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

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?

Diabetes Primer for the Correctional Nurse

Lori Roscoe, PhD, MSN, CCHP-RN, is a Nurse Practitioner and Correctional Health Consultant in Atlanta, GA. This post is based on her session “Diabetes Primer for the Correctional Nurse” taking place at the Spring 2015 NCCHC Spring Conference on Correctional Health Care in New Orleans, April 11-14, 2015. Learn more about the conference and register HERE.

Stethoscope and device for measuring blood sugar levelIf you have been in correctional nursing for a while, you may have noticed an increase in the number of diabetic patients you are managing. The recently released BJS Special Report on Medical Problems of State and Federal Prisoners and Jail Inmates provides national statistics on the medical conditions of our patent population. It compares this data with that found in 2004 (the last time this information was collected). Diabetes Mellitus (DM) doubled in our patient population in that span of years. That means it is more important than ever to understand this chronic condition and the various treatment modalities available. Consider this nursing sick call situation.

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.

What Type Is It?

As nurses we learned long ago about Type I and Type II Diabetes. However, we may have an outdated mental shorthand about the differences. For example, you may categorize diabetes by those who need insulin and those who do not. You might also, then, categorize your diabetic patients by those that could be hypoglycemic because of too much insulin and those that couldn’t because they don’t take insulin. But, these categories can be unhelpful. Better is a differentiation based on physiology.

Type I Diabetes – No or Low Insulin Production. In Type I DM the body either stops making insulin or makes too little to effectively manage glucose. Therefore, it is a lack of insulin production.

Type II Diabetes – Inability to Use Insulin. In Type II DM the body loses the ability to use insulin to manage glucose. In this case, insulin is being produced by the body but is not metabolizing the glucose. There also may be inadequate insulin production over time.

Med Madness

Understanding insulin production and use in the body is one part of diabetes management. Another part is understanding the complexity of medication options. Over the past few years, new types of insulin and new medication classes have made the treatment of diabetes complex. Our patients may now be entering the correctional system with unusual insulin regimens and unfamiliar oral medications or medication combinations for maintaining a glucose equilibrium.

Although correctional nurses do not prescribe medications, an understanding of their effect/side effect is necessary to administer these newer preparations. In addition, we may be called upon to interpret a regimen change to a patient; this can be especially true in settings where a limited formulary requires that generic substitution be made to standard treatment while the patient is incarcerated.

Besides effects and side effects, nurses need to be aware of any interactions among medications or with food. Medication timing with or between meals can affect drug absorption and can be difficult to manage in the secure setting where our patients do not have control over when they eat or the type of food available.

Go to the Head of the Class

Categorizing medications by therapeutic class provides an organizing framework for better recall of important information in a clinical situation. A therapeutic class is determined by the drug’s mechanism of action and resulting effects/side effects, and interactions. While Biguanides (like Metformin/Glucophage©) and Sulfonylureas (like Glipizide/Glucotrol©) are common therapeutic classes of antidiabetics, you may be seeing other, newer, classes arrive with patients on intake or being added to the standard formulary. Meglitinides (Repaglinide/Prandin©), D-Phenylalanine Derivatives (Nateglinide/Starlix©),  Thiazolidinediones (Pioglitazone/Actos©), DDP-4 Inhibitors (Sitagliptin/Januvia©), Alpha-Glucosidase Inhibitors (Acarbose/Precose©), and Bile Acid Sequestrants (Colesevelam/Welchol©) are being prescribed more frequently in our setting.

Then, there are the combination antidiabetic medications. These combination pills are often non-formulary for a correctional setting and must be switched to the singular medications once the patient is incarcerated. The patient in the above-mentioned sick call situation was originally taking Metaglip©, which is a combination pill containing both metformin and glipizide. After incarceration, she was switched to the equivalent medications as generic single-medication pills.

Confused? The Joslin Diabetes Center provides a handy table of antidiabetic drug classes and combination pills HERE. You might want to print one out and post on your unit (hint, hint).

How to Get Up to Speed

So, how do you stay up-to-date on diabetes treatment, or, for that matter any of the myriad of new medications and therapies becoming available? Here are a few ideas to incorporate into your professional development plan.

