Issue:
Traditional home care nursing to clients living in Vancouver's Downtown Eastside who have a combination of HIV/AIDS, substance abuse and mental health problems (i.e., multi-diagnosed) has proven inadequate. The challenge is how best to change our approach to serve this population.

Demographics Population is over 8000  74% Male  Poorest area of Vancouver  Double the mortality rate  Large First Nations population: 10% of the men and 25% of the the women diagnosed as HIV+ in 1995 were aboriginal. All tested self-identified transsexuals are HIV+.  Over 5000 registered with needle exchange  Over 600 known HIV positives (probably double). It is estimated that people infected with HIV and TB are 400 times more likely to develop active TB.  New sero-conversions in 1995 averaged 1 per day-50% of all BC sero-conversions. If we continue at this rate it is estimated that by the year 2000 all beds in St. Paul's Hospital will be occupied by people with HlV and AIDS.

Typical Client very low self-esteem  unemployable  lived in multiple foster homes  usually comes from an abusive background, physical and/or psychological  first experience with an illegal substance by the age of 12

The diagnosis of HIV+ doesn't rate high on a client's list of relevant situations.

Their immune system has already been adversely affected by:

• IV drug use
• poverty
• poor nutrition
• transient housing & suboptimal personal hygiene

Typical Living Situation Single room occupancy hotel  No fridge - no stove  Shared toilet and bath  Mice and cockroach infested  $325 to $425 per month rent

Because of their unpredictable lifestyle, this population is not suitable for anti-retroviral therapy, yet without this intervention they will become sick more quickly.

Supplying appropriate nursing service to our clients often requires methodologies outside the boundaries of traditional practice.

We have developed some strategies that work for us. They are described below in terms of a particular project and a set of procedures.

Project:
A group of frontline home care nurses has defined the effectiveness of a particular mix of modalities. The Portland Hotel was selected and a program designed for its residents.
 

The Portland Hotel This is a home for the difficult to house multi-diagnosed person. 70 room hotel  funded by Downtown Eastside Residents Association and Greater Vancouver Mental Health  staffed by workers experienced with mental health and drug use problems  residents can remain active drug users without fear of eviction  in-house needle exchange and methadone programs available

Procedure:
Elements of the program include:

• work collaboratively with clients to establish a plan of care which recognizes their autonomy
• provide regular and consistent service by primary nurses
• follow a harm reduction philosophy that includes sterile mixers and information on vein maintenance and safer injection techniques
• provide a client's daily cigarettes, pocket money and nutritional supplement as a reward for successful nursing transactions
• provide care that is non-judgmental and recognize that for most clients abstinence from drug use is not a viable option
• support the client, not the habit
• establish an environment of trust by being consistent and reliable through regular visits-at the same time with the same nurse when possible

Major problems for our clients are abscesses caused by injecting a variety of drugs (cocaine, heroin, pyribenzamine, etc.).
 
 

Pyribenzamine  In Vancouver's multi-diagnosed community pyribenzamine, which is an over-the-counter antihistamine, is a particular problem. Cheap, at $.25/tablet, it gives a quick buzz. Easily obtained at any drug store, pyribenzamine causes deep wounds with purulent drainage that often undermine to form craters. This is probably due to the buffers used in the tablets. A long term effect is keloid formation which limits mobility.

Our approach to care of these wounds is guided by our client's tolerance to pain, attention span and preference for wound care products. We have discovered a combination of products that work well: application of silver sulfadiazine cream (antifungal, antibiotic, possibly antiviral) covered with a hydrocolloid dressing. In doing this, we do not adhere to traditional protocols. The advantage of this dressing is that it occlusively covers the wound but leaves access for the client to inject around it; it is less likely to be taken off by the client 2 minutes after we finish the dressing.

This being said, one keeps in mind that care is client-driven. Some clients do not like the hydro-colloid dressing but insist upon traditional gauze. Our goal is always to clean and cover a wound:

• by any means acceptable
• as quickly as possible

• wash hands before injecting
• use alcohol swab
• use clean equipment (new or bleach-cleaned syringe)
• use clean water
• use good tying off technique
• avoid sharing needles
• know where to shoot and where not to shoot
• encourage clients to "save" one vein
• encourage clients to reduce the number of injections by one per day
• link the client to available resources

To ensure the client's cooperation with nursing care we and the hotel's staff have created a policy that daily cigarettes and money are distributed after a successful nursing transaction. Nutritional supplements are handed out following care. These actions have significant impact on obtaining success with the care plan.

Our goal is to maintain these individuals in their own environment:

• they resist hospitalization until their situation becomes acute
• their acute needs increase the cost of already-expensive hospital care
• they do not function well in a hospital setting
• their substance needs are often not addressed in a manner that is adequate for them

Results:

• There has been an increased visibility and acceptance of home care nursing services by the hotel's residents.
• The program is well accepted by clients in the hotel.
• Word-of-mouth referrals have risen: clients not previously on the caseload drop in for care.
• There seems to be decrease in emergency department admissions for problems such as cellulitis and abscesses.
• There is increased client involvement with nursing care, resulting in better outcomes, e.g., healing of wounds, resolution of infection.
• Personalized attention encourages them to develop interest in improving their health status.

• Development of a proven mix of client-centred methods used in negotiating health care with multi-diagnosed individuals can improve the overall effectiveness of treatment.
• Keeping the approach client-centred and not strictly hewing to traditional guidelines can result in significantly better outcomes for the client.
• The nursing practice is enriched.
• Client-driven experiences guide further interventions.

1. Duncan, D. et al. "Harm Reduction: An emerging New Paradigm for Drug Education," J. Drug Education, Vol. 24(4) 281-290, 1994.

Nursing Close to the Street:
Home Care Nursing in Vancouver's Urban Core

Evanna Brennan, R.N.
Susan Giles, R.N.
Photography by Brooke Richardson

© Susan Giles & Evanna Brennan, 1996

Revised April 2003.