LQD® Spray is a wound care dressing which is applied as a spray but dries within two minutes to form a thin, semi-permeable dressing over the wound. It was evaluated in two different mental-health settings to see if it could help as part of a wound-care regimen for seven people with wounds and mental-health problems. The results showed that LQD spray promoted healing in a short time-frame, but, more importantly, was tolerated in patients who had not cooperated with the use of traditional dressings in the past.

BACKGROUND

Mental health is defined by the World Health Organisation (2019) as: ‘a state of well-being in which the individual realizes his or her own abilities, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to his or her community.’

Mental illness refers to diagnosable mental disorders that involving significant changes in thinking, emotion, and/or behaviour, accompanied by distress and/or problems functioning in social, work or family activities. Mild illness can have a small impact on life, whereas severe illness makes daily life extremely difficult.

There has been an increase in the number of severe cases of mental illness, the number of people being detained under the Mental Health Act and prescribed antidepressants (BBC News, 2018). There has also been an increase in patients self-harming, particularly in girls aged 13-16 years (Morgan et al, 2017).

The pressures of society, stressful employment, poverty and physical appearance fuelled by social media are all factors affecting the mental health of the population. In addition to the issues facing the younger generation, we are, as a society, growing older. With far higher numbers of patients reaching their 80s than ever before (ONSI, 2017). This also means that more patients will be living with long-term chronic conditions such as venous disease, diabetes and arterial disease that are associated with the development of wounds that frequently became chronic, particularly if not correctly managed.
 

WOUND CARE DELIVERY FOR PATIENTS WITH MENTAL ILLNESS

Patient with mental illness present a number of challenges in relation to wound management. They obviously suffer from the same wound problems as the general population but can have difficulties in understanding wound management aims and often are unable to comply with treatment. They may have difficulty in understanding treatment choices, remembering that they are being treated, actively choosing not to comply with treatment, or use it as a further opportunity to self-harm, for example, with the deliberate removal of dressings, complex self-inflicted wounds such as burns (physical and chemical), insertion of foreign bodies under the skin, repetitive picking or gouging at wounds, to name a few.

All of this put the patient at a high risk of developing complications such as wound infection, enlargement and delayed healing. Kilroy-Findley (2010) suggested that non-adherence with treatment can be common and that healing patients in the mental-health setting may not be the main goal of treatment; instead avoidance of infection should be a priority.

There is little published literature about delivering wound care to patients with severe mental illness. The life expectancy of this vulnerable population is 10–20 years less than the general population and the reasons for this are complex but it includes poorer access to health services (Chesney et al, 2014). This also includes wound care services. Many people with wounds and mental health problems are in-patients in privately run institutions which do not have the same access to district nurses and do not employ trained nurses with the necessary wound-care skills. There is often a lack of continuity in staffing with bank or agency staff filling sessions and their experience in wound care can vary dramatically.

In such circumstances, clinicians need to think ‘outside the box’ to find novel ways of achieving healing which the patient finds acceptable. The availability of a simple to apply dressing that all staff are able to use confidently, and which can promote healing, have anti-microbial action and that is not obviously a dressing for removal, could be useful in this patient group.


WOUND ASSESSMENT

Wound care for all patients should begin with a thorough, holistic assessment, however, in some cases, this assessment focuses on the physical status of the wound and of the patient and does not necessarily consider their mental health. Wound assessment does include consideration of any pre-existing medical conditions, however, forms mostly record tissue types, exudate volume, signs of infection and no reference to how a patient tolerates dressings. There are also very few guidelines on how to manage wounds in this patient group who may not understand or tolerate standard wound care therapies.
 
Patients with severe illness may not understand the cause of their wound nor their treatment, they may view bandages and dressings as uncomfortable or ‘annoying’. They may naturally attempt to remove any dressings and bandaging.  
Patients who self-harm have wounds that are a physical manifestation of a deep-rooted psychological issue. Often these patients are not treated with the same empathy as other patients and instead the attitude of clinical staff to self-harm patients is that this behaviour is irrational and illogical, however, for the patient the wounding is supported by their own internal logic and is a coping mechanism. Therefore, being dismissive is not an ideal strategy when caring for this patient group.  
 
This view is supported in a paper by McHale and Felton (2010) where patients reported on their experiences of care when admitted with self-harm related wounds. Patients reported negative attitudes towards them reflecting a lack of education and training, as well as a lack of understanding of the condition. Positive experiences mentioned in the studies included well trained and educated staff and staff who had a deeper understanding of the issues relating to self-harm.  


CHOOSING A WOUND DRESSING FOR PATIENTS WITH MENTAL HEALTH ISSUES

As with all patients, it is important to consider the individual needs of the patient when choosing a dressing regimen. The ideal treatment in the clinician’s opinion may not be one that the patient considers to be acceptable. The patient may try to remove the dressing when it is applied. Similarly, if the patient does not understand the need for the dressing then they may try to remove it when it is reapplied. In situations where patients repeatedly remove dressings there is a risk that the wound and the surrounding skin can become further damaged due to the repeated trauma of adhesive dressings being pulled from the skin.

