Title: MIU Boils carbuncles folliculitis paronychia and staphylococcal whitlow

Ref No: 1948 Version: 2

Document Author: Matron - Minor Injury Date 17 October 2017 Units

Ratified by: Care and Clinical Group Date: 17 October 2017 Clinical Director of 21 December 2017 Pharmacy

Review date: 12 January 2021

1. Purpose of this document

This clinical protocol provides a clear framework for nurse/paramedic practitioners employed by Torbay & South Devon NHS Foundation Trust when providing care to patients presenting with boils, carbuncles, folliculitis, paronychia and staphylococcal whitlow.

2. Scope of the Policy:

This protocol is for the use by Minor Injury Unit (MIU) and Emergency Department (ED) practitioners employed by Torbay and South Devon NHS Foundation Trust who has achieved the agreed Trust clinical competencies to work under this protocol

3. Assessment

3.1. Presenting signs and symptoms; may include some of the following;

Redness, heat, tenderness/pain, erythema/swelling, tracking, lymphadenopathy, pus, fluctuance, pyrexia, generally unwell, nausea, malaise.

3.2 History: refer to protocol for History taking and Clinical Documentation. Specific History; Traumatic (direct/indirect), non –traumatic

· Onset/duration of symptoms. · Cause known e.g. nail biting, dry skin, hair treatment · Reoccurring problem. · Past medical history especially diabetes · Medications · Allergies,

Collated by Clinical Effectiveness MIU Boils carbuncles folliculitis paronychia and staphylococcal whitlow Page 1 of 5 4. Clinical Examination:

4.1. Look/observe

· Size and position · Redness, swelling/nodules, tracking · Proximal lymphadenopathy · Pus/discharge

4.2 Feel/palpate · Tenderness · Fluctuance · Proximal lymphadenopathy

4.3 Move · Refer to relevant protocol

4.4 Special Tests · Sensation/circulation

4.5 Clinical Observations

· Record vital signs i.e. temperature. Where patients appear systemically unwell complete all vital signs to include pulse, heart rate, respirations and blood pressure.

· If reoccurring problem check patient’s blood sugar levels.

5. Treatment

5.1 Boils and Carbuncles.

· Clinical Indications: · Boil: Red, hot, tender, inflammatory nodule with walled-off purulent material, arising from a hair follicle. Pus exudates · Carbuncle: infection of a group of adjoining hair follicles which develop into large, swollen, tender masses with multiple points draining. Localised surrounding inflammation · Treatment : Non fluctuant · Advise patient to apply moist heat three to four times a day. · If large lesion, pyrexia or cellulitis present treat with antibiotics (flucloxacillin) as per Patient Group Direction (PGD). If the patient is allergic to penicillin please give relevant antibiotic as per Patient PGD or where there is no second line choice of antibiotic please refer patient to the patient’s GP or non- medical prescriber. · If required advise or provide the patient with analgesia as per PGD and in accordance to patients pain level.

Collated by Clinical Effectiveness MIU Boils carbuncles folliculitis paronychia and staphylococcal whitlow Page 2 of 5 · Advise the patient to see their GP if their condition does not improve or returns. · Treatment: Fluctuant. · Where competent perform incision and drainage. · Treat with the antibiotics (flucloxacillin) as per PGD. If the patient is allergic to penicillin please give relevant antibiotic as per Patient PGD or where there is no second line choice of antibiotic please refer patient to the patient’s GP or non- medical prescriber. · If required advise or provide the patient with analgesia as per PGD and in accordance to patients pain level. · Dress appropriately and review in 48hrs or refer to practice nurse for follow up.

5.2 Folliculitis

· Clinical Indications: superficial infection of the hair follicles which develop into small inflammatory papules or pustules. · Treatment: Advise people to avoid aggravating factors (e.g. tight clothing, occlusive dressings or plasters, if shaving to shave in direction of growth). · Daily washing with over the counter antiseptic may help to prevent or control mild cases. · Treat with antibiotics (flucloxacillin) as per Patient Group Direction (PGD) for more extensive/ severe folliculitis. If the patient is allergic to penicillin please give relevant antibiotic as per Patient PGD or where there is no second line choice of antibiotic please refer patient to the patient’s GP or non- medical prescriber.

