Crushing Injury: Are You Helping or Harming When You Crush Pills?

Inmate Dexter was found cheeking his psyche meds. The facility has a blanket policy that all narcotics are crushed and, in addition, all pills are crushed for patients found to divert their medications. This morning he is to receive Effexor XR, Ery-Tab, and Kaletra. Now what?

Some correctional systems require that medications be crushed to avoid diversion. There are few studies about this practice and many concerns. Besides the increased time needed to crush medications, some formulations are not absorbed correctly once crushed. In particular, time release capsules and slow-release tablets are based on the medication remaining in the manufactured format for correct absorption. Other medications are caustic to the intestinal system and require enteric coating to avoid adverse effects. Thus, pharmacy experts strongly advise against crushing both time-released and enteric coated preparations. The ISMP provides a detailed listing of medications that should not be crushed.

Little is available on the practice and outcome of crushing medications in the correctional setting but much can be learned from observation of nursing practice in long-term care. One study in Australia found many medications being crushed with communal crushing equipment and multiple medications being crushed at the same time. Both practices can cause adverse effects or expose patients to an allergic reaction according to experts.

Harm to Patient – Harm to Nurse

Other concerns with indiscriminate crushing of medications is the possibility of teeth staining and irritation of the mouth, esophagus, and stomach lining.  Binders or other substances included in the tablet formation may be needed to buffer Ph or other irritating qualities of the medication. The erythromycin (Ery-Tab) that Inmate Dexter is to receive is enteric coated for this purpose.

Opening capsules or crushing medications can be harmful to staff, as well as patients. Exposure to active ingredients may be carcinogenic and harmful to an unborn fetus (teratogenic or fetotoxic). Sensitive individuals may have an allergic response. In the example above, Kaletra should not be crushed and a pregnant staff member should not come in contact with the active ingredients.

Harm to the Treatment Plan

The effectiveness of medication can be altered or eliminated by crushing. For example, medications that are sublingual or effervescent should not be crushed for this reason.

Medication toxicity can result when sustained-release or extended release tablets are crushed or capsules opened. The patient may receive the entire dose immediately rather than over a longer time period, as intended by the formulation. Inmate Dexter’s Effexor XR is such a medication.

Sometimes you can immediately identify these danger medications by their prefix or suffix. Common controlled-delivery indicators are:

      • CC
      • CD
      • CR
      • ER
      • LA
      • Retard
      • SA
      • Slo-
      • SR
      • XL
      • XR
      • XT

Time Pressed

Crushing medication properly is a time-consuming operation that can increase the time-stress of medication administration, thus increasing error risk. So, medication crushing should not be required indiscriminately but used judiciously when necessary for the patient and patient community’s safety. For example, some settings limit crushing to highly abused medications such as psychotropics and narcotics. Other settings require crushing for individual patients who have been identified as diverting their medications like Inmate Dexter.

Avoiding Crushing Injury

Based on the literature (also here, here, and here) the following safety measure should be considered when crushing medications.

  • Establish a list of common medications that should not be crushed.
  • Limit crushing to high risk medications or high risk patients to reduce error potential and increase medication administration efficiency.
  • Require the prescriber to order crushing as the mode of PO administration.
  • Require pharmacist oversight of crushing (through the order) as a double check that medications ordered for crushing are appropriate for this delivery method.
  • Transcribe crushing as the route of administration onto the MAR.
  • Make every attempt to obtain the medication in liquid formation to avoid crushing.
  • Only crush medications with approved devices. Use a fully self-contained device such as this one. Avoid mortar and pestle or twist devices that need cleaning between doses.
  • Use individual packets with communal crushing devices to eliminate the potential for mixing medications.
  • Do not make a slurry of combined medications. Each crushed medication should be administered separately to avoid incompatibilities.
  • Mix crushed medications with water and not food (like applesauce) or other liquids (like juice) that might interact with the medication.

Another good practice is to eliminate highly abused medications from the formulary; replacing them with an appropriate substitute of lesser abuse potential. Quetiapine (Seroquel), gabapentin (Neurontin), and bupropion (Wellbutrin) have been eliminated as options from some jail formularies due to the high level of abuse in the particular inmate population. While this may reduce abuse, it is important to have alternative medications on formulary to use when therapy is needed for an actual patient condition.

