to identify the anesthesia services required by the homeless in an urban .... of the residents of emer-. Journal of the American Association of Nurse Anesthetists.
Anesthesia for the homeless SUSAN BENEDICT, CRNA, DSN, FAAN Charleston, South Carolina
WILLIAM P. FEHDER, CRNA, MS Havertown, Pennsylvania
Healthcarefor the homeless is often crisisorientedand fragmented.Homelessness may be associated with ongoing healthcare problems such as tuberculosis, human immunodeficiency virus (HIV), acquired immune deficiency syndrome (AIDS), and substance abuse. The purpose of this study was to identify the anesthesia services required by homeless individualsfrom an urban area. The anesthesia records of all individuals (N = 40) identified as being homeless and receiving care at one New York City medical center during a 12-month period were reviewed. Approximately one-half (47.5%) of the 40 patients in the study did not require general anesthesia but intubationonly. Most of these intubations were for cardiac/respiratoryarrests of unknown cause, drug/alcoholoverdose, or multiple trauma. Of the 21 patients requiring surgery, 15 had emergency proceduressuch as splenectomy, appendectomy, exploratory laparotomy, incarceratedhernia repair,and reduction of fractures. The findings of this study support previous research which indicates thatmost homeless people enter into care for emergency rather than elective services. Key words: Homeless, undomiciled, perioperative.
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Introduction Homelessness is a major societal problem. According to the Coalition for the Homeless, there were an estimated 3 million homeless people in the United States at the beginning of 1990. Approximately 70,000-90,000 of these people are in New York City. At least four subgroups of homeless have been identified: 1. Chronically mentally ill 2. Street people 3. Chronic alcoholics 4. Situational homeless, such as unemployed, evicted, and transient persons.' Many of these people inhabit parks, subways, and public buildings. A number of cities and various organizations have attempted to alleviate the problem by providing emergency shelters and temporary housing for the homeless. However, many homeless individuals choose not to go to the shelters for a variety of reasons, including the crime and living conditions prevalent in many of these public facilities. Healthcare for the homeless is crisis-oriented. There is often a lack of personal and economic resources necessary to promote wellness in a lifestyle which is the antithesis of wellness. Minor health problems are often ignored in a life oriented toward day-to-day survival. Nonparticipation in health services by the homeless may occur because the client may not perceive a need, because referrals are made to facilities that are not nearby, or economic resources are insufficient. ' Healthcare is usually not sought unless there is an emergency or
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until the health problem can no longer be ignored or tolerated. Many of the homeless with health problems are seen in emergency surgical situations. Nurse anesthetists are often involved in these situations. It is important to identify the major health problems that bring the homeless into the acute care setting. This identification can facilitate the provision of optimal care to people who usually receive only episodic healthcare. The purpose of this study was to identify the anesthesia services required by the homeless in an urban medical center and the health problems that necessitated those services. Review of the literature A survey of 979 homeless people conducted in 1989 revealed that one-third of the subjects had physical health problems that the individuals believed required medical care. 3 Health problems of the homeless are often precipitated or exacerbated by their homeless condition. The most self-evident of the negative influences includes exposure to inclement weather, violence, poor nutrition, overcrowded or inadequate shelter, and the stress of living a day-to-day existence. Researchers investigating the health problems of the homeless have identified problems in three general areas: physical problems, psychiatric problems, and problems associated with substance abuse. * Physical problems. The use of intravenous street drugs is a major source of human immunodeficiency virus (HIV) infection among the homeless. Accurate estimates of the prevalence of HIV seropositivity among the homeless are difficult to make, because many individuals have not been tested. Laws protecting anonymity and the confidentiality of HIV testing allow for disclosure of HIV status only