  • Think diabetes (and hypertension) in nursing sick call as both these conditions are on the increase in our patient population according to the BJS report. Our patients may be on new medication regimens or may be suffering from lack of treatment or, even, have undiagnosed conditions.
  • Have a current and easy-to-read drug book handy in the sick call and medication administration areas. No one can keep all that information in active memory.
  • Look up new medications when you first hear of them or begin seeing them on the MAR.
  • Categorize medication knowledge into drug classes and add new classes or new medications to your current mental structure as they become prevalent in your setting.
  • Ask prescribers to provide information about new medications coming into use in your setting. You may want to have an informal education session or have someone from the medical staff speak at a monthly staff meeting.

Chronic Disease and Sick Call Evaluation

Back to that sick call patient with a swollen ankle. The astute nurse, after reviewing the chart and examining the ankle, asked the patient these follow-up questions:

  • Have you been feeling dizzy at all?
  • When does it usually happen?
  • What do you do about it?
  • Have the episodes increased since you started treating the yeast infection?

Once asked, the patient offered that she occasionally feels dizzy but just eats a honeybun from the commissary when that happens. Once she thought about it, she realized that her tumble coincided with just such a dizzy spell and that, yes, she has been getting dizzy more frequently of late. Based on a full assessment of both the acute ankle injury and her diabetes management, this patient had her ankle wrapped and was set up for a provider visit later that day to have her medications adjusted. Glipizide is one Type II oral antidiabetic that can cause hypoglycemia and this side effect is potentiated when taken in combination with fluconazole (Monostat).

How do you keep up with the latest changes in diabetes management? Share your tips in the comments section of this post.

This post is part of a series discussing topics that are addressed during sessions of the 2015 NCCHC Spring Conference on Correctional Health Care. All posts in this series can be found HERE.

Photo Credit: © maya – Fotolia.com

Book Review: Nursing in Criminal Justice Services

Nursing In Criminal Justice ServiesI am intrigued by correctional nursing practice in other countries. So, It was with great interest that I obtained a review copy of “Nursing in Criminal Justice Services” edited by UK correctional nurse experts Ann Norman and Elizabeth Walsh. I interviewed Ann on a prior Correctional Nursing Today Podcast and met both Ann and Elizabeth at the last Custody and Caring Conference in Saskatchewan, Canada. Their book lifts the hood (or should I say bonnet?) on the inner workings of UK criminal justice services and the concerns of nurses working in the system. It provides insight into the similarities and differences in practice between US and UK systems and provides food for thought to apply to correctional nursing in the U.S. Here is my take on some of the gems found in the thirteen chapters of this book.

What’s in a Name?

I remember well our discussions about the title of our specialty on the ANA Taskforce while revising the Correctional Nursing Scope and Standards of Practice a couple years back. We settled on the term “Correctional Nursing” while defining the specialty as being in the Criminal Justice System. The evolution of practice in Britain was a bit different; as the terms for locations in the criminal justice system are different. However, it seems that UK correctional nurses are “Nurses in Criminal Justice Services” and that includes subsets like custody nurses (jail equivalent), prison nurses, and immigration centre nurses. There seems to be some continued discussion on the term for this specialty nursing practice, though. The authors of the chapter on “Professional attitudes and behaviors” (Chapter 12) used the term “secure care workers” and the author for the chapter “Custodial caritas: Beyond rhetoric in caring and custody” (Ch8) also used the term ‘custodial’. I assume that comes from having patients ‘in custody’ but I’m not sure I’m happy with being custodial. It has the feel of mopping floors in American parlance.

Moving from Prisoner to Patient

Of note is the obvious evolution of health care in the UK criminal justice system toward a patient focus and away from a prisoner focus. Editors Norman and Walsh describe in their introduction (Chapter 1) that prison health care has moved from management through HM (Her Majesty’s) Prison Service to the National Health Service (NHS). A move that aligns with general population health care management in the UK and, therefore, creates patient focus. We have seen similar movement over the last decade in US correctional nursing practice as nurses in jails and prisons struggle with the tension, as described in Chapter 1, of “prisoner and patient, custody and care, security and therapy” (pg. 2). A dialog across the pond on these common issues might be fruitful for nurses in our respective justice systems.

