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									INSERT WORKING GROUP NAME                                     FINAL REPORT



1. Do the demand projections in the CSF fit with your understanding of your
   specialty’s future morbidity /mortality trends? And if not, why not?

     We do not envisage our dermatology admissions to escalate significantly.
     The majority of dermatology is out-patient based with very small numbers of
     patients admitted for psoriasis, eczema and erythrodermic eruptions such as
     drug eruptions predominantly. The demand projections in the CSF, in the
     majority of cases, are most likely not related to dermatology per say and
     related to surgery or medical admissions for cellulitis or breast treatment and
     thus are not representative of overall dermatology admissions. We feel that
     with the onset of biological agents and ulcer clinics, this will prevent the
     potential for admission for the future.


2. What conditions, currently treated by your specialty as inpatients, could have
   been prevented by timely and effective care?

   The major admissions that are required by dermatologists relate to psoriasis,
   widespread eczema and periodic drug eruptions such as toxic epidermal
   necrolysis which are unpredictable. Other rare admissions would include
   pyoderma gangrenosum and bullous disorders. Of all these entities psoriasis is
   the major disorder that can be prevented by appropriate out-patient treatment.
   There is currently a new range of therapeutic agents called biological agents.
   These new agents are very expensive and are monoclonal antibodies and fusion
   molecules specifically targeting the immune system. These agents are currently
   not available within the health system. If these agents were available for use
   then patients would be able to be treated on an out-patient basis and avoid in-
   patient admission. Other treatments that may be effective to prevent admissions
   to hospital would include having establishing an out-patient based Ingram’s
   regime. This is a procedure where topical Dithranol combined with light therapy
   can be used on an out-patient basis to prevent admission to hospital. This would
   require the training of a specifically designated dermatology nurse. The nurse
   could also act as a coordinator for eczema education which would also be
   helpful in preventing admission of patients with eczema.

Dermatology Final Report – pdf 120506

3. How should patients who have diseases or co-morbidities that extend beyond
   any one specialist medical group be best cared for?

  Currently most inpatients are treated by a dermatologist although there is an
  overlap with rheumatologists, plastic surgeons, infectious diseases and burns units.
  No change from the current practices would be required.

4. What would your speciality need to do differently to reduce total bed demand
   by 30%, whilst maintaining/improving patient outcomes?

     Currently dermatology has a very low rate of admission and this is unlikely to
     increase dramatically over the next ten years. A factor that could reduce total
     bed demand would include using day hospital facilities for wet dressings as well
     as using Ingram’s regime as discussed in question 2. Also domiciliary care
     nurses may be able to care for patients in the community by helping with
     treatment with steroid preparations under wet dressings in a home environment.


5. For patients in your specialty with chronic conditions, how many have easy
   access to:

           a) Best practice guidelines?
           b) Regular follow up and monitoring/ case management?
           c) Early medical intervention as required?
           d) Patient education and empowerment?

   Best practice guidelines are present in the American Academy of Dermatology
   and British Journal of Dermatology and are regularly published. The out-patient
   clinics follow best practice guidelines, early medication intervention for chronic
   conditions practiced through the out-patient clinics. Patients have access to
   education via communication with their treating doctor, but also would have
   access to information via the internet with dermatological sites such as the New
   Zealand Dermatological Society for many common disorders.

Dermatology Final Report – pdf 120506
6. What needs to be put in place to allow 20% of your specialty’s current
   inpatients to be cared for in other environments eg day hospital, outpatients,
   community, step down facilities?

 This question has been answered previously in question 2. This would include the
 treatment of psoriasis with the new modality of therapy of biological agents.
 Other modalities would be using out-patient clinics for Ingram’s regime as well as
 community and domiciliary nursing for wet dressings to treat severe eczema.


7. What relationships does your speciality have with other specialities or services
   that the architects need to be mindful of, when designing new/refurbished
   hospitals including those where it makes clinical or economic sense to co-locate

  1)          The clinical out-patient would require easy access to minor theatre
  2)          An appropriate laser facility to be located near the out-patient clinic
              with all the appropriate laser protective facilities present.
  3)          Access to modular air-conditioning in the out-patient clinic, as often
              patients with severe skin disorders have thermoregulatory disorders.
  4)          Vinyl floor coverings as often these patients disperse a large amount of
              epithelium and this would make hygienic cleaning more effective.


8. With the knowledge that the health workforce is predicted to diminish in the
   future, how could:

               Your role be done differently
               Some of your work be done in a different setting
              Elements of your role be done by another Health Care Worker while still
              achieving best clinical outcomes, efficiency and safety?

 Educational aspects can be performed by a Health Care Worker where the general
 nature of skin disorders are explained to the patient by a dermatological education
 nurse. Sub-specialty clinics such as psoriasis, patch testing and nail and hair

Dermatology Final Report – pdf 120506
9. What would you change to make to the WA health system safer and to help
   retain existing staff?