to and by the individual. Hence, the HIV status of a homeless individual will not be known to healthcare providers unless it is disclosed by the individual. According to geographical location, a fairly high incidence of HIV seropositivity may be assumed. For example, it is known that 44% of the patients seen in the emergency departments of New York City municipal hospitals are people with acquired immune deficiency syndrome. (AIDS).4 Trauma is a major problem for the homeless, especially those in urban areas. The homeless are often victims of violence, both on the streets and in the shelters. Accidents resulting from the use of open fires, falls, cuts, and fractures are common. Stab wounds and fractures accounted for 65% of the major trauma admissions of homeless patients to San Francisco General Hospital in 1983. 5 Overall, 30% of 524 homeless people in San Francisco were treated for trauma within a 6-month period. 6 Simi-
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larly, trauma was reported to be a significant cause of disability and death among the homeless. 7 Peripheral vascular disease is prevalent among the homeless. Chronic venous insufficiency and leg ulcers were present in an estimated 10% of the homeless in New York City.8 Peripheral vascular disease was seen in 14% of the homeless men and 11% of the homeless women in a study by the Committee on Health Care for the Homeless. Edema of the feet and lower legs occurs as a result of not being able to lie down. Poor nutrition, poor hygiene, ill-fitting shoes, the use of tobacco, and exposure to cold and damp weather can all contribute to the development of cellulitis and leg ulcers. 7 Tuberculosis occurs with greater frequency among the homeless than among others. For example, screening in 1988 revealed that 35-50% of a sample of homeless men in San Francisco had positive tuberculin skin tests. 9 Similarly, positive tuberculin tests were reported to occur in 38% of the homeless men and 30% of the homeless women in a 1985 New York City sample. 10 The living conditions of the homeless, including poor nutrition, overcrowding in shelters, and exposure, contribute to this problem. The association between the presence of tuberculosis and HIV seropositivity is becoming apparent. Other pulmonary conditions prevalent among the homeless are upper respiratory infections, chronic obstructive pulmonary disease, and asthma. Upper respiratory infections were reported to occur in 33% of the homeless.6 Respiratory problems were reported to be the chief problem of the homeless during winter months," with respiratory complaints being the single most common problem of 232 emergency shelter residents. 12 * Psychiatric problems. A study of 979 homeless individuals in 19 counties of Ohio documented that 30% of those interviewed had been hospitalized at least once for mental health problems. 3 Lenehan and associates reported that nearly 50% of the residents of an urban shelter had significant psychiatric problems. 13 Interviews with 80 homeless women residing in family shelters in 1988 determined that approximately 55% had "contact with the mental health system at some point in their lives"' 4 In an urban Washington, DC clinic for the homeless, 18% of the clients were reported to have had experienced a major mental illness.' - A British study documented that 31% of homeless men had a history of psychiatric hospitalization. 6 * Substance abuse. Chronic alcohol use is common among the homeless, with reported incidences ranging from 20 to 94% for alcoholism or alcohol 3 abuse among homeless shelter residents. 1213.15.16A
1986 study found that 63% of the residents of emer-
Journalof the American Association of Nurse Anesthetists
gency shelters in Minnesota had indications of chemical dependency, yet only 2% were reported to have a dependency on a substance other than alcohol. 12 Crack and heroin, as well as other street drugs, are reported to be used with some frequency by the homeless in urban areas. Crack is often preferred by younger persons, with those over the age of 35 preferring heroin. In New York City, drug abusers account for 1-30% of the populations of four singleroom occupancy hotels." Overall, the estimated rate of drug abuse has been reported to be approximately 10-15% among the homeless. 18 Although research has identified the major physical, psychiatric, and substance abuse problems of the homeless, the anesthesia services the homeless require when they seek care for these problems have not been investigated. This study examined the anesthesia services required by 40 homeless people who were admitted through the emergency department of one urban medical center.