A Vulnerable Patient Population

It is no surprise that the patient population in the UK criminal justice system is aging along with those in the US system. Nor is it surprising that there is increasing concern for mental illness services as this segment of the incarcerated population is growing, as well. Other vulnerable groups such as women, youth, and children are addressed. Of note is an increasing emphasis on disability. Chapter 9 discusses “Caring for vulnerable people: Intellectual disability in the criminal justice system”. We would do well to be more cognizant of the vulnerable nature of those in the US system who have learning disabilities, head injury, and low literacy.

The Struggle to Care

The struggle to care is given a fresh (or should I say Freshwater?) perspective in the previously mentioned Chapter 8 on custodial caritas by author Dawn Freshwater. I was moved by her keynote at the 2013 Custody and Caring Conference where she shared the main themes of this chapter. Here she emphasizes the need for compassion and competence in our nursing practice and highlights the dynamics of a caring relationship. I must admit, this gem is my favorite chapter in the book and has provided many a moment of reflection on the caring/custody friction we all feel.

Making a Connection

Finally, I enjoyed reading about the connection correctional nurses have with some areas we might think of as peripheral to our practice. Chapter 4 on “Forensic nurse examiners: Caring for victims of sexual assault”, Chapter 7 “On the out: Supporting offenders in the community”, and Chapter 11 “Learning opportunities from inquests” got me thinking about our need to ‘think outside the box (or bars?) about our correctional nursing practice.

Conclusion

While nursing in the UK criminal justice system may have ‘grown up’ under different conditions, our key concerns as professional nurses within the system remains the same. The patient population and unique work environment create both opportunities and barriers for meaningful patient outcomes. The seventeen chapter contributors to the book “Nursing in Criminal Justice Services” have helped to clarify these issues for British nurses and, by doing so, provide an interesting reading opportunity for us all. Do put this book on your reading list!

What are your thoughts on correctional nursing practice in other countries? Share your ideas in the comments section of this post.

Avoiding Documentation Pitfalls in an Electronic World

Jackie Griffin-Rednour, RN, BAS, CCHP, is Clinical Nurse Educator for Correctional Health Services in Phoenix, AZ. This post is based on her session “Protecting Your Nursing License: Avoiding Documentation Pitfalls in an Electronic World” taking place at the Spring 2015 NCCHC Spring Conference on Correctional Health Care in New Orleans, April 11-14, 2015. Learn more about the conference and register HERE.

Stethoscope and laptopThe Electronic Health Record (EHR) in the clinical setting has been hailed as the answer to all our documentation issues. Indeed, EHRs provide many benefits, but correctional nurses can still find themselves in hot water if they don’t follow basic documentation principles…..and, if they don’t consider the risks along with the benefits of documentation technology.

Electronic Health Record – Thumbs Up or Thumbs Down?

There are many benefits to an electronic health record.  A key one being improved patient outcomes.  Improved legibility, efficiency and availability of patient health information allow clinicians to deliver timely, accurate, and relevant care.

HealthIT.gov lists key benefits of electronic health documentation

  • Availability at the point of care
  • Clinical alerts and reminders such as drug-drug incompatibility and patient allergies
  • Improved quality of care screenings

The electronic health record also affords users with the ready availability of clinical decision support (like drug/allergy interactions or best practice guidelines), which has the potential to prevent errors and improve patient outcomes.

Good systems, though, are costly. Initial costs for purchase and maintenance of an electronic health record may seem excessive. However, when compared to the manpower hours involved in maintaining paper records, the cost difference is likely minimal.  Another difficulty can be basic human nature and the reluctance to change.  It requires a shift in paradigm from a paper mentality to a technological one; not to mention the need to change policies and procedures to accommodate new documentation processes.

Do EHRs Improve Nursing Documentation?

It can be difficult to say whether a move to an EHR in the correctional setting improves nursing documentation. Jackie Griffin-Rednour shares her experiences in transitioning to an electronic record within a correctional setting.  “From the point of legibility, the use of an electronic health record has certainly improved the readability of the documentation.  It has certainly improved efficiency and reduced our need to have staff transcribe orders or file loose paperwork.”, she stated. According to Griffin-Rednour, one of the major improvements has been the ability for managers to review and evaluate nurse’s documentation to comply with NCCHC’s standard J-C-02 Clinical Performance Enhancement.  Prior to electronic records, managers had to manually retrieve, review, and in some instances, decipher, the paper documentation.  The use of an electronic record facilitates ready access to patient records for review, allowing timely feedback for staff.