What about Inmate Dexter?

Inmate Dexter’s medications were delayed while the med nurse consulted with the pharmacy about options for his daily medications. Although not the most convenient solution; it was the safest and best practice. Later that day she set up a nurse sick call appointment for him to discuss the reason for his medication diversion. The root cause needs investigated. For example: Is it because he doesn’t want to take the med? Is it a medication that someone else is pressuring him for? Is it something he thinks he can sell? Armed with this information, she plans to discuss the situation with the provider to see if there are any alternatives such as medication discontinuation or exchange.

What do you do when pills need crushing in your practice setting? Share your procedure and best practices in the comments section of this post.

Photo Credit: © Rob Byron – Fotolia.com

The Acid Bath of Cynicism (Podcast Episode 98)

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cnt-podcast_cover_art-1400x1400Guest Robert Greifinger, MD, a correctional health care consultant and co-editor of the International Journal of Prison Health talks about the dangers of cynicism in correctional health care practice.  Dr. Greifinger is editor of the book Public Health Behind Bars: From Prisons to Communities. His guest editorial entitled “The Acid Bath of Cynicism” can be found in the Spring 2015 CorrectCare Magazine.

What is Cynicism?

Cynicism develops when health care professionals distrust the motives of the inmate health request. It alters clinical  judgment and patient perspective. The attitude can be pervasive, like a communicable disease spread among both custody and health care staff. There is a tension between the professional duty to ‘first do no harm’ and the correctional punishment mindset. It can lead to ‘dual loyalties’ where correctional health care staff have both a loyalty to their patient the inmate while feeling a loyalty to the institution. This tension and friction can be a major work stress.

The Trouble with Cynicism

Cynicism can cloud clinical judgment and affect the course of treatment. Treatment delays or misdiagnoses result from misinterpreting patient motives.

Avoiding and Eliminating Cynicism

Here are some suggestions to help avoid or eliminate emrging cynicism.

  • Be healthily skeptical rather than being cynical. Every health professional needs to be questioning and validating of symptoms. Seeking validation is an important part of health care practice, no matter the setting.
  • Mindfulness about cynicism is helpful in avoiding being drawn into cynicism. Thinking about this for a moment with each encounter can help improve perspective and reduce cynicism.
  • Reframe the issue from ‘manipulative’ to adaptive. How is the patient adapting to the situation to obtain what they think they need and a semblance of control over their lives.
  • Learn the best ways to take a leadership role when the concern at hand is a health care issue. This develops respect among the disciplines.

News Items

Nurses in the Highest Category for Occupational Injury

Women’s Brains May Have Tougher Time Recovering from Concussion

How do you protect yourself from becoming cynical in your correctional practice? Share your thoughts in the comments section of this post.

NOTE: The Correctional Nurse Manifesto can be helpful if you are struggling with cynicism and other common correctional nurse challenges. Check it out!

Should Correctional Nurses be Compassionate?

Heart of IceA while back a blog reader emailed me to thank me for providing visibility for our specialty and to take issue with my blog byline: Inspiring Compassionate Professional Nursing in the Criminal Justice System. Seems that the word ‘compassion’ was not sitting well with this nurse leader who actually taught new correctional nurses to “check their compassion at the gate before they come in”. The email concluded with this statement: “I encourage new nurses to show compassion in the care they provide, but I clearly define the difference between showing it and actually feeling it. On the continuum of emotion, compassion is incredibly close to love and I challenge anyone in our profession to justify using the word love in the way we care for our patients.”

I appreciated hearing from this reader (email me at lorry@correctionalnurse.net anytime!) and have been pondering the perspect of showing compassion and not feeling compassion for a while now. Is that possible? What would that look like? Is it dangerous to deliver compassionate professional nursing in the criminal justice system?

The Issue

The compassion issue in correctional nursing hinges on the friction of care and custody so often encountered in our setting. Most correctional nurses work in a security conscious para-military setting where the predominant culture is punitive and uncaring. Many correctional patients live lives based on deceit and manipulation. How do we practice nursing in this environment? I discuss this issue in my book – The Wizard of Oz Guide to Correctional Nursing. It is a fitting analogy that nurses in the criminal justice system find themselves in a strange land with very different colleagues, language, and culture. Yet, we must remain professional nurses, all the same. Trying to ‘fit in’ in this new Land of Oz can lead to some dysfunctional work styles, as I describe in this earlier post.

