Developing a Nurse-led Integrated ‘Red Legs’ Service – Caring for People with a Complex Diagnosis/Condition with Causes other than Acute Cellulitis

For some time the clinicians from the lymphoedema and dermatology services within the University Hospital of North Staffordshire (UHNS) have had concerns that a significant number of patients are admitted to the acute trust with an apparent diagnosis of cellulitis, when they may have been misdiagnosed due to the complexity of their condition. Wingfield (2012) describes that the simple clinical criteria for the diagnosis of the condition cellulitis are a well demarcated area of redness (erythema); with associated tenderness and warmth and swelling. If there is no increased warmth over the skin it is unlikely to be cellulitis. The leg is the most common presenting site and as Chronic Resource Efficiency Support Team (CREST, 2005) describe that bilateral leg cellulitis is extremely rare and therefore if there are bilateral symptoms a diagnosis other than cellulitis should be excluded.

The diagnosis of cellulitis has been confused with a condition which is commonly called ‘red legs’ amongst specialist clinicians and drawing on their clinical experience is described  as: ‘uniform redness throughout both legs, usually below the knee only. There can be associated warmth and tenderness but no systemic upset or malaise.’ This condition is often chronic in nature and causes significant distress to patients with the symptoms of ‘red legs’ who are admitted to hospital and are treated for cellulitis, which includes intravenous antibiotic therapy (IV) and unnecessary investigations and is associated with an average hospital admission of two weeks. In many cases the symptoms of ‘red legs’ may be attributed to gravitational eczema, dermatitis or other chronic conditions, which will not respond to intravenous antibiotics (IV) and are dermatological in nature (Chronic Resource Efficiency Support Team (CREST), 2005).

This project was developed to set up a new nurse-led service based on the needs of patients diagnosed with ‘red legs’. Upon gaining patients’ experiences of their condition, it became clear to the project leader that a number of different clinical specialties were involved in caring for this group of patients. Representatives from these specialties and patients were invited to create a stakeholder group whose purpose was to develop integrated care pathways, focus on referral criteria, diagnostics and treatment to inform a new nurse-led service. There was a commitment to utilise a number of facilitation approaches and practice development methods in the progression of the project with the support of the Foundation of Nursing Studies (FoNS).

As well as clinical representatives, the directorate matron and the service manager were involved to assist with the development of the commissioning documents and the work force planning. The trust board were also kept informed with the involvement of the chief nurse at the outset of the project, and the use and distribution of a project newsletter to show the progress of the project. Following a three month pilot of the nurse-led service and positive feedback from patients the nurse-led service has now been fully commissioned and a secondment opportunity has been developed to lead the new service. It is anticipated that significant financial savings will be achieved and regular revision of the integrated care pathways with all groups, including the patients will take place.

The approaches learned by the project leader, as part of the year-long FoNS programme have been transferrable to other aspects of work life. The project leader has utilised the approaches learned at a patient focus group, in other trust areas at the request of the directorate matron and developed further art based projects for use at a team away day.

This project was supported by the Foundation of Nursing Studies Patients First Programme in partnership with the Burdett Trust for Nursing.