Worth the Risk? Double-Checking High Risk Medication Calculations

Double checkOliver usually worked the pm shift at the prison but was helping out in a staffing pinch over the summer vacation period. He regularly does the evening medication round so volunteering to do morning medications didn’t seem like a bad deal. Everyone is harried as there was a man-down called for one of the housing units and the patient is being settled in the infirmary. Although there is a standing policy to have anticoagulant doses double-checked by another nurse, he decides to do the simple calculation himself. Without a calculator handy, he does the math in his head and documents that he had administered 7.5 mg of warfarin to Inmate Strump. In reality, he just gave double the prescribed dose as the tablets were 10mg rather than 5mg, as he thought he was using.

The need to calculate a dose based on available forms or strengths of medication can lead to mathematical error. If at all possible, medication formulation needs to be in the strength necessary for the prescribed dose. When medication is being titrated, like the warfarin above, the changes come too fast for this pharmacy oversight. Nurses often need to calculate the dose and convert to available pill strength from stock.

Even simple math calculations can be challenging in a noisy housing unit with many distractions. While limiting the variety of strengths of various medications in stock may reduce the error of selecting the wrong strength of medication for a particular patient; relying on only one stock strength of medication increases the need to split scored medications and to make on-the-spot mental mathematical calculations. Both increase error risk.

Calculation Double-Checks

Complicated calculations or high-risk medication calculations call for an added level of safety. We cannot always see our own mistakes and a set of independent ‘fresh eyes’ are needed in high risk situations. However, double-checking medication doses is time consuming and other nurses are not always available to stop and help. So selective use of an independent double-check process before administering certain medications is recommended by the Institute of Safe Medication Practices

What to Double Check

Health care safety organizations such as the Institute for Safe Medication Practices (ISMP) publish lists of high risk medications based on ongoing analyses of life-threatening medication administration errors. Some medications make the list based on look-alike/sound-alike qualities and the dangerous patient outcome if the wrong medication is administered. An example of this might be confusing MetFORMin (Glucophage) with MetroNIDAZOLE (Flagyl). Most, however, are high risk related to the danger of providing an incorrect overdose. This is of particular concern for pediatric, oncology, and geriatric patient populations as they have less reserves to process an inappropriate dose and may have complex medication regimens prone to error. Categories of high risk medications in acute care settings according to the Joint Commission and ISMP include anticoagulants, opiates, insulins, chemotherapeutics, and sedatives.

What high-risk medications should require a double check in the correctional setting? Certainly, if chemotherapeutics are provided, particularly as an IV additive, they should be independently checked by another nurse before administration. But, how about other, more common, categories such as anticoagulants and insulins? Both medications can have a seriously adverse patient outcome if an incorrect dose is administered. Insulin, in particular, has many strengths and formulations; making administration errors even more likely.

Too Much Trouble

A major reason many settings do not enforce a double-check policy (even when it is on the books) is because it is time consuming and often incorrectly performed. Here are some recommendations from ISMP on how to perform an effective medication double-check process:

  • Only use a double check process for the highest risk medications otherwise the process is likely to fall to the wayside due to time and availability issues.
  • Make sure the double check is totally independent. The second nurse should check the order, calculate the dose, and compare to the first calculation without additional information or interpretation. This reduces the chance that the double-check follows the same error path as the first calculation.
  • Don’t let the double-check process become superficial. Make the review an active engagement in the process. Do not assume it is correct because the practitioner is a trusted and high-level colleague. Mistakes happen to everyone!
  • Establish a standardized process (mental or written checklist) for calculation double-checks. Consider these items in the list.
    • Is this the medication ordered?
    • Is this the dose ordered?
    • How is the dose calculated? Redo the calculation independent of the original calculation.
    • Is this the correct patient?
    • Is this the correct time for administration?
    • Is this the correct route for administration?

Although standardized dose calculation double-checks are an important part of reducing medication administration error, they cannot overcome a faulty system and should not be the only safety mechanism in place.

Do you use medication calculation double checks in your setting? Share your experiences in the comments section of this post.

Photo Credit: © raywoo  – fotolia

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

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.

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.

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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.

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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