5.3 Acute Paronychia

· Clinical Indications: involves the border of the nail causing redness, swelling, pain, throbbing and may have a visible collection of pus Fall onto outstretched hand or direct blow · Treatment Fluctuant (Pus filled): · Where competent perform incision and drainage. · Treat with the antibiotics (flucloxacillin) as per PGD. If the patient is allergic to penicillin please give relevant antibiotic as per Patient PGD or where there is no second line choice of antibiotic please refer patient to the patient’s GP or non- medical prescriber. · If required advise or provide the patient with analgesia as per PGD and in accordance to patients pain level. · Dress appropriately, elevate limb and review in 48hrs or refer to practice nurse for follow up. · Treatment (Non-Fluctuant) · Advise warm soaks 3 -4 times a day · Treat with the antibiotics (flucloxacillin) as per PGD. If the patient is allergic to penicillin please give relevant antibiotic as per Patient PGD or where there is no second line choice of antibiotic please refer patient to the patient’s GP or non- medical prescriber. · If required advise or provide the patient with analgesia as per PGD and in accordance to patients pain level · Elevate limb and review in 48hrs or refer to practice nurse for follow up.

5.4 Staphylococcal Whitlow

· Clinical Indication: abscess formation of the fleshy area of the palmar aspect of the fingertip (Pulp). · Treatment: with Fluctuance: refer to the emergency department for further management. · Treatment non fluctuant

Collated by Clinical Effectiveness MIU Boils carbuncles folliculitis paronychia and staphylococcal whitlow Page 3 of 5 · Advise warm soaks 3 -4 times a day · Treat with the antibiotics (flucloxacillin) as per PGD. If the patient is allergic to penicillin please give relevant antibiotic as per Patient PGD or where there is no second line choice of antibiotic please refer patient to the patient’s GP or non- medical prescriber. · If required advise or provide the patient with analgesia as per PGD and in accordance to patients pain level. · Elevate limb and review in 48hrs or refer to practice nurse for follow · Refer all patients if antibiotics fails, the person is unwell, or there is proximal lymphangitis or cellulitis for senior Emergency Department review.

5.5 Refer to the Emergency Department senior clinician the following presentations:

· Systemically unwell · Significant cellulitis · Lymphandenopathy · Significant pyrexia · Not responding to antibiotics. · Staphylococcal Whitlow with Fluctuance or non- fluctuant where antibiotics fails, the person is unwell, or there is proximal lymphangitis or cellulitis present to Emergency Department

6. Documentation 6.1. Clinical records must be written in accordance with Torbay and South Devon NHS Foundation History Taking and Clinical Documentation protocol, Nursing & Midwifery Council standards including record keeping or relevant registering body e.g. Health & care professional Council (HCPC) standards including record keeping guidance.

6.2. A summary letter of the MIU/ED attendance and the care delivered must also be sent to the General practitioner and also the health visitor if less than 5yrs or school nurse if aged between 5yrs and 16yrs to ensure the central medical record of the patient is accurate.

6.3. For patients being transferred to the Emergency department, ensure clinical records are completed in a timely manner on shared symphony IT system. A summary letter will be sent to the General practitioner in the normal manner.

6.4. For patients seeing the General practitioner or specialist within the next 24 hours ensure the patient has a copy of the attendance record to take with them. A copy will be sent to the General practitioner in the normal manner.

7. Discharge information

7.1 Ensure those patients who have been referred for further acute intervention has appropriate transport to meet their needs, all relevant treatment has been prescribed and/or administered and correct information & documentation is given to the patient. 7.2 The patient /carer understand that if the condition deteriorates or they have any further concerns to seek medical advice.

