucous membranes Weakness Consider investigations Glucose weight electrolytes and creatinine faecal specs Consider trial of oral fluids IV fluids antiemetic Normal Saline 1000mls stat Review hydration status If needed give 500 1000 mls over 2 4 hours DISCLAIMER This guideline is intended to assist clinical decision making and provide General Practitioners with guidance on the appropriate use of the Primary Options Programme Northland services It is not entirely inclusive or exclusive of all methods of reasonable care It should not replace clinical judgement in managing each individual patient Authorised Kyle Eggleton 7 f e aao S Manaia Health Portfolios Primary Options Manual POPN Manual Clinical Director NPHOS LS oe Version 10 with amendments June 2014 docx Signature 49 EARLY DISCHARGE SERVICE Introduction The Primary Options Programme Northland POPN Early Discharge pathway has been designed to reduce admissions from the hospital emergency department and to reduce the number of bed days required for patients within a medical ward The service is aimed at patients who have been medically cleared but are not quite well enough to return home These services are provided short term only Some examples may be e Patients with a
2. IV Antibiotic treatment first day which can be found under the Procedures options in the drop down box 2 In another entry field underneath select IV Antibiotics treatment subsequent days 3 In another new entry field select IV giving kit incl springfuser tubing from the Consumables section of the drop down box and in the quantity box enter 2 Please note that it is not necessary to add an admin fee as this is included in the amount for the IV Antibiotics treatment IV treatment for cellulitis is expected to be complete in three days or less If treatment is expected to require more than 3 days you will need to advise the Primary Options coordinator by calling 0800 PRIMARYOPS The Coordinator will need to get clinical approval for the funding of treatments outside the 3 day guidelines PLEASE ALSO CONTACT US IF YOU HAVE ANY QUERIES REGARDING CLAIMING we are happy to help Primary Options can be contacted on 0800 PRIMARYOPS or via email to primaryops manaiapho co nz Authorised Kyle Eggleton zA FE rb Kp S Manaia Health Portfolios Primary Options Manual POPN Manual Clinical Director NPHOS at ee Version 10 with amendments June 2014 docx Signature L 21 Services Internal services that may be supplied by practice are e V therapy if you would prefer not to provide this in your practice please contact the coordinator to arrange an alternative provider e Fluid administra
3. e There will most likely be fever cough and new focal chest signs suggesting CAP with other diagnoses being unlikely e Social circumstances must be considered Drug Profiles Community Acquired Pneumonia Refer to data sheet for full product information Discuss with specialist in cases of pregnancy AMOXYCILLIN CLAVULANATE Contraindications amp cautions Hypersensitivity to B lactams history of amoxycillin clavulanate associated jaundice infectious mononucleosis hepatic dysfunction Caution in hepatic renal impairment Dosage and Administration 500 mg orally every 8 hours Adverse Effects GI upset mucocutaneous candidiasis superinfection less common Rare haematological changes prolonged prothrombin time pseudomembranous colitis hepatitis cholestatic jaundice hypersensivity reactions crystalluria convulsions ROXITHROMYCIN Contraindications amp cautions Hypersensitivity to macrolides concomitant ergot alkaloids Caution in hepatic failure pregnancy Dosage and Administration 300mg orally daily at least 15 minutes before food or on an empty stomach swallowed whole with a drink Adverse Effects Nausea vomiting abdominal pain diarrhoea pancreatitis hypersensitivity hepatic dysfunction central or peripheral nervous system events fungal overgrowth DOXYCYCLINE Contraindications amp cautions Hypersensitivity to tetracyclines severe renal insufficiency pregnancy Caution i
4. Uncomplicated pyelonephritis e Female 16 70 e Non pregnant e Clinically stable no co morbidities requiring admission Suitable for management at home e Satisfactory IV access e Home environment safe e Adequate social supports e Access to telephone Exclusion criteria Male Female lt 16 or gt 70 Pregnant Vomiting and unable to maintain oral intake Bilateral pyelonephritis Diabetes Immunocompromised Hospital acquired UTI UTI post instrumentation Catheter in situ Evidence of sepsis including e Fever gt 39 e Tachycardia gt 110 e BP systolic lt 100 e Postural drop gt 15mmHg e Confusion delirium Caution if using gentamicin Impaired renal function eGFR lt 60 Previous ototoxicity or vestibular toxicity to any aminoglycoside avoid Prior or current other renal disease including e Renal transplant e Single or dominant kidney e Anatomic anomaly e Prior reconstructive surgery e Known renal scarring Dose adjustment may be required especially for subsequent doses Gain specialist advice Uncomplicated Pyelonephritis Pathway Authorised Kyle Eggleton Ae Fok Kp S Manaia Health Portfolios Primary Options Manual POPN Manual Clinical Director NPHOS l E a Version 10 with amendments June 2014 docx Signature 69 Consider IV fluids analgaesia antiemetics Give one dose Gentamicin 3mg kg iv or Amoxicillin clavulanic acid iv and send home on oral antibiotics see below for antibiotic selection Review within 24h
5. check results clinical examination of patient if improved then continue oral antibiotics could give further dose of iv antibiotics if improved but still vomiting and unable to tolerate orals If second dose of gentamicin is given must have checked eGFR If given Gentamicin then give Ciprofloxacin 250mg 500mg bd for 7 days If given Amoxicllin clavulanic acid then give oral Amoxicllin clavulanic acid 500 125mg 8 hourly for 14 days Followup MSU at day 14 If not improved at review then refer to ED ED Un complicated Pyelonephritis Pathway Patient presents to ED has uncomplicated pyelonephritis initial treatment as above and then referred to GP for review the next day Given voucher for free visit POPN will pay for antibiotics in general practice followup visit and giving IV fluids antibiotics analgesia antiemetics and observation time Authorised Kyle Eggleton 7 74 T o S Manaia Health Portfolios Primary Options Manual POPN Manual Clinical Director NPHOS SR Version 10 with amendments June 2014 docx Signature 70 ZOLEDRONIC ACID IV ADMINISTRATION OF Zoledronic acid also known as zoledronate is a bisphosphonate that is administered intravenously as a 5mg 100ml ready to use infusion once a year This medicine is now funded in the community for the treatment of osteoporosis Patients who meet the Special Authority criteria can be prescribed this agent Applications for subsidy by Special Authority can be made by any relev
6. e With severe illness Legionella and Staphylococcal infections are more common e Moraxella catarrhalis Authorised Kyle Eggleton Yn rb At a S Manaia Health Portfolios Primary Options Manual POPN Manual Clinical Director NPHOS denie j A Version 10 with amendments June 2014 docx 62 CLINICAL ASSESSMENT OF SEVERITY Assessment of severity is crucial to the safe management of CAP POPN use a CRB CURB tool to assess severity Selecting the most appropriate site of care is the single most important decision in the overall management and is to a large extent determined by the severity of the patient s illness An accurate assessment of severity requires clinical judgment which in turn depends on the experience and skill of the clinician CAP is a serious disease with a significant mortality Recovery will be determined by appropriate and timely intervention There is a need for ongoing vigilance as deterioration can occur rapidly Note also the following points AGE Age over 65 is in the exclusion criteria for POPN However fitness may not be related to age directly Therefore if the clinician considers the over 65 yr old to be fit and no other high severity exclusion factors are present then POPN will allow CAP to be funded at the clinician s own risk Be aware that by including this severity factor that the mortality rate increases to 3 5 Therefore extra vigilance and close monitoring will be essential UREA If a recent res
7. www medsafe govt nz New Zealand Pharmaceutical Schedule URL http www pharmac govt nz Renal Update Best Practice Journal Issue 6 June 2007 Authorised Kyle Eggleton E A S Manaia Health Portfolios Primary Options Manual POPN Manual Clinical Director NPHOS l ES e Version 10 with amendments June 2014 docx Signature 15 Patient Information Sheet Zoledronic Acid Infusion Aclasta Zoledronic acid also known as zoledronate or Aclasta is the most potent medicine in the bisphosphonate class currently available Bisohosphonates work by preventing resorption of bone by inhibiting the function of bone dissolving cells called osteoclasts Bisphosphonates are commonly used in the treatment of osteoporosis and is also used for preventing some forms of cancer from spreading in bone Zoledronic acid is given by intravenous infusion into a vein in the arm via a drip over about 15 30 minutes and can be given each 12 24 months as needed for treatment of osteoporosis Zoledronate increases the bone density in patients with osteoporosis to about the same extent as other medicines such as alendronate Fosamax and is effective at reducing fracture rates by 35 70 Other than flu like symptoms after the first infusion side effects from zoledronate treatment are uncommon and in general no different form placebo treated patients in randomised trials It should be remembered that major fractures can be very dangerou
8. 2 and if the ultrasound scan can not be done on the same day ie within 8 hours then administer Enoxaparin Clexane provided there are no contraindications pending the scan being done Refer to drug profile and treatment table below e Clexane kits are available through Kensington Pharmacy please call 09 437 3722 Authorised Kyle Eggleton P FE E A S Manaia Health Portfolios Primary Options Manual POPN Manual Clinical Director NPHOS EE E Version 10 with amendments June 2014 docx Signature 41 DVT pathways for Northland Patients with a high Primary Care Decision Rule i e gt 2 If a D dimer or scan cannot be obtained on the same day 8 hours then it is recommended that the patient has a single dose of Enoxaparin This is available through White Cross or at Kensington Pharmacy Enoxaparin can be delivered at your practice These patients need a scan They need a D dimer beforehand They need to be referred to Northland Pathology Rust Ave for a D dimer test Patients must take with them to lab o The completed Primary Care Decision Rule o The radiology request form o The lab request form Contact the Radiology Dept at Whangarei Hospital ext 7591 to arrange ascan If the D dimer is negative contact the Primary Options Coordinator on O8300PRIMARYOPS to arrange a private scan Patients with a low Primary Care Decision Rule BUT a positive D dimer These patients need a scan please contact the ul
9. access to clinical information will only be made available to a suitably qualified registered medical practitioner Authorised Kyle Eggleton Ae Fok Kp S Manaia Health Portfolios Primary Options Manual POPN Manual Clinical Director NPHOS gt ae Version 10 with amendments June 2014 docx Signature 82 Claiming The Doctor agrees to adhere to the claiming instructions as defined in the POPN Information Manual and as modified from time to time by NPHOS The Doctor agrees to complete a referral form for each claim made by the Doctor or the Doctor s Practice and notifies the POPN office of a referral within 24hrs of initiation The Doctor agrees to forward all relevant information along with the claim to the POPN office within 30 days of completion of the episode of care Payment for the Service NPHOS agrees to pay for all referrals made by the Doctor to the Service up to a total cost price of S400 per referral or if over S400 as approved by the Service Co ordinator or Clinical Director Cost Control Payment of the Service is subject to the POPN Referral Cost Control Process as contained in the POPN Service Manual Doctor Acknowledgement In signing the Referral Form or submitting a referral electronically the Doctor acknowledges that he she has read understood and agrees to be bound by these Terms and Conditions when referring to the Northland Primary Health Organisations Primary Options Programme Northland Service NPHOS reserves
10. nausea vomiting anorexia abdominal pain diarrhea constipation Dizziness tremor peripheral oedema Local reaction at infusion site including redness swelling pain Conjunctivitis eye pain iritis Hypocalcaemia Osteonecrosis of the jaw Anaphylaxis renal failure Authorised Kyle Eggleton ig ye A S Manaia Health Portfolios Primary Options Manual POPN Manual Clinical Director NPHOS p05 calle oa Version 10 with amendments June 2014 docx Signature 74 NOTE RENAL FUNCTION eGFR can be used for drug dose adjustment for most patients of average height and weight except for potentially toxic drugs with small safety margin critical dose drugs with narrow therapeutic index in elderly frail patients and those at extremes of the weight range In these cases use absolute GFR or creatinine clearance Creatinine Clearance ml min 140 age x body weight kg 0 815x serum creatinine micromol L multiply by 0 85 for females Use lean body weight LBW for obese patients LBW males 50 kg 0 9 kg for each cm over 150 cm in height LBW females 45 kg 0 9 kg for each cm over 150 cm in height References Automatic eGFR reporting its role in screening for kidney disease and drug dosing decisions Rational Assessment of Drugs and Research August 2008 British National Formulary BNF BMJ Publishing Group and Royal Society of Great Britain September 2008 Zoledronic acid ACLASTA Data sheet URL http
11. short term e Transport to and from primary care locations e Rest home care up to three days Primary Options is flexible and easy to use A completed referral form is required to be sent electronically or by fax to the coordinator for services and a phone call is required to request external services e g organising radiology or rest home O800PRIMARYOPS Primary Options coordination is currently available between the hours of 0830 1700 Monday to Friday excluding public holidays Authorised Kyle Eggleton Ae Fok Kp S Manaia Health Portfolios Primary Options Manual POPN Manual Clinical Director NPHOS EE ae Version 10 with amendments June 2014 docx Signature Rationale for Primary Options Programme Northland The Primary Options Programme POPN recognises that people may often be admitted to hospital because of financial and or barriers to gaining access to services in the community Moreover POPN recognises the unequal burden of diseases faced by Maori Therefore POPN s purpose is to e Ensure that the programme is offered equitably to Maori and non Maori e Enable primary care teams to access community based services offering alternatives to hospital admission e Build knowledge about service options including optimum skill mixes client whanau focus e identify and where appropriate address communication and service gaps that contribute to hospital admissions e Encourage general practice support for reducing