Defining Compassion

One of the difficulties encountered right away is defining what compassion really means as it relates to health care practice. On a search for this answer I came across the national debate on compassion in healthcare currently going on within the British National Health System (NHS). Their chief nurse set out a vision for compassion in practice in 2012 that led to this definition of compassion.

Compassion is how care is given through relationships based on empathy, respect and dignity - it can also be described as intelligent kindness, and is central to how people perceive their care.

A concept analysis can sometimes help identify important components of the meaning of a word. Here are some key elements gleaned from an analysis of compassion done by a nurse researcher:

  • Entering in to the suffering of another
  • An internalized motivation for doing good
  • Personal engagement in the alleviation of suffering
  • Therapeutic empathy
  • Empowers to not only acknowledge, but to act toward removing suffering or pain

In Defense of Compassion

Although poorly defined, compassion has been identified as foundational to professional nursing practice in key documents. For example, The Code of Ethics for Nurses Provision 1 states:

The nurse practices with compassion and respect for the inherent dignity, worth, and unique attributes of every person.

The Correctional Nurse Scope and Standards of Practice list principles that guide correctional nursing practice (pg. 17). Among them is this one:

  • Professionalism, compassion, care, and concern are displayed in every patient encounter.

So, it seems that compassion is a part of ethical practice and written in to our specialty’s guidelines.

Better to be Compassionless?

But, maybe correctional nursing is so different from nursing in other specialties that we must leave our compassion at the entry gate each shift. Maybe it is too risky to by empathetic to the suffering of our patients. Maybe we need to be emotionally detached from our patients and the care we render in order to maintain equilibrium. I think it is something worth pondering and may just be one of the most challenging dilemmas of nursing in the criminal justice system.

So, what do you think? Is compassionate professional care an inappropriate goal for nursing in the criminal justice system? Help me decide if I need to change my blog byline.

Photyo Credit: © Stocksnapper – Fotolia.com

Are You Thinking Clearly? Rooting Out Biases in Clinical Evaluations

Jigsaw puzzleI was raised on Agatha Christie and Arthur Conan Doyle novels and still find shows like Elementary and Sherlock captivating. In fact, it is the detective work inherent in nursing assessment and diagnosis that drew me to the nursing profession and still keeps me interested some 3 decades later. Oh, for the clarity of mind of Hercules Poirot and Sherlock Holmes when tracking down the cause of a patient’s erratic behavior or unexplainable loss of function!

Unlike these fictional characters, though, we mere humans can be burdened by unconscious biases of thought that cloud our judgement and send us toward wrong conclusions. Improving clinical judgement, then, involves intentionally looking for and rooting out these mental biases in our evaluative practices.

Here is a chart of common cognitive biases I developed for my book The Correctional Health Care Patient Safety Handbook.  Let’s take a look at a few of them as they may emerge in a typical nursing sick call encounter.

Bias Definition Corrective Strategy
Availability Determination based on ease of recalling past cases Verify with legitimate statistics
Premature Closure Relying  too heavily on initial impressions Reconsider determination in light of new data or a second opinion, consider extremes
Framing Effects Being swayed by the description of the  problem Examine the case from alternative perspectives
Blind Obedience Showing undue deference to authority or technology Reconsider when authority is more remote; assess test accuracy
Confirmation Seeking data to confirm, rather than refute, a favored hypothesis Consciously seek both confirming and refuting data
Representativeness Guided by typical features of a disease and missing atypical variants Take into account typical and atypical findings before settling on a diagnosis
Sunk Costs Difficulty considering alternative diagnoses once significant time, effort, and resources have been invested in a particular diagnosis Consider involving a second practitioner free of attachment to the favored diagnosis

 

Remember the patient encounter discussed in the Diabetes Primer post? Here it is again.

