Risky Business: Pre-Pour Meds in Jails and Prisons
The prison is on lock-down due to a suspicious inmate death. Cell searches are underway. The lock-down is expected to last several days and inmate movement is extremely limited. Medications need to be delivered cell-side. This might have been manageable, if not time consuming, if the prison was new enough to have elevators to the upper levels. However, in this case, only narrow stairwells are available and medication carts cannot be pushed up stairs. What’s a responsible nurse to do?
Medication administration is one of the riskiest nursing tasks in any clinical situation due to the many opportunities for error. Medication administration in a jail or prison has added layers of risk. Correctional nurses must daily administer thousands of doses of medication to inmate-patients in general population, segregated units, and specialty housing areas. Even medication that don’t require a prescription may need administered by healthcare staff to reduce opportunity for abuse in the prison black market.
The three main ways medications are administered in correctional settings are: Med Line (Watch Take), Keep on Person (KOP), and Pre-Pour. This post focuses on key elements for safe pre-pour administration.
Administering medication prepared in advance is risky and should only take place in unavoidable situations where medication cannot be administered directly from the labeled supply. Medications prepared prior to administration are usually placed in small labeled and sealed envelopes for direct transport by the nurse who will administer them. During a pre-pour situation, the following safeguards should be in place:
- Medications are prepared immediately before they are transported to the patient.
- The same nurse prepares, transports and administer the medication.
- Medication envelops have at least 2 patient identifiers (name and ID#) and include the date and time of the doses.
- All medication rights are checked at the time of medication preparation.
- Patient identification processes happen again at the time of administration. For example, confirming the patient’s name and ID#.
- When possible, the patient confirms that these are the medications they were expecting to take. Although inmates may not be aware of their specific medications based on how they look, nurses should double check any medication an inmate questions.
- Documentation of administration should take place at the time of administration or directly after returning to the unit – not before administration. Medication may be refused or delayed for a variety of reasons. Documenting administration at the time of preparation is inappropriate.
What other safeguards do correctional nurses use when pre-pouring medications? Provide your additional tips in the comments section of this post.
Image Credit: © Toopy – Fotolia.com
Dealing with Inmate Food Allergies
Food allergies can be a real challenge for correctional nurses. It is important to document these allergies during intake screenings and put safeguards in place to avoid allergic reactions behind bars. However, inmates can report food allergies that are really preferences (I’m allergic to bologna sandwiches) or food intolerances (I’m allergic to onions). How can true allergies be sorted out from among the many reported?
I recently interviewed Dr. Jeff Keller, correctional physician from Idaho Falls, ID, about the issue on the Correctional Nursing Today Radio Show. This episode is full of interesting and important information for correctional nurses. I highly recommend you download or livestream the 30 minute program. Here are some important points from my notes of the session.
- There are IgE mediated and non-IgE mediated allergic reactions. The medical concern is with IgE mediated allergies, which involve immune system mast cells that respond violently to contact with the allergen. Check out this animation to remind you of the IgE allergic reaction process.
- Peanuts make up 85% of food allergies. The remaining 15% are from tree nuts and shellfish. Other food allergies such as fin fish or strawberries are rare.
- Almost all food allergy deaths happen to teenagers and those in their early 20’s.
- Allergic reactions include hives, angioedema and asthma/wheezing.
- Ways to test for true allergy include a food confrontation test and skin prick testing. There is also a fairly inexpensive blood test for IgE circulating levels.
- Epinephrine is the main treatment for a life-threatening food allergic reaction.
Managing Food Allergies Behind Bars
If an inmate is determined to have a peanut allergy, a peanut-free diet is needed. However, precautions do not end here. Cellmate assignment and work detail must also be considered. This inmate may not be able to be housed with other inmates who have peanut products in their possession. For example, peanut butter and peanut butter products such as sandwich crackers may be available in the commissary. A peanut-allergic inmate may not be able to be assigned kitchen duty if peanut products are present. Shellfish and tree nuts are fairly easy to deal with as pecan-crusted shrimp are rarely on the menu. However, peanut butter is an inexpensive protein source in frequent use in corrections.