Collated by Clinical Effectiveness MIU Boils carbuncles folliculitis paronychia and staphylococcal whitlow Page 4 of 5 7.3 The patient and /or carer demonstrate understanding of advice given during consultation. 7.4 The patient/carer has been provided with written advice leaflet to reinforce advice given during consultation. 7.5 The patient/carer demonstrates and understanding of how to manage

8. Training and implementation:

· MIU Network meeting Cascade. · All staff adhering to protocols must have agreed training and proven competence to work within protocol. Each protocol must be agreed and signed by line manager.

9. Monitoring tool Regular review of clinical practice to ensure individuals are adhering to clinical protocol.

10. References

· Accident & Emergency, theory into practice. Dolan B, Holt L. 2000 · Acute Medical Emergencies, a nursing guide. Harrison R, Daly L. 2000 · British National Formulary 2017 · Clinical Knowledge summaries NICE. Paronychia –acute revised 2017 · Differential Diagnosis. Rafley, A. Lim, E. 2nd edition 2005 · Guide to physical examination and History Taking. Bickley 2003 · Nurse Practitioners, clinical skills & professional issues. Walsh M, Crumbie A, Reveley S. 1999 · Minor Emergencies Splinters to fractures. Butteovolli P, Stair T 2000 · Minor Injuries, A Clinical guide. Purcell D. 2nd edition 2010 · South & West Devon Formulary · www.patient.co.uk

Amendment History

Issue Status Date Reason for Change Authorised

1 Ratified February 2013 Merger of Torbay Care Trust and Matron - Minor NHS Devon Protocols for boils, Injury Units carbuncles, folliculitis, paronychia, and staphylococcal whitlow 1 Ratified August 2015 Reviewed –no clinical change Matron - Minor Documentation – amendments to Injury Units reflect symphony IT system 2 Ratified 12 January Revised Care and Clinical 2018 Group Clinical Director of Pharmacy 2 12 February Review date extended from 2 yeas 2018 to 3 years

Collated by Clinical Effectiveness MIU Boils carbuncles folliculitis paronychia and staphylococcal whitlow Page 5 of 5 The Mental Capacity Act 2005

The Mental Capacity Act provides a statutory framework for people who lack capacity to make decisions for themselves, or who have capacity and want to make preparations for a time when they lack capacity in the future. It sets out who can take decisions, in which situations, and how they should go about this. It covers a wide range of decision making from health and welfare decisions to finance and property decisions

Enshrined in the Mental Capacity Act is the principle that people must be assumed to have capacity unless it is established that they do not. This is an important aspect of law that all health and social care practitioners must implement when proposing to undertake any act in connection with care and treatment that requires consent. In circumstances where there is an element of doubt about a person’s ability to make a decision due to ‘an impairment of or disturbance in the functioning of the mind or brain’ the practitioner must implement the Mental Capacity Act.

The legal framework provided by the Mental Capacity Act 2005 is supported by a Code of Practice, which provides guidance and information about how the Act works in practice. The Code of Practice has statutory force which means that health and social care practitioners have a legal duty to have regard to it when working with or caring for adults who may lack capacity to make decisions for themselves.

“The Act is intended to assist and support people who may lack capacity and to discourage anyone who is involved in caring for someone who lacks capacity from being overly restrictive or controlling. It aims to balance an individual’s right to make decisions for themselves with their right to be protected from harm if they lack the capacity to make decisions to protect themselves”. (3)

All Trust workers can access the Code of Practice, Mental Capacity Act 2005 Policy, Mental Capacity Act 2005 Practice Guidance, information booklets and all assessment, checklists and Independent Mental Capacity Advocate referral forms on iCare http://icare/Operations/mental_capacity_act/Pages/default.aspx

Infection Control

All staff will have access to Infection Control Policies and comply with the standards within them in the work place. All staff will attend Infection Control Training annually as part of their mandatory training programme.

