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.

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.

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.

Photo Credit: © gustavofrazao – Fotolia.com

February 2015 Correctional Health Care News Round Up (Podcast Episode 92)

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cnt-podcast_cover_art-1400x1400Gayle Burrow and Denise Rahaman return to talk about this month’s correctional health care news items*.

Medical Problems Of State And Federal Prisoners And Jail Inmates, 2011-12

Our first news item is the publication of a US Department of Justice special report on the Medical Problems of State and Federal Prisoners and Jail Inmates, 2011-12. This is a long awaited update to their prior reports over a decade ago. The report validates what correctional nurses know to be true: inmates are more likely to have a chronic or infectious condition than the general population and female prisoners have more chronic conditions than males. A few interesting findings:

Clallam County working to avoid measles outbreak in jail

The Clallam county jail in Port Angeles, Washington is now providing measles vaccination for inmates. They are concerned about an outbreak after their Department of Health confirmed the state’s fourth active case of measles recently. As you may know, a measles outbreak has hit California traced to an active case in Disneyland. Will jails and prisons be ramping up measles vaccination?

When Prisoners Are Patients

Next up is an opinion piece that hit the New York Times about dealing with prisoners as patients in traditional settings. Nurse Teresa Brown shares her experiences caring for one prisoner for several weeks. She talks about giving ‘needed, accessible care to the most despised and potentially violent among us’. That surely sums up what correctional nurses do. Insights from the article helpful to correctional nurses include a need to separate the patient from their crimes, maintaining a different perspective than officers, and wondering why necessary health care isn’t provided to all citizens, not just incarcerated ones.

Long-running public service project sends Johns Hopkins students behind prison walls

The Johns Hopkins Gazette tells the story of Hopkin’s students tutoring inmates at the Baltimore City Detention Center. The University’s Jail Tutoring Project currently has 36 undergrads tutoring inmates from the general population, substance abusers working to maintain sobriety and some with mental health issues. The program has been in place for 40 years and stories from the students and the inmates indicate that it is changing lives.

What are your thoughts on this month’s news? Do you agree with our panelists? Share your comments below.

* Views of the panelists are their own and do not necessarily reflect the views of their employers, their clients, or their families.

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.

Photo Credit: © jacquimoo – Fotolia.com

My Story: Making the Right Turn to Corrections in My Journey to Public Health

This guest post by Mary Loos, BSN, MPH, shares her story of correctional nursing. Mary spent her correctional nursing career in the Multnomah County Health Department, providing care in the Multnomah County Jail System.

Detour sign - old orange and black  road signEvery person who discovers Corrections Health as a career has their own story to tell about how they got there.  Mine? It started with a right turn in my path to work in the Public Health arena. After earning my BSN, I decided to get RN experience for a year or two.  Before I knew it, I had spent 14 years in hospital nursing, working my way up from staff nurse to hospital nursing supervisor.  My clinical experience provided me with a wealth of experience in pediatrics, general and vascular surgery, post-op open heart / telemetry, quick decision-making and working with many different disciplines.

In 1985, I realized that I didn’t want to work in a hospital anymore.  The first time I looked in the local newspaper for a nursing position, I saw an ad for a Nurse Manager position in our county’s Corrections Health program within the Public Health Department.  My mind started making the connection right away – the public’s health includes all sectors of the population.  I immediately completed an application for this position, toured facilities and had several interviews.  I was hired to work with a person I soon realized was a visionary and a national leader in the Corrections Health professional arena.

At last, I was in public health!  And that is the way my Program Director and I, along with our entire team carried our mission out.  We grew from three facilities to six, doubling our census of patients between the years I was there.  We dealt with the onset of AIDS and the corresponding issues of confidentiality and safety precautions, which was an extremely sensitive issue with custody and program staff.  Our infirmaries grew along with higher complexity patients, our funding cycles went up and down, and threats of litigation motivated all staff to chart precisely and timely.  Interdisciplinary challenges aside, I found working in this environment stimulating, educational, and truly worthwhile.

We established many joint public health programs within the jail facilities.  Among these was our participation in a joint project with community corrections and community health, ensuring that drug-addicted pregnant women in custody were connected with community health nurses both in and out of custody.  We also set up an official Food Handler Certificate program for inmates, putting them one step closer to a job on release.  Corrections Health has evolved over the years into a high technology program that provides basic and complex care to a population that rotates in and out rapidly, and often arrive in booking with unstable and/or acute symptoms.  The staff is incredible – experienced, knowledgeable, skilled, compassionate yet limit-setting, and they juggle a patient load that no other