A 42 year old female inmate submits a sick call request about her ankle. She thinks she sprained it when she stumbled while walking to the exercise yard one morning a couple days ago. A chart review indicates she is a Type II diabetic and is on a combination of metformin and glipizide. She was recently treated for a vaginal yeast infection with fluconazole (Monostat). She has no other acute or chronic conditions of note. Her ankle is only slightly swollen and painful when she bears weight.

The nurse in that situation analyzed all the information and came to an astute conclusion. What might have happened if a few of the common mental biases had been active?

  • Availability: If the pavement is, in fact, uneven on the way to the exercise yard and the nurse has had other patients stumble or fall, it might be easy to conclude that this is a safety issue rather than a medication issue.
  • Premature Closure: Availability bias might then lead to a premature closure of investigation before seeking out all possible causes. Here, the nurse would focus entirely on the ankle and not bring in any additional evaluation data.
  • Framing Effect: If the patient framed the injury in such a way that being dizzy did not enter into the description, the effect might also be to focus only on the safety issue and musculoskeletal injury.
  • Confirmation: Once favoring a focus on the musculoskeletal injury, the nurse might limit the assessment to the ankle and not pursue any medical causes of the stumble.

Clinical evaluation is a highly specialized skill in professional nursing practice that is of particular need in nursing sick call and emergency man-down situations. Intentionally rooting out mental biases in our assessment and nursing diagnosis practices can avoid error and improve patient outcomes.

Have you struggled with any of these common mental biases in your clinical practice? Share your thoughts in the comments section of this post.

Photo Credit: © Tsiumpa

April 2015 News Round Up (Podcast Episode 97)

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cnt-podcast_cover_art-1400x1400Correctional nurse leaders Johnnie Lambert, Margaret Collatt, and Jodie Glewwe join Lorry to discuss the latest correctional health care news items.

CDCR To Limit Punishments for Inmates With Mental Health Issues

Our first story is an update on activities in the California Prison System. They are a happening place – always in the news. This month California Healthline is reporting that CDRC has changes policies about punishing mentally ill inmates. This is a result of a federal lawsuit. Changes include creating segregation units in 16 of their prisons where solitary confinement restrictions can be eased and these inmates can have access to more treatment and therapy. We are hearing a lot about the incarcerated mentally ill in the news.

Challengers to prison solitary gain support from Justice Kennedy

Our next story is a good follow-up to the California update. Here Supreme Court Justice Anthony Kennedy weighed in on the solitary confinement issue while giving testimony to a House committee on the Supreme Court budget. With many civil rights cases about the detrimental effects of solitary confinement, Kennedy is quoted as saying: “Solitary confinement literally drives men mad”. He also said, in regard to our criminal justice system, that “In many respects, I think it’s broken.” There is a ground-swell of support is developing for changes in some of our standard security practices.

Inmates at America’s oldest women’s prison are writing a history of it—and exploding the myth of its benevolent founders.

Inmates in the Indiana Women’s Prison are researching and writing about the institution – which is the oldest women’s prison in the US. The prison was started as the Indiana Reformatory Institute for Women and Girls by Quaker reformers in 1873. That is over 140 years ago! This historical research is uncovering some interesting bits about the institution, the founders, and what incarceration was like for women in the 19th century. Take aways from the news item:

  • The project develops research skills for some of the current inmates
  • Things are never as they seem at first light
  • Context is everything. Culture was very different in the mid 19th

‘RN on wheels’ to treat N.C. inmates

Our final story is about a paraplegic nurse who is setting new standards for disabled workers. Latisha Anderson lost the use of her lower limbs after her cousin fired a gun while arguing with her boyfriend. The bullet hit Latisha, leaving her a paraplegic at age 17. Undeterred, though, she pursued first her G.E.D. and then a nursing degree. She applied for and was accepted into a position at the Central Prison in Raleigh, North Carolina. Will this be an ADA celebration or a security nightmare?

What are your thoughts on this month’s news items? Joint the conversation using the comments section below.

Time Crunch: What to Do When Med Pass is Cancelled

Time of medicineConsider this scenario: Just as you are preparing for morning med pass at a large city jail a man-down alarm is sounded. Your partner is assigned to emergencies today and she grabs the emergency bag and heads to the announced floor. You continue your preparations, making note that you may be handling both passes this morning if your partner is tied up for very long. A few minutes later, as you are rolling the cart out of the medication room, a call comes in. The man-down is an officer assault, the entire facility is in lockdown, and morning medication rounds are cancelled. Now what?