viewed for the preoperative and postoperative diagnoses, anesthesia services, type of procedure, type of anesthesia given, and whether the patient required emergency services. For 50% of the anesthesia records, chosen at random, both investigators independently categorized the data, and a 99.5% interrater reliability was obtained. Findings A summary of the procedures necessitating anesthesia is presented in Table I. Of the 21 patients with anesthesia records, 17 (80.9%) received general anesthesia, 2 (9%) received spinal anesthesia, and 1 (4.7%) had local anesthesia. Of the 40 patients requiring anesthesia, all but 4 (90%) were emergency procedures. Fifteen (37.5%) of the diagnoses, including fractures, stab wounds, and head injuries, were related to trauma. The next largest group requiring emergency attention included incomplete abortions, appendicitis, and incarcerated inguinal hernias. The most common diagnoses for nonemer-
Methodology * Preliminary phase. As a preliminary com-
ponent of this study, the health problems of the homeless residents of one shelter located across the street from a major medical center in New York City were identified by a review of on-site clinic records. The purpose of this investigation was to determine characteristics of the homeless in the geographical area served by the medical center. The shelter houses approximately 950 homeless men, ranging in age from 18 to 60. The mean age is 32. Approximately 30-40% of the residents are alcohol-dependent, 60% are users of crack cocaine, and 30% have a history of psychiatric treatment. In descending order, the following health problems necessitated residents' visits to the on-site walk-in clinic: upper respiratory infections, trauma, asthma, seizures related to alcohol, diseases associated with HIV infection, and hypertension. * Sample. The sample for this retrospective study was obtained by reviewing all anesthesia records at one large medical center that serves the homeless shelter for one 12-month period from March 1990 through April 1991. Only records of patients specifically identified as "homeless" or "undomiciled" were included There were 40 such records identified for the 1-year period. There were 29 males and 11 females with mean ages of 44.5 and 60.8, respectively. Ages were unknown for 13 males and 6 females, who represent 47.5% of the sample. Eleven of the patients were known to be drug users and 3 were on methadone maintenance. * Procedure. Each anesthesia record was re-
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Table I Anesthesia services performed (number = 40) Number Percent
19 5
3
47.5 12.5
7.5
Diagnosis v
Respiratory arrest Fracture Mandible Femur Tibia (2) Zygomatic Abdominal trauma Ruptured spleen Stab wound Stab wound
2
5
3
7.5
2
5
Incomplete abortion Subdural hematoma Other emergencies Appendicitis
6
15
Incarcerated inguinal hernia Nonemergencies Leg/foot ulcers (3)
Procedure Intubation only Closed reduction Open reduction Debridement Closed reduction Open reduction
Splenectomy Exploratory laparotomy Exploratory laparotomy; removal of coat hanger Dilation and curettage Burr holes Appendectomy Hernia repair
Lipoma of thigh
Debridement; skin graft Hernia repair Excision
Condyloma and cyst
Excision
Inguinal hernia
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gency anesthesia and surgical care were for skin lesions and hernia repairs. Of the 40 homeless patients requiring anesthesia services, 19 (47.5%) did not require surgery but required intubation only. The conditions necessitating intubation are presented in Table II. The most common conditions requiring emergency intubation were cardiac or respiratory arrest from unknown causes. Multiple trauma not requiring surgery was the next most common problem resulting in intubation. Other conditions requiring intubation included drug and alcohol overdose, infections, myocardial infarction, and seizures. Table II Intubations only (number = 19) Number 5 2 1 1 2 2 3 1 1 1
Diagnosis Cardiac and/or respiratory arrest (cause unknown) Drug overdose Hyperthermia Pneumonia Alcohol overdose Head injury Multiple trauma Acute myocardial infarction Seizures (cause unknown) Sepsis
