providing healthcare in a supervised injecting facility ... - providing healthcare...portland hotel...
TRANSCRIPT
Providing Healthcare in a Supervised Injecting Facility: Nursing Culture at Insite
Canadian Association of Nurses in AIDS Care ConferenceApril, 2007
Introduction
BackgroundNorth America’s first Supervised Injection Site (SIS), Insite opened in September, 2003Open 18 hours per day, 365 days per yearPilot project with extensive research/ evaluation component (ESIS)Jointly operated community health initiative
Vancouver Coastal HealthPortland Hotel Society
Goals
Public Health InterventionIncreased public health (affecting OD death, transmission of disease, contraction of injection-related infections).Bridging marginalized population to primary health care, addictions treatment, and social services.Increased public order.
The Team
Interdisciplinary Team
Program workersPeer workers (LINES)Registered Nurses Counselors
Insite at a Glance
Reception Desk
Insite at a Glance
Reception Desk
Program staff welcome participants into InsiteProvide needle exchange services
Insite at a Glance
Injection Room
Insite at a GlanceInjection Room
Participants are greeted in injection room with sterile suppliesNurses and Program Workers make first contact
Key opportunity to identify harm reduction needs of participants, physical (head to toe) and psychosocial assessments
Insite at a GlanceChill Out Lounge
Insite at a Glance
Insite at a GlanceChill Out Lounge
Peer workers are the link between our harm reduction program and the local community.Peer workers bring experience, skills and expertise in harm reduction practice particular to the local population.
Insite at a Glance
Insite at a Glance
Infection Control
Hand washing encouraged prior to participants initiating injection practicesDisinfecting of each booth after every use
Insite at a Glance
Harm ReductionTeaching best practice when injecting
Encourage site rotationCleansing site with alcohol swabsFiltering/cooking drugsUsing tourniquets Doing test dosesDiscarding used supplies into sharps box
Insite at a Glance
Harm ReductionNursing Teaching Tools
On-site education sessions for participants, including safer techniques and risks associated with IV drug useParticipants can practice safer injecting techniques with use of prosthetic arm
Insite at a Glance
Treatment RoomOne-on-one time spent with clientsWound care & injuriesAssessments, vital signsFoot carePregnancy testingFlu shotsPsychosocial supportReferrals
Insite at a Glance
A quick glimpse of some of our chronic wounds:
Rethinking Harm ReductionInsite - More than the Sum of its Services
Nursing PracticeNeeded to Evolve - to maximize access and meet the complex scope of participant needsVolume of Participants (average 750 visits/day) -precipitates high degree of intensity– must keenly search out opportunities to engageMarginalization – psychosocial & medical determinants of health are poor, infection rates are high, most participants are profoundly poor, limited links to health care services
Rethinking Harm Reduction
Insite – More than the Sum of its ServicesLow Threshold Service – Insite is for the most disenfranchised group - chaotic, multiple-barriered, hard to serve, generally very low functioning - insite staff ‘level the playing field’ to ensure equal access for those at riskRelationship building – the most 'real' role we can fill is to be a fellow human being and walk alongside users, witness their lives, and advocate for a better quality of life with and for themConflict and de-escalation – crucial skill-set and dependent on a ‘team approach’ and staff self-awareness
Rethinking Harm ReductionInsite – More than the Sum of its Services
Sacred Space – many participants were instrumental in developing Insite and feel sense of pride and ownership – Insite is also a comfort zone or ‘safe haven’Boundary Issues & Burnout – staff must be very aware of maintaining own boundaries yet be able to engage with participants with empathy and without judgmentRe-visioning Success - often what we can do is simply keep users alive - success is measured simply by being able to continue providing the service
The ResearchApprox. 8000 registered participants – 750 average visits per dayHighest number of visits in an 18 hour day so far: 1050In a 1 year period from 2004 – 2005, there were 272 overdose interventions with no deaths to date (Tyndall et al, 2005)Rates of addiction treatment access are twice as high amongst IVdrug users who use the SIS compared to those who do not (Wood etal, in press)In a 1 year period from 2004 – 2005, 2171 individual referrals were made with majority (37%) being referred for addictions counseling (Tyndall et al, 2005)Public disorder in DTES is impacted positively by SIS – 75% reduction in public drug use consumption (Wood et al, 2004)90% of Insite participants are Hepatitis C +35% of Insite participants are HIV +
Case Study
Male client, HIV + for 18 yearsRapidly deteriorated over the last year.Links made from Insite include: housing (shelters), detox, recovery housing, primary care, active participation with community palliative program. Currently a client of CTCT
Letter written by one of our participants:"They saved my life when I did too much drugs and went into seizures. And they did not ignore me when I was crying. They talked to me when I kept leaving the hospital and coming back to Insite to do more drugs, they went out of their way to get me back to the hospital because I had Osteomyelitis of the collar bone due to drugs. I could have died from it. They came to visit me. It takes a special person to do this kind of work. They helped me get into detox, they listened to me. They planted the seed suggesting a certain recovery house that they knew would fit for me. I have gone thru detox, I relapsed and they did not judge me...I am now in a recovery house. I have a choice to go back out using or stay clean and take care of myself, I choose to stay clean."