In traditional health care settings, emergencies may delay some services but accommodations are made to overcome resource limitations to keep care delivery on schedule. Delivering health care is the prime mission of these organizations so plans for emergency need are ever present. In a correctional setting, health care is a support service and not the primary organizational mission. Safety trumps health care needs at all times. Yet, nurses working in secure settings have an obligation to make sure needed medical care, including medication, is provided in a timely manner. It definitely takes determination and creativity to pull this off.

To be effective, many medications must be delivered during specific times related to meals or blood levels of prior doses. Yet, medication timing may be affected by any number of security needs in a correctional setting. Security administration does not often consider the implications of delays or cancellation of medication administration processes when making security decisions. It is often left to health care staff to determine ways to provide the required medication in a timely manner to remain effective in treating the patient condition.

Making Choices

Therefore, it is important to establish a working relationship with security administration and develop a mutual understanding of the therapeutic nature of medication administration and the implication of timing in that therapy. Often a mutually agreeable solution can be reached when medication administration must be delayed or cancelled for a security reason. Here are steps to take when normal medication administration processes are halted.

  • Review medications for the particular timing delay/cancellation to determine if any are time-critical (see table below).
  • Shifting non-time critical medications to the next administration time frame. For example, daily or weekly medication can be moved to a later medication administration time.
  • Consult with prescribers for any gray areas. For example, a stable patient on an anticoagulant may be able to have their medication moved to the evening administration time while a patient with fluctuating INR levels may not be able to delay a dose.
  • Negotiating a method for delivering time-critical medications. Methods can include
    • Cell-side administration: A nurse takes the medication directly to the inmate in the housing unit.
    • Officer escort to the medical unit: Specific patients needing time-critical medications are brought to health care for their doses.

Some settings also allow officer-delivered medication. This requires a clear policy and procedure in addition to a review of the state nurse practice act regarding medication delivery and medication administration. There are many safety concerns with this approach and it is not the best option, if it can be avoided.

In all cases, the process for response to medication administration delay should be written into a policy and procedure that is approved by both security and health care leadership. That way there will be no surprises when an emergency situation like the scenario above arises.

Time Critical and Non-Time Critical Medications

The following listing provided by the Institute of Safe Medication Practice is a helpful guide for making determinations when normal medication administration processes are interrupted.

Time Critical Medications

  • Antibiotics
  • Anticoagulants
  • Insulin
  • Anticonvulsants
  • Immunosuppressive agents
  • Pain medication
  • Medications prescribed to be administered within a specific time period
  • Medications that must be administered apart from other medications for optimal therapeutic effect
  • Medications prescribed more frequently than every 4 hours
  • Medications that require administration related to before, after, or with meals

Non Time Critical Medications

  • Daily, weekly, or monthly medications
  • Medications prescribed more frequently than daily but less than every 4 hours (bid, tid) if not in the time critical listing

How do you handle cancelled medication passes? Share your procedures in the comments section of this post.

Photo Credit: © peerayot – Fotolia.com

The Social Order of the Underworld with Author David Skarbek (Podcast Episode 96)

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Social OrderDavid Skarbek, Lecturer in the Department of Political Economy at King’s College in London, England and author of the book The Social Order of the Underworld: How Prison Gangs Govern the American Penal System joins Lorry to talk about prison gangs. He became interested in this topic while a California native. As an economist, Skarbek studies how individuals respond to changes in costs, benefits, and incentives. He contends that economics can provide an organizing framework for understanding prison life and its effect on society as a whole. Indeed, with the total population of US jails and prisons at 2.2 million, this is a large sector of the general population; larger than all but three US cities and greater than the population of 15 states.

Although gangs might seem like a negative influence in the prison system, they actually can provide order and structure to the prison culture and likely reduce some of the brutality that might otherwise be displayed. Prison life involves rules, both formal and informal, and customs.  An economic framework applied to prison culture looks at incentives and consequences of these rules and customs.

