Skin Lesion Service Briefing Notes Nov 2018

SKIN LESION SERVICE BRIEFING NOTES 2018

Introduction The WBoP PHO has an agreement with the BoP District Health Board to deliver the Western Bay of Plenty Skin Lesion Service. The current period will expire on 30 June 2020

Eligible Patients An eligible patient: a)

Has one of the identified skin lesions;

b) Is referred by a General Practitioner; and c)

Resides in one of the following locations: - Tauranga District - Western Bay of Plenty District - Mayor or Motiti Island - Waihi Beach

Entitled Lesions Lesions entitled under the service are: 1.

2.

3.

Pigmented when histology indicates the following types: 

Melanoma



Melanoma in situ



Dysplastic naevus



Other pigmented cutaneous malignancy

Non-Pigmented when biopsy testing indicates the following types: 

Basal cell carcinoma



Squamous cell carcinoma including in situ



Other non-pigmented cutaneous malignancies including keratoacanthoma

Suspicious Lesions

Suspicious pigmented or non-pigmented lesions not of a type set out under exclusions below: Exclusions 1. Immune suppressed patients under the care of a hospital dermatologist.

2. Patients who are entitled under other funding streams or funded by any other funder.

3. Punch biopsies or other investigations prior to First Referred Appointment are not entitled under this service; 4. Any surgical procedures to remove the following types of lesions       

Sebhorrhoeic Keratoses Lipomas Sebaceous cysts Warts Solar Keratoses Benign Naevi All other non-malignant lesion not listed above

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Referral Pathway All referrals for skin cancer lesions must be made to the WBoP PHO Skin Lesion Service.

Delay will occur for cases referred using the Dermatology midland e-referral to the Tauranga Hospital Referral Centre.

Punch Biopsies / Full Skin Assessment Patients pay for their own Punch Biopsy and Full Skin Assessment.

Where a doctor does not feel competent to assess the patient they may refer the patient to another GP who is skilled within their own practice or elsewhere prior to referring to the Skin Lesion Service. The patient will be expected to pay for any Punch Biopsy or Full Skin Assessment arising from this assessment.

Second Opinion Where a doctor seeks a second opinion, they may refer the patient to the Skin Lesion Service who will arrange a GPSI to provide that opinion. The Skin Lesion Service shall pay for the second opinion. Lesions suspicious for melanoma will be mostly considered for this pathway and must have attached photos. All other lesions will require a punch biopsy.

All Lesions Require Approval All lesions require Skin Lesion Service approval if funding is to be assigned. Approval is lesion by lesion. Any surgery undertaken without approval will not be funded.

Three Lesions per Day Each patient may receive surgery up to a maximum of three approved lesions per day. GPSIs are encouraged to undertake up to this limit each day, where it is clinically appropriate to do so.

Referral Process This is an electronic form using Best Practice. It is important that this process is fully understood. While five referral pathways exist, Pathway 1 (see diagram) will be the most commonly utilised.

It is mandatory that referrals be accompanied by one dermoscopic photograph and one clinical photograph of the lesion being referred. The photographs must be clear and of good quality. A referral will be returned to the referring GP if photographs are not provided or if the quality is poor.

Processing Referrals The Skin Lesion Service has engaged an independent triage clinician to assist in the processing of referrals. At least once each month, referrals shall be considered and scored against the Surgical Priority Schedule. Lesions will be placed in descending order of priority. Funds will be assigned going down the schedule until the funds are fully assigned.

Where a referral is of particular clinical urgency, consideration may occur more immediately. This will be an exception to the rule however. The referrer will need to justify this in the ‘Clinical Lesion Notes’ section of the electronic referral form.

GPSI Invoicing / Histology Reports An invoice with the histopathology report and a copy of the patient discharge letter should be forwarded at the completion of the surgical process. It should be submitted to the Skin Lesion Service prior to the 10th of the following month. This allows for timely payment and better financial management.

All invoices shall include GST.

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The Skin Lesion Service receives referral and prepares for triage by an ‘Independent Clinician’ Grading will result in one of three options.

Pathway 2

Second Opinion A GP may seek a second opinion through the Skin Lesion Service by details on the ‘Electronic Referral Form’ to the Skin Lesion Service. The second opinion option is considered mainly for suspicious melanoma lesions with attached photos. All other lesions will require a punch biopsy.

Skin Lesion Service may refer on to a GPSI for a second opinion.

This is ‘not an approval for surgery’ at this point.

Not competent to assess skin lesions. GPs are encouraged to refer within their own practice or elsewhere prior to a referral being forwarded to the Skin Lesion Service.

Skin Lesion Service receives referral from the GP assessment Grading will result in one of three options as above

Other

Pathway 5

Pathway 4

Pathway 1

Practice Initiates Referral Form Patient is assessed and pays for assessment (initial consult and PBx). Practice may refer to the Skin Lesion Service by completing the electronic referral form with attached histopathology & photos.