12. D dimer the low and medium risk patients are grouped separating them from high risk patients for clinical management 2 The positive and negative predictive values of ultrasound are about 95 for proximal DVT Ultrasound scanning is less sensitive to calf DVT but only 20 of patients with symptomatic DVT have clots isolated to the calf Calf DVT carries a low risk of pulmonary embolism but 20 to 30 may extend to proximal veins although a recent study suggests this may be only 3 gt 3 The negative predictive value of ultrasound scanning is significantly better in low risk patients 99 7 vs those at high risk approx 82 making it a good screening test to exclude DVT in the low risk patients 4 Superficial thrombophlebitis is usually a benign self limiting condition Although it may extend to deep veins but the risk of deep vein thrombosis DVT following a superficial Authorised Kyle Eggleton Ae Fk b S Manaia Health Portfolios Primary Options Manual POPN Manual Clinical Director NPHOS eS eee Version 10 with amendments June 2014 docx Signature 43 thrombophlebitis is low in people who do not have a past history of DVT about 2 7 compared to 0 2 in age and sex matched controls 5 D dimer is raised in patients with thrombosis Raised D dimer levels are also associated with many other conditions including infection malignancy trauma or surgery significant infection eg cellulitis inflammation other thromboemboli
13. June 2014 docx Signature 31 Background Cellulitis is a regular cause for admission to hospital in Northland primarily for the administration of IV antibiotics It is now possible for most adults with cellulitis to be treated in the community through Primary Options Programme Northland 1 Definition Cellulitis is diffuse soreading acute inflammation within solid tissues characterised by hyperaemia WBC infiltration and oedema without cellular necrosis or suppuration 2 Cause The usual pathogens are Streptococcus pyogenes group A B haemolytic streptococcus and Staphylococcus aureus The incidence of Staphylococcus aureus is increasing Staphylococcus aureus usually causes superficial cellulitis but it is typically less extensive than that of streptococcal origin It is more likely associated with open wound or cutaneous abscess though differential diagnosis is difficult Approximately 10 of Staphylococcus aureus may be B lactam resistant MRSA Differential diagnoses such as a DVT is particularly difficult when oedema occurs in the lower limbs Recurrent leg cellulitis may be prevented by treating concomitant tinea pedis 3 Symptoms and Signs Cellulitis is often preceded by a skin problem such as trauma cut puncture wound insect bite ulceration tinea pedis and dermatitis Areas of lymphoedema or other oedema seem particularly susceptible The skin is hot red and oedematous often with an infiltrated surface
14. Manual Version 10 with amendments June 2014 docx 38 Investigation advice for suspected deep vein thrombosis algorithm Examine the patient according to the table below Add each of the individual scores to achieve a total score Follow the suspected DVT algorithm according to the total clinical score and manage as directed If clinically unsure or the patient characteristics fall outside the algorithm suggest discussing with relevant specialist Primary care decision rule for suspected deep vein thrombosis to accompany USS request Use of hormonal contraception Active cancer in the past 6 months Surgery in the previous 30 days ee Distention of collateral leg veins a Difference in calf circumference gt 3cm P Abnormal d dimer assay clearview simplify result a calf circumference measured 10cm below tibial tubercle pC If the TOTAL CLINCAL SCORE lt or equal to 3 the risk of DVT being present is low However the risk is not zero Deep vein thrombosis may still be present in up to 1 4 of patients who have a low score Hence it is imperative that patients with a low score are advised to report any increase in leg swelling or pain or symptoms which might indicate the subsequent development of DVT or pulmonary embolism chest pain SOB or haemoptysis It is recommended that clinical follow up takes place within 7 days of presentation as well as a phone review at 3 months to ensure that DVT has not developed subseque
15. Zoledronate Who else can provide Primary Options services IV therapy can be coordinated to be provided 7 days per week by iwi nurses district nurses Kensington hospital White Cross The choice should be made in conjunction with the coordinator and should be based on the best services for the patient Other providers include e Private x ray services including ultrasound for e g suspected DVT e Residential care facilities This can be a GP or hospital based referral and is for a maximum of 3 nights e Home support providers short term e Equipment suppliers short term e Transport providers for transport to and from appointments in primary care if it fits the criteria All external services must be arranged by the Coordinator Q80OOPRIMARYOPS If your practice is unable to provide IV therapy for a patient please contact the coordinator who will arrange an alternative provider for this service This treatment option is available 7 days per week in most areas Authorised Kyle Eggleton 7 f A LOLS S Manaia Health Portfolios Primary Options Manual POPN Manual Clinical Director NPHOS gt E eee Version 10 with amendments June 2014 docx Signature 12 Who takes clinical responsibility for my patient when enrolled with Primary Options The doctor who initially refers the patient carries clinical responsibility unless that doctor has specifically handed over care to another doctor Please see Clinical Responsibility Form ww
16. hospital admissions e Support culture and practice changes required to achieve the goals of reducing the level of acute admission and achieving integrated service e Support evidence based practice Internationally health services are struggling with increasing Emergency Department presentations and hospitalisations and this trend includes Whangarei Hospital The increases are driven by the aging population and the increase in chronic disease The impact of these increases are that the system becomes backlogged especially the Emergency Department and there is evidence that the longer older people stay in Emergency Department the more at risk of complications they are just as a hospital admission also increases these risks Research also shows that many but not all people prefer to be able to stay in their own home if they can safely do so To cope with these increases programmes are being developed across the health system to reduce unnecessary hospitalisations The service The criteria for a patient to be eligible for primary options are e That the patient would otherwise be referred to the hospital for management e That the patient consents to be managed through Primary Options e That the patient can be safely managed in the community e That the expected duration of the event is 3 5 days approval from the coordinator should be obtained for treatment requiring more than 3 days e That the patient can be managed within a b
17. nausea skin rash rarely polyarthritis PSeudomembranous colitis if severe diarrhoea develops consider stool culture for Clostridium difficile Stop drug and seek advice Specialist Endorsement Clindamycin prescriptions for more than 4 capsules require specialist endorsement For endorsement use Dr A Davis Whangarei Hospital NOTE ASSESSING RENAL FUNCTION eGFR can be used for drug dose adjustment for most patients of average height and weight except for potentially toxic drugs with small safety margin critical dose drugs with narrow therapeutic index in elderly frail patients and those at extremes of the weight range In these cases use absolute GFR or creatinine clearance Creatinine Clearance ml min 140 age x body weight kg 0 815x serum creatinine micromol L multiply by 0 85 for females Use lean body weight LBW for obese patients LBW males 50 kg 0 9 kg for each cm over 150 cm in height LBW females 45 kg 0 9 kg for each cm over 150 cm in height S Manaia Health Portfolios Primary Options Manual POPN Manual Version 10 with amendments June 2014 docx 37 DVT SUSPECTED DEEP VEIN THROMBOSIS Algorithm Patient presents with symptoms of SUSPECTED DEEP VEIN THROMBOSIS Please note lower limb only Apply Primary Care Decision Rule PLUS d dimer see overleaf for full details High score gt 4 Low score lt 3 plus DVT LIKELY negative D Dimer
18. not clearly related to bisphosphonate therapy If you have any other questions about this medicine or your bone condition you should feel free to ask your doctor or nurse Authorised Kyle Eggleton Ve wa A LS S Manaia Health Portfolios Primary Options Manual POPN Manual Clinical Director NPHOS ES eee Version 10 with amendments June 2014 docx Signature NORTHLAND PRIMARY HEALTH ORGANISATIONS Primary Options Referral Form Zoledronic Acid Infusion Patient information Date of referral Address Home phone Mobile Ethnicity DOB Male Female please circle Reason for referral to Primary Options Fractures Y N Essential data 1 Serum creatine eGFR Date oftet j 2 Serum calcium Date oftet 3 Isthe patient on vitaminD Y N 4 Special Authority Number Referring GP information Practice address GP signature X NOTE REFERRAL WILL NOT BE ACCEPTED IF IT HAS NOT BEEN SIGNED BY REFERRING GP By signing this form I agree to abide by the Primary Options Terms and Conditions declare this patient has been informed and consent provided and that the patient understands the information on this form and other information relating to this illness will be made available to any sub contracted health providers Primary Options Patient Information Brochure should be provided to the patient Authorised Kyle Eggleton Z A LS S Manaia Health Portfolios Primary Options Manual POPN Manual C
19. the patient requires a needs assessor contact the Needs Assessment Service Coordinator on 09 430 4131 Healthpoint www healthpoint co nz also has information regarding services for older people under Health for Older People Authorised Kyle Eggleton Yn rb a S Manaia Health Portfolios Primary Options Manual POPN Manual Clinical Director NPHOS ETR r A Version 10 with amendments June 2014 docx 15 How to submit a referral and make a claim If submitting electronically 1 In Medtech go to Advanced forms and click on Primary Options and then OK 2 Inthe Primary Options screen select New Referral then OK 3 The following screen requires you to tick all boxes to ensure the patient is eligible for the Primary Options Programme After ticking the boxes click OK 4 Complete the referral screen including Provisional Diagnosis Coding which relates to the provisional diagnosis and also Add consult notes which will automatically add patient notes from Medtech Consult notes or additional comments may also be typed into the blank box In the drop down box next to Provider select your name Once all fields are complete click on Submit referral to Primary Options 5 Finally in the next screen click on OK to save the form If submitting manually Referrals outcomes and invoicing can also be submitted manually Forms can be found on the primary options websit
20. the right to modify or limit the availability to the Service without further notice Record of Amendments The below table lists details of any amendments made post authorisation of this document 13 06 2014 30 Cellulitis pathway exclusion criteria amended Dr T Kistemaker Acting Clinical Director 0 13 06 2014 7 Referral to specific bisphosphonates Dr T Kistemaker Acting removed Clinical Director Acknowledgements Special thanks to Primary Options Acute Care Counties Manukau POAC and Waitemata Primary Options POAK AND Pegasus Health Christchurch for their invaluable assistance in developing this manual Authorised Kyle Eggleton Ae Fok Kp S Manaia Health Portfolios Primary Options Manual POPN Manual Clinical Director NPHOS eS eee Version 10 with amendments June 2014 docx Signature
21. 014 docx Signature 42 Patients with low Primary Care Decision Rule but a positive D dimer These patients need a scan please contact the Primary Options coordinator to organize this If scan not available within 8 hours it is recommended that the patient has a single dose of Enoxaparin please call Kensington Pharmacy on 09 437 3722 to order this Patients with a high Primary Care Decision Rule i e gt 2 If a D dimer or scan cannot be obtained on the same day 8 hours then it is recommended that the patient has a single dose of Enoxaparin This is available through Kaitaia Hospital or Shackleton s Pharmacy These patients need a scan They need a D dimer beforehand They need to be referred to Kaitaia Hospital for a D dimer test Patients must take with them to lab The completed Primary Care Decision Rule The radiology request form The lab request form Contact the ultrasonographer at Kaiatai hospital to organize scan Ifthe DVT is positive then contact MOSS at Kaitaia Hospital for treatment or administer Enoxaparin dose as per attached drug profile Enoxaparin is available via special authority once a DVT is confirmed Advice for General Practitioners General Comments 1 Patients are separated into low medium and high risk groups based on a simple 8 point scoring system The prevalence of DVT in each group is approximately 3 17 and 75 for low medium and high risk respectively With the use of
22. 25mg orally 8 hourly plus roxithromycin 300 mg daily If the patient is allergic to these antibiotics they are not eligible for Primary Options FOLLOWED BY ORAL ANTIBIOTICS AS ABOVE Please note e Monotherapy is usually successful however atypical coverage is also appropriate to cover with roxithromycin e 12 hourly IV antibiotics may not be practical therefore IV treatment may be resumed following oral therapy if the patient may benefit from this following clinical judgement e g the first dose of IV abs given in surgery then oral dose at home in the evening and back in the morning for another IV dose Please refer to drug profile page LOW SEVERITY COMMUNITY ACQUIRED PNEUMONIA Clinical judgement is essential with individual management based on all the clinical information available at the time The following are important prognostic factors which could increase the level of concern even if the clinical features suggest a low severity illness Over 65 years Bedridden Residential care Vv VV WV Co morbid illnesses e Initial treatment is considered standard general practice and so it is not eligible for POPN funding If the patients condition subsequently deteriorates to moderately severity then a POPN claim can be initiated Authorised Kyle Eggleton 7 f A LOS S Manaia Health Portfolios Primary Options Manual POPN Manual Clinical Director NPHOS gt E eee Version 10 with amendments June 2014 docx Signature 66
23. 45 Adverse events Haemorrhage anaemia thrombo cytopenia injection site reactions skin necrosis allergic reactions Rare anaphylactic anaphylactoid reactions Sourcing of Enoxaparin syringes IV kits for Enoxaparin are compiled by Kensington Pharmacy in Whangarei and distributed out to depot pharmacies around the north for local distribution Please fax order form to Kensington Pharmacy on fax number 09 437 3726 or contact your local pharmacy for supply Practice pharmacy to keep stock of 150mg 1 0ml x 2 ready to use pre filled syringes with graduated markings for single use in patients who meet DVT criteria References 1 Clexane and Clexane Forte Approved Data Sheet December 2008 2 QSUM Medication Alert Low Molecular Weight Heparin Treatment in Renal Impairment Alert 5 January 2008 3 Nutesca EA Spinler SA Wittkowsky A Dager W Low molecular weight heparins in renal impairment and obesity available evidence and clinical practice recommendations across medical and surgical settings Ann Pharmacother 2009 43 1064 1083 Epub 2009 May 19 Authorised Kyle Eggleton ie Pik LoS S Manaia Health Portfolios Primary Options Manual POPN Manual Clinical Director NPHOS l EL En Version 10 with amendments June 2014 docx Signature 46 DEHYDRATION Background Assessment of dehydration is always imprecise but it still helps to come up with a rough estimate of mild moderate severe dehydration to guide fluid replacement Deh