The Convict Code

Gangs have a domination over prison life in California but that was not always so. The first 100 years of prison history were managed by something called the convict code; a loose framework of rules for acceptable behavior  such as never inform, never steal, don’t talk a lot, pay your debts, and do your own time. Inmate leaders would meet out justice for those who violate the code. This worked well while the prison population was small and stable.

Gangs Take Over

The inmate code structure began to unravel in the 60’s as prison growth exploded and the inmate population’s cultural background became diverse. It then became difficult for inmates to know each other and deal with reputation. As the inmate code became less effective, gangs emerged to remedy the ensuing chaos. Each gang creates their own rules of conduct and kept tabs on member reputation. Gangs often form along racial lines.

What Gangs Contribute

The popular belief that gangs are only a negative influence misses their positive impact. Here are some findings on the positive outcomes of prison gangs.

  • Rules of conduct are maintained such as respect for individuals and property.
  • Regulation of the membership by providing punishment for rule infraction.
  • Creation of communication networks and channels inside and outside the facility.
  • Regulation of the black market movement of goods and services within the inmate population.
  • Conflict and violence reduction among individuals; providing protection for gang members.

Skarbeck contends that prison gangs have reduced violence and inmate death since their rise in the 70’s when rioting was more common. It is to the gang’s advantage to reduce violence and the consequences as security’s response to quell the upheaval curtails lucrative activities such as drug sales among the inmate population.

Inside Out

Prison gangs are able to maintain power while behind bars as the underworld community on the outside is aware that they are likely to be back inside at some point in their life. Recognizing this possibility, gang members are willing to take direction from prison gang leaders on the inside. So, prison gangs are able to project their power into the surrounding community. Gang activity inside and outside of prison is more cohesive than may be thought.

What has been your experience with gangs in your facility? Share your thoughts in the comments section of this post.

Are You Imprisoned by a Messy Med Room?

Cupboard with opened drawerThe medication room is one of the most complex areas of a jail or prison health unit. The set up and maintenance of a medication room can make or break the medication administration process and eat up hours of nursing time every shift. Medication administration can take up to 40% of a nurse’s time in traditional settings. Some correctional nurses spend the majority of their time preparing for, administering, and then documenting medication administration.  Organizing the layout and management of a medication room can smooth the process and reduce error.

Patient Need and Delivery Method

When first organizing a medication room, analyze the needs of the patient population – both size and make-up. For example, a mixed gender population such as that in a large jail will require a wider variety of medication classes than a male-only prison. A large facility with an older patient population will have expanded need for medication delivery and, therefore, larger storage space.

The type of facility, jail or prison, may also dictate medication room needs. A busy jail has a high rate of intake and release meaning many medications are coming in with the patients and awaiting disposal or pick up at release. Storage of these medications can take up space and require an organized system for management.

The method of medication delivery is also a consideration in creating a medication room. If pill line is centralized, a distribution window is often located within the room and medications need to be easily accessed from that location.  A dispersed system where nurses take carts out to housing areas requires room in the medication room to lock the carts when not in use.

The numbers of people working in the room at the same time is also a factor in medication room management. Sufficient space is needed to prepare for medication administration such as supplying the medication cart and organizing equipment.

Room Layout

Many facilities must make due with the room that is available. Fortunate, indeed, are nurses working in facilities with spacious medication rooms. Some facilities merely have a few cupboards in the corner of a clinical room for medications. It is ideal for the room to be laid out according to function. If space is available, a medication room can have areas for the following functions.

  • Ordering, receiving, scanning in and putting stock away
  • Area for the medication carts in easy reach of stock and supplies
  • Locked areas for narcotics and locked box/cabinet with expired or discontinued medication awaiting pick up or shipment to the source pharmacy

Storage Conditions

Consideration should be given to the storage of medications for efficiency and to maintain potency.

  • Bubble packs work well in containers allowing them to stand up so patient and drug name are easy to read
  • Creams, lotions, inhalers, and liquids require separate storage; away from oral preparations to avoid wrong route errors
  • A reliable refrigerator is needed to maintain chilled temperatures for some medications
  • If intravenous services are provided in an infirmary, an additional area for storing IV supplies and solutions may be needed
  • Emergency medications are also kept in the locked medication room and need to be quickly accessible to take to a man-down situation
  • Sharps for medication administration, such as needles and lancets, are also often secured in the medication room

Standardized Processes

The following maintenance systems should be in place to ensure that medications are available when needed for chronic care, acute conditions, and emergency situations.

