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Don't overlook clinical needs of homeless patients in your ED
Simple interventions 'can go a long way'
Each time a homeless person comes to your ED, you are faced with many challenges. Your patient is likely to have poor hygiene, multiple chronic medical problems, no funds for prescriptions, no transportation, and also might be intoxicated.
"Many of the homeless that we see on a regular basis suffer from mental illnes
s and/or some type of chemical dependence," says Tina Alafa, RN, ED nurse at Kaweah Delta Medical Center in Visalia, CA. "Oftentimes, they arrive in our department with soiled clothing, disheveled, and lacking proper hygiene. This can make simply approaching them a challenge for ED staff."
U.S. cities are reporting increases in homeless people and families of 12% to 40%, according to the Center on Budget and Policy Priorities. This means that ED nurses are caring for many more homeless.
Alafa says her ED is seeing a marked increase in homeless patients. "Although they come to the ED seeking medical attention, they are often unwilling to complete a medical exam," she notes. "This poses its own challenges when trying to accurately assess their medical status."
Anette Bickett, RN, CEN, CPEN, TNCC, an ED nurse at Jewish Hospital Medical Center South, a rural community medical center in Shepherdsville, KY, says, "Once a person becomes my patient, I have a responsibility to assist them with managing their new or chronic medical problems."
Rates of chronic medical illness are high among homeless adults seen in the ED, says Mairead O'Regan, RN, an emergency nurse and administrative director of logistics at Newark (NJ) Beth Israel Medical Center. In addition, homeless patients usually have social or psychological problems in addition to their physical ailments.
It's a mistake, though, to label homeless patients as "non-compliant," adds O'Regan. "Many of our homeless population have psychological issues. Their perception of compliance is often very different from the expected norm."
Poor access to meds
You're used to telling your patients why a medication is needed, but if your patient is homeless, you need to worry about how they will get it.
Bickett says, "It is one thing to see these patients get diagnosed and treatment for their ailments. But what do I do when they are given three or four prescriptions, with no financial resources to get them filled?"
Alafa says, "We send the homeless out with prescriptions for antibiotics and no source of income to pay for them, discharge instructions to follow up with their primary pro vider when they have none, or directions to keep wounds clean and dry, but no supplies or education on how to do so."
Bickett says that once she realizes her patient has limited resources, she does these interventions:
This list might help your ED patient receive health care, dental care, mental health services, meals, counseling, or affordable housing.
"It just takes a few minutes to make some phone calls and surf the net, in order to help my patient in an appropriate direction," says Bickett. "It is my job to get this information into the hands of my patient upon discharge."
One elderly woman being discharged from Jewish Hospital's ED was unable to care for her own needs. ED nurses worked with emergency medical services (EMS) staff, who transported the patient, to set up short-term assistance.
"We then involved our local adult protective services," says Bickett. "An agent personally reviewed her situation and got her the assistance she so desperately needed."
Poor hygiene affects patients' well being from a mental and physician standpoint, O'Regan says.
"Assist the patient with daily activities, showers, and clothing," she says.
Alafa typically offers homeless patients a meal and the opportunity to clean themselves. "Offering a meal sustains the body's need for nutrition. Allowing them the opportunity to clean themselves improves wound healing and decreases the risk for infection," she says. "A simple boxed sandwich lunch and a basin with some soap and warm water can go a long way."
Denise Foster, RN, MSN, ED director at Oregon Health & Science University in Portland, says that the number of homeless patients at her facility has steadily increased. She says that because ED nurses are the ones who spend the most time with these patients, they are the best ones to assess the person's ability to provide self-care.
"Commonly the homeless are sent out, only to return to the ED shortly thereafter," says Foster. "In the worst case scenarios, their condition significantly deteriorates due to lack of follow-up care."
For more information on homeless ED patients, contact:
Assess for hypothermia in homeless patients
Due to the increasing number of homeless patients seen at the ED at Oregon Health & Science University in Portland, nurses started a clothing donation center in the department. Staff and patients brought in items that otherwise would have been discarded.
"The result is we currently have a decent stock of clothing," says Denise Foster, RN, MSN, ED director. "In the cold winter months, a warm coat can make the difference between life and death for the homeless. We are sensitive to the fact that many of our homeless are ill-prepared to dress for the elements and thus can arrive with hypothermia." To improve assessment, consider these items:
Hypothermia develops gradually over several hours.
Cases have these characteristics, says Foster:
Patients with mild hypothermia have temperatures of 93.2-96.8°F and might present with uncontrolled shivering, loss of memory, depression, fatigue, and poor judgment.
Patients with moderate hypothermia have temperatures of 86.0-93.2°F. "The heart rate, blood pressure, and respiratory rate falls, and cyanosis occurs," says Foster.
In severe cases with temperatures below 86.0°F, cardiac arrhythmias can occur along with unconsciousness. "Death usually occurs when the temperature falls below 78°F," says Foster.
Patients with hypothermia are hypoxic, dehydrated, and hypoglycemic.
Treatment involves preventing further loss of heat and re-warming. "Address both external and internal warming techniques, fluid resuscitation, and treatment of hypoglycemia," says Foster.