Discussion A lack of resources to provide early intervention healthcare is common to all homeless people; therefore, care for the homeless is often crisisoriented. In this study, 25 patients (62.5%) had conditions which would have resulted in death if they had not received immediate medical attention. Even when problems were not true emergencies, they generally represented urgent situations. Only two of the surgical procedures that were performed were nonurgent (excision of lipoma and excision of condyloina). If left untreated, the ulcers and hernias that brought the homeless in for care would have eventually necessitated emergency procedures. In this New York City sample, 37.9% of those patients requiring surgery were treated for traumarelated conditions such as fractures, subdural hematomas, and stab wounds. The incidence of trauma in this sample is consistent with the 30% trauma rate reported among the homeless in San Francisco in 1988. 6 Chronic venous insufficiency and leg ulcers have been reported to occur in an estimated 10% of
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the homeless. 8 Of the 29 subjects requiring surgery, 3 (10.3%) had surgery related to foot and leg ulcers. CRNAs are often presented with a patient who has no medical history available and who requires immediate attention. Among other things, mental illness or acute drug/alcohol intoxication may impair the patient's ability to provide any medical history. In this study, no information was provided" on the anesthesia records of history of mental illness. However, 4 (10%) of the patients had diagnoses related to drug or alcohol use which could have impaired their ability to give a coherent or accurate medical history. Almost all the homeless patients in this study were rendered unable to communicate within a very short period of coming into contact with perioperative nurses. Ninety percent of the patients were either intubated for nonsurgical reasons or received general anesthesia for their surgical procedures. The opportunity to obtain a comprehensive health history was therefore limited. The limitation imposed by this abbreviated time for interaction is important, in that assumptions must be made in planning the care of the patient as well as protecting the health of other patients and caregivers. It must be assumed that there may be an increased likelihood of the individual having some of the health problems prevalent among the homeless such as tuberculosis, HIV, or a history of substance abuse. Of the three main reasons cited in the literature for which the homeless receive healthcare - psychiatric problems, substance abuse problems, and physical problems - the subjects in this study primarily received anesthesia services for physical problems. However, substance abuse may have been an underlying cause of respiratory arrest, cardiac arrest, fractures, or trauma. Adequate information about substance abuse is particularly important in the perioperative period, so that patients can receive adequate premedication prior to surgery and adequate pain relief after surgery. A patient with a history of drug use may face overdose or withdrawal if the type of drugs he or she has been taking is not known and taken into account. 19 No pertinent history of infectious disease appeared on any of the anesthesia records. Notations were made on 10% of the charts indicating a history of intravenous drug abuse, which would place the patient in a high risk category for HIV. Although not documented on the anesthesia records reviewed for this study, the high reported incidence of infectious diseases that is believed to exist among homeless patients requires that the surgical team have an effective plan of care to prevent exposure to infection. Because it might not be known at the time of intubation or surgery that a patient has a positive
Journalof the American Association of Nurse Anesthetists
history of an infectious disease, the use of universal precautions is imperative. The high incidence of tuberculosis among homeless people is currently a matter of great concern, especially since the identification of drugresistant strains of the tuberculosis bacterium. The association of tuberculosis with HIV seropositivity is also a major source of concern. Summary The findings of this study support other re-
search that indicates that both male and female homeless patients most often enter into care for emergency situations. The challenge for CRNAs is to provide care for the homeless to ensure that they have a comfortable and safe surgical experience in the absence of adequate information about concomitant health problems such as substance abuse, psychiatric illness, or infections. This study provides a beginning for establishing characteristics of a sample of homeless people who require anesthesia services. Further research is needed to provide additional documentation of specific problems experienced by patients who are homeless.
Health Care of Homeless People. New York: Springer Publishing Com-
pany. 1985:121-129. (9) Slutkin G. Management of tuberculosis in urban homeless indigents. Public Health Rep. 1986;101:481-485.
