Louise Mullen

Epidemiological findings and medical, legal, and public health challenges of an investigation of severe soft tissue infections and deaths among injecting drug users -- Ireland, 2000.

In May 2000, public health authorities in Dublin, Ireland, identified a cluster of unexplained severe illness among injecting drug users (IDUs). Similar clusters were also reported in Scotland and England. Concurrent investigations were undertaken to identify the aetiology and source of the illnesses. In Dublin, 22 IDUs were identified with injection-site inflammation resulting in hospitalization or death; eight (36%) died. Common clinical findings among patients with severe systemic symptoms included leukaemoid reaction and cardiogenic shock. Seventeen (77%) patients reported injecting heroin intramuscularly in the 2 weeks before illness. Of 11 patients with adequate specimens available for testing, two (18%) were positive by 16S rDNA PCR for Clostridium novyi. Clinical and laboratory findings suggested that histotoxic Clostridia caused a subset of infections in these related clusters. Empiric treatment for infections among IDUs was optimized for anaerobic organisms, and outreach led to increased enrolment in methadone treatment in Dublin. Many unique legal, medical, and public health challenges were encountered during the investigation of this outbreak.

A National Study of the Retention of Irish Opiate Users in Methadone Substitution Treatment

Background: Retention in treatment is a key indicator of methadone treatment success. The study aims to identify factors that are associated with retention. Objectives: To determine retention in treatment at 12 months for Irish opiate users in methadone substitution treatment and to indicate factors that increase the likelihood of retention. Methods: National cohort study of randomly selected opiate users commencing methadone treatment in 1999, 2001, and 2003 (n = 1269). Results: Sixty-one percent of patients attending methadone treatment remained in continuous treatment for more than 1 year. Retention in treatment at 12 months was associated with age, gender, facility type, and methadone dose. Age and gender were no longer significant when adjusted for other variables in the model. Those who attended a specialist site were twice as likely to leave methadone treatment within 12 months compared with those who attended a primary care physician. The most important predictor of retention in treatment was methadone dose. Those who received <60 mg of methadone were three times more likely to leave treatment. Conclusion: Retention in methadone treatment is high in Ireland in a variety of settings. The main factors influencing retention in methadone treatment was an adequate methadone dose and access to a range of treatment settings including from primary care physicians. Scientific Significance: Providing an adequate dose of methadone during treatment will increase the likelihood of treatment retention. Methadone treatment by the primary care physician is a successful method of retaining opioid users in treatment.

Delivering care to oncology patients in the community: an innovative integrated approach

A community oncology nursing programme was developed in Ireland between the hospital and community health services for patients receiving systemic cancer therapy, in response to a service need. A robust evaluation of the pilot programme was undertaken, which found that defined clinical procedures traditionally undertaken in hospitals were safely undertaken in the patients home with no adverse effects. There was a dramatic decrease in hospital attendances for these defined clinical procedures, and hospital capacity was consequently freed up. Patients valued having aspects of their care delivered at home and reported that it improved their quality of life, including reduced hospital visits and travel time. Community nurses expanded their scope of practice and became partners with oncology day-ward nurses in caring for these patients. Community nurses developed the competence and confidence to safely deliver cancer care in the community. This initiative shows that defined elements of acute cancer care can be safely delivered in the community so long as the training and support are provided. The findings and recommendations of the evaluation resulted in university accreditation and approval for national roll-out of the programme. Integration of services between primary and secondary care is a key priority. This innovative programme is a good example of shared integrated care that benefits both patients and health-care providers.

Community Oncology Nursing Programme making integrated people centred care a reality in Ireland

Background and Content : In Ireland community nurses currently provide care from ‘cradle to grave’ to patients in their geographical areas but historically not cancer care. In this project, community nurses were provided with training and support that equipped them with knowledge and skills to competently and safely provide care at home to patients undergoing systemic cancer therapy. Aim : The aim of the Community Oncology Nursing Programme is to enable community nurses to provide shared nursing care to acute oncology patients at home. Theoretical and skills based training was delivered over six months. It met an identified service need, which was highlighted by the hospital oncology team in Ireland’s North West. A resource book was developed to support nurses caring for these patients. It is a practical informative guide for nurses who have completed the training programme illustrating patient head to toe clinical assessment, step by step approaches to interventions and actions community nurses should take when managing potential cancer treatment related side effects. Ongoing support and communication is maintained with the cancer centre as needed. Methodology : An evaluation of the pilot programme was undertaken in 2012 using a mixed method approach which included qualitative and quantitative components involving: • Patient telephone interviews • Focus groups with hospital and community personnel • An analysis of community and hospital data Analysis : This evaluation focussing on 120 patient visits found patient experiences were positive. Patients described being ‘more at ease at home’…‘saved me 1.5 hours travel when I wasn’t well’. There was an expansion of community nurses scope of practice, they stated that it, ‘made you look at the bigger picture’ ‘I take what I learnt into the patient’s house each day’. Hospital capacity was freed-up and most importantly no adverse patient events occurred. Weak information technology structures for data collection made the evaluation of this programme challenging. Conclusions : This integrated care model was successfully delivered because of the safety features built into the programme, commitment from all stakeholders, strong national and local leadership and a resource book which supported nursing practice. The programme has been adapted since the evaluation to incorporate patient, hospital and community personnel feedback. It is now a university accredited level nine programme. As a direct result of this programme patients in many areas around Ireland can have elements of their cancer care delivered at home. National roll out of this programme continues.