Preparing for an Allergic Reaction
A coordinated response to food allergies is needed in every facility. Dr. Keller recommended a protocol be developed addressing actions custody and medical staff will take to respond to true food allergies. Besides diet, housing and work detail issues, a coordinated emergency response to a reaction is needed. Epi pens are the standard mechanism for emergency treatment of an allergic reaction. Inmates are not able to carry needles on their person so the location and accountability for epi pens should be considered. Housing officers may need to have pens available and know how to use them. Correctional nurses may need to provide information and demonstration of epi-pen use. Officers are also likely to be the first responders in an allergy emergency. They need to know the signs of allergic reaction so that they can act quickly to summon assistance and administer epinephrine.
How has your facility dealt with food allergies? Tell us your experiences using the comments section.
Photo Credit: © Jaimie Duplass – Fotolia.com
4 Correctional Healthcare Game Changers from 2011
This post originally appeared on CorrectionsOne.com
Another year is about to roll up and we can look back on plenty of correctional healthcare news from 2011. What top stories from the past year are most memorable to you? Here are my top picks for 2011 game changers along with suggested action to reduce their impact.
#1 Legal eagles rule the roost
Healthcare is now the most common legal issue raised by inmates according to a Harvard Civil Liberties Law Review article. The legal system has led the way in correctional healthcare reform even before the landmark Estelle v. Gamble Supreme Court case of 1976. In that case, the Supremes ruled that healthcare was a prisoner’s Eighth Amendment right. Continued case law has further delineated that right. Lack of healthcare, inadequate healthcare, faulty or denied healthcare are frequent claims of inmate defendants. Not only are the costs of healthcare skyrocketing, so are the costs of medical liability insurance. The financial burden of defending against spurious and serious claims is high.
Game changer actions: Do everything you can to strengthen the healthcare delivery system to reduce serious medical claims. This means solid communication and tracking of outside services and diagnostics. In addition, monitor medication delivery and formulary practices. Medication administration is a high risk and problem-prone area of correctional healthcare.
Consider implementing basic customer service principles to reduce spurious legal claims. Closely monitor inmate grievances in this sector. Early intervention can stem later legal cases. Remember, even if a claim is invalidated, legal costs can still be incurred in developing a defense.
#2 Cost shifting along the corrections pipeline
Although California is the state prison system most in the news about overcrowding, other states are looking for ways to reduce incarceration costs by shifting custody responsibilities to local jurisdictions or mental health services. From a medical perspective, there are renewed calls for improved compassionate release processes.
Game changer actions: Appropriate early release of severely ill and dying prisoners can reduce prison health care costs but burden other systems such as long term care and indigent care services. A practical review of current compassionate release policies and procedures is warrented.
Read the rest of this list on correctionsone.com
Photo Credit: © Arcady – Fotolia.com
Danger Zone – Christmas Week in Jails and Prisons
The week between Christmas and New Year is traditionally one of feasting, family and fun as we celebrate the season and the start of a new year. However, there are many reasons why this time of year is dangerous in our workplace. Correctional nurses need to be on high alert in the days ahead. Here are my three reasons for concern this week.
Reason #1: We lose our focus
The last month of the year is busy with many things. You and your colleagues are taking that final stretch of vacation time. Kids have holiday and end-of-year school activities. Work sites have holiday parties and extra treats in the break room. It is easy to lose focus on personal safety or to be working short-staffed. Those who might do you harm take advantage of opportunity. In addition, your own emotions might be swinging between elation and despair as the holidays approach. Emotional turmoil is a magnet for inmate psychopaths or sociopaths. Therefore, this is a time of year with increased vulnerability to inappropriate relationship. Check out my prior posts on dealing with psychopaths and signs of unhealthy relationships.
Reason #2: Our patients are not merry
For inmates, the lack of family support and distance from children or spouse is accentuated during the holidays. Guilt over not being able to provide gifts for children and family estrangement can be acute. The holidays can lead to deeper depression, anger and aggressive behavior. Be particularly alert for increased evidence of suicide potential during the holiday season.
Reason #3: Our co-workers and managers are with their families
On occasion I review medical charts in cases involving inmate plaintiffs. A common scenario involves lack of treatment or inaction during a weekend or holiday. Reduced staffing and vacant management offices leave staff with few resources to deal with emergent issues. Be sure to know all administrative contacts when working weekends and holidays. Policy manuals and treatment guides should also be accessible to staff. It is not unusual to find these important materials locked in a manager’s office; unavailable to those who need their guidance in an urgent situation.
Do you have some other reasons to add? Have you had some dangerous Christmas Week experiences in your setting? Share your thoughts in the comment section below.