  Given that the majority of staff working in public hospitals are not full time this
  question is not relevant. All hospitals are staffed well at this current time by visiting


10. What changes in the way that clinical information is captured and exchanged
    between clinicians can you see working for your clinical specialty?

   1) Electronic records will allow exchange of information between clinicians and
      general practitioners for follow up once patients are discharged from hospital.
      This will also allow an accurate assessment of medications used before and after
      discharge. This will also help prevent drug interactions.
   2) Photodynamic therapy. This is a new evolving treatment regime for skin cancers.
      This involves the use of a light source combined with a photosensitiser such as
      Metvix® which can be performed in an outpatient setting through the hospital
8.    clinic to treat many superficial skin cancers.
   3) The use of biological agents to treat psoriasis. Biological agents are
      revolutionising the treatment of many immune mediated diseases in medicine
      including, rheumatoid arthritis and inflammatory bowel disease. It also has a
      very active role in psoriasis and may, in the future, progress to help other
      dermatological conditions.
   4) With improved laser technology, new lasers may become available in the future
      to help skin conditions and the purchasing of these lasers in the future may be
      required for use in an out-patient setting.
   5) Diagnostic equipment to improve the diagnosis of pigmented lesions is currently
      evolving, and in the future these may become useful in the out-patient clinic to
      help diagnosis and monitor pigmented skin lesions.

11. What changes to the way that clinical decision support eg clinical guidelines,
    are used in the course of your everyday work would improve the reliability,
    safety & appropriateness of clinical care?

 Dermatology has a very low admission rate with the majority of patients seen in the
 out-patient department. Clinical guidelines can be used as a general guide to the
 management of patients and having these clinical guidelines readily available on the
 internet within the hospital would be of benefit for easy access of the guidelines
 when treating patients in an out-patient or in-patient situation. These guidelines
 would require a large amount of work to be undertaken.
Dermatology Final Report – pdf 120506

12. What medical equipment or technology will be important to the way you
    practice in 10 years time.

  Lasers, photobiology equipment, diagnostic equipment (e.g. confocal laser
  microscopes, optical machines for the diagnosis of lesions, especially melanoma,
  in vivo )

13. What experience have you had in other health systems that should be imported
    into WA?.

  These have been discussed in the above questions but would include use of
  biological agents for treatment of psoriasis, photodynamic therapy and the use of
  specific lasers.


14. For your specialty, what common conditions should have a more aggressive
    prevention strategy implemented. Do you have suggestions for doing this?

  1) Skin cancer prevention. Better public education with regard to the risks of
  exposure and public education with regard to sun protective measures are
  important. Also public education with regard to recognizing changes that would
  suggest skin cancer are important.
  2) Industrial dermatitis. Better education for occupations where hands are
  exposed in irritants and the development of severe occupational hand dermatitis
  may occur. If better hygiene measures were emphasized this would reduce the
  rate of industrial dermatitis.


15. Given the answers above, how do we ensure that teaching and research still
    have their appropriate priority?

   All public hospital dermatology clinics are staffed by part time dermatologists
   doing one to two sessions per week. This makes doing research difficult in a
   hospital situation as the majority of the time is spent treating patients as well as
   teaching medical students, residents and registrars. Possibly, in the future, the
   formation of an Academic Department of Dermatology may be appropriate
   where full time academic staff would be available to perceive further research.

Dermatology Final Report – pdf 120506
Dermatology Final Report – pdf 120506

      16. Any other additional key clinical planning issues relevant to your specialty.

        1) The establishment of education of staff with the cutaneous manifestations of
        bio-terrorism and the strategies to deal with these if they become apparent are
        important. Further education of emergency staff who may be exposed to these
        clinical presentations may be important given the changing political climate in
        the future and the possible use of bio-terrorism attacks in the future.

      17. After reviewing worlds best practice and your 2005 multi day inpatient activity
          projections, please provide a ‘guesstimate’ of what percentage of today’s
          patient cohort will be treated in the following settings by the year 2011?

Care Setting                                                                 Percentage of activity in 2011

Hospital Care
                                        Same day :surgery/procedures
                                        (including DO23)
                                        Medical care
                                        Subtotal % of hospital care                                           %
Out of hospital care
                                        Primary care
                                        Step down
                                        Medi hotel
                                        Chronic care management
                                        Subtotal % of out of hospital care                                    %
Home care
                                        Hospital in the home
                                        Other domiciliary care
                                        Other (please specify)
                                        Subtotal % of home care                                               %

                                        TOTAL                                                             100%

      Dermatology Final Report – pdf 120506
Dermatology Final Report – pdf 120506

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