Treating the hard to treat — wound care as part of a wellbeing model for IV drug users20th March 2013
Leanne Cook, Vascular Nurse Specialist at Mid Yorks NHS Trust told Wound Care Today about the Wakefield Substance Misuse Service (WISMS) and its wellbeing model, which is helping drug users transform their lives.
The wellbeing team successfully treats patients who would otherwise slip through the net. Consider the woman who was dressing her own wounds with sanitary towels and curtain net when the wellbeing nurses began to treat her. She was living in appalling conditions with her two children. Her wounds were such that she was making pseudomonas puddles, i.e. dripping bacteria-filled exudate on the carpet-free floor. Having been kicked off a recovery programme by her GP due to non-attendance, she had been pretty much left to care for herself despite living in chaotic conditions and having a leg ulcer that had remained unhealed for eight years. However, the drug service became aware of her from her methadone use and referred her to the wellbeing team. Now this woman runs patient forum groups at the clinic, her ulcer has healed and her life has been transformed in one year, and she is now helping others to do the same.
WISMS runs a drop-in centre in Wakefield, Yorkshire, and an outreach service, both run by specialist nurses. They helped this woman and many others like her with their truly holistic approach, tackling all aspects of a patient’s life rather than just treating their wounds or their illnesses. By offering linked-up multidisciplinary support, they give practical help for housing and work issues, mental health support, advice and treatment for sexual health issues and routine screening and vaccinations. The ultimate aim is to help the patient become drug or alcohol-free and reintegrate into mainstream society, but in the meantime offers support and finds solutions for the patient’s health and social needs despite their addictions.
Part of its aim is to provide wound care to the vulnerable group of patients with drug addictions who have developed leg ulcers as a result of their drug misuse. Intravenous (IV) drug use goes hand-in-hand with skin problems and infections, with about one-third of users reporting an injection-related abscess, sore or open wound in a one-year period (Health Protection Agency [HPA], 2009). Non-prescribed drugs are often produced and injected in less than sterile conditions. IV drug users are also susceptible to venous insufficiency, which eventually will lead to leg ulceration. The leg ulcers can go untreated, as the drug addiction dominates the person’s life so treatment is not a priority. They become chronic and non-healing due to a combination of chaotic lifestyle, poor general health and continued substance misuse.
The clinic uses a multidisciplinary care pathway to help treat leg ulcers, along with addressing other health needs that can so easily snowball for a person with addictions. The pathway, created by the wellbeing nurse team (with Spectrum health care) and Mid Yorkshire Hospitals NHS Trust’s vascular nurse specialist team, aims to improve the general and mental health of its patients and their long-term health outcomes. There is an emphasis on outreach and on building up trusting relationships with the patients, so that they will be encouraged not to abandon any care plans and attempts to improve their lives.
The wellbeing team delivers care wherever it is needed. They provide counselling, brief interventions, solution-focused therapy, motivational interviewing, cognitive behavioural therapy (CBT), and psychosocial interventions. They attempt to engage patients and keep them engaged so that they are motivated to come to the centre. However, if the patient slips out of view, the team will not write them off, rather they will go to their homes, meet them in McDonald’s, or wherever suits the patient. In this way, they are more likely to keep the appointment. The team make a point of tracking down people who may be in need of help, for example, by visiting places where users or homeless are known to hang out.
IV users pass the word around and, in the beginning, the centre was inundated with self-referrals. The team are reluctant to say no to anyone who needs their help, and their main intention is to reach the previously unreachable.
The clinic has received a great deal of investment and is now well placed to look after all aspects of health care for the patient group, including:
- Risk assessment
- Up to date vaccinations
- Sexual health
- Routine screening
- Assessment of leg ulcers.
After an assessment by a specialist to confirm the presence of venous ulceration, patients are put on the venous ulcer pathway. Patients are encouraged to care for their wounds themselves, as well as being treated by professionals. Compression hosiery kits suit patients with addictions, as it means that they are not dependent on attending clinics, which does not always fit in well with their chaotic lifestyles. They are also less bulky than compression bandaging and this is thought to promote concordance.
WISMS treats people from a population of 800,000. Of these, 50,000 have been through the pathway with chronic wounds. For many years the healing rates of this patient group did not compare well with normal healing rates, but this is now changing with the interventions of the wellbeing team. The majority of patients stay on the pathways. Some may drift and then come back, but with the continued support of the team they are given the opportunity to become active partners in their own care. The wellbeing team helps patients to start withdrawing from their chaotic lifestyles. To date, only one patient treated by the team has failed, i.e. continued to actively use drugs, failed to keep appointments and resisted continued engagement.
The success of this centre is that wound healing comes in a bundle of support to improve the patient’s lifestyle. In isolation, the wounds might heal with compression but then patients would fall by the wayside again —back into addiction and off the radar and perhaps return again with more ulceration. With the wellbeing model, even those patients who are still using drugs are doing so in a safer environment where they receive treatment and support.
The benefits to the patients are obvious — vast improvements to their quality of life as they are given true holistic care that offers practical help to improve their family life, work life, general health, mental health, as well as any necessary wound care and support to help them fight their addictions and reintegrate with society. Other outcomes that benefit the NHS include improved healing rates, a reduction in the need for acute services, a reduction in wound care costs and less complications arising from chronic leg ulceration.
In the year 2010–2011, 50 patients in and around Wakefield benefitted from the service. If this model was adopted by NHS trusts around the UK, many more of the country’s most vulnerable people could access healthcare that could transform their lives.
Health Protection Agency, Health Protection Scotland, National Public Health Service for Wales, CDSC Northern Ireland (2009) Shooting Up: Infections among injecting drug users in the United Kingdom 2008. HPA, London