Photo Credit: © Graça Victoria – Fotolia.com
Top 5 Correctional Nurse Posts of 2011
As the year draws to an end I’m doing a lot of looking back and looking forward. Thank you for being a part of CorrectionalNurse.Net by reading and commenting over this past year. I hope you will be even more active in the year ahead. My first blog post was 2.5 years ago when I asked the questions “Should You Consider Correctional Nursing?”. Since then I’ve written almost a hundred posts on correctional nursing practice. Here are the top five visited posts in 2011:
1. Correctional Nurse Interview Prep Guide: Part I
Many nurses visit the blog to find out about this specialty and prepare for a job interview. This post is a popular first stop. I’m hoping to develop the newbie material on the blog in the coming months. I’m delighted that more nurses are considering working behind bars.
This concept strikes a chord in many nursing specialties and has some particular twists for nurses in jails and prisons. We can easily become jaded about patient complaints and fail to act in a medical situation. Correctional nurses must be ever vigilant to guard against cynicism.
3. Unhealthy Inmate relationships: 5 Danger Signs
Working with manipulative patients can be psychologically dangerous. Those working in corrections can be drawn into unhealthy relationships. This post is from my CorrectionsOne column and got good play over there, as well.
4. Eight Medication Rights – Not 5?
This guest column by nurse buddy, Lisa Bonsall, originally appeared on the NursingCenter’s in the Round blog. Medication administration is the riskiest process in nursing. The eight rights are good reminders of best practices.
5. Alcohol Withdrawal: Jail Nurse Alert
Although this post is almost 2 years old, it still gets plenty of play and reached the number 5 spot in 2011. Alcohol withdrawal can be dangerous and a missed diagnosis can be deadly.
So, what’s on tap for 2012? A blog renovation project is in the works – so the site will soon have a new look. I’ll also be adding some embedded video and slide presentations, so, stay tuned and visit often.
What would you like to read about in the coming year? Make your topic suggestions in the comment section of this post. Help me decide the publication calendar for the months ahead!
Photo Credit: © Giuseppe_R – Fotolia.com
New Latent TB Regimen from CDC: Good News for Correctional Nurses
The Centers for Disease Control and Prevention (CDC) announced recommendations for a new treatment option for latent tuberculosis infection (LTBI) this past week. These recommendations are welcome news for correctional nurses challenged with managing LTBI treatment for their inmate population. Correctional nurses are in contact with a significant portion of the more than 11 million people in the US who are infected with the TB bacterium (4% of the population). Reports clock the incarcerated TB infection rate in US prisons at least 4 times higher. This rate is escalated further in under-developed countries. Improving behind-bars treatment of LTBI can significantly improve public health, in addition to the immediate benefit of decreasing infection transmission to inmates and corrections staff.
The current medication regimen for LTBI treatment is onerous, especially in secure settings. Treatments can last for 9 months and require daily doses of one or more mediations. The serious nature of tuberculosis makes this treatment most often given by direct observation, requiring the patient to be transported to the medical unit daily and observed taking the medication. The new guidelines still require DOT administration, but now the medication is only needed once weekly for 12 weeks for most patients with LTBI. This is a much more efficient regimen for the correctional setting.
New CDC Recommended Treatment for LTBI
- Isoniazid (INH) and rifapentine (RPT) – a long acting rifamycin-class antibiotic
- Once weekly in direct-observation dosing for 12 weeks
- Monthly clinical appointments for side effects and physical assessment
Patients Inappropriate for this Regimen
- HIV-infected patients receiving antiretroviral treatment
- Pregnant women
- Patient with LTBI and presumed INH or RIF resistant
- Children under 2 years
The CDC is currently collaborating with the Infectious Diseases Society of America and the American Thoracic Society to update their guidelines to include these recommendations. In addition, it is likely that the Federal Bureau of Prisons (FBOP) will include these significant changes in the next update of their January, 2010 Clinical Practice Guidelines.
2012 will be a good year to re-evaluate and revamp your TB clinical processes. How will these new guidelines change your practice as a correctional nurse?
Photo credit: George Kubica/CDC
On Interruptions and Correctional Nursing
A nurse stands at a small window in a small room with shelves around the interior. Lined up at the window, much like a bank teller’s queue, are inmates waiting for their morning pills. An MAR (Medication Administration Record) is in front of the nurse on her side of the window, with pages organized in alphabetical order by patient last name. The nurse must positively identify the patient by photo ID card, organize the medication to be delivered for this patient on this date and time, and collect the pills from various single dose bubble-packs into a paper soufflé cup. She hands the medication to the patient with a paper cup of water. Fortunately for this correctional nurse, the custody officer in charge of the pill line does the oral cavity check to be sure the patient does not ‘cheek’ the medication for sale on the prison black-market. All this happens in less than a minute. This nurse must administer medication to almost 200 inmates in the course of 2 hours.