One Size Does Not Fit All

An EHR must be tailored to the specific needs of the clinical setting. A system created for an acute care facility, for example, will not have workflows that accommodate the special processes in correctional health care. So, a first step is to identify current clinical processes before reviewing options.  Though there are many generalities within a correctional environment, each facility has processes that are unique to their particular setting and should be a strong consideration when selecting a product.

Customization is an important feature as every facility will need to alter various processes to accommodate site-specific policies and procedures.  For example, setting vital sign parameters for alerts.

The best system would also integrate with an organization’s custody system and any other outside service providers, such as pharmacy or labs. This improves information integration and streamlines data-sharing.

Lastly, development of an education plan to roll out the new electronic health record is necessary for success. The plan should include an assessment of clinician readiness with evaluation of staff’s technical abilities. Pre-implementation training may be necessary to prepare staff with basic computer skills.

Avoid These EHR Documentation Pitfalls

No matter what type of nursing documentation in use, missing documentation is always a concern. Whether by paper or electronic documentation, if it doesn’t appear on the record, it is legally suspect as to whether it was actually completed. Here are some issues specific to EHR documentation.

  • Cloning information and copying/pasting: The ease of copying information from one part of the record to another can lead to misinformation populating the patient’s record.
  • Over-reliance of templates: Templates are a great time-saver when used correctly but templates can also add in extraneous information not applicable to every patient. Staff need to understand how to customize templates to the patient condition.
  • Ignoring alerts: Flashing or ringing alerts in a documentation system can become background noise much like a touchy IV alarm. Nurses must guard against a tendency to become ‘tone-deaf’ to documentation alerts; thereby, rendering them ineffective.

Staff education and convenient information resources are ways to combat the above pitfalls. These can include a training portal specific to the electronic health record that lists all approved documentation processes as a quick reference.  A specific “Test” environment can be set up that mirrors the electronic production environment.

The EHR must be integrated into staff development programs including:

  • New staff training and practice time prior to orientation in clinical units
  • Reinforcement classes every two to three months to allow staff to refresh skills, learn new features, and practice in the “Test” environment
  • Ongoing information relevant to pertinent changes, emerging trends or problem areas provided to staff in newsletters or emails

What are your experiences with using electronic documentation in your correctional nursing practice? Share your thoughts in the comments section of this post.

This post is part of a series discussing topics addressed during sessions of the 2015 NCCHC Spring Conference on Correctional Health Care. All posts in this series can be found HERE.

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Pain Management in Patients with Substance Use Disorders

Aleksander Shalshin, MD, CCHP is the former Deputy Medical Director Correctional Health Services for the City of New York Department of Health currently in private practice. This post is based on his session “Pain Management in Patients with Substance Use Disorders” taking place at the 2015 NCCHC Spring Conference on Correctional Health Care in New Orleans, April 11-14. Learn more about the conference and register HERE.

Addiction wooden sign with a beach on backgroundPain in some form is one of the most common symptoms that bring patients to nursing sick call. Even in traditional practice settings pain is often undertreated and many health care practitioners are particularly concerned about medicating a patient with a history of substance abuse. This is magnified in the correctional setting where substance use disorders are common in the incarcerated patient population. Yet, pain is a legitimate patient concern that we need to manage effectively.

Addiction Complicates Pain Treatment

Substance users present several challenges for pain treatment. First, use of psychoactive drugs results in the development of drug tolerance so pain medication at normal dose levels may be ineffective. Additionally, those with addictions appear to have decreased pain tolerance and, therefore, an increased perception of their pain experience.

The majority of inmates are immediately withdrawn from drugs and alcohol on entry into the criminal justice system. Withdrawal can be intensely uncomfortable, exacerbating any underlying chronic pain. Once withdrawn, practitioners can be concerned that pain treatment may contribute to a relapse.

Finally, pain is subjective, often without any objective confirming characteristics. Clinicians may not trust the patient to accurately describe the level of pain and assume ‘drug seeking’ behavior when patients with a history of substance abuse identify a need for pain treatment.

