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My experience of running a wound care clinic for drug users

Dawne Squires
BSc(Hons) DipN RGN
Clinical Nurse Specialist in Tissue Viability
Wound Care Unit Doncaster Primary Care NHS Trust

I've worked in nursing for a number of years, from daffodil-yellow, uniformed cadet nurse, qualifying as state registered nurse, then into navy and white butcher-striped dress with detachable collar and neck-marking stud and starched white cuffs, to today's multisuite position of clinical nurse specialist in tissue viability. Now as I'm racing towards retirement, I find it hard to believe where the last two and a half years have taken me.
I've been on a steep learning curve because in September 2004 I started a wound care drop-in clinic in the needle exchange room at the Garage, home of the Doncaster Drug Team, for clients attending the coffee slot. With this new service came an introduction to the lifestyle of addictive behaviour, of bargaining and relapses, and of new beginnings. Its means learning a new language, that of the street and the culture surrounding substance abuse, paraphernalia and imaginative pathways to support this chosen lifestyle.

Meeting needs
My introduction to this service started when the Health Inequalities Team Annual Report produced by Primary Care Services in March 2002 for the homeless and other socially excluded groups, recognised certain wound care issues that were not being met, such as:(1)

  • Infected skin conditions.
  • Abscesses at injection sites.
  • Infected suture lines/broken-down suture lines.
  • Inappropriate covering to trauma/injury sites.
  • Care of amputation sites.

Following this report a meeting was held between the specialist health visitor and myself, in my role as clinical nurse specialist in tissue viability, to investigate the feasibility of supplying a service to address these tissue viability/wound care needs. At that time the service provision from the Health Inequalities Team was undergoing reorganisation and relocation of premises, and it was not possible to commit to any formal service provision. My mobile phone number was the point of contact for the specialist health visitor for wound care referrals on an as-and-when basis.
In April 2004 the needle exchange worker noted that service users were presenting with problems of infected injection sites and were not attending acute services or GP services for wound care. He asked service users: "If a wound care nurse was available at the needle exchange, would you use the service?" The answer was "Yes".
This was followed by a meeting with members of the Doncaster Drug Team and a visit to the Garage premises to establish if the facilities being offered, the shared needle exchange room, were appropriate and safe. We also joined some of the clients at coffee time and listened to their thoughts on the proposed service. The positive visit and responses resulted in the proposal to set up a wound care drop-in clinic alongside the coffee slot each Wednesday from 11am to 1pm.
April to September was a busy period of research and reference chasing resulting in the development of:

  • Terms of reference for a wound care drop-in clinic.
  • Pathways of care for presenting wounds.
  • Patient group directions for wound care products.
  • Criteria for signposting to acute trust.

Getting started
With all the documentation finalised, patient group directions ratified and costed, pathways confirmed and signposting agreed, it was time to start the wound care drop-in clinic. The service was advertised on posters on the Garage noticeboard and through a leaflet drop in lounges and noticeboards used by the client group. This was supported by a leaflet drop for information to staff in contact with the client group.
During the first session it became apparent that more than a weekly drop-in service was needed for wound care follow-up and support, for the following reasons:

  • Infected injection sites required, in the first instance, daily dressing changes.
  • Leg ulceration required differential diagnosis through Doppler assessment, to establish appropriate dressing and bandaging regime.
  • Multiple broken areas/fungal infected feet required twice daily attention.
  • Discharging surgical sites required daily attention.

This was problematic because a "safe" environment for follow-up visits could not be readily established.
At the same time it was noted that there was a link between the service users and being homeless. For example, drug users find themselves homeless because of their lifestyle; homeless people turn to drugs to manage their lifestyle. Therefore it seemed appropriate to approach the M25 Housing and Tenancy organisation. This led to a visit to the M25 premises, the Bike Shop, to assess the suitability of the "clinic room" which had previously been used by a doctor and staff at M25 for confidential sessions. With blinds on the windows, chairs and a sink for handwashing, this room provided minimal clinical facilities for wound dressing. There was no clinical waste facility, and therefore the addition of a safe method for transporting clinical waste was added to the Garage service provision criteria. In October the Bike shop wound care drop-in clinic was launched alongside a sandwich and coffee slot on Fridays at 2pm-4pm.
The wound care drop-in clinic was advertised on the Garage and Bike Shop noticeboards and a leaflet drop in lounges that the client group visited, eg, Union Street night shelter and Open House in College Road. This was further supported by information to staff in contact with the client group. However, the most proactive system of advertising the service provision has been through word of mouth among the client group and by the nurse facilitating the clinic being available and approachable through sitting, talking and socialising in the lounge coffee slot.

Drop-in structure well received
The wound care drop-in clinics have been well received by the client group. The quick take-up of the clinic seems to be because the "drop-in" structure is linked to an established coffee slot or soup kitchen, providing a point of structure within their chaotic lifestyle. The drop-in structure is preferred to attending at allocated appointment times and long periods of waiting, which other services have offered, and which have created difficulties for this client group.
Expansion of the "drop-in" wound care clinics resulted in reviewing the time commitment within the tissue viability outreach service for workload commitments. Within my role I designed and developed the working guideline and protocols and provided the wound care drop-in clinic, but I had to look to other members of the team for help to continue to provide the service. Senior members of the team accompanied me to the wound care drop-in clinics. They needed to demonstrate their advanced wound management skills because of diversity of service needs and their comfort with the client group. The team members found the client group and their lifestyle very different to other wound care patients and voiced their concerns that they needed information, education and support to manage this client group. After discussion with staff from the Doncaster Drug Team, education sessions were accessed and support organised for the three members of staff who would be the main providers at the clinics. This system of supervision and support is still active today.
All the members of the team have advanced wound management skills and all have found the complexities of the client group a challenge. It is very different to inpatient care and domiciliary visit wound care. For example, when a rough sleeper presented at the Bike Shop with ulcerated feet with fungal infection the "usual" regime of washing the feet twice daily in warm water, patting dry with a soft towel, applying cream and putting on clean socks daily could not be achieved. So a more appropriate regime needed to be introduced. This particular regime resulted in the nurse supplying cleansing foam and wipes for self-care on a park bench, a tube of cream and couple of pairs of socks for in-between clinic visits. Then at clinic visits warm water could be accessed for washing. The need for a continual supply of socks has been resolved by nurses on the wound care unit not sending Christmas cards to each other but donating pairs of socks in kind.

More access
Further wound care drop-in clinics were developed at other locations used by the client group: two different church halls and a breakfast call at the night shelter. Through provision of the wound care drop-in clinics and associated signposting to other professionals, it is possible to offer this client group individual support to stay focused and motivated to access healthcare. This promotes wellbeing through changes to risk and protective behaviour. The availability of drop-in clinics on different days at different times provides an opportunity for attendees with complex wound care needs to access an appropriate environment to facilitate
dressing change.
Wound care clients have been signposted to other healthcare colleagues such as the medical assessment unit for further investigation/treatment following screening for probability of deep vein thrombosis. Signposting and telephone calls to the acute trust means that clients are expected and processing can be speedy, thereby reducing the client's anxiety about their reception and possible extended waiting times.
Cooperative working with Doncaster Drug Team/Garage needle exchange ensures clients have access to safer injecting information, alternative techniques and consideration of accessing a methadone programme. Cooperation working with M25 staff ensures that clients have access to accommodation information and assistance with processes. Working with Doncaster Housing for Young People (DHYP) staff ensures clients have access to accommodation information and employment opportunities.
If a client from the drop-in clinic is "lost to service" because of a period away in prison they are quick to inform the hospital wing staff about their wound care. Communication channels can be established and, if needed, joint visits can be arranged for assessment or information exchange about the dressing products and regime.

New experiences
The development and delivery of this service of a wound care drop-in clinic involved many new experiences for me. I have developed and supported coworkers to also engage with this unique client group. The provision of an innovative accessible service to a client population who had little engagement with healthcare professionals was essential. The nurses providing the wound care drop-in clinics have achieved the delivery of the professional provision of wound care and the flexibility to assist with the coffee slot and soup kitchen and associated socialising.
Through this client group I have found myself entering new worlds of experiences. For example, I have attended the Magistrate's court to verify that:

  • A client with a leg ulcer needed regular dressing and therefore their electronic tag needed relocating.
  • A client needed to attend a wound care drop-in clinic at a time outside their curfew.
  • A client needed to attend a wound care drop-in clinic within their ASBO area.

These situations now have an agreed protocol, although I haven't established a protocol for when I found myself giving a statement in a murder enquiry:a client known to the wound care drop-in clinic was seen on CCTV with blood on his trousers in the area of a stabbing, and I had to account for the presence of his wound and the likely cause of the strikethrough.

Happy occasions
Working with this client group has also provided some very happy experiences. Myself and other clinic nurses are honorary aunties to a beautiful baby boy - both the mum and dad are known clients of the wound care drop-in clinic, so when dealing with their dressings they shared news of the pregnancy. With signposting to the midwife and drug worker for access to a detox admission unit, an uneventful and successful pregnancy was achieved.
One of the proudest events happened this week when all our partners in the wound care drop-in clinics were invited to join us for a celebration lunch. The wound care drop-in clinics provided by Doncaster Primary Care Tissue Viability Outreach Service nurses are a finalist in the Health and Social Care Awards 2007 - Inequalities in Healthcare category. While the film crew were making the video for the evening event, one of the service users told them how his foot was saved because of the wound care drop-in clinics, and he can now play football with his young son. I was asked about the background to this disclosure; the young man was signposted to the Garage drop-in clinic because he was facing amputation of his foot due to infected injection sites, deep vein thrombosis and recurring episodes of cellulitis. He attended the clinics regularly and spent a period as an inpatient on the wound care unit. He still attends the drop-in session for "well legs" support and replacement of compression socks when appropriate.
Whatever the result at this prestigious event I know that the service we provide is a winner. But we all need an excuse to pop down to London and wear a posh frock!

References

  1. Health Inequalities Team.Annual report. Doncaster: Doncaster Health; 2002.

Your comments: (Terms and conditions apply)

"I would just like to congratulate Dawn and her team on her success. I run a full-time clinic that addresses wound/leg ulcer management in past/present injecting drug users and this also encompasses all the other interventions available within the service such as BBV testing/satelitte treatment clinic, hepatitis vaccinations, needle and syringe exchange and triage into substitute prescribing - to name but a few of the interventions. There needs to be recognition that these services and required as a core compenent to any drug intervention programmes. Hope your team won the award and you all looked swell in your posh frocks." - Marie White, Clinical Specialist Nurse, Rochdale Community Drugs Team