Collated by Clinical Effectiveness MIU Boils carbuncles folliculitis paronychia and staphylococcal whitlow The Mental Capacity Act Page 1 of 1 Rapid (E)quality Impact Assessment (EqIA) (for use when writing policies) Policy Title (and number) Version and Date Policy Author An (e)quality impact assessment is a process designed to ensure that policies do not discriminate or disadvantage people whilst advancing equality. Consider the nature and extent of the impact, not the number of people affected. Who may be affected by this document? Patients/ Service Users ☐ Staff ☐ Other, please state… ☐ Could the policy treat people from protected groups less favorably than the general population? PLEASE NOTE: Any ‘Yes’ answers may trigger a full EIA and must be referred to the equality leads below Age Yes ☐ No☐ Gender Reassignment Yes ☐ No☐ Sexual Orientation Yes ☐ No☐ Race Yes ☐ No☐ Disability Yes ☐ No☐ Religion/Belief (non) Yes ☐ No☐ Gender Yes ☐ No☐ Pregnancy/Maternity Yes ☐ No☐ Marriage/ Civil Partnership Yes ☐ No☐ Is it likely that the policy could affect particular ‘Inclusion Health’ groups less favourably than Yes ☐ No☐ the general population? (substance misuse; teenage mums; carers1; travellers2; homeless3; convictions; social isolation4; refugees) Please provide details for each protected group where you have indicated ‘Yes’.

VISION AND VALUES: Policies must aim to remove unintentional barriers and promote inclusion Is inclusive language5 used throughout? Yes ☐ No☐ NA ☐ Are the services outlined in the policy fully accessible6? Yes ☐ No☐ NA ☐ Does the policy encourage individualised and person-centred care? Yes ☐ No☐ NA ☐ Could there be an adverse impact on an individual’s independence or autonomy7? Yes ☐ No☐ NA ☐ EXTERNAL FACTORS Is the policy a result of national legislation which cannot be modified in any way? Yes ☐ No☐ What is the reason for writing this policy? (Is it a result in a change of legislation/ national research?)

Who was consulted when drafting this policy? Patients/ Service Users ☐ Trade Unions ☐ Protected Groups (including Trust Equality Groups) ☐ Staff ☐ General Public ☐ Other, please state… ☐ What were the recommendations/suggestions?

Does this document require a service redesign or substantial amendments to an existing Yes ☐ No☐ process? PLEASE NOTE: ‘Yes’ may trigger a full EIA, please refer to the equality leads below ACTION PLAN: Please list all actions identified to address any impacts Action Person responsible Completion date

AUTHORISATION: By signing below, I confirm that the named person responsible above is aware of the actions assigned to them Name of person completing the form Signature Validated by (line manager) Signature

Please contact the Equalities team for guidance: For South Devon & Torbay CCG, please call 01803 652476 or email [email protected] For Torbay and South Devon NHS Trusts, please call 01803 656676 or email [email protected] This form should be published with the policy and a signed copy sent to your relevant organisation.

Collated by Clinical Effectiveness MIU Boils carbuncles folliculitis paronychia and staphylococcal whitlow Rapid Equality Impact Assessment Page 1 of 1 Clinical and Non-Clinical Policies – New Data Protection Regulation (NDPR)

Torbay and South Devon NHS Foundation Trust (TSDFT) has a commitment to ensure that all policies and procedures developed act in accordance with all relevant data protection regulations and guidance. This policy has been designed with the EU New Data Protection Regulation (NDPR) in mind and therefore provides the reader with assurance of effective information governance practice.

NDPR intends to strengthen and unify data protection for all persons; consequently, the rights of individuals have changed. It is assured that these rights have been considered throughout the development of this policy.

Furthermore, NDPR requires that the Trust is open and transparent with its personal identifiable processing activities and this has a considerable effect on the way TSDFT holds, uses, and shares personal identifiable data. The most effective way of being open is through data mapping. Data mapping for NDPR was initially undertaken in November 2017 and must be completed on a triannual (every 3 years) basis to maintain compliance. This policy supports the data mapping requirement of the NDPR.

For more information: · Contact the Data Access and Disclosure Office on [email protected], · See TSDFT’s Data Protection & Access Policy, · Visit our GDPR page on ICON.

Collated by Clinical Effectiveness MIU Boils carbuncles folliculitis paronychia and staphylococcal whitlow New Data Protection Regulation Page 1 of 1