There are a number of wound dressings that are designed to be gentle on the skin when removed, and these products often contain silicone. Silicone provides a gentle adhesion to the tissue surrounding the wound and this makes removal much simpler and less traumatic to the wound and the surrounding skin. However, is still not ideal if the patient does not tolerate even these gentle dressings and continual removal can lead to spiralling costs if a new dressing is used each time.
 

LQD spray

For a number of years, scientists have been studying the benefits of Chitosan on wound healing.  
Chitosan is a natural biopolymer found in the exoskeleton of insects and crustaceans such as prawns and crabs.  
 
LQD spray contains chitosan that is derived from the shells of the Norwegian sea prawn.  Chitosan is said to be more active when there is a higher level of deacetylation. LQD spray contains Chitosan FHO2, which has the highest degree of deacetylation of any Chitosan product, making it a more potent version of the chitosan biopolymer (Dai et al, 2011).  
 
Chitosan has a range of properties that have been proven to assist wound healing at every stage.
It is a natural haemostat and this function is independent of the normal haemostatic cascade.  The action of chitosan enables the activation of platelets within the wound, leading to clotting through platelet aggregation (Kozen et al, 2008).

Chitosan is also a natural antimicrobial agent. LQD spray has shown to be effective against a number of wound pathogens, including Staphyloccous aureusPseudomonas aeruginosa and has also shown to be anti-fungal.
 
Chitosan has been shown to stimulate the activation of polymorphonuclear leukocytes and macrophages that are known to help control the acute inflammatory process by encouraging the destruction of bacteria and removal of dead cells and debris, and the stimulation of the proliferative phase of wound healing (Dai et al, 2011).  These macrophages synthesize growth factors which influence wound healing (Ueno et al, 2001).  
 
Chitosan stabilises fibroblasts within a wound. Fibroblasts are key cells involved in the formation of granulation tissue and in the creation of new blood vessels through angiogenesis.    
 
Reduction of scar formation and control of remodelling phase:  Chitosan has been shown to influence the production of key cytokines, and among these is Transforming Growth Factor β.  TGFβ is associated with control of the remodelling phase of wound healing and also scar formation (Ueno et al, 2001). It is believed that chitosan can help to support this phase of wound healing.  
 
 



A SMALL TWO-CENTRE EVALUATION OF PATIENTS WITH WOUNDS AND MENTAL ILLNESS

This small evaluation took place over two sites where patients had presented with wounds that were related to their mental health status.  In patients who self-harm or who have dementia, it may prove difficult to find an acceptable wound dressing that they will keep in place. This can result in further skin trauma, if multiple wound dressings are being applied and removed on a regular basis.
 
LQD spray is designed to be used with or without a secondary dressing. Once applied, LQD spray forms a semi-permeable membrane that contours to the wound surface. Chitosan works on the wound tissue to promote healing while its antimicrobial efficacy offers protection against infection from external pathogens.  
 

THE PATIENTS

LQD spray was evaluated in two centres on seven patients (five males, two females) with mental illness and wounds. Their wounds were documented as resulting from self-harm in three cases, neglect in two cases and two patients had wounds related to their diabetes. The longest duration of the wounds was six months and the shortest had been present for only two days. The patients all seemed to have a problem with keeping wound dressings in place and in the cases where self-harm was a factor, it was known that occluding the wound from sight was not always welcomed by the patients.

The details of the evaluation are shown in Table 1.
 
Table 1. Patient data (l/c d)

RESULTS

Seven patients with seven wounds had LQD spray applied daily or x3 per week depending on the wound type. Three patients had wounds that had been present for one month or more.  Exudate volume ranged from low to high, and although LQD spray is not recommended for highly exuding wounds it was used in conjunction with an absorbent secondary dressing, using clinical judgement, in two of the patients. All wounds healed within 2–3 week period.

Due to difficulties with obtaining patient consent in this patient group, images of the individual cases cannot be presented. However, case histories for 2 patients are presented (Cases 1 and 2).


Case 1. Adele Linthwaite
Tissue Viability Lead & Continence Advisor,
Birmingham and Solihull Mental Health NHS Foundation Trust

Managing any type of wounds within a mental-health setting can be challenging, not just those resulting from self-harm. I was surprised when I started working in this field at the volume and different types of wounds I am asked to assess, and every wound has to be risk assessed, for example I have to consider; what’s the risk of indigestion of the dressing? Is there a ligature risk? These are questions I have never really considered when assessing wounds before.