Qualitative Research:
Insite Participant InterviewsI can turn around, I can look in the mirror, I can see the nurse. They’re watching, right? If anything goes wrong, I mean… you could yell. But if you are by yourself…you could yell if anything happened, nobody answers. Nobody listens. Nobody lifts a finger. Nobody. Y’know? ‐ Female Participant # 47The one nurse, she told me to come in every day and she’d pack it [soft‐tissue infection] and dress it. They took care of me right from the get‐go and, like, right from the onset of it, right ‘til it was done. And…I mean, it was excellent. –Female Participant # 50
Qualitative Research
Insite Participant InterviewsI’ve had a coup le of abscesses, and there was another one, a big bump and I thought this one’s gonna go abscess too. She gave me some advice of what to do about that, and I followed her advice and it didn’t abscess, and the bump went away.–Male Participant #9This man I know overdosed, and like, they were on it. They were quick. They didn’t waste any time. They were prompt, and…they were experienced. They knew what they were doing. Yeah. They came and Narcaned him, and 911 – the ambulance – came and took the guy out. Like, they were right on it… the guy was going to die, and I think they were really good. They’re experienced, in other words, in that type of thing. ‐ Female Participant #30
Nursing Culture at Insite
“In one word, describe what nursing at Insite means to you:”
HumanitarianPassion
DynamicHumblingPrevention
Cutting-EdgeA necessityChallenging
Nursing Culture at Insite
“Why have you chosen to work at Insite?”“I believe that people with addiction issues are severely marginalized in our society, and our current medical system is not able to meet their unique healthcare needs. I am proud to work at Insite where we accept each individual for where they are at in their addiction, and offer them easily accessible nursing care.” -E.G.“The situation on Vancouver's DTES is dire. I wanted to become engaged in a way that attempts to restore humanity and reflect value for human lives. Canada is one of the world's wealthiest nations on earth yet Vancouver's DTES remains third world, with many of the residents very ill, living in squalor and chaos. I didn't want to be someone who looks the other way.” - C.P.
Nursing Culture at Insite
“Why have you chosen to work at Insite?”“Originally, to get into HIV care. I stayed because I love working with this population. They have so much to teach me, and I have so much to teach them. Insite does important work that saves lives. That's why” – D.P.“I will always remember the spiritual enlightenment I experienced when I had my first real contact with a client from Insite. It is this empathy and love which reinforces why I have chosen to work with the DTES. I am honored to have the opportunity of sharing my knowledge of health prevention and health promotion with such a marginalized group and at the same time treating each client as an autonomous beautiful human being.” B.L.
ReferencesTyndall, M.W., Kerr, T., Zhang, R., King, E., Montaner, J.,
Wood, E. Attendance, drug use patterns and referrals made from North America’s first supervised injection facility. Drug and Alcohol Dependence, In Press November 2005.
Wood, E., Kerr, T., Small, W., Li, K., Marsh, D., Montaner, J., Tyndall, M. Changes in public order after the opening of a medically supervised safer injecting facility for illicit injection drug users.CMAJ 2004, 171 (7) 731-734.