The daunting daily task, performed by hundreds of correctional nurses every day, is complicated by distracting noise and frequent interruption. This medication room in a county jail also doubles as a nurse’s station. The medication nurse is working where other nurses are sharing report and physicians are stopping by to change orders and ask about patient status.
A recent study published in the Archives of Internal Medicine tracked the toll of interruptions on medication errors by viewing nurses administering medications in 2 hospital settings. Each interruption was associated with a 12.7% increase in clinical error. When three interruptions occurred in the administration of a single medication there was a 38.9% rate of error. Nursing experience played no part in the error rate. It was consistent for new nurses and those with years of experience. This is astounding objective data to support efforts to reduce interruptions in the medication administration process.
Here are some ideas for reducing interruptions in medication administration that might be applicable in the correctional setting:
- Establish Quiet Times when medications are being administered in a public area. Ask staff members to commit to evacuate the area while pill line is in effect.
- Place posters indicating Quiet Time is in session as a visual alert. (No, you can’t keep them up all the time!).
- Have the medication nurse where an item of clothing, such as a brightly colored vest or apron, when administering medications. No staff member can approach a nurse when wearing this vest.
- Educate all staff members to the patient safety basis of uninterrupted medication delivery.
- Educate custody staff and patients of the need to decrease nurse interruptions during medication administration processes.
What do you think? Can we reduce interruptions in medication administration in corrections?
Photo Credit: © Dana Heinemann – Fotolia.com
Time to be Thankful
It is that time of year! I love starting the holiday season with a day of thanks for all our blessings. No matter how dire the circumstances, we can find something to be grateful for. Here is my correctionalnurse.net list of thanks:
- Correctional Nurses: Of course correctional nurses top the list for a blog like this! Nursing is hard work in any setting. Nurses working in jails and prison do amazing things with little resources and challenging spaces. Our patients do not always appreciate the effort and sometimes work against us. The rewards are not always thank-yous from our patient’s families and many wonder why we do it. But, correctional nursing is as much a calling as a career and so many would not do anything else. Thank you!
- Correctional Physicians: I have worked in a variety of specialties in my 25+ years as a nurse. I have been employed by teaching hospitals and community hospitals, by corporations and by colleges. Hands down, correctional physicians are the best medical colleagues I have ever worked alongside. There is something very earthy about working behind bars. Most medical professionals don’t have attitude and don’t expect preferences. It is refreshing to see collegiality and collaboration work in health care.
- Custody Officers: Yeah, some officers don’t understand us or ’get’ the therapeutic relationship ‘thing’ that correctional nurses need with their inmate-patients. But, so many do and these professionals keep us safe in our work everyday. Hats off to our officer partners.
- The Internet: Without the wonders of the WWW, you and I would probably never have met and never had an opportunity to network around our very specialized field of nursing. I am grateful for that connection and for every one of you who read this blog and leave comments. I look forward to another great year together.
- Advocacy Groups: I know they can make our lives crazy and living under a court order or consent decree is no picnic. But, advocacy groups have made improvements in correctional healthcare by making visible some of the situations we, as nurses, know need improved. I am grateful that there are people in the free world that care about our patients, too.
- Being with Family: Thanksgiving is often a time to gather with loved ones. Many of our patients are alone and lonely. Connection and relationship are major elements of a healthy life. I hope you give your family members an extra hug this holiday and remember our patients who won’t be able to do that.
Photo Credit: © Strakovskaya – Fotolia.com
Even Minimal Exercise is Important
Even small amounts of regular physical activity can have big benefits for your patients, according to research recently published in the Lancet. That means correctional nurses should be encouraging physical activity for all inmate-patients, and especially those with chronic conditions such as cardiovascular disease. The astounding news is that even 15 minutes a day of low-level activity 6 days a week can ‘reduce all-cause mortality by 14%, cancer mortality by 10%, and mortality from cardiovascular disease by 20%.” (pg 1202). Holy smoke, that is good news for our patients in confinement or with exercise-limiting disability!