24. MER This guideline is intended to assist clinical decision making and provide General Practitioners with guidance on the appropriate use of the Primary Options Programme Northland services It is not entirely inclusive or exclusive of all methods of reasonable care It should not replace clinical judgement in managing each individual 56 Authorised Kyle Eggleton Ve ge S Manaia Health Portfolios Primary Options Manual POPN Manual A Version 10 with amendments June 2014 docx Clinical Director NPHOS Signature 57 PAMIDRONATE PATHWAY Background In the mid and far North patients requiring Pamidronate infusions previously required hospital admission in order to receive Pamidronate infusions The Pamidronate pathway was developed in order to allow patients residing in the mid and far North to access this treatment in primary care through Primary Options Programme Northland Patients in the Whangarei area will continue to receive their infusions in an outpatient clinic at Whangarei Hospital The Pamidronate pathway has two sub pathways the Prevention of skeletal events pathway and the Pain pathway The intention of the Prevention of skeletal events pathway is to prevent skeletal fractures from a metastatic process The Pain pathway is aimed at reducing the severity of bone related pain from bone metastases Both pathways are illustrated in the Pamidronate algorithm Authorised Kyle Eggleton Yi FE 4 A a S Manaia Health Po
25. N If oral rehydration is fe oes limited by ongoing Consider management in Primary care if no signs of shock older than 2 months Have had diarrhea less than 7 days If they are vomiting with no diarrhea this has been occurring for less than 24 hours vomiting in children with gastroenteritis not with surgical or _ infective causes of vomiting Excluding children lt 6months old or lt 8kgs Single dose WEIGHT DOSE WAFER 8 15KG 15 30KG gt 30KG Review at two hours to ensure ORS being taken After four hours review fully If rehydrated provide advice to care giver and follow up after 6 12 hours If there are still signs of dehydration admit to hospital DISCLAIMER This guideline is intended to assist clinical decision making and provide General Practitioners with guidance on the appropriate use of the Primary Options Programme Northland services It is not entirely inclusive or exclusive of all methods of reasonable care It should not replace clinical judgement in managing each individual patient Authorised Kyle Eggleton Y A bs t Z S Manaia Health Portfolios Primary Options Manual POPN Manual Clinical Director NPHOS r eP E Version 10 with amendments June 2014 docx Signature L 48 Adult Dehydration Algorithm e Vomiting and or diarrhoea e Intractable vomiting in pregnancy Hyperemesis lt 20 weeks gestation see hvneremesis nathwav for entrv
26. NORTHLAND PRIMARY HEALTH ORGANISATIONS PRIMARY OPTIONS PROGRAMME NORTHLAND INFORMATION MANUAL Phone 0800 PRIMARYOPS 0800 774 627 Fax 09 438 3210 Email primaryops manaiapho co nz PO Box 1878 Whangarei 0140 www manaiapho co nz primary_options Issue 10 Dec 2013 PRIMARY OPTIONS PROGRAMME NORTHLAND Funded by Northland District Health Board NOUR NSTRICT HEALTH BOAR Te Poari Hauora A Rohe 3 O Te Tai Tokerau In association with 1 TOKE PRIMARY HEALTH ORGANISATION Her Ora nga Ra Manaia Health The Primary Options Programme Team Lisa Russ Programme Coordinator Jayne Hill Practice Facilitator Phone 0800 PRIMARYOPS Phone 0800 PRIMARYOPS Email primaryops manaiapho co nz Email primaryops manaiapho co nz Dr Taco Kistemaker Primary Options Clinical Director Acting Phone 0800 PRIMARYOPS Email primaryops manaiapho co nz Contents Section One General Primary Options Information cccccccssseccccesecccceesececeenececeeeeceeseusecessueceeseneceesenes 6 Rationale for Primary Options Programme Northland cccescccccsseccccessececesececeeecceeeeeeceseuecesseeceeteneeeetas 7 NS NC corsets rea ec cis erectus ode ti trey an eto ures not peony ae E E E E E poeane tonweaeanee seats 7 TAS SENICE CONNUE aa tense areas cyncteo ons va coansecncoeisyauauesnn Roo ows vai coseve cooausuannarsee cmon nusaanenueees 8 PRET ENT Al process algorit IIN sensira E E 9 FFEQUENTIY aske
27. URB Oo ASSCSSINCIIE TOOL aa aa a Ata ladeaacedceeated 64 Drug Profiles Community Acquired Pneumonia ecesessscecceeeeseessnneeeeceeeeseeeeneeeeeesesseeesneeeeeeeenens 66 PYELONEPHRITIS ADULT PYELONEPHRITIS PATHWAY cicnnitasraa ec eee en eliheteeeects 67 AduiCPyelonepuritis Alcort h eea E a Ta 67 Adult FPyelonephri is Pathway sienien a a a e a ies 68 ZOLEDRONIG ACID IV ADMINISTRATION OF spccoesenasis iceperanewencoieteaiantoraeratic EEEN 70 Patent ENEIDI e E A acacia teat Sam ee ote eee Saat ieee Greeti 70 Checklist Zoledronic Acid Infusion Aclasta ccccecsssssscccccccsssessnneeecceecessessneneeceesesseessneeeeeesesens 72 Drug Profile Zoledronic Acid Aclasta ccssssccccccessssssnneececcessssssnneeccecessssseaeeeeeesesseeesnaeeesesesees 73 Patient Information Sheet Zoledronic Acid Infusion Aclasta ccccccccccccsssssececeeeeesseessteeeeeeeeees 75 Primary Options Referral Form Zoledronic Acid INfusion cccesssececceeeeeesssnneeeeceeeseesssnneeeeeeeeens 76 Rererral CUA TIN FOr sais asec eat cleanse ea etesdiael E 77 Outcome OUI has ieee sete teeta a vemeta bn dal ene aeauea adits Semele dats E teense 78 Clinical Responsibility Forms chad wae ional ioe ee ee 79 Terms ANG CONGITION S 55455555555 oce eco cnsdeanasesisa e e a leet ode Saeed 80 RECORG OF Amendment S erorian a N E acetates eee 82 ACKNOQWICOPEMECINS ecseri a n ae ie ee 82 Section One General Primary Options Informati
28. administrator Nursing management of IV therapy All nurses who give IV antibiotics must be deemed to be IV competent Registered nurses are responsible for ensuring their own competency For any queries regarding IV training please contact the administrator on 0800 PRIMARYOPS POPN and NPHOS are committed to keeping the training in line with national standards NZNO guidelines and required competencies for IV cannulation IV administration kits for IV Antibiotics These are available from EBOS on 0800105501 EBOS IV Antibiotic kits contain dedicated tubing for springfusor pumps Please contact the administrator if you do not have a springfusor pump and or would like a demonstration of how these are used Refer to Cellulitis algorithm for Management of Cellulitis Authorised Kyle Eggleton Yi FE 4 A a S Manaia Health Portfolios Primary Options Manual POPN Manual Clinical Director NPHOS denie s pr Version 10 with amendments June 2014 docx Drug Profiles 36 DRUG PROFILES MANAGEMENT OF ADULT CELLULITIS ALGORITHM Refer to data sheet for full product information CEPHAZOLIN Contraindications amp cautions Previous hypersensitivity reactions to cephalosporin penicillin Use with caution in patients with history of colitis history of seizures Renal Impairment Creatinine Clearance 11 34 ml min reduce dose to 1gm 24hrs Creatinine Clearance lt 10 ml min refer to hospital Dosage and Administration 2
29. al form be faxed or sent electronically to POPN Authorised Kyle Eggleton Ae Fk b S Manaia Health Portfolios Primary Options Manual POPN Manual Clinical Director NPHOS eS eee Version 10 with amendments June 2014 docx Signature 11 Immediately Particularly if it is being sent through Medtech This simple process can be done during the consult with the patient If the referral is a paper system then the form should be received within 24 hours of the patient s initial consultation or the next normal working day Does the patient have to pay for any services The patient only has to pay for the initial consultation thereafter services provided related to that episode of care are free to the patient How much is allocated per patient There is an allocation of 400 including GST per episode plus ultrasound costs Discuss with the coordinator O800PRIMARYOPS if it appears that costs not including scans may exceed 400 How many days can a patient be treated under POPN The episode of care should be likely to have completely resolved within five days Treatment lasting more than 3 days requires approval from the coordinator O800PRIMARYOPS Can the practice team provide Primary Options Services Yes some examples of Practice based services are e After hours consults e Home visits by GP or practice nurse e Practice observation for e g asthma or renal colic e V therapy e g antibiotics for cellulitis e V rehydration e V
30. alth Portfolios Primary Options Manual POPN Manual Clinical Director NPHOS eS eee Version 10 with amendments June 2014 docx Signature 19 Consumables Consumables are to be charged at standard price MPSO funded drugs are not claimable this includes bags of saline _ Day 1 Includes leur 122 67 insertion Subsequent i 71 56 days Where deemed clinically necessary Primary Options will fund an additional day toa maximum of the Day 2 3 fees without prior approval needing to be sought However we expect the amount charged to reflect the work undertaken as some patients may require further IV therapy whilst for others a brief clinical review may be sufficient Authorised Kyle Eggleton Ve S Manaia Health Portfolios Primary Options Manual POPN Manual Clinical Director NPHOS SA Version 10 with amendments June 2014 docx Signature he 20 Kits IV administration kits are available from EBOS 0800 105501 Enoxaparin or ondansetron kits are also available at Kensington pharmacy These can be ordered by calling Kensington Pharmacy 094373722 Reorder forms are supplied in the kits IV Antibiotic Kit which includes springfuser tubing 41 00 and syringe IV Giving Set 20 00 Guidelines on IV antibiotics claiming in the electronic POPN system An example of how you would claim for a 2 day IV Antibiotics treatment is as follows 1 Once inthe Primary Options outcome and invoice or Invoice page select
31. ant hospital specialist Haematology General medicine or Emergency care Investigation for Deep Vein Thrombosis The probability of a DVT is based on the total score lt 2 Low Medium Probability gt 2 High Probability This clinical model and algorithm does not cover o Pregnancy o Children under 18 years of age e Inpatients with symptoms in both legs the more symptomatic leg is used e Please remember to complete the Primary Care Decision rule for suspected DVT sheet which the patient needs to take and give to the ultrasonographer e This protocol should ONLY be used where a DVT remains likely after performing a history and examination e Also consider oral contraceptive or long distance travel impact High probability comments e Ifthe Primary Care Decision Rule is gt 2 then the risk is high 13 to 75 and an ultrasound scan is needed even if the D dimer test is negative e AD dimer test is still needed even if the risk is gt 2 as this may change the decision as to the need for a follow up scan and where the scan is to done e Ifthe Ultrasound scan is negative then a repeat scan is usually required if the Primary Care Decision Rule is gt 2 AND the D dimer is positive Authorised Kyle Eggleton Yi Fp S Manaia Health Portfolios Primary Options Manual POPN Manual Clinical Director NPHOS l Sy Version 10 with amendments June 2014 docx Signature e 40 e If the probability is high Primary Care Decision Rule gt
32. ant medical practitioner Funding of the infusion does not include the cost of administration This can be covered by Primary Options provided that the patient meets the eligibility criteria as detailed below For practices that are unable to provide this service please contact the POPN coordinator who will arrange an alternative provider for the IV administration The referral form for this process can be found in the appendices of the Primary Options Manual Patient Eligibility Patients must e Be eligible for funding under Special Authority criteria e Have been trialled on oral bisphosphonates and be shown to be intolerant due to GI side effects e Not currently taking oral bisphosphonates e Not have an allergy to bisphosphonates e Have an eGFR gt 35 ml min e Be normocalcaemic 2 0 2 6 mmol L e Have adequate levels of vitamin D as a deficiency can result in severe hypocalcaemia post infusion Pre Infusion Recommendations o Check eGFR and confirm no significant renal impairment o Check serum calcium and confirm that it is within normal range o Check status of oral health o Check vitamin D supplementation and if not been taken commence with o one tablet of 1 25mg cholecalciferol vitamin D to be taken in the week prior to infusion o Withhold diuretics and NSAIDs the morning of infusion to help prevent temporary renal impairment o Advise patients to drink an extra 2 glasses of fluid on day of infusion to en
33. ay under POPN Services available Uptoamaximum of three nights residential care IV therapy GP consultations GP Nurse home visits Transportation Home help Follow up A follow up GP appointment must be made on the day of discharge If patient deteriorates the service provider will contact the patient s GP or refer back to the hospital If an extension of services is required eg home support the service provider will contact POPN directly to discuss NB Please also see Referring Older People Primary Options contact details Ph 0800 PRIMARYOPS Fax 09 438 3210 email primaryops manaiapho co nz C Manaia PHO PO Box 1878 Whangarei 0140 Authorised Kyle Eggleton Ae Fk ba S Manaia Health Portfolios Primary Options Manual POPN Manual Clinical Director NPHOS a SS ae Version 10 with amendments June 2014 docx Signature 51 Early Discharge Pathway ED or Ward designated staff member contact POPN coordinator 0800 PRIMARYOPS with patient referral Check criteria as detailed earlier in this section POPN Coordinator assesses suitability for Early Discharge Pathway in consultation with POPN Clinical Director as necessary Referral declined and patient remains in hospital care GP DECLINES CLINICAL RESPONSIBILITY DISCLAIMER This guideline is intended to assist clinical decision making and provide General Practitioners with guidance on the appropriat
34. ays Ensure adequate hydration Dosage and Administration 90 mg every 4 6 weeks By slow intravenous infusion via cannula in a relatively large vein to minimize local reactions at infusion site Reconstitute each vial with a calcium free infusion solution 0 9 sodium chloride of 5 glucose The infusion rate should not exceed 60mg h Img min and the concentration of pamidronate in the infusion fluid should not exceed 30mg 250ml References In breast cancer patients 90mg in 250ml should be infused over 2 hours In multiple myeloma patients it is recommended not to exceed a concentration of 90mg in 500ml administered over 4 hours Adverse effects Most commonly reported Asymptomatic hypocalcaemia pyrexia influenza like symptoms Local reaction at infusion site Other Hypophosphataemia Symptomatic hypocalcaemia Nausea vomiting anorexia abdominal pain diarrhoea constipation gastritis Headache insomnia drowsiness Hypertension arthralgia myalgia bone pain Atrial fibrillation Anaemia thrombocytopenia lympocytopenia Conjunctivitis Osteonecrosis of the jaw Atypical fractures of femur Haematuria acute renal failure deterioration of pre existing renal disease Reactivation of herpes simplex or zoster Allergic reactions including anaphylactoid shock Data sheets Pamidronate BNM http www medsafe govt nz New Zealand Pharmaceutical Schedule URL h New Zealand Form