(10) McAdam J, Bricker P, Glicksman R, Edwards D, Fallon B, Yanowitch P. Tuberculosis in the SRO/homeless population. In: Bricker P, Scharer L, Conanan B, Elvy A, Savarese M, eds. Health Careof Homeless People. New York: Springer Publishing Company. 1986:155-175. (11) Pearson L. Providing health care to the homeless-Another role for NPs. Nurse Pract. 1988;13:38-48. (12) Kroll J, Carey K, Hagedorn D, Fire Dog P, Benevides E. A survey of homeless adults in urban emergency shelters. Hosp Community Psychiatry. 1986;37:283-286. (13) Lenehan GP, Mclnnis BN, O'Donnell D, Hennessey M. A nurses' clinic for the homeless. Am ] Nurs. 1985;85:1236-1240. (14) Bassuk E, Rubin L, Lauriat A. Characteristics of sheltered homeless families. Am JPublic Health. 1986;76:1097-1101. (15) Bargmann E. Washington, DC: The Zacchaeus Clinic-A model of health care for homeless persons. In: Bricker P, Scharer L, Conanan B, Elvy A, Savarese M, eds. Health Care of Homeless People. New York:
Springer Publishing Company. 1985:323-332. (16) Toon R, Thomas K, Doherty M. Audit of work at a medical centre for the homeless over one year. JR Coll Gen Pract. 1987;37:120-122. (17) Conanan B, O'Brien M. New York City: The St. Vincent's Hospital SRO and Shelter Programs. In: Bricker P, Scharer L, Conanan B, Elvy A, Savarese M, eds. Health Care of Homeless People. New York:
Springer Publishing Company. 1985:301-310. (18) Wright J, Weber E. Homelessness and Health. Washington, DC: McGraw-Hill Healthcare Information Center. 1987. (19) Wood P, Soni N. Anesthesia and substance abuse. Anesthesia. 1989; 44:672-680.
REFERENCES
AUTHORS
(1) Fischer P, Shapiro S, Breakey W, Anthony J, Kramer M. Mental health and social characteristics of the homeless: A survey of mission
Susan Benedict, CRNA, DSN, FAAN, is professor of Nursing, professor of Nurse Anesthesia, and assistant dean for Graduate Programs in the College of Nursing of the Medical University of South Carolina in Charleston, South Carolina. She graduated from Charity Hospital School of Anesthesia in New Orleans, Louisiana, and received her doctorate from the University of Alabama in Birmingham, Alabama. She is a Fellow of the American Academy of Nursing. William P Fehder, CRNA, MS, is a staff nurse anesthetist and clinical and didactic instructor at Lankenau Hospital School of Anesthesia, St. Joseph's University in Philadelphia, Pennsylvania. He received his BA degree from Hunter College in New York and his MS degree from Pace University-New York Medical College. He is a graduate of the Nurse Anesthesia Program of the Medical University of South Carolina in Charleston, South Carolina. Mr. Fehder is a doctoral student in the School of Nursing, University of Pennsylvania, Philadelphia.
users. Am JPublic Health. 1986;76:519-524.
(2) Nichols J, Wright L, Murray J. A proposal for tracking health care for the homeless. J Community Health. 1986;11:204-209. (3) Roth D, Bean G. New perspectives on homelessness: Findings from a statewide epidemiological study. Hosp Community Psychiatry.
1986;37:712-719. (4) Will G. The trauma in trauma care. Newsweek. March 12, 1990:98. (5) Kelly J. Trauma: With the example of San Francisco's Shelter Programs. In: Bricker P, Scharer L, Conanan B, Elvy A, Savarese M, eds. Health Care of Homeless People. New York: Springer Publishing Com-
pany. 1985:77-91. (6) Vladick B and the Committee on Health Care for Homeless People, Institute of Medicine. Health problems of homeless people. Homelessness, Health, and Human Needs. Washington, DC: National Acad-
emy Press. 1988:39-75. (7) Bricker P, Scanlan B, Conanan B. Homeless persons and health care. Ann Intern Med. 1986;104:405-409.
(8) McBride K, Mulcane R. Peripheral vascular disease in the homeless. In: Bricker P, Scharer L, Conanan B, Elvy A, Savarese M, eds.
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ACKNOWLEDGMENT The authors gratefully acknowledge the assistance of Terry Doddato, CRNA, MS, director of the MSN Nurse Anesthesia Program, Columbia University School of Nursing, New York, New York.
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