A big factor in starting and increasing physical activity among patients is simple and repeated advice to do so. Correctional nurses are the health care professionals most likely to be in contact with inmates. Be sure you have a game plan that includes regular reminders to exercise. Scope out possible exercise venues in your facility and encourage patients to use them. If permitted, consider creating a simple exercise plan sheet to provide to interested patients. Even those in Ad Seg, Special Housing, or other restricted locations can find a way to do low-level physical activity daily for 15 minutes.
If your facility encourages group activities, you may want to try organizing a group exercise program. If you get something like this going, be sure to videotape it and get it posted on YouTube! Here is a video done by inmates at Cebu Provincial Detention and Rehabilitation Center (CPDRC), a maximum security prison in the Philippines.
Photo Credit: © Anton Vakhlachev – Fotolia.com
4 Myths About Hangings in Jails and Prisons
The prison intercom crackles with the news of an emergency on Pod 7. Arriving with the emergency bag in tow, the nurse finds a crime scene in full swing. An inmate is hanging from a makeshift bed linen noose creatively tied around the upper bunk slats.
The actions taken in the first few minutes after a discovered hanging can be the difference between a hospital transfer and an in-custody death. Hanging is the most common form of successful suicide in corrections.
Correctional nurses are confronted with situations unusual in other care settings. Be sure to prepare yourself by eliminating these common jail and prison nursing myths from your practice.
Myth #1: It won’t happen here – this is a small jail.
Although it might appear that most hangings happen in large urban jails, the Bureau of Justice Statistics (BJS) Special Report on Suicide in State Prisons and Local Jails reports that the country’s smallest jails had suicide rates 5 times higher than the largest jails. Jails holding fewer than 50 inmates accounted for 14% of all jail suicides. With smaller staffs and fewer resources, small jails need to remain vigilant to the potential for hangings. Detailed policies and procedures on prevention and post-hanging interventions should be in place. Emergency procedures for a hanging situation should be periodically practices and involve both custody and medical unit staff.
Myth #2: It won’t happen here – We have great suicide screenings and watch suicidal inmates closely.
Improved suicide prevention and management processes have definitely reduced hanging suicides in the correctional setting over the last two decades. As outlined in a prior column I wrote for CorrectionsOne, incarcerated suicide rates in both jails and prisons have declined sharply; with jail suicides still over 3 times the rate of state prisons. Suicidal inmates are creative and will use any resource available to craft a noose and the leverage to asphyxiate by hanging body weight. Screenings can help weed out obvious potential for self-injury, but require a good mechanism for protecting those who do not pass the screen. A strong communication process with mental health services is needed to complete the protective program. All staff must be vigilant for indications of self-harm. Suicide attempts can take place later in the incarceration period triggered by court hearings, family issues such as divorce proceedings or custody issues, and classification changes such as administrative segregation placement. Do you have a process that allows for re-evaluation following such events.
Myth #3: Hangings are lethal. If found strung up and lifeless, no need to intervene.
The major factors leading to a hanging fatality is height of the drop during hanging and the suspension of the body (full or partial). Most hangings in corrections take place in the housing area (primarily the inmate cell) which leaves little chance for a full body suspension and great height. This results in good chances of survival with early intervention. One study concluded that even if the victim is found to be lifeless, aggressive intervention with CPR and emergency medical transport is warranted. Another study found overall mortality associated with hanging was 33%. Those who survived to admission to the hospital had a relatively low rate of severe functional disability. Initiate medical intervention immediately when a hanging is found.
A significant percentage of hanging victims will have spinal fracture, therefore spine immobilization and jaw thrust maneuvers should be taken into account at the scene. In order to accomplish this, easy access to a rescue tool, such as this seatbelt release device, is needed to quickly lower the person to the floor for emergency resuscitation intervention.
Myth #4: Every hanging is a crime scene. The inmate can’t be cut down until the location is photographed and evidence accumulated.
There have been reports of medical staff being delayed from attending to a hanging victim while crime scene investigation takes place. Minutes are precious in emergency treatment and can make a difference in ultimate survival. Cut down the victim and initiate emergency medical intervention as soon as the scene has been secured. Saving a person’s life trumps all need for determining criminality. Nurses must advocate for immediate patient treatment in this situation. Even better, pre-empt an emergency situation like this by reviewing a hanging medical intervention process with custody administration before a hanging event.
What has been your experience with post-hanging treatment. Share in the comment box below.
Photo Credit: © LituFalco – Fotolia.com