35. by ambulance e Children with bronchiolitis or pneumonia e Patients with complex conditions and needs e Patients who are requiring long term palliative care e EXCEPTION IV Pamidronate infusions may be funded under Primary Options for mid and far North patients as per the Pamidronate Pathway e Patients whose required care is covered by ACC or maternity benefits EXCEPTION Hyperemesis is accepted under POPN e Patients who do not agree to the terms and conditions of Primary Options e If there is any doubt please contact the Coordinator on O800PRIMARYOPS Who can clarify whether Primary Options is the right programme for your patient and or that your patient is eligible e The Primary Options Programme Coordinator and or administrator can be contacted by phoning O800PRIMARYOPS How can services be accessed for patients For services that meet the guidelines in this manual and that can be provided by your own practice or service If you are on Medtech you can make an electronic referral on the Primary Options Programme Northland advanced form fax the referral form and relevant clinical record note through to the programme within 24 hours For coordination of services provision by an external provider e g rest homes scans phone the coordinator on O800PRIMARYOPS and send an electronic referral and relevant clinical records via advanced form or fax to 094383210 if electronic option not available When should the referr
36. c conditions eg stroke myocardial infarction acute arterial thrombosis and medical conditions such as congestive heart failure renal failure 6 Do not over rely on a normal D dimer result if clinical symptoms are worsening 7 For patients who have low risk of DVT based on Primary Care Decision Rule or D dimer then it is safe to withold enoxaparin administration for 12 247 hours pending a D dimer test 8 The risk of DVT over 3 months is low 0 4 2 for those patients with normal ultrasound and D dimer results 9 Low and medium risk patients a pre test probability lt 2 with normal D dimer results or normal ultrasound should be contacted after 1 week for review If symptoms worsening then a repeat D dimer test or ultrasound may be necessary References 1 Wells PS et al Value of assessment of pretest probability of deep vein thrombosis in clinical management Lancet 1997 350 1795 1798 2 Scarvelis D Wells P Diagnosis and treatment of deep vein thrombosis CMAJ 2006 175 9 1087 1092 3 Kahn S R Macdonald S Miller N amp Obrand D The natural history of untreated isolated calf muscle vein thrombosis rate timing and predictors of extension Blood 2002 100 4 Anand Setal Does this patient have deep vein thrombosis JAMA 1998 279 14 1094 1099 5 http www cks nhs uk thrombophlebitis superficial evidence supporting evidence risk of dvt_or pe 6 http www uptodateonline com online content image do i
37. ccupation travel and hospitalization within the last two weeks e Hobbies e g bird keeping gardening with potting mix e Of note bacteraemic pneumococcal pneumonia is more likely if one of the following features is present Female History of no cough or a non productive cough Excess alcohol Diabetes mellitus COPD New onset confusion POPN notes should include HR RR O2 sats temp chest auscultation notes clinical picture Please refer to the World Health organization guidelines for the diagnosis of pneumonia POPN recommends the CURB 65 confusion urea respiratory rate blood pressure age assessment tool to assess the severity of the patients CAP A score of 1 2 under the CURB tool would indicate moderate pneumonia which would be eligible for funding under POPN if the patient fits the criteria Social circumstances must also be considered when making the assessment urea levels may not be available Authorised Kyle Eggleton Ae Fok Kp S Manaia Health Portfolios Primary Options Manual POPN Manual Clinical Director NPHOS gt ae Version 10 with amendments June 2014 docx Signature 64 CURB 65 Assessment Tool Risk factors gt Confusion gt Urea gt 7mmol l l Blood Urea Nitrogen gt 19 gt Respiratory rate gt 30 Breaths per minute gt Blood pressure lt 90 mmHg systolic or 60mmHg diastolic gt Age 65 or older Scoring Each risk factor scores one point for a maximum score of 5 Analysis Sc
38. complex social situation that is complicated by an acute illness e Weakness due to illness and requiring convalescence before returning home e Sudden deterioration and awaiting assessment for increased cares e Lack of support at home and unable to cope at home alone e Lives alone and in need of assistance short term e Patient requires IV therapy but is stable enough to manage in community Early discharge patient criteria gt Patient can be managed safely in the community gt Patient would otherwise be admitted to hospital or require additional bed days in hospital gt Medically fit for discharge gt Management plan prepared for when discharged from POPN gt Patient s GP or nominated deputy or another GP ie residential facility GP after hours doctor or A amp M doctor must accept clinical responsibility for the patient If a GP declines the patient will remain in hospital gt Patient provides informed consent gt Patient is a Northland resident enrolled with a Northland PHO gt Funding is not available for the patient via another source 50 Conditions accepted The following are examples of but not limitations to conditions which may be referred to POPN Cellulitis DVT investigation Respiratory infection Urinary Tract Infection Asthma Dehydration including hyperemesis Abdominal pain Other acute short term medical conditions ACC patients are not eligible for the Early Discharge Pathw
39. d Refer to hospital services in the usual way It is essential that all patients are admitted when necessary risks should never be taken to avoid an admission Primary Options will cover the episodes of care within the Primary Options criteria Stabilisation of patients who are on their way to hospital is not covered under Primary Options Can services be accessed for the same patient for more than one episode of care Yes funding is allocated per patient per episode of care How much should charge Refer to claiming guidelines on the Primary Options website www manaiapho co nz primary options claiming guidelines Authorised Kyle Eggleton 7 f A LOS S Manaia Health Portfolios Primary Options Manual POPN Manual Clinical Director NPHOS gt E eee Version 10 with amendments June 2014 docx Signature 13 How is Primary Options monitored All Primary Options Programme Northland referrals are reviewed and any referrals which do not fit within the guidelines are referred to the clinical director of NPHOS for assessment The Clinical Director may accept a reviewed case or decline the case and send it to a Clinical Review Board Consists of the Clinical Director of NPHOS an Emergency Department physician and NDHB physician who make the final decision Notification of a declined referral is sent to the GP An opportunity to discuss the case is offered Please call 0800 PRIMARYOPS if you are unsure whether or not your referral fits th
40. d QUESTIONS Jesciacicsdesacecxaeicsesatwcndecessausocsdecateentndsiancdwentecevasaheandoansedeseisenaaiueniedesnaadoesdeonteeeweacseeaes 10 Handing over to another GP or after hours services during Primary Options cccccssseccceeseeeeeeeseeeeeeneees 13 Hand Over to another GP for Patient Management in a Rest Home Private Hospital or Home Care Services Sedo cele dint cent EENE A AEE EEE E E AEE E EN E E E EE E EEN 14 Relerring older people sser nen n E 14 How to submit a referral and make a claim ssssssssssssseennsessssssssssssssssrerrrreeessssssssssssssrrrrerrereesssssssssssrerrereeeeees 15 ekaia a a E o A E E A A A E A EE E E E E oe 18 CONSUMES er E a sasesesaentncesattee eee 19 Guidelines on IV antibiotics claiming in the electronic POPN SySt M sesseeessesserreresrrresrrrresrrressrereserrsseeeee 20 NC e E E 21 Section Two Guidelines for treatment common conditions ccccccceeeeceeeeceeeeeeeeceeeeceeceeceeececeeeeeeeeeeeees 22 PS VIA ADULTAND CHILD peyss ie Er E E E san soncbeusclenooeseesneteasescoeaase t 23 Acute Adult Asthma Algorithm cc cccccccccccccssssssssssssssnaaaeeceeseeeeeeesssssssssnsaasaaaaeeeeeseeeeeesessesenenaaaaaaas 24 Aute AGUIT Asthma SCV erly SeA EE EAA 27 Acute Child Asthma Algorithm eeeeeeeseeeesssssseeeeresesrrrrsssssssreserrrrreeessrrrsssessseeeteerereeeserrssssssseeeettrrreere 28 Acute CMld Asthma Severity Scale nersini a n eii 29 CEEE era EE E T A E 30 Treitm
41. e criteria How does the electronic claiming work The Primary Options electronic claim management system is integrated with your PMS and enables claims to be lodged electronically directly on to your PMS How do get set up for electronic claiming Contact the service coordinator or administrator on O8300PRIMARYOPS How do get additional forms Contact the service coordinator or administrator on O8300PRIMARYOPS or primaryops manaiapho co nz Who can assist with medical management advice The Clinical Director of Northland PHOs is available for advice as necessary on 09 4381015 Who can assist with administration advice Contact the service administrator on O800PRIMARYOPS or on primaryops manaiapho co nz Handing over to another GP or after hours services during Primary Options When a patient s condition requires ongoing treatment or follow up out of hours by another GP or Accident and Medical Centre 1 GP must inform Primary Options by phoning O800PRIMARYOPS or faxing 438 3210 the following working day 2 The referring GP must make direct verbal contact with the other GP or Accident and Medical Centre 3 The GP receiving the referral undertakes clinical responsibility for the patient s episode of care When the after hours care has been completed the GP Accident and Medical Centre must inform the referring GP about the treatment and the patient s condition Authorised Kyle Eggleton Yi S S Manaia Health Por
42. e is significant associated cellulitis Remember that abscesses need drainage O An animal or human bites these are ACC and not included under this scheme O Post orbital cellulitis or peri orbital cellulitis unless there is an obvious skin lesion If periorbital cellulitis has an obvious skin lesion including a sty or impetigo then the likely cause is Staphylococcus aureus or perhaps Streptococcus pyogenes If the origin of the cellulitis is the sinuses then the organism is likely to be Haemophilus influenzae or Streptococcus pneumonia and so require hospitalisation 3 Consider Laboratory Investigations o FBC The FBC provides a baseline in the event that the person is eventually admitted to hospital and if the person has toxic changes and a WCC of gt 20 x10 u L with 15 bands then this would be a reasonable indication of the need for hospitalisation e CRP This is useful if the clinical picture is equivocal If the infection is improving then the CRP improves within hours o Electrolytes glucose creatinine Consider a glucose test finger prick test as a chance to screen for diabetes If a person is at risk such as having hypertension and being gt 55 years old consider electrolytes and creatinine A swab if the lesion is discharging or if there is broken skin 4 IV Treatment The first dose of IV antibiotic is given in the general practice or in the presence of a medical practitioner i No history of Penicil
43. e not eligible for POPN funding as management in the primary setting is considered unsafe Patients with MILD pneumonia are not eligible for POPN funding as management in the primary setting is not considered appropriate as they would normally be managed by their GP Patients with a MODERATELY severe pneumonia are potentially eligible for POPN funding provided that management can be undertaken safely Guideline on the Assessment and management of moderately severe adult community acquired pneumonia 1 Aetiology and Epidemiology No organism is identified in 20 40 of cases e Streptococcus pnuemonaie is the most commonly identified organism especially in winter and in crowded settings e Mycoplasma pnuemonaie is more common in epidemics e H influenzae is more common in COPD and those over 65 e Influenza virus more common in the winter e Staphylococcus aureus uncommon occurs more in the winter and may be associated with the influenza virus It causes severe illness with a high mortality e Gram negative enteric bacilli are uncommon e Legionella e Atypical pathogens include Mycoplasma pneumonia Chlamydophilia pneumonae amp Chlamydophilia psittaci the latter is uncommon Mycoplasma is more common during epidemic periods e Aspiration is a risk in the elderly especially in Residential Care Facilities 10 have coincidental S aureus usually multiple organisms including anaerobes e Bacteraemia is more common in diabetics
44. e use of the Primary Options Programme Northland services It is not entirely inclusive or exclusive of all methods of reasonable care It should not replace clinical judgement in managing each individual patient Authorised Kyle Eggleton lV ea S Manaia Health Portfolios Primary Options Manual POPN Manual Clinical Director NPHOS oe e Version 10 with amendments June 2014 docx Signature fo 52 FOSFOMYCIN for patients with multi resistant UTIs Authorised Kyle Eggleton jj i S Manaia Health Portfolios Primary Options Manual POPN Manual Clinical Director NPHOS m E Ee Version 10 with amendments June 2014 docx Signature a 53 Algorithm GP contacts ID Consultant or Clinical Microbiologist Dr David Hammer NDHB ID recommends agrees with the use of Fosfomycin GP generates POPN claim either electronically if available or paper Phone POPN on O800PRIMARYOPS Carolyn or Lisa for further information Script from GP must contain ea POPN claim number and ethe name of the consultant Fax script to Kensington pharmacy Please write PRMARY OPTIONS on the script DISCLAIMER This guideline is intended to assist clinical decision making and provide General Practitioners with guidance on the appropriate use of the Primary Options Programme Northland services It is not entirely inclusive or exclusive of all methods of reasonable care It should not replace clinical judgement in managing each individual pat
45. e www manaiapho co nz primary options forms Complete the referral form and fax to the coordinator on 09 438 3210 Remember to also fax through all relevant clinical notes and also D Dimer result and Primary Care Decision Rule if the referral is for a suspected DVT An outcome must also be submitted at the conclusion of the episode of care Following submission of the outcome an invoice may be issued to Primary Options if you are making a claim The postal address is Primary Options c Manaia PHO PO Box 1878 Whangarei Authorised Kyle Eggleton Ve wa A LS S Manaia Health Portfolios Primary Options Manual POPN Manual Clinical Director NPHOS ES eee Version 10 with amendments June 2014 docx Signature 16 IMPORTANT Referring patients with suspected DVT e IN WHANGAREI Ultrasounds can be organised at Whangarei Hospital with the radiology department directly by the GP if the patient has a d dimer result of 500 or greater and has had a Primary Care Decision Rule done Please also see DVT section If there is a low d dimer but the clinical suspicion of a DVT remains high contact 0800 PRIMARYOPS and we will organise a private scan for you e IN OTHER PARTS OF NORTHLAND Primary Options can organise a private scan Call the POPN Coordinator on O800PRIMARYOPS e The Primary Options coordinator MUST be contacted to arrange PRIVATE ultrasound scans on O800PRIMARYOPS If the coordinator is by passed the cost of the service may not be co