Pharmacologic Treatment Options

Opiates are the go-to drugs for pain treatment however other drug categories are underutilized and may be good options for this patient population. Nonsteroidal anti-inflammatory drugs (NSAIDs) and even tricyclic antidepressants have been helpful therapies. Depending on the source of pain, topical agents or muscle relaxants may be useful.

When opiates are necessary, they present some concerns in the correctional setting. Security of narcotics must be maintained in the medical unit and precautions against diversion during administration may need to be taken. For example, some settings crush and float narcotics so that the patient is less likely to ‘cheek’ pills for hoarding or barter on the prison black market. Liquid narcotics may also be used for the same reasons. Newer delivery methods such as the dissolving film available for buprenorphine (Suboxone) can also help assure the right patient gets the right dose.

Non Pharmacologic Treatment Options

Non pharmacologic treatments of pain are also often underutilized modalities; but, can play an important role in effectively treating chronic pain for this patient population. Depending on the resources in a particular correctional setting, physical therapy programs and exercise plans can be of benefit. Nurses can play an important role in initiating non pharmacologic treatment options for chronic pain. Treatments are discussed in more depth in this post on chronic pain and this post on managing arthritis behind bars.

Overcoming Resistance in the Correctional Setting

There can be significant resistance to pain management in the correctional setting. Officers and administration may harbor fear of diversion or manipulation in obtaining narcotics from health care staff. Even providers and nurses can have biases against pain treatment for patients with a history of a substance disorder. It takes a multidisciplinary process to be most effective. It also takes organization-wide education about pain treatment and how it is managed for this patient population. A good relationship among the disciplines of security and health care is a must.

Online Resources

American Society for Pain Management Nursing Position Statement: Pain Management in Patients with Substance Use Disorders

Pain Management in Patients with Substance-Use Disorders (American College of Clinical Pharmacology)

This is the first of a series of posts discussing topics addressed during sessions of the 2015 NCCHC Spring Conference on Correctional Health Care. Find all posts and podcasts on conference sessions HERE.

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What have been your experiences with pain management for inmate-patients with history of a substance use disorder? Share your thoughts in the comments section of this post.

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You Are A Courageous Nurse!

little girl wearing a superhero costumeDid you know you were courageous in accepting the challenge to work with our incarcerated patient population and in our locked-in work environment? Many nurses are not that bold. They do not seek out experiences that involve security escorts, the clanging of automatic barred doors, or the need to have their personal belongings searched when entering and leaving the workplace. Yes, you are a courageous nurse!

Three Types of Courage

Courage is key to effective correctional nursing. Bill Treasurer, in his book Courage Goes to Work: How to Build Backbones, Boost Performance, and Get Results, describes three types of courage we need to develop.

TRY Courage

TRY Courage is described by Treasurer as “the courage of initiating an action— making first attempts, pursuing pioneering efforts, and stepping up to the plate”. TRY Courage motivates us to act when needed – even if it is hard. Have you had to advocate for the needs of one of your patients? Have you had to confront cruel or disrespectful actions of a staff member? Have you had to address inappropriate patient behavior? It takes courage. You are a courageous nurse.

TRUST Courage

TRUST Courage is described by Treasurer as “the courage of confidence in others— letting go of the need to control situations or outcomes, having faith in people, and being open to direction and change”. TRUST Courage allows us to let go of controlling the outcomes of what we do. We are responsible for right action, but can’t control the outcomes of those actions. Do you have the courage to take a right action and let go of the outcome? You are a courageous nurse.

TELL Courage

TELL Courage is described by Treasurer as “the courage of voice— raising difficult issues, providing tough feedback, and sharing unpopular opinions”. TELL Courage is the courage to speak up when the issue is difficult or you are the only one in the situation who is disturbed. Correctional nurses are sometimes put in situations where there are no other health professionals available for consultation. Social pressure might be applied to ‘go along’ with the situation. Have you spoken up in a difficult situation? You are a courageous nurse.

What Are You Afraid Of?

Navy SEAL, Brent Gleesen, knows a bit about overcoming fears and addresses some common fears of leaders in a Forbes article. Using this list as a basis, here are my suggestions for common fears correctional nurses may need to face.