  • Check in and storage of new medications arriving from the pharmacy vendor
  • Filing of paperwork and order manifests
  • Inspection of expiration dates and stock rotation (esp. emergency medications)
  • Inventory par levels for stock medications, over-the-counter, and protocol medications with standard ordering process
  • Medication return process with pharmacy vendor
  • Monitoring narcotic control
  • Monitoring storage temperatures for room and refrigeration
  • Processing of new prescription orders
  • Reordering of keep-on-person/self-administered medications
  • Shift counts of controlled substances and sharps
  • Turning over the MARs for a new month

Stable Staffing

Consistent staffing in the medication room is a safety factor.  The complexity of the standard medication room processes needs an in-depth understanding of pharmacy processes and patient needs. This requires an individual who values safety and efficiency. Some sites have a pharmacy technician while others have a med room nurse. If “Everyone” is responsible for med room organization, The result is most often a messy med room.

Principles for Medication Room Systems

Here is a summary of key medication room system principles to maintain organization and safety.

Category Principles
Security
  • Keep the medication room locked at all times
  • Reduce the number of staff with key access to the medication room
  • Do not allow food in the medication room
Layout
  • Minimize what is stored in the medication room since access is limited
  • Keep only medications, medication preparation equipment, and controlled items like sharps locked in the medication room to avoid key control issues
Staffing
  • Limit the number of staff who receive, organize, store, maintain, and dispose of medications
  • Have consistent, knowledgeable staff managing the medication room
Storage
  • Keep topical medication clearly labeled and stored separate from oral medications
  • A quality refrigerator and thermometer are needed to maintain proper temperature and humidity for some medications and vaccines
Medication Intake Processing
  • Check medication delivered to the medication room against the delivery manifest and ordering records
  • Report any missing medications to the pharmacy
  • Process and organize new medications such as on medication delivery carts, baskets, or shelves
Medication Organization
  • Organize medication by inmate name or number
  • Medication may also be organized by housing unit or medication rounding system
Medication Disposal
  • Regularly review and rotate stock based on expiration dates
  • Follow environmental regulations when disposing of expired or contaminated medications.
  • Do not flush medication into the septic system
Medication Security
  • Do not allow patients  in the medication room
  • Avoid using inmate porters for medication room cleaning
  • Staff must monitor inmate porters at all times when they are in the medication room
Medication Administration Equipment and supplies
  • Have necessary medication storage and administration equipment and supplies available in the room
  • Supplies can include pill slicers and crushers, disposable pill cups, sharps containers, and drug book

How are you managing the medication room at your jail or prison? Share your tips and tricks in the comments section of this post.

Gayle Burrow, long-time correctional nurse administrator in Portland, OR and frequent Correctional Nursing Today news panelist, contributed significantly to this post. Thanks, Gayle!

Photo Credit: © Oliver Sved – Fotolia.com

Disaster Planning for Infectious Disease Outbreaks (Podcast Episode #95)

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Sue Lane, RN, CCHP and Sue Smith, MSN, RN, CCHP-RN join Lorry to talk about “Disaster Planning for Infectious Disease Outbreaks”. They are presenting this topic at the 2015 NCCHC Spring Conference on Correctional Health Care in New Orleans, April 11-14. Learn more about the conference HERE.

cnt-podcast_cover_art-1400x1400Correctional facilities are prone to the rapid spread of infectious disease. The incarcerated patient population has a greater likelihood of being diagnosed with an infectious disease due, in part, to poor lifestyle choices and poor hygiene habits. The overcrowded nature of many correctional settings and the age of some structures add to the potential for an infectious disease outbreak.  In addition, the stress of incarceration can weaken the immune system.

Some of the most common outbreaks include tuberculosis, norovirus, and chicken pox. Flu season brings in H1N1 and there was concern about Ebola recently. If we are not prepared, it can be a disaster.