46. ed When invoicing please ensure you provide enough detail for us to understand what you are claiming for This includes detailing drugs administered only non MPSO funded drugs may be claimed for Please call O8900PRIMARYOPS if you would like assistance with invoicing for Primary Options Refer to our Claiming Guidelines on the next page for information about commonly claimed services and consumables All other items services should be claimed at your usual rate ie The rate at which the patient would normally be charged Questions Please call the Primary Options coordinator on O800PRIMARYOPS Authorised Kyle Eggleton Ae Fok Kp S Manaia Health Portfolios Primary Options Manual POPN Manual Clinical Director NPHOS EE ae Version 10 with amendments June 2014 docx Signature 18 Claiming guidelines Consultations and Procedures Claim Rate GST incl GP consultation 15 minutes Patient pays for initial consultation Usual consult rate approx 17 50 38 ep ania S 76 66 per visit discuss possibility ofa mileage claim with Coordinator 112 75 per after hours visit Patient pays for initial consultation E P It Usual consult rate approx 17 50 56 ices tomei 246 per visit discuss possibility of a mileage claim with Coordinator aione mnao Up to 200 00 incl consumables 15 33 admin fee Zoledronic acid infusion S60 incl consumables 15 33 admin fee Authorised Kyle Eggleton 7 f A LOS S Manaia He
47. ed guideline management of asthma in children aged 1 15 years 2005 www paediatrics org nz Authorised Kyle Eggleton Clinical Director NPHOS Vig Ek A S Manaia Health Portfolios Primary Options Manual POPN Manual aa g Version 10 with amendments June 2014 docx Signature 24 Acute Adult Asthma Algorithm Authorised Kyle Eggleton ig see Dz S Manaia Health Portfolios Primary Options Manual POPN Manual Clinical Director NPHOS oe e 3 Version 10 with amendments June 2014 docx Signature Patient re assessed as having MILD asthma Not eligible for POPN DISCLAIMER This guideline is i 25 Patient assessed as having MODERATE asthma ventolin via spacer or nebulizer 15 mins apart x 2 then REASSESS Eligible Not for POPN eligible for POPN ntended to assist clinical decision making and provide General Practitioners with guidance on the appropriate use of the Primary Options Programme Northland services It is not entirely inclusive or exclusive of all methods of reasonable care It should not replace clinical judgement in managing each individual patient December 2013 Authorised Kyle Eggleton Clinical Director NPHOS S Manaia Health Portfolios Primary Options Manual POPN Manual Version 10 with amendments June 2014 docx Signature 26 Authorised Kyle Eggleton BESA Lo S Manaia Health Portfolios Primary Options Manual POPN Manual Clinical D
48. ent ol ee Ao aa mentee nmr mennrtee ere or mem reer ener ere eee ne erent er 30 Ph ETON seer eo ctsatinciosieis cee none EE E A E EAE AE E 31 Intravenous antibiotics for treating cellulitis in the community cccccccccccsessssteteeeeeeeessesstteeeeeeeeees 32 Nursing management of IV therapy sesser Er 35 IV administration kits for TV ANtIDIOUCS sesccssssecvesecsancccetevesssesbaeteasoceenssadaentexassvwessed eeteasbennensadsentaxaticesssas 35 Drar Prone eae E 36 Dv T SUSPECTED DEEP VEIN THROMBOSIS erarnan 37 ASO e E E E E E E E ee ere 37 Investigation advice for suspected deep vein thrombosis algorithm sesssssessssssserrsrssserrrrrssrssssrrrees 38 Primary care decision rule for suspected deep vein thrombosis ssssssssssssseserrrrrsrsssssssssssrrrrrrrreeee 38 Oar conn ny U TeS ea E ae mente senna se Meee ee onen ee mente seers 38 Investigation for Deep Vein Thrombosis ccccessseececeeeessesnneeeeeeeeesseennneeeeeeeeseseeenaeeeeeeeeeseeesnaeeeeeeseneas 39 DVT pathways Tor Northland tres cctecacs hese eascctennied E E haan sabaceteceuataratenscctenpestesntabentesmetaea 41 Drug Profile for administration as per Suspected DVT Algorithm cccessssssseeeeeeeeeeeeeeseeeeens 44 EE AO rr E E E eanssucitindsneavscaceentnena eet esueniedecsseceee 46 Beale STO UNG aes pelea ste hese aise he testa cee nels ae Marta oath nee carl a nae lye E cadens Se nasal it ut Git catebay meleGe tel 46 ACUI Denydraton Alor
49. ers Primary Options Patient Information Brochure should be provided to the patient This episode of care can be managed within 400 ultrasound additional or as per the Cellulitis Fee Schedule or as approved by the Primary Options Programme Coordinator A copy of the Cost Management Policy is available upon request Authorised Kyle Eggleton 7 f A LOS S Manaia Health Portfolios Primary Options Manual POPN Manual Clinical Director NPHOS l SE Version 10 with amendments June 2014 docx Signature 78 Outcome Form Primary Options Programme Northland POPN Outcome Form Patient Name NHI Referrers Name Date of referral Part 2 Outcome complete and fax to 09 438 3210 within 7 days and all relevant clinical notes must accompany this form Final diagnosis Patient was Managed in primary Eventually admitted Deceased please tick 3 to hospital m 0 Tax invoice for practice based services initial consult paid by Patient as normal charged to POPN should be charged in full Claims exceeding 5400 excluding ultrasound without prior approval risk non payment of the Excess Cost Prior approval may be obtained by calling the Primary Options Programme Northland Coordinator on 0800 PRIMARYOPS 0800 774 627 Detail Item Eg Time spent for consult or obs consumables or kits used etc Refer to claiming guidelines if needed Date of Visit Patient pays initial GP consult Refer to the claiming guidelin
50. es section of the Primary Options Programme manual A corresponding invoice must be sent to Primary Options for payment to be made Primary Options Programme Northland c o Manaia Health PHO PO Box 1878 Whangarei 0140 Phone PRIMARYOPS 0800 774627 Fax 09 438 3210 Email primaryops manaiapho co nz Authorised Kyle Eggleton ge Fak Loe S Manaia Health Portfolios Primary Options Manual POPN Manual Clinical Director NPHOS Version 10 with amendments June 2014 docx Signature A 79 Clinical Responsibility Form PRIMARY HEALTH ORGANISATIONS ea NORTHLAND Primary Options Programme Northland POPN CLINICAL RESPONSIBILITY FORM To be sent to Primary Options Programme Coordinator at completion of inital consultation Email primaryops manaiapho co nz or fax 09 438 32710 Case Number Place Case Reference Number sticker here PATIENT DETAILS INSTRUCTIONS Referring GP eile form and fax to GP accepting clinical GP accepting BRER Sion the faxed form and send to POPN on 09 436 3210 and referring GP mm m i Primary Options Programme Northland PO LAJA m GH aT fa at a iti Ei p i Ph 0800 PRIMARYORS ORO 774 627 Fax 09 438 3210 Authorised Kyle Eggleton Ae Pook Loe S Manaia Health Portfolios Primary Options Manual POPN Manual Clinical Director NPHOS EE ae Version 10 with amendments June 2014 docx Signature A 80 Terms and Conditions Bac
51. f fosfomycin The contents of the sachet must be dissolved in water and may be taken with or without food Preparation Pour the entire contents of a single dose sachet into half a cup of cold water and stir to dissolve Do not use hot water The solution should be taken immediately after dissolving in water Drug interactions Metoclopramide lowers the serum concentration and urinary excretion of fosfomycin References Adverse effects Most frequently reported Diarrhoea nausea abdominal pain dyspepsia Headache dizzinesss weakness rhinitis pharyngitis Menstrual pain back pain vaginitis Asthenia rash Serious adverse events have been rarely reported and include Angioedema aplastic anaemia asthma exacerbation cholestatic jaundice hepatic necrosis toxic megacolon Warnings Clostridium difficile associated diarrhoea CDAD has been reported and may range in severity from mild diarrhea to fatal colitis Data Sheet Monurol fosfomycin tromethamine Sachet www frx com pi Monurol_pi pdf December 2013 Authorised Kyle Eggleton V2 Et Le a Clinical Director NPHOS n E oe Signature L S Manaia Health Portfolios Primary Options Manual POPN Manual Version 10 with amendments June 2014 docx HYPEREMESIS PATHWAY ea NORTHLAND PRIMARY HEALTH ORGANISATIONS Obstetrician agrees rehydration is v appropriate Make referral to GP or other appropnate health professional DISCLAI
52. g the day but the Erythema and pain presents later in the evening This makes evaluation difficult but if there is any doubt referral to the hospital is recommended 7 Switching back to oral antibiotics The patient should be reviewed with the aim to initiate oral antibiotics in 48 hours If it is decided to start oral antibiotics give the third 48 hours dose of Cephazolin and initiate the oral antibiotics that day Oral antibiotics are ideally Flucloxacillin 500 mg 1 gm four times daily one hour before food or two hours after Cont Oral antibiotics are suitable if Authorised Kyle Eggleton Ae Fok Kp S Manaia Health Portfolios Primary Options Manual POPN Manual Clinical Director NPHOS EE ae Version 10 with amendments June 2014 docx Signature 35 Temperature lt 38 C for gt 24 hours Clinical redness swelling and laboratory WCC blood pressure heart rate respiration signs of improvement 8 Availability of Community IV therapy IV therapy can be provided by the practice team either at the clinic or at the patient s home by a general practitioner or a nurse who is IV designated For providers who do not have the capacity to implement community IV therapy the coordinator can arrange this service through another provider Please contact the coordinator to arrange this if your practice does not offer these services Training for nurses in cannulation and IV therapy can be arranged Please contact the
53. gm administered IV once daily Reconstitute each 1g vial with water for injection Add 2g dose to make up to 30ml with normal saline 0 9 and administer IV over 15 minutes Adverse effects Hypersensitivity reactions Pain at injection site watch for extravasation Nausea vomiting anorexia oral candidiasis Diarrhoea consider pseudo membranous colitis May need to stop treatment or refer to hospital PROBENECID Contraindications amp cautions Blood dyscrasias Uric acid kidney stones Acute gout Elite athletes banned substance in sport Caution in pregnancy lactation peptic ulcer disease Probenecid decreases excretion of methrotrexate and increases serum concentrations of NSAIDs lorazepam acyclovir Not recommended for concurrent use with antibiotic in patients with known renal impairment Dosage and Administration 500 mg orally twice daily December 2013 Authorised Kyle Eggleton 7 Clinical Director NPHOS Signature Version 10 Discuss with specialist in cases of pregnancy Adverse effects Headache nausea anorexia pruritis fever flushing CLINDAMYCIN Contraindications amp cautions Previous hypersensitivity to clindamycin or lincomycin Use with caution in patients with history of colitis Dosage and Administration 300mg orally every 8 hours taken with a full glass of water to avoid oesophageal irritation Adverse Effects Diarrhoea skin rash oesophagitis abdominal pain
54. ient Authorised Kyle Eggleton ig 3 E S Manaia Health Portfolios Primary Options Manual POPN Manual Clinical Director NPHOS SA Version 10 with amendments June 2014 docx Signature f 54 Fosfomycin Treatment for Multi Resistant UTIs Multi resistant organisms are an increasing problem in NZ Oral Fosfomycin trometamol is indicated in the treatment of urinary tract infections due to a gram negative organism that is resistant to commonly prescribed oral antibiotics For example oral Fosfomycin has been used to treat uncomplicated ESBL positive E coli and Klebsiella UTI in primary care thus avoiding an acute hospital admission for IV antibiotics Gram negative bacilli expected to be Fosfomycin resistant include Morganella Acinetobacter and Stenotrophomonas Fosfomycin is not licensed or funded in NZ but is available through POPN at a cost to the patient of approximately 168 31 per dose Primary Options will pay e the full amount of the drug that would normally be charged to the patient e anadministration fee Fosfomycin is usually administered as a single or repeated oral megadose ie 3g on day 1 3g on day 4 Each sachet of Fosfomycin should be dissolved in approx half a cup of cool water or juice It is well tolerated and has a low incidence of harmful side effects However development of bacterial resistance under therapy may occur which makes Fosfomycin unsuitable for sustained monotherapy of severe infections Fo
55. irector NPHOS er YF a Version 10 with amendments June 2014 docx Signature 27 Acute Adult Asthma Severity Scale Acute Mild to Moderate Asthma e PEFR gt 75 e Speech normal e Respiration rate lt 25 breaths minute e Pulse lt 110 beats minute Acute Moderate Asthma e PEFR gt 50 e Speech normal e Respiration rate lt 25 breaths minute e Pulse lt 110 beats minute Acute Severe Asthma e PEFR lt 50 predicted or best e Cannot complete sentences e Respiratory rate gt 25 breaths minute e Pulse gt 110 beats minute Authorised Kyle Eggleton Yi FE 4 A a S Manaia Health Portfolios Primary Options Manual POPN Manual Clinical Director NPHOS a EE oe Version 10 with amendments June 2014 docx Signature l 28 Acute Child Asthma Algorithm Patient assessed as having MODERATE asthma ventolin via spacer or nebulizer 15 mins apart x 2 then REASSESS Patient re assessed as having MILD asthma Not eligible for POPN eligible for POPN Eligible for DISCLAIMER This guideline is intended to assist clinical decision making and provide General Practitioners with guidance on the appropriate use of the Primary Options Programme Northland services It is not entirely inclusive or exclusive of all methods of reasonable care It should not replace clinical judgement in managing each individual patient Authorised Kyle Eggleton PEA 4 A E S Manaia Health Portfolios Primary O
56. is is a positive reason to use Erythromycin as a sensitivity marker See drug profiles for specific dosing in renal impairment adverse effects and IV administration 1 Monitor for potential complications o Local suppuration and skin necrosis occasional o Bacteraemia o Thrombophlebitis particularly of the lower limbs o Recurrent cellulitis may cause local persistent lymphoedema o Clostridium difficile As Cephazolin is a broad spectrum antibiotic infection with clostridium difficile should be considered if diarrhoea occurs Provide the patient and or caregivers with the Home Cellulitis Treatment patient information leaflet so they are aware when to report to the general practitioner Methods of monitoring that may help the patient decide whether to contact the general practitioner sooner than the 24 hours in which they would normally be checked include marking the inflamed area to monitor any spread 6 Monitor for improvement Review the person within 24 hours at the time of the next antibiotic dose although if you have concerns about the domestic environment or think the person may be unduly anxious a telephone call from the general practitioner or practice nurse sooner than this is recommended If a person has a Streptococcus Pyogenes cellulitis the infection may be improving but the symptoms such as redness and inflammation may continue to progress because of the prior tissue damage like sunburn the tissue damage occurs durin