Fear of Criticism

Most people have some concern over being criticized, even if the criticism is delivered gently. Correctional nurses can find themselves working in a very negative work culture where any new idea is ‘shot down’ before it can even take flight. Nurses can also work in facilities where any act of care or concern gets labeled by colleagues as ‘Inmate Loving’ or ‘Hug a Thug’ activity. Overcoming fear of criticism is necessary to fully engage in professional nursing activity behind bars.

Fear of Consequences

The militaristic organizational structure of some correctional settings makes the negative consequences of words and actions very real. Correctional nurses have been banned from facilities for questioning an unethical practices or taking action on behalf of a patient. Words and actions need careful consideration in light of this possibility.

Fear of Failure

Sometimes it is just easier not to try at all rather than risk the chance for failure. Like fear of criticism, this fear is concerned with the acceptance of others whose regard we value. Fear of failure can cause correctional nurses to avoid addressing system issues that are affecting health care delivery.

Fear of Responsibility

Surprisingly, the possibility of success can also lead to fear. What if an idea is accepted and now needs implemented? The responsibility for making a change often rests on the one who suggests it. Like fear of failure, fear of responsibility can lead to inaction.

Take the First Step

Are you afraid to be courageous? The good news is, you have the capacity for gaining more courage. Fear is an invitation to courage – accept that invitation!  Yes, you can build your courage. It is a learnable skill like all your other nursing abilities.  “The important thing is to take the first step. Bravely overcoming one small fear gives you courage to take on the next” – Daisku Ikeda

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What courageous thing have you done recently in your correctional profession? Share your experience in the comments section of this post.

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Post Traumatic Stress Disorder Behind Bars

PTSD signsThe past life experiences of many incarcerated patients lead to post traumatic stress disorder (PTSD). According to the National Institutes of Mental Health, PTSD develops after a terrifying event or when a person is regularly put in danger or in a deadly situation. Inmate patient histories frequently include physical or sexual abuse and many have been involved in violent crime. Incarcerated military veterans can also exhibit signs of PTSD. Imprisonment can intensify the PTSD experience as some facilities have an inmate culture of intimidation, coercion, and victimization.

Survivor Response to Trauma

Individuals respond to trauma in various ways based on their own background, developmental phase and the type of trauma inflicted. Like the pain experience, a survivor’s response to trauma is unique. However, there are commonalities among these responses. Here are three main categories of symptoms related to post traumatic stress disorder (PTSD):

  • Reexperiencing the event. Your patient may experience nightmares and flashbacks of a traumatic event. For example, a woman who had been sexually assaulted as a child may have difficulty sleeping as memories of the assault flood into her mind when she tries to relax.
  • Avoidance. You patient may become anxious when confronted with objects or activities that can be associated with the trauma. For example, a stern command from an officer may trigger domestic violence memories. Severe manifestations of avoidance can lead to social isolation and even psychological dissociation.
  • Hyperarrousal. Victims of trauma can also exhibit increased irritability and exaggerated responses to environmental danger signals. For example, the patient described above may run for the corner of the room screaming when given the command by the officer.

Emotional and Psychological Support Interventions

With these survivor responses in mind, you can provide emotional and psychological support for your patients who are dealing with PTSD. It can be challenging to balance objectivity and empathy when dealing with victims of violence.

  • Establish rapport. A patient can pick up a caring attitude and interest by facial expression and body language. Eye contact and listening show concern and establish rapport without getting personal with the patient.
  • Respect and patience. As you listen to the patient, actively attend to being respectful and patient. This provides emotional support.
  • Help the patient express their feelings. Traumatized patients will have difficulty finding words to communicate their distress and the details of their experience. Fear, sadness, or rage is hard to describe when the feelings are present. Helping victims give words to their feelings can be very therapeutic. Don’t impose your own words on the experience, but, rather, help your patient find their own words.

Counseling and Crisis Intervention

A traumatized patient will, most likely, need professional support beyond what you can provide in a brief nursing encounter. Seek out other possible interventions available in your setting. Mental health services, group therapy, peer-to-peer support, or outside resources may be part of support services that can be provided for patients with severe PTSD.

Do you see signs of PTSD in your incarcerated patients? How do you handle it? Share your thoughts in the comments section of this post.

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