Many times I have looked at wound and though ‘how am I going to heal that?’ Many mental health nurses have very little training in wound care and dressings are not widely used or understood. When I was shown LQD spray I could identify service users instantly as there is no risk of ingestion or ligature. The risk of infection and sepsis within our setting is high especially with self-harm wounds due to the non-sterile instruments used to inflict harm. Knowing that LQD spray is also antimicrobial is reassuring. LQD spray has been used on self-harm wounds, skin tears and burns with fantastic results and no infection occurred in the wounds. All wounds went onto heal quicker than expected in this setting, which is wonderful. Staff find it easy to use and understand and, if appropriate, service users could use it themselves. As well as ingestion another problematic area is concordance with dressing wear. One gentleman with dementia had multiple skin tears and fragile skin due to long-term steroid use. He kept removing his dressing and this led to an increase in spend on foam dressings and nursing time. After two weeks of treatment with LQD spray, all skin tears had healed with no complications or secondary dressing needed. Another patient had a large burn which we treated and managed in partnership with the burns team, however, all but a small area had healed. The service user kept picking at the remaining wound due to irritation and itching causing it to bleed and return to the inflammatory stage. LQD spray was used and after three weeks the area had healed. Staff reported that the service user picked at the wound less and the itching and irritation had resolved.
Case 2. Marc Hinchliffe
GP, providing care at four secure units

A morbidly obese man in his early thirties with significant learning disabilities and challenging behaviour presented with multiple wounds to his lower limbs. He suffers from chronic venous insufficiency with hyper-pigmented skin which is very susceptible to ulceration. He self-inflicts wound to his legs possibly out of frustration or as attention seeking. Any dressings applied are removed which significantly delays healing and causes exasperation among the staff.

As the visiting GP, I was presented with the usual scenario on my weekly visit to the secure unit where he is an in-patient. He had numerous superficial ulcerated areas on both legs which were not healing. This time I was armed with a bottle of LQD spray which I had trialled at another unit with impressive results. I instructed the staff in its use and the patient was happy to have the ulcers sprayed every three days without any secondary dressings. On review a week later there was a remarkable improvement and the following week the wounds had healed completely. We had never achieved such a quick healing of his leg ulcers before. It is also interesting to note that the patient has not self-harmed since then. It is early days but it is possible that the simple application of a spray every three days does not provide the increased attention he was seeking by the self-harming behaviour and that this has had the unexpected benefit of modifying his behaviour.
 
 

CONCLUSION

With a growing elderly population and an increase in the numbers of patients with complex physical and mental-health needs, there is a need to ensure that we have a broader understanding of the issues affecting these patient groups. There is evidence to suggest that self-harm is increasing in the UK and that there is still a stigma attached to this particular illness when patients present to emergency departments (McHale and Felton, 2010). Kilroy-Findley (2010) asserted that a non-judgemental approach is an essential starting point for the management of individuals who self-harm.  
 
Wound care has traditionally been associated with the application of a dressing, bandage system or a combination of both. While this may be normal practice and acceptable to the vast majority of patients, there are also patients who do not fully understand the need for wound dressings, and this lack of understanding can lead to dressings being removed and potentially leading to further skin damage.  In the case of self-harm patients, the patient may not be keen to have the wound covered.

LQD spray is a dressing that can be applied to the wound bed, forming an antimicrobial semi-permeable membrane, that promotes wound healing. In this small evaluation on the wounds of patients with mental health issues, LQD spray demonstrated healing in a short time frame and more importantly was tolerated, when the patient had not been keen to use traditional dressings in the past.  

References

Morgan C, Webb RT, Carr MJ, et al (2017) Incidence, clinical management, and mortality risk following self-harm among children and adolescents: cohort study in primary care. BMJ 2017; 359:j4351
 
Chesney E, Goodwin GM, Fazel S (2014) Risks of all-cause and suicide mortality in mental disorders: a meta-review. World Psychiatry 13: 153–60
 
Dai T, Tanaka M Huang YY and Hamblin MR (2011) Chitosan preparations for wounds and burns: antimicrobial and wound-healing effects Expert Rev Anti Infect Ther. 2011 Jul; 9(7): 857–879. doi:  10.1586/eri.11.59
 
Harris J (2000) Self-Harm: Cutting the Bad out of Me. Qualitative Health Research, Volume: 10 issue: 2, page(s): 164-173 Issue published: March 1, 2000, https://doi.org/10.1177/104973200129118345
 
Kilroy-Findley A (2010) Tissue viability in mental health. Nursing Standard. 24, 45,60-67. doi: 10.7748/ns2010.07.24.45.60.c7909
 
Kozen BG, Kircher SJ, Henao J, et al (2008) An alternative haemostatic dressing: comparison of CELOX, HemCon, and QuikClot. Acad Emerg Med 2008;15(1): 74–81
 
McHale J, Felton A (2010) Self‐harm: what's the problem? A literature review of the factors affecting attitudes towards self‐harm, The Journal of Psychiatric and Mental Health Nursing,  https://doi.org/10.1111/j.1365-2850.2010.01600.x
 
ONSI (2017) Overview of the UK population: July 2017
 
Ueno H, Mori T, Fujinaga T. (Ueno et al 2001)  Topical formulations and wound healing applications of chitosan. Adv Drug Deliv Rev. 2001;52(2):105–115
 
World Health Organisation (2019) https://www.who.int/features/factfiles/mental_health/en/.