Preparation Pointers

The basics of disaster planning for infectious disease outbreaks are just that – basic. The difficult part comes in finding the time and motivating staff and organizational leaders to plan ahead to avert a disaster when infection strikes. Here are a few preparation pointers:

  • Create an understandable policy and procedure for managing the various types of possible outbreaks.
  • Regularly education health care staff about the outbreak plan. This should be at orientation and at least annually.
  • Share infection management information with the officer staff. This can reduce panic and stress if an outbreak occurs.
  • Practice the outbreak plan as one of the possible disasters in the disaster drill schedule.
  • Refresh staff and officer information during regular flu seasons and any time there is a high alert for an infection entering the facility.

Are you ready to avert an infection outbreak disaster in your setting? Share your tips in the comments section of this post.

This podcast is part of a series discussing topics addressed during sessions of the2015 NCCHC Spring Conference on Correctional Health Care. All posts and podcasts in this series can be found HERE.

Clinical Management of Polydipsia (Podcast Episode 94)

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Scott Eliason, MD, CCHP-MH, Regional Psychiatric Director for Idaho through Corizon Correctional Health Care talks about polydipsia, its various manifestations, and management in the correctional setting. He is presenting this topic along with Mark Fleming, PhD, CCHP-MH at the 2015 NCCHC Spring Conference on Correctional Health Care in New Orleans, April 11-14. Learn more about the conference and register HERE.

cnt-podcast_cover_art-1400x1400Psychogenic polydipsia, excessive fluid-seeking, is a life-threatening condition that is more common than believed and very difficult to manage in the correctional environment. The excess water consumed in this state leads to hyponatremia; a diluted sodium level. The low sodium then results in water intoxication; a condition that causes neurological symptoms as the brain swells with fluid. Patients exhibit behavior changes, confusion, slurred speech, and, if left untreated, progress to seizures and death.

Causes

Excessive thirst can result from the hyperglycemia of untreated diabetes, a significant blood loss, dehydration, or bodily fluid shift such as from kidney failure. This symptom resolves once the condition is managed and fluid balance returns to normal. Psychogenic polydipsia, however, is a condition of psychological rather than physiologic origin. When the intake of water exceeds the body’s ability to manage it, imbalance ensues.

Schizophrenia is one of the most common causes of psychogenic polydipsia with as many as 20% of schizophrenic patients having some periods of polydipsia and up to 5% compulsively drinking enough water to lead to self-induced water intoxication.

Even higher rates of polydipsia are found in individuals who are schizophrenic and are also anorexic, have seizures, or are substance abusers. Then, too, medications such as carbamazepine (Tegretol), oxcarbazepine (Trileptal), and fluozetine (Prozac), part of many mental health treatment plans can lower sodium levels. Plus, so many medication have dry mouth as a side effect; increasing the desire to drink.

Management Priorities

When treating psychogenic polydipsia, Dr. Eliason likes to start by reviewing the patient’s list of medications to see if any can be adjusted or replaced. He has seen some success with adding clozaril (Clozapine) to decrease water seeking behavior. Although the mechanism is unknown, adding a beta blocker to the regimen may be helpful, as well.

While medication adjustments help long-term outcomes, water restriction is the best treatment for the acute phase of water intoxication. Sodium levels usually correct naturally in a couple days. Significantly low sodium levels need close monitoring in an acute care setting; sometimes even critical care.

Treatment Challenges

The compulsive nature of psychogenic polydipsia combined with restrictions of the correctional environment make treatment difficult. Releasing chronic water seekers from water restriction is tricky. Dr. Eliason describes an inmate’s situation of being locked in a cell with a sink and a toilet as the equivalent of locking an alcoholic in a bar.

Dr. Eliason has had success with excess drinking behavior management through a daily weight monitoring regimen. A patient’s weight is usually baseline in the morning as the body has re-equilibrated overnight. Then, during the day the patient over-hydrates resulting in water weight gain. A weight gain of 4% typically equates to a 10 meq blood sodium reduction. By using a morning and evening weight as a feedback mechanism, a patient can be moved in and out of water restriction status until able to self-manage the desire to drink. As can be expected, a team effort is needed to make this work. Both officers and health care staff must be observant of the regimen over time.

Have you had a patient who could not control their water drinking? How was it handled in your setting?