57. kground This document represents a Contract between Northland Primary Health Organisations and Doctors wishing to refer to the Primary Options Programme Northland POPN Northland Primary Health Organisations NPHOS consists of Manaia PHO Te Tai Tokerau PHO Whangaroa PHO Hokianga Health Integrated PHO and Kaipara Care Inc POPN is operated by NPHOS under contract to the Northland District Health Board NDHB The contract with the NDHB specifies a service that will have an immediate and significant impact on health outcomes for Patients and the growth in acute hospital referrals by empowering primary care providers to provide more flexible and responsive alternatives to an acute hospital referral The range of acute alternative services includes but is not limited to the range of services listed in the POPN Directory POPN is available to Patients who are normally resident in the NDHB area Objective The objective of POPN is to have an immediate and significant impact on health outcomes for Patients and the growth in acute hospital referrals by empowering primary care providers to provide more flexible and responsive alternatives to an acute hospital referral Outcomes The overall outcome of POPN is to demonstrate Primary Care s ability to reduce acute demand at Northland Hospitals The specific outcome sought by POPN is 85 of referrals managed without admission at an average cost of 400 or less per referral Definitio
58. l judgement to ensure that patient safety is not compromised It is expected that they will adhere to the quality standards of the RNZCGP or other professional body approved by the medical council for the purposes of accrediting health providers and the quality standards established by the PHO including standards that ensure that services are delivered in a culturally appropriate and competent manner Non accredited service Practitioners are expected to meet the requirements of code of health and disability services consumer rights Records In addition to regular Clinical Records Doctors referring to POPN will complete the Referral Form Intervention Record and Evaluation Form Invoice as required by POPN and ensure the correct Case Reference Numbers are attached to all forms Indemnity When using POPN the Doctor agrees to take full clinical responsibility for managing the treatment and ongoing care of their Patient in the community The Doctor indemnifies Northland Primary Health Organisations against any loss damage or expense incurred by NPHOS Assessments as a result of any action or poor performance by the Doctor Audit The Doctor agrees to cooperate with NPHOS in its audit responsibilities under the contract between NPHOS and NDHB The Doctor agrees to allow NDHB reasonable access to premises all relevant information and POPN Service Patients or their families as required for audit purposes For the purposes of carrying out any audit
59. lection based on convenience perhaps Non compliance with bed rest leg elevation More infections 1 Inclusion criteria for IV treatment of cellulitis in the community e Adult S Clear diagnosis of cellulitis S Medically stable e Satisfactory for IV access Suitable social and environmental circumstances e Oral antibiotics should have been tried for 48 hours previously Treatment of 12 18 year olds is at the discretion of the general practitioner depending on accessibility of an IV line home support and environment Oral medications should have been tried for 48 hours previously and the cellulitis is not improving adequately or the first presentation may be so severe or over a joint or in the face and you would normally admit the person 2 Exclusion criteria for IV treatment of cellulitis in the community Admission is recommended for people with O Signs of haemodynamic instability O Tachycardia O Relative hypotension O Severe dehydration where re hydration with IV fluids in the community would not be appropriate O Extreme or worsening pain or swelling or circulation is compromised no pedal pulses Authorised Kyle Eggleton Yi Fp S Manaia Health Portfolios Primary Options Manual POPN Manual Clinical Director NPHOS l ay Version 10 with amendments June 2014 docx Signature e 33 O Unstable co morbidities such as heart failure diabetes O Immunosuppression O A drainable collection unless ther
60. lin Cephalosporin hypersensitivity and not a known MRSA carrier Cephazolin IV 2 gms daily Probenecid orally 500 mg BD IV administration Reconstitute each 1gm vial with water for injection and dilute in 100mls normal saline 0 9 and administer over 20 mins ii History of immediate penicillin hypersensitivity Clindamycin 300 mg 8 hourly orally This hypersensitivity should be an anaphylactic reaction rather than just a rash The cross sensitivity between penicillins and cephalosporins is only 8 iii MRSA Carrier If there is no response to the oral antibiotic to which the MRSA is susceptible e g Cotrimoxazole or Clindamycin depending of proven susceptibility refer to hospital for IV Vancomycin Authorised Kyle Eggleton Ae S Kp S Manaia Health Portfolios Primary Options Manual POPN Manual Clinical Director NPHOS gt ae Version 10 with amendments June 2014 docx Signature 34 The decision regarding the presence of MRSA should be based on sensitivity history or a previous infection Note that the laboratories do not give Clindamycin sensitivity but use Erythromycin as a surrogate If the organism is Erythromycin sensitive then use Clindamycin This is because Clindamycin is better tolerated than Erythromycin and there is inadequate information on Roxithromycin Note that if an organism is sensitive to Clindamycin but resistant to Erythromycin resistance is very inducible and Clindamycin resistance is likely to occur rapidly Th
61. linical Director NPHOS l EE eee Version 10 with amendments June 2014 docx Signature 71 Referral Claim Form NORTHLAND PRIMARY HEALTH ORGANISATIONS Primary Options Programme Northland POPN Referral Claim Form All relevant clinical notes must accompany this form For patients residing in the Northland district only Date of referral Part 1 Patient and Referrers information complete and fax to 09 438 3210 within 24 hours NHI Surname First name Address Home phone Mobile Ethnicity Male Female please circle Reason for referral to Primary Options This service is available to patients who would otherwise be referred acutely to hospital ACC or maternity funded conditions are NOT covered by Primary Options For ultrasound appointments respite care or home assistance please phone Primary Options Programme Northland Coordinator on 0800 PRIMARYOPS 0800 774 627 to arrange services for you Organisation Name Organisation Phone Organisation address Referrers signature X gt gt NOTE REFERRAL WILL NOT BE ACCEPTED IF IT HAS NOT BEEN SIGNED BY REFERRING GP By signing this form I agree to abide by the Primary Options Terms and Conditions declare this patient has been informed and consent provided and that the patient understands the information on this form and other information relating to this illness will be made available to any sub contracted health provid
62. mageKey hema_pix cause131 htm amp title Causes 20 elevated 20D dimer 7 Bernardi E et al D dimer testing as an adjunct to ultrasonography in patients with clinically suspected deep vein thrombosis prospective cohort study BMJ 1998 317 1037 1040 8 British Society for Haematology BJH Guideline The diagnosis of deep vein thrombosis in symptomatic outpatients and the potential for clinical assessment and D dimer assays to reduce the need for diagnostic imaging British Journal of Haematology 2004 124 15 25 9 Dryski M et al Evaluation of a screening protocol to exclude the diagnosis of deep venous thrombosis among emergency department patients J Vasc Surg 2001 34 1010 5 10 POAC Authorised Kyle Eggleton Ws Pek D S Manaia Health Portfolios Primary Options Manual POPN Manual Clinical Director NPHOS a a ae Version 10 with amendments June 2014 docx Signature 44 Drug Profile for administration as per Suspected DVT Algorithm ENOXAPARIN SODIUM CLEXANE AND CLEXANE FORTE Refer to data sheet for full product information Contraindications Refer to hospital gt Allergy to enoxaparin heparin or its derivatives gt Active bleeding gt High risk of bleeding e g thrombo cytopenia brain metastasis oesophageal varices recent GI or intracranial bleed lt 3 months Recent haemorrhagic stroke lt 1 month Recent neurological or ophthalmological surgery Uncontrolled hypertension On warfarin
63. n of the POPN Service POPN and its procedures are defined in the Primary Options Programme Northland Manual POPN may be modified from time to time by NPHOS Qualifying Patients All Patients of Qualifying Doctors who are normally resident in the NDHB region are eligible to be referred to the POPN Service Any Patient who following a normal consultation the Doctor would normally refer acutely to a Northland Hospital but who the Doctor considers could be safely managed in the community with extra support or diagnostic services can be referred to POPN Qualifying Doctors Any Registered Medical Practitioner who holds a current Annual Practicing Certificate and has not been found guilty of disgraceful conduct under the Medical Practitioners Act 1995 81 Medical and Nursing Staff All medical and nursing staff employed by the referring doctor will be registered with their appropriate statutory body and hold a current annual practicing certificate Clinical Responsibility When a Doctor who is not the Patient s GP refers a Patient to POPN the Initiating Doctor he she agrees to advise and hand over care to the Patient s GP at the earliest practical opportunity e g next working day The Initiating Doctor carries clinical responsibility for managing the Patient s acute illness until the responsibility has been accepted by the Patient s GP Quality Standards Medical practitioners referring patients to POPN will apply sound clinica
64. n renal impairment Dosage and Administration 100 mg orally twice daily with plenty of fluid Adverse Effects Dizziness vertigo superinfection GI disturbances skin reactions haematological effects renal toxicity hypersensitivity reactions Rare oesophageal ulceration tooth discolouration benign intracranial hypertension hepatic failure Authorised Kyle Eggleton Ve wa A LS S Manaia Health Portfolios Primary Options Manual POPN Manual Clinical Director NPHOS ES eee Version 10 with amendments June 2014 docx Signature 67 PYELONEPHRITIS ADULT PYELONEPHRITIS PATHWAY Adult Pyelonephritis Algorithm NORTHLAND PRIMARY HEALTH ORGANISATIONS Primary Options Programme Northland POPN Acute pyelonephritis pathway Patient presents with symptoms of pyelonephritis fever chills flank pain costavertabral angle tenderness dysuria frequency nausea vomiting Investigations MSU urine dipstick urine pregnancy test eGFR consider FBC Clinical features of pyelonephritis including flank pain or tenderness and fever 238 positive Therapy Consider IV fluids analgaesia leucocytes and or antiemetics positive nitrites on Give one dose Gentamicin 3mg kg iv or dipstick Amoxycillin clavulanic acid iv and send home on Female 16 70 oral antibiotics see below for antibiotic selection Non pregnant Clinically stable no co Review within 24h check results clinical mo
65. ntly If the TOTAL CLINICAL SCORE gt or equal to 4 the patient should be referred for leg ultrasound scan Authorised Eggleton Vie Fok qe S Manaia Health Portfolios Primary Options Manual POPN Manual Clinical Director NPHOS ganarse ar sae Version 10 with amendments June 2014 docx 39 IMPORTANT Referring patients with suspected DVT e IN WHANGAREI Ultrasounds can be organised at Whangarei Hospital with the radiology department directly by the GP if the patient has a d dimer result of 500 or greater and has had a Primary Care Decision Rule done Please also see DVT section If there is a low d dimer but the clinical suspicion of a DVT remains high contact O800PRIMARYOPS and we will organise a private scan for you e Kaitaia patients can be referred directly to Kaitaia radiology PLEASE CALL FIRST to discuss with the ultrasonographer e In other parts of Northland call O9OOPRIMARYOPS to arrange a private scan If the USS scan does not show a DVT then the patient should be reviewed the next day and the same clinical management plan followed as for those with a low clinical score Patients with a clinical score gt or equal to 4 and negative ultrasound scan may still have a significant risk of DVT They require very clear advice regarding any increase in symptoms which may indicate development of a DVT or Pulmonary Embolus If tests are negative but clinical suspicion for DVT is high then consider seeking advice from a relev
66. on Primary Options Programme Northland POPN is a service allowing doctors to access investigations care or treatment for their patient as an alternative to an acute hospital referral where the patient can be safely managed in the community It is intended to reduce the pressure on acute demand at Northland hospitals A range of community diagnostic therapeutic and logistical services are provided at no cost to the patient the initial consult is paid for by the patient Some of the most common conditions are included in the manual with guidelines for treatment Included are Cellulitis Suspected DVT Community Acquired Pneumonia Early Discharge Dehydration Pyelonephritis IV Pamidronate and IV Zoledronate administration Patients with these conditions who take up the option of being cared for in primary care will be expected to be managed according to the best practice guideline provided in this manual as far as practicable Many other conditions can be managed under the POPN criteria these include e g renal colic and abdominal pain Additionally other patients who meet the POPN criteria and who could benefit from accessing the available services will also be accepted onto the programme These vary by locality but can include e Diagnostic procedures for example x ray and ultrasound e GP and practice nurse home visiting e Follow up and return visits to general practice e Intravenous therapy e Home help and equipment hire
67. ore Mortality S OO 41 5 2 Management when eligible for POPN i e 1 2 severity Day one gt Urgent chest x ray with rapid reporting same day latest next morningO Urgent lab tests CBC Urea Electrolytes Glucose LFT and CRP Advise rest avoiding smoking adequate fluids and nutrition Consider rest home placement for suitable short term observation under POPN Confirm caregiver and arrange for follow up within 24 hours Y VV WV Start antibiotic therapy as appropriate see below Day two gt Review investigations and clinical progress gt Review of therapy is appropriate oral or second IV gt Admit to hospital if condition has deteriorated Day three four gt Assess if stable on oral therapy or if had a second IV ready to switch to oral gt Admit to hospital if condition has not improved Authorised Kyle Eggleton Ae Fok Kp S Manaia Health Portfolios Primary Options Manual POPN Manual Clinical Director NPHOS gt E eee Version 10 with amendments June 2014 docx Signature 65 Day five if indicated gt Review progress gt Admit to hospital if condition has not improved gt Arrange to follow up with chest x ray at 6 weeks 3 ANTIBIOTIC THERAPY Low risk patients Amoxycillin 500 mg 8 hourly Roxithromycin 300mg daily for 7 10 days Smoking or CORD patients higher risk Amoxycillin clavulanate IV 1 2g 12 hourly plus oral roxithromycin 300mg or Amoxycillin clavulanate 500mg 1
68. ptions Manual POPN Manual Clinical Director NPHOS gt SE E Version 10 with amendments June 2014 docx Signature e 29 Acute Child Asthma Severity Scale ACUTE ASTHMA ACUTE ASTHMA SEVERITY TOOL ACUTE MILD e speaks feeds normally e pulse normal e respiratory rate normal e mild indrawing ACUTE MODERATE speaking feeding interrupted by breaths e indrawing accessory muscle use present e pulse 1 to 5 years gt 110 min over 5 years gt 100 min respiration counted over 60 seconds 1 to 5 years gt 40 min over 5 years gt 20 min ACUTE SEVERE e cant complete sentences in one breath or too breathless to talk or feed e pulse 1 to 5 years gt 130 min over 5 years gt 120 min e respiration counted over 60 seconds 1 to 5 years gt 50 over 5 years gt 30 e indrawing accessory muscle use obvious ACUTE LIFE THREATENING e hypotension e exhaustion e confusion e coma e silent chest e cyanosis Authorised Kyle Eggleton y S Manaia Health Portfolios Primary Options Manual POPN Manual Clinical Director NPHOS waa Version 10 with amendments June 2014 docx Signature f 30 CELLULITIS Treatment of Cellulitis Algorithm These guidelines provide support for W Management of Cellulitis in the community when initial oral treatment has failed The treatment period should be for a minimum of 48 hours This is to be used for guidance only and not replace clinical judgement Contirm Cellulitis Mark area of erythema with marke