Pathway 3

WBoP PHO Skin Lesion Referral Pathway

Non-Urgent Lesions Where a GPSI finds a lesion other than the one approved for surgery.

Urgent Lesions Where a credentialed GPSI finds an urgent or another concerning lesion other than the one referred for surgery.

Re-excision (wider ellipse) Staged procedure requests

Approved lesions Assigned to correctly credentialed GPSI Surgery to occur (ASAP) i.e. < 20 working days Declined lesions Referring GP notified within 5 working days Hospital lesions All relevant documentation forwarded and GP notified within 5 working days Assigned GPSI advises initiating GP of that opinion and forwards a copy to the Skin Lesion Service.

Or approval for skin surgery may occur, whereby the GPSI refers to for urgent fast-track triage.

A surgery discharge letter will result to the referring GP

The GPSI is to advise the referring GP and Skin Lesion Service in a discharge letter back to patient’s own GP. The GPSI is to advise the Skin Lesion Service. The request is fast-tracked for URGENT triage and if approved the GPSI is notified to undertake the surgery.

Appropriate notification for approval, hospital level, or decline.

A referral may result from the patients GP

Appropriate notification for approval, hospital level, or decline.

If considered non-urgent triage will occur in the usual time frame.

All re-excisions require a referral for triage, prior to surgery taking place.

Re-excision approval on melanoma sites will take priority.

Predicted staged procedures require notification to the Skin Lesion Service in referral via Pathway 1. If this has not been done in the first referral, approval is required for any subsequent surgery in a second referral.

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Skin Lesion Service

Surgical Priority Schedule

Cancer Type

Histology

Score

MIS (Melanoma Insitu), MMR (Melanoma Radial Growth Phase), MMO (Melanoma Vertical Growth Phase, Nodular Melanoma or Desmoplastic)

100

Suspected Melanoma without Dermoscopy (Second Opinion)

MIS / MMR / MMO

100

Rare Malignant Tumours

OPM / ONPM

100

Invasive SCC Head / Neck

SCCO

100

Keratoacanthoma / EFG (Elevated Firm Growing)

KA

100

BCCO / BCCN

100

Suspected Melanoma on Dermoscopy Melanoma re-excision with wide margins

Aggressive BCC Head / Neck (Micronodular, Sclerosed, Infiltrating) Nodular BCC over embryonic fusion plates Nodular BCC >10mm Head / Neck outside embryonic fusion plates

BCCN

80

Poorly differentiated SCC Trunk / Limbs

SCCO

80

SCC insitu Head / Neck if topical treatment not indicated

SCCI

70

Nodular BCC <9mm Head / Neck outside of embryonic fusion plates

BCCN

60

SCCO / BCCS

50

BCC >10mm Trunk / Limbs >5mm Hands / Feet

BCCO, BCCN, BCCS

50

All other BCC Trunk / Limbs

BCCO / BCCN / BCCS

40

SCC insitu Trunk / Limbs

SCCI

40

Moderately and well differentiated SCC Trunk / Limbs BCC superficial Head / Neck if topical treatment not indicated

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Post Triage Assessment Once the assessment and placing of lesions in descending order of priority has occurred, the GPSI will be assigned. GPSIs will be assigned cases that match their level of competency. Location of where a patient resides and if the GPSI is in the same general practice are given priority consideration for GPSI assignment.

Where a lesion has been approved for surgery, the referring doctor and assigned GPSI surgeon will be notified. The relevant documentation shall be forwarded to the GPSI. Where a lesion has not been approved for surgery, the referring doctor and patient shall be notified within five (5) working days of the assessment. The notification shall indicate the assigned score.

Re-Excisions and Incompletes All Re-excisions and Incomplete excisions are required to be referred to the Skin Lesion Service by GPSIs. In most cases, surgery will be approved immediately.

Grading Lesions by Location and Size The following parameters shall apply. These arise as the method of measurement changed from size of ellipse to lesion diameter.

Exceptions are re-excisions for melanoma lesions, these will attract a grade that reflects the size of the ellipse required as well as the anatomical site.

Skin Lesion Service Grading of Lesions by Lesion Diameter and Location Anatomical Location

Lesion Diameter

Head and Neck Intermediate Advanced Advanced Plus Hospital

< 5 mm 6 to 10 mm > 11 to 15mm > 16mm

Advanced Advanced Plus Hospital

< 4 mm 5 to 8 mm > 9mm

Intermediate Advanced Advanced Plus Hospital

< 5 mm 6 to 10 mm 11 to 15 mm > 16mm

Basic Intermediate Advanced Advanced Plus Hospital

< 5 mm 6 to 10 mm 11 to 15 mm >16 to 20mm > 21mm

T Zone

Below the Knee

Elsewhere

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