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December 2002, Vol 92, No. 12 | American Journal of Public Health 1915-1917
© 2002 American Public Health Association

FIELD ACTION REPORT

Expanding Harm Reduction Services Through a Wound and Abscess Clinic

Lauretta E. Grau, PhD, Silvia Arevalo, LVN, Christopher Catchpool, BA and Robert Heimer, PhD For The Diffusion Of Benefit Through Syringe Exchange Study Team

Lauretta E. Grau and Robert Heimer are with the Department of Epidemiology and Public Health, Yale University School of Medicine, New Haven, Conn. Silvia Avevalo and Christopher Catchpool are with Casa Segura/Safehouse, HIV Education and Prevention Project of Alameda County, Oakland, Calif.

Correspondence: Requests for reprints should be sent to Lauretta E. Grau, PhD, Department of Epidemiology and Public Health, Yale University School of Medicine, PO Box 208034, New Haven, CT 06520-8034 (e-mail: lauretta.grau{at}yale.edu).


   ABSTRACT
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A wound and abscess clinic, held concurrently with a syringe exchange, provided economical treatment and aftercare for injection-associated soft tissue infections. During 20 two-hour clinic sessions, 173 treatment episodes were logged, and the visit cost was estimated at $5 per patient.

Increased patient–clinician interactions provided opportunities beyond those afforded by the syringe exchange for patients to obtain resources and referrals to services such as HIV counseling and testing, medical care, and drug treatment.

Distribution of cards advertising the clinic was substantially less effective than word of mouth in increasing community awareness of the clinic.


   INTRODUCTION
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INJECTION-RELATED SOFT tissue infections are common among injection drug users.1,2 In a 1997 sample of injection drug users from one San Francisco neighborhood, the prevalence of soft tissue infections was 32%.1 These infections place injection drug users at risk for serious medical problems, including cellulitis, septicemia, and necrotizing fasciitis.

Although soft tissue infections can be treated in outpatient settings, most community-based clinics do not perform incision and drainage procedures. Hence, treatment is typically hospital based, and estimated costs range from $185 to $360 (excluding medications and physician fees). Many injection drug users are reluctant to seek hospital-based treatment because they lack financial resources or are concerned about negative or punitive interactions with health care providers.3,4

Syringe exchange programs have been demonstrated to improve public health.5,6 Injection drug users have grown to trust syringe exchange and affiliated programs because they espouse a non–abstinence-based harm reduction philosophy while encouraging customers to adopt healthier habits (e.g., hygienic injection practices, vein care, nutrition) to reduce their health risks. Syringe exchange programs that treat injectionassociated wounds and soft tissue infections have the potential to expand their effectiveness by reducing negative sequelae of infections and providing injectors with access to needed health care resources and social services.


   THE PROGRAM
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The Wound and Abscess Clinic at Casa Segura/Safehouse in Oakland, Calif, which opened its doors in March 1997, is the oldest clinic of its sort operating in a nonmedical setting. The clinic has no formal agreements in place with hospitals or academic institutions, but it receives funding from the North American Syringe Exchange Network, the Alameda County Department of Health, the Substance Abuse and Mental Health Services Administration, and the AIDS Walk.

Between September 1999 and June 2000, we conducted a study examining the clinic’s operations. During the study period, the clinic operated 3 days and 2 evenings per week during normally scheduled syringe exchange program hours (Monday and Friday, 2:00–4:00 pm; Tuesday and Thursday, 6:00–8:00 pm; Saturday, 10:00 am–12:00 pm). The clinic had dedicated space within the syringe exchange program facilities, and most patients were seen on a walk-in basis, typically when they came to exchange syringes. Appointments to return to the clinic for follow-up were sometimes made, but there were no reminder calls or mailings.

Syringe exchange program customers were anonymous, but the Wound and Abscess Clinic maintained medical treatment and prevention case management records. All services, medications, and materials provided were free to clinic patients. Patients who needed services not provided on-site (e.g., laboratory analyses, x-rays) were referred to other free or low-cost medical services. Referrals to psychiatric or day treatment care, parenting classes, and housing were also available.

Clinic staff included 2 physicians, 2 physician assistants, 1 nurse, 1 emergency medical technician, 1 full-time clinic employee, and several untrained volunteers. With the exception of the full-time employee, who maintained clinic supplies and coordinated staffing, training, and documentation of research and clinic protocols, all staff were volunteers. The clinic relied on several Spanish-speaking members of the syringe exchange program staff to serve as translators when needed.

After local community hospitals had treated several recent cases of necrotizing fasciitis, hospital emergency department staff visited the Wound and Abscess Clinic to discuss potential prevention strategies. As a result of these visits, several physicians and health care workers began volunteering at the clinic. Awareness of the clinic spread among hospital staff, and subsequently there has been a steady stream of volunteers, including local university students interested in entering medical or public health programs. Volunteers trained in medical or allied health fields have provided patient care, and untrained volunteer staff have either assisted the professional staff (e.g., with triage, wound cleaning, or posttreatment bandaging) or performed administrative tasks.