69. r Recommend photo for monitoring Therapy If no history of immediate penicillin cephalosporin hypersensitivity and not known to be an MRSA carrier Cephazolin 2z m daily IV plus oral Probenecid Electrolytes glucose 500 mg twice daily creatinine Aswab if lesion is If history of immediate penicillin discharging hypersensitivity Clindamycin 300mg orally 8 hourly specialist endorsement required If a known MRSA carrier lf there is no response to oral antibiotic to which the MRSA is susceptible refer to hospital for IV Vancomycin Refer to drug profile sheet Switching back to oral antibiotics Review in 48 hours with the aim to initiate oral flucioxacillin 500mg lem gid one hour before food or two hours after food in 48 hours lf starting oral antibiotics give the third 48 hour dose of Cephazolin and initiate the oral antibiotic on the same day DISCLAIMER This guideline is intended to assist clinical decision making and provide General Practitioners with guidance on the appropriate use of the Primary Options Programme Northland services It is not entirely inclusive or exclusive of all methods of reasonable care It should not replace clinical judgement in managing each individual patient Authorised Kyle Eggleton Ve ge S Manaia Health Portfolios Primary Options Manual POPN Manual Clinical Director NPHOS fo Version 10 with amendments
70. rbidities requiring examination of patient admission Yes No If improved Continue oral antibiotics could give further dose of iv antibiotics if improved but still vomiting and unable to tolerate orals If second dose of gentamicin is given must have checked eGFR If given Gentamicin then give Ciprofloxacin 250mg 500me_ bd for 7 days If given Amoxicllin clavulanic acid then give oral Amoxicllin clavulanic acid 500 125mg 8 hourly for 14 days Followup NSU at day 14 DISCLAIMER This guideline is intended to assist clinical decision making and provide General Practitioners with guidance on the appropriate use of the Primary Options Programme Northland services It is not entirely inclusive or exclusive of all methods of reasonable care It should not replace clinical judgement in managing each individual patient Authorised Kyle Eggleton ig 3 E S Manaia Health Portfolios Primary Options Manual POPN Manual Clinical Director NPHOS Version 10 with amendments June 2014 docx Signature 68 Adult Pyelonephritis Pathway Presentation Symptoms suggestive of pyelonephritis fever chills flank pain costo vertebral angle tenderness urinary symptoms dysuria frequency nausea vomiting Investigations MSU urine dipstick urine pregnancy test eGFR consider FBC Inclusion criteria Clinical features of pyelonephritis including flank pain or tenderness and fever 238 positive leucocytes and or positive nitrites on dipstick
71. resembling an orange skin Borders are usually indistinct unlike in erysipelas in which the borders are sharply demarcated and raised For good photos of cellulitis go to http www dermnet org nz bacterial cellulitis html 4 General Cares Elevating the limb is very important and is probably the main reason people who are hospitalised do better than in the community Ensure that the person has complete bed rest while at home Mark the area of erythema with indelible marker to monitor progress of the cellulitis 5 Potential Complications e Local suppuration and skin necrosis occasional e Bacteraemia Thrombophlebitis particularly of the lower limbs e Recurrent cellulitis may cause local persistent lymphoedema However the prognosis is generally excellent Authorised Kyle Eggleton Ae Fok Kp S Manaia Health Portfolios Primary Options Manual POPN Manual Clinical Director NPHOS EE ae Version 10 with amendments June 2014 docx Signature 32 Intravenous antibiotics for treating cellulitis in the community The potential strengths of home IV antibiotics include The patient being at home with family and able to continue work school A sense of empowerment for the patient e Fewer nosocomial and cannula associated infections Continuity of care by the General Practitioner To balance this some potential challenges include Disruption of family routine A sense of abandonment Inappropriate antibiotic se
72. rised Kyle Eggleton Yi S S Manaia Health Portfolios Primary Options Manual POPN Manual Clinical Director NPHOS l ey Version 10 with amendments June 2014 docx Signature e 73 Drug Profile Zoledronic Acid Aclasta Refer to data sheet for full product information Contraindications Known hypersensitivity to zoledronic acid or other bisphosphonates Hypocalcaemia Pregnancy and lactation Renal Impairment Do not use in patients with severe renal impairment eGFR lt 35 ml min Special Precautions Caution in patients taking medications that cause renal impairment and patients taking non steroidal anti inflammatory drugs and diuretics Dosage and Administration A single intravenous infusion of 5 mg zoledronic acid in a 100ml aqueous solution The solution is infused intravenously via a vented infusion line at a constant rate for not less than 15 minutes Infusion may be given more slowly up to 30 minutes in older patients Instructions for Use and Handling e Prepare ready to use infusion by removing vial cap inserting IV administration set with vent needle prime tubing e Check solution is clear free from particles and discolouration e Do not mix or give with any other medication e Single use only Discard any unused solution e Flushing of line is recommended Adverse effects Fever myalgia flu like symptoms chills arthralgia headache malaise fatigue bone pain pain in extremities GI upset
73. rry out any work actrities Up and about more than 50 of waking hours 3 Capable of only limited selfcare confined to bed or chair more than 50 of waking hours 4 Completely disabled Cannot carry on any selicare Totally confined to bed or chair Oren MM Creech ALA Tormey DC Horten I Bows TE Afcfodden ET Gorbone PP Touwerty And Response Criterio DISCLAIMER This guideline is intended to assist clinical decision making and provide General Practitioners with guidance on the appropriate use of the Primary Options Programme Northland services It is not entirely inclustve or exclusive of all methods of reasonable care It should mot replace clinical judgement in managing each individual patient Authorised Kyle Eggleton ig 3 E S Manaia Health Portfolios Primary Options Manual POPN Manual Clinical Director NPHOS SA Version 10 with amendments June 2014 docx Signature December 2013 Authorised Kyle Eggleton JZ Clinical Director NPHOS gig T Signature Pamidronate Drug Profile DRUG PROFILE PAMIDRONATE 59 For use in Pain Pathway or Prevention of Skeletal Event Pathway Refer to data sheet for full information PAMIDRONATE Contraindications amp cautions Known hypersensitivity to pamidronate or to other bisphosphonates Renal impairment Pre existing hypocalcaemia Active dental disease Renal Function Assess renal function before each dose eGFR gt 60 for inclusion in pathw
74. rs of 0830 1700 Monday to Friday excluding public holidays Authorised Kyle Eggleton Ae Fok Kp S Manaia Health Portfolios Primary Options Manual POPN Manual Clinical Director NPHOS EE ae Version 10 with amendments June 2014 docx Signature Referral process algorithm Would you normally refer this patient to hospital Can you safely manage this patient within 400 for up to 3 days Can you take clinical responsibility for this patients care Contact Service Coordinator for external services YES Complete referral form and attach the clinical record Send to POPN coordinator electronically or fax After completion of care complete outcome form and send to POPN Authorised Kyle Eggleton is typ A S Manaia Health Portfolios Primary Options Manual POPN Manual aIr Clinical Director NPHOS Version 10 with amendments June 2014 docx Signature 10 Frequently asked questions Which patients are eligible to receive Primary Options Services e New Zealand residents who would normally be admitted or referred acutely to a hospital in Northland and e who are expected to be able to be managed within the 400 budget and e itis expected that their episode will be resolved in 3 5 days and e who can be managed safely in the community Which patients are NOT eligible for Primary Options Services e Patients with chest pain of cardiac origin should be sent immediately to hospital
75. rtfolios Primary Options Manual POPN Manual Clinical Director NPHOS denie s pr Version 10 with amendments June 2014 docx 58 Pamidronate Algorithm NORTHLAND PRIMARY HEALTH ORGAHISATIONS Primary Options Programme Northland POPN Pamidronate Infusion Patient identified by their GP as suitable for monthly Pamidronate Infusions for either management of pain Pain Pathway or for preventation of skeletal events Prevention of Skeletal Events Pathway can be safely managed in the community and meets inclusion criteria Therapy Dosage 90mes 4 6 weekly by slow intravenous infusion see drug profile for recommendations Consider administering Dexamethasone 3 days prior to initial dose only 4me 3 days in order to dampen down possible inflammation Exit Criteria Poor renal function eGFR lt 60 Active dental disease Patient declines further treatment for Prevention of Skeletal Events Pathway Performance status gt 2 Le wheel chair bound not ambulatory consider Pamidronate pain pathway for Pain pathway After 2 years of Pamidronate treatment take a rest period of 6 months H ECOG Performance status O Fully active able to carry on all pre disease performance without restriction 1 Restricted in physically strenuous activity but ambulatory and able to carry out work of a light or sedentary nature g light house work office work 2 Ambulatory and capable of all self care but unable to ca
76. s so this should be balanced against the small risk of ill effects from treatments Treatment is usually accompanied by some vitamin D tablets given at the time of the infusion to keep blood calcium levels normal Side effects with zoledronate include 1 About 30 of individuals may experience a flu like feeling after their first treatment which usually last 24 72 hours but can occasionally go on for longer sometimes with associated muscle or joint aching This usually responds to regular paracetamol or ibuprofen The chance of this side effect occurring after the second or third zoledronic acid infusions is much lower about 3 4 2 Individuals with severe pre existing kidney damage can sometimes experience deterioration in their kidney function after the administration of zoledronate Its normal practice not to use zoledronate in people whose kidneys are not functioning well 3 Very rarely drugs in the bisphosphonate class can cause eye inflammation Unproven side effects with zoledronate include 1 O0steonecrosis of the jaw ulceration in tooth socket or the gums observed in a small number of cancer patients receiving high dose treatment but not increased in those treated for osteoporosis or Paget s disease 2 Atrial fibrillation an abnormal heart rhythm noted by one group of overseas investigations but not seen in other clinical trials 3 Upper leg fractures reported in isolated cases by doctors in Singapore and the USA but
77. sfomycin is not officially approved in New Zealand and patients need to be informed of this and the possible unwanted effects Information for patients on POPN website under patient information and provided with medication from Kensington pharmacy Please send a script to Kensington pharmacy with Primary Options marked on it A phone call to Kensington Pharmacy assists to expedite the process On dispensing the fosfomycin Kensington pharmacy will provide the patient name to the Ministry of Health as with any unapproved medication Authorised Kyle Eggleton Ve wa A LS S Manaia Health Portfolios Primary Options Manual POPN Manual Clinical Director NPHOS ES eee Version 10 with amendments June 2014 docx Signature 55 DRUG PROFILE FOSFOMYCIN FOR MULTI RESISTANT UTI Fosfomycin is not a regisistered medicine in New Zealand and falls under use of unapproved medicine under Section 25 and 29 of The Medicines Act 1981 The patient must be made aware of this and that it is a requirement that information about the supply including the patient s name be forwarded to Medsafe by the pharmacy Consultant endorsement must be obtained from an ID consultant at NDHB Dr David Hammer Refer to data sheet for full product information FOSFOMYCIN Contraindications amp cautions Known hypersensitivity to fosfomycin Dosage and Administration One sachet containing 5 631 grams of fosfomycin tromethamine equivalent to 3 grams o
78. sianie a a a e a veueayietaeesian 47 BARLY DISCHARGE SERVICE raae e E A N ea edecoeeaaeeat 49 Barly discharge patient Criteria aione a a a a osha ewes elles 49 Condono accepte desne aaa 50 EE a AU AOC EA E N A N 50 Early Discharge Pathway nucensiiieiinii E T E T S 51 FOSFOMYCIN for patients with multi resistant UTIS ccccccsseccccsssececeesececeeseccceeesececseececeeneceesenecessensess 52 AOI oie neta acta asta saatssece emcee neta dated tata A E N 53 Fosfomycin Treatment for Multi Resistant UTS ceeccccsssceeceeeeeeessnneeeeeeeeeseesneeeeeeeeseeeesneeeeeeseeees 54 HYREEREME SIS PATHWAY Ancesesocti cele tot oet eae casae te teeta N 56 PANMIDRONATE PATHWAY sieccictautetiuchiaece ee tietetc e Ui dead acne E i 57 TAC Wee OUI O teased Sahat settee chin ated ba dhe serene oemaato edad aha A ast reteat A O 57 Pamidionale AlO eoa oe tauccdesucigsouanuesdauas nets ysceucsdanecseiemreneasaaees ania wceuvisunesseo wenuescaescaena Wikeetoass 58 Pamidronare Drug PROT GC s 545 05 cosnicaaseenbashebetentkcn unde Sosed base oven so seeanibcadua de a a 59 PNEUMONIA COMMUNITY ACQUIRED PNEUMONIA ccccccccccccccccceceeeessssseeeeeecececeeeeesssseuaaaaeesseseeees 60 Alor scichets seine E E E N A AS 60 Investigation and Management of Community Acquired Pneumonia eseseessessssssserrrrssserrrrssrssserrrrees 61 Guideline on the Assessment and management of moderately severe adult community acquired Poemon dreisoni E E E E A E A E a 61 C
79. sure good hydration o Warn patients of 30 risk of flu like symptoms fever chills muscle bone and joint pain nausea fatigue and headache within 3 days of infusion Authorised Kyle Eggleton ie Pik Lg S Manaia Health Portfolios Primary Options Manual POPN Manual Clinical Director NPHOS l 2 e Version 10 with amendments June 2014 docx Signature e 71 Post Infusion Recommendations o Advise patients to maintain an adequate fluid intake o Prescribe paracetamol or ibuprofen to reduce flu like symptoms o Continue vitamin D supplementation by prescribing one tablet of 1 25mg cholecalciferol vitamin D once a month or two tablets of multivitamins daily Patient Information Leaflet Refer to website WWW MANAIAPHO CO NZ PRIMARY OPTIONS for a copy of this document Authorised Kyle Eggleton 7 f A LOS S Manaia Health Portfolios Primary Options Manual POPN Manual Clinical Director NPHOS eS eee Version 10 with amendments June 2014 docx Signature 72 Checklist Zoledronic Acid Infusion Aclasta CHECK LIST Has patient met eligibility criteria Has patient been instructed to stop oral bisphosphonate tablets if currently taking them Is patient s eGFR gt 35 ml min Is patient on vitamin D or had a pre infusion dose of vitamin D Is patient s serum calcium normal Is the patient s oral health normal Has patient read the patient information sheet and had questions answered Autho
80. tfolios Primary Options Manual POPN Manual Clinical Director NPHOS l S Version 10 with amendments June 2014 docx Signature e 14 Hand Over to another GP for Patient Management in a Rest Home Private Hospital or Home Care Services When a Primary Options patient has been referred to a rest home private hospital or home care services and the GP is unable to provide care and take clinical responsibility for example during a weekend 1 The GP must ensure a nominated GP can provide care and take clinical responsibility during the allocated times 2 The referring GP must make direct verbal contact with the other GP 3 The referring GP must complete a Primary Options Clinical Responsibility Form see forms on Primary Options website www manaiapho co nz and fax to the service coordinator who will fax to the selected service provider Referring older people Please consider the following points before referring older people to Primary Options Programme Northland e Frail older people with multiple medical problems who present with an acute condition unless the diagnosis is very clear should be referred to hospital for assessment e lf referring to Primary Options services e g rest home there should be a clear expectation of recovery within 3 days and a discharge plan in place for the patient e lf there are already support services in place these patients may need assessment for a greater level of care by NASC If
81. the higher the score the more likely DVT present DVT UNLIKELY NO DVT ON USS If no DVT pt may still have significant risk of DVT REFER ULTRASOUND SCAN USS Suggest review the RISK OF DVT IS LOW CONSIDER following day or discuss with If delay in getting scan gt Clinical follow up within 7 days specialist if clinical Ae Pee ee concerns Warn pt if symptoms worsen to immediately contact GP Phone review at 3 months Give patient information handout IMPORTANT ADVICE TO CONSIDER FOLLOWING LOW CLINICAL SCORE e Despite negative tests the risk of DVT may still persist for up to 3 months Use clinical judgement if DVT strongly suspected but tests are negative Seek specialist advice if concerned Watch for change in clinical symptoms especially increased leg swelling pain chest pain or SOB Authorised Kyle Eggleton Clinical Director NPHOS Signature presentation consider stat dose clexane OR refer to hospital see attached advice re clexane DISCLAIMER This guideline is intended to assist clinical decision making and provide General Practitioners with guidance on the appropriate use of the Patient in Whangarei Primary Options Programme Northland services It is not entirely Rest of Northland inclusive or exclusive of all methods of reasonable care It should not replace clinical judgement in managing each individual S Manaia Health Portfolios Primary Options Manual POPN
82. therapeutic INR Severe hepatic or renal impairment Y VV VY Y WV Anaemia Hb lt 100g L Precautions Risk of bleeding history of heparin induced thrombocytopenia gastro intestinal ulceration bleeding diathesis impaired haemostasis agents affecting haemostasis recent ischaemic stroke diabetic retinopathy organic lesions liable to bleed renal and hepatic impairment pregnancy lactation low body weight women lt 45 kg and men lt 57 kg obesity high does elderly Dosage and Administration Patients up to 100kg 1 5 mg kg body weight once daily administered subcutaneously Patients over 100kg 1 mg kg bodyweight every 12 hours administered subcutaneously High risk patients e g patients with severe renal impairment creatinine clearance or eGFR lt 30 ml min patients with iliac vein thrombosis or cancer obese and underweight patients and the elderly will need dosage adjustment should they be proven to have DVT and require treatment Refer to hospital Calculation of dose Based on body weight in kilogram kg Volume to be injected should be measured and administered precisely according to the dosage calculated e g 90kg patient requires 90 x 1 5 mg 135 0 mg Administer 135 mg from 150mg 1ml syringe i e 135 150 0 9ml Authorised Kyle Eggleton Yi S S Manaia Health Portfolios Primary Options Manual POPN Manual Clinical Director NPHOS l S Version 10 with amendments June 2014 docx Signature e
83. tion e Asthma stabilization e Pain management if requiring prolonged observation e g renal colic e Observation External Services Provision of external services is arranged by the Primary Options service coordinator Please contact the coordinator on O800PRIMARYOPS gt Zoledronic acid infusions gt V therapy Enoxaparin Clexane administration Equipment hire Home care home support Lab services Physiotherapy Radiology US x ray Y VV VV WV Residential care rest home care for up to three nights private hospital care for two nights gt Transportation Services are subject to final service agreements MOU s being put in place and nurses receiving IV designation Authorised Kyle Eggleton Ae Fok Kp S Manaia Health Portfolios Primary Options Manual POPN Manual Clinical Director NPHOS EE ae Version 10 with amendments June 2014 docx Signature 22 Section Iwo Guidelines for treatment common conditions Please note The POPN programme is not limited to these conditions only please see eligibility criteria Authorised Kyle Eggleton Yn rb A E S Manaia Health Portfolios Primary Options Manual POPN Manual Clinical Director NPHOS ganarse j pr i Version 10 with amendments June 2014 docx 23 ASTHMA ADULT AND CHILD Based on e The NZ guidelines group best practice evidence based guideline Sept 2002 email info nzgg org nz e Paediatric Society of New Zealand Best practice evidence bas
84. trasound dept ext 7591 at Whangarei Hospital to organise this If the scan cannot be done on the same day then it is recommended the patient has a single dose of Enoxaparin White Cross or ordered from Kensington Pharmacy and administered at your practice Dargaville and the Mid North Kaikohe Kerikeri Kawakawa Moerewa Paihia Russell also Whangaroa Patients with a high Primary Care Decision Rule gt 2 Contact the Primary Options coordinator to arrange a scan negative or positive D dimer will be scanned privately if available If scan is not available within 8 hours it is recommended the patient has a single dose of Enoxaparin please call Kensington Pharmacy on 09 437 3722 to order this if you do not have this in stock If an ultrasound scan is available send patient to radiology usually Northern Radiology with Primary Care Decision Rule lab form and radiology form If positive DVT refer to MOSS BOI hospital or administer Enoxaparin dose as per attached drug profile Enoxaparin is available via special authority once a DVT is confirmed If required Primary Options will fund one follow up consult following a positive DVT Further funded consults are by arrangement only and are dependent on avoiding a presentation to ED or admission to hospital Authorised Kyle Eggleton Ae Fok Kp S Manaia Health Portfolios Primary Options Manual POPN Manual Clinical Director NPHOS eS eee Version 10 with amendments June 2
85. udget of 400 00 ultrasound additional Authorised Kyle Eggleton Yi S S Manaia Health Portfolios Primary Options Manual POPN Manual Clinical Director NPHOS l ey Version 10 with amendments June 2014 docx Signature e The service continued To be eligible for POPN funding where patients have the common conditions Cellulitis Pheumonia Asthma Suspected DVT and Dehydration they are expected to be managed according to the best practice pathway included in this manual acknowledging that these are guidelines and clinical judgment remains paramount If in doubt please check with the coordinator The POPN services that are funded are gt GP or nurse consultations gt Nurse observation gt IV therapy either antibiotics or fluid replacement gt Private x ray or scan gt Rest home stay gt Home support gt Equipment Hire services gt Transport support Services can be provided by either the practice team or by external services External services are arranged by the POPN coordinator by phoning 0800 PRIMARYOPS Additionally there will be an opportunity for other flexible solutions such as short term cell phone provision to be provided in consultation with the coordinator POPN has a clinical governance group and a clinical director who can provide additional advice about the use of this programme The patient can be referred to Primary Options electronically or by fax Service coordination is available between the hou
86. ulary v16 1 October 2013 http Hint ore S Manaia Health Portfolios Primary Options Manual POPN Manual Version 10 with amendments June 2014 docx 60 PNEUMONIA COMMUNITY ACQUIRED PNEUMONIA Algorithm Adult patient age gt 16 presents with clinical features consistent with CAP Assess Severity using CRB 65 tool 1 2 CRB score Order Investigations including CXR and Urea test Outcome of investigations indicate pneumonia Outcome of investigations do not indicate Commence antibiotic treatment pneumonia Amoxycillin 500 mg 8 hourly orally Roxithromycin 300mg daily orally for 7 10 day OR Amoxycillin clavulanate IV 1 2g 12 hourly plus Roxithromycin 300 mg orally daily Reconsider diagnosis Has patients condition deteriorated DISCLAIMER This guideline is intended to assist clinical decision making and provide General Practitioners with guidance on the appropriate use of the Primary Options Programme Northland services It is not entirely inclusive or exclusive of all methods of reasonable care It should not replace clinical judgement in managing each individual patient Authorised Kyle Eggleton jj i S Manaia Health Portfolios Primary Options Manual POPN Manual Clinical Director NPHOS wa S Version 10 with amendments June 2014 docx Signature a 61 Investigation and Management of Community Acquired Pneumonia Patients with SEVERE pneumonia ar
87. ult is available it should be used in the severity assessment Otherwise it should be included in the requested lab test and used at reassessment Note If the urea is gt 7mmoll I and the age is over 65 the mortality rate rises up to 9 and referral to hospital should be given serious consideration Differential diagnosis e Influenza e Asthma and COPD e Pleurisy e Bronchiectasis e Pneumothorax e CHF and Cardiac Ischaemia e Pulmonary Embolism e Lung Cancer and other Lung Pathologies e Inhaled Gastric Contents amp Foreign Bodies e Tuberculosis Authorised Kyle Eggleton Ae Fok Kp S Manaia Health Portfolios Primary Options Manual POPN Manual Clinical Director NPHOS EE ae Version 10 with amendments June 2014 docx Signature 63 CLINICAL FEATURES e The aim is to identify the 5 12 with moderate community acquired pneumonia from the majority with acute non pneumonic lower respiratory tract infections or other diagnoses e This is particularly difficult in the presence of co morbid illnesses such as LVF chronic lung disease or COPD and those over 65 yrs of age who frequently present with non specific symptoms and an absence of chest signs e Making an accurate diagnosis of CAP therefore requires an x ray e The aetiological agent causing CAP cannot be accurately predicted from clinical features e Pneumonia can present atypically in as many as 22 and this can lead to diagnostic uncertainty e Remember to ask about o
88. vered by the Primary Options programme The following paperwork is to be faxed to Primary Options if a private scan is arranged and the scan provider prior to the scan gt D Dimer test result gt Completed Primary Care Decision Rule can be downloaded from the Forms section of the Primary Options page of our website www manaiapho co nz primary_options gt Radiology request form faxed to radiology provider must have patients phone number on it Authorised Kyle Eggleton Ve wa A LS S Manaia Health Portfolios Primary Options Manual POPN Manual Clinical Director NPHOS a ee Version 10 with amendments June 2014 docx Signature 17 Outcomes amp Invoicing Outcomes An outcome must be completed at the conclusion of the episode of care This tells us how the episode of care was managed and also allows the provider to invoice at the same time Please note Clinical notes should be added to the outcome either by clicking the add consult notes button which will go back a consult with each click or by typing notes in manually After an outcome has been submitted an invoice can also be completed in the system Invoicing in the Primary Options system automatically feeds information into Medtech this appears in the patient s Daily Record Invoicing If you need to claim for services consumables an invoice should be completed in the system either at the same time as an outcome or separately after an outcome has been submitt
89. w manaiapho co nz primary options forms What if the patient is enrolled with another GP When a doctor the initiating doctor who is not the patient s GP refers a patient to the service he she agrees to advise and handover care to the patient s GP at the earliest practical opportunity e g the next working day How are practice based services claimed back It is intended that referrals will be sent electronically however if the referral is paper based 1 Notification complete the patient details on the referral form and fax the form to the programme coordinator on fax 09 438 3210 2 Completion of care complete the outcome and invoice form and fax or post to us once the episode of care has been completed no later than 30 days following initiation along with clinical notes for each day of treatment If there are any queries regarding electronic referrals contact Lisa Russ on O800PRIMARYOPS What happens after hours Office hours for the coordinator are 0830 1700 Monday Friday excluding public holidays If treatment is to be carried out within the practice after hours then that can continue and the referral can be sent through via Medtech advanced form However Primary Options cannot coordinate external services currently after hours Primary Options pays for planned or referred after hours follow up services provided by the GP or after hours medical centre if needed What if my patient eventually needs to be admitte
90. ydration produces different signs from acute fluid loss eg blood loss or severe sepsis A 50 acute loss 40mls kg produces a moribund very sick child but the same amount of total body fluid lost gradually produces signs of only mild dehydration When making any assessment of dehydration it is important to review the patient and to monitor for ongoing losses and signs of improvement Mild dehydration 3 deficit o Upto 3 loss of body weight o Thirst Moderate dehydration 6 deficit o Up to 6 loss of body weight o Dry mouth o Sunken eyes o Irritability restlessness o Cool hands feet o Reduced urine output o Reduced skin turgour think of altered serum Na if present Severe dehydration gt 9 o Up to 9 loss of body weight o All of moderate signs symptoms PLUS o Tachycardia o Poor peripheral pulses o Cold peripheries o Reduced capillary refill centrally sternum o Signs of acidosis breathing thanks to Dr Richard Aicken Starship Hospital Authorised Kyle Eggleton Ve wa A LS S Manaia Health Portfolios Primary Options Manual POPN Manual Clinical Director NPHOS a ee Version 10 with amendments June 2014 docx Signature 47 Child Dehydration Algorithm Child dehydration vomiting and diarrhoea Assess level of dehydration Mild 3 deficit Moderate 6 deficit Severe gt 9 not suitable for Primary options See criteria for assessment previous page CONSIDER THE USE OF ONDANSETRO

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