   DISCUSSION AND EVALUATION
TOP
 ABSTRACT
 INTRODUCTION
 THE PROGRAM
 DISCUSSION AND EVALUATION
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Casa Segura, in collaboration with our team at the Yale School of Public Health, sought to characterize the Wound and Abscess Clinic’s population and services and to evaluate the effectiveness of using "palm cards" (resembling business cards) to advertise the services offered. These cards, developed by Casa Segura in collaboration with the team, were inserted into bags of supplies distributed to syringe exchange program customers. After 1 month of advertising, clinic staff began collecting data during evening clinics in Oakland’s Fruitvale district; information on 173 treatment episodes was collected during 20 clinic sessions taking place between September 1999 and June 2000.

The Yale team developed the data entry forms, created the database, and performed all analyses for the study. Syringe exchange program staff continued distributing the palm cards throughout the data collection period. Table 1Go provides a summary of the data collected. The mean age of patients (44.5 years) was consistent with the age of the population seen at the exchange. However, the Wound and Abscess Clinic treated a higher percentage of female patients (approximately 50%) than the exchange (33%).


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  		TABLE 1— —Characteristics of Wound and Abscess Patients
 
On average, 8 patients were treated per clinic session; when the clinic was particularly busy, however, limited staffing precluded recording of information on all patients seen. Therefore, actual numbers of patients seen were probably underestimated slightly. Although the majority of patients were local residents, many traveled substantial distances to obtain treatment.

Most clinic services provided, supplies distributed, and referrals made directly targeted soft tissue infections. The estimated cost per patient ($5), based on administrative records for the entire clinic (i.e., not data from this study), was calculated by dividing total monthly expenditures for clinic supplies by the mean number of patients (170 per month) seen at all clinic sessions. Overhead was not included in the calculations, because it was covered under the syringe exchange program’s budget.

The vast majority of patients reported that they learned of the clinic by word of mouth or, less frequently, through outreach activities. Distribution of printed flyers and palm cards did not appear to be an effective method of advertising clinic services; rather, these materials appeared to serve as convenient reminders of clinic hours and locations.

The present results indicate that soft tissue infection clinics held in conjunction with syringe exchanges can be economical and can make more appropriate use of emergency departments, in that clinic staff refer patients only as needed. Our results also suggest that awareness of such programs among injection drug users is increased more effectively via verbal exchange than distribution of written materials and that it is important for harm reduction staff to describe available services to customers. The Casa Segura clinic provides a hard-to-reach population with easy access to injection-associated health care services and links to other medical and social services within a trusted environment.


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Future plans include the purchase of a mobile unit that will allow access to services to be expanded to other locations and other populations, particularly undocumented day workers. Increased outreach efforts and increased networking with local community-based organizations and hospitals will also heighten community awareness of the clinic.


   Acknowledgments
 
We would like to thank the National Institute on Drug Abuse for funding the Diffusion of Benefit through Syringe Exchange Project (grant 1-P0-MH56826).

The members of the Diffusion of Benefit through Syringe Exchange Study Team are the 4 authors of this article along with Jaime Spiess, who collected the data at the Oakland site.


   Footnotes
 
Peer Reviewed

L. E. Grau assisted in the study design, developed the study forms, and analyzed the data. S. Arevalo was responsible for data collection and also assisted in the development of study forms and the writing of the report. C. Catchpool assisted in the study design and contributed to the writing of the report. R. Heimer planned the study and contributed to the writing of the report.

Accepted for publication August 21, 2002.


   References
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 ABSTRACT
 INTRODUCTION
 THE PROGRAM
 DISCUSSION AND EVALUATION
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 References
 
1. Binswanger IA, Kral AH, Bluthenthal RN, et al. High prevalence of abscesses and cellulitis among community-recruited injection drug users in San Francisco. Clin Infect Dis. 2000;30: 579–581.[Medline]

2. Ciccarone D, Bamberger JD, Kral AH, et al. Soft tissue infections among injection drug users—San Francisco, California, 1996–2000. MMWR Morb Mortal Wkly Rep. 2001;50:381–384.[Medline]

3. Sterk CE, Dolan K, Hatch S. Epidemiological indicators and ethnographic realities of female cocaine use. Subst Use Misuse. 1999;34:2057–2072.[Medline]

4. Porter J. The street/treatment barrier: treatment experiences of Puerto Rican injection drug users. Subst Use Misuse. 1999;34:1951–1975.[Medline]

5. Normand J, Vlahov D. The effects of needle exchange programs. In: Normand J, Vlahov D, Moses LE, eds. Preventing HIV Transmission: The Role of Sterile Needles and Bleach. Washington, DC: National Academy Press; 1995:198–262.

6. Heimer R. Syringe exchange programs: lowering the transmission of syringe-borne diseases and beyond. Public Health Rep. 1998;113(suppl 1):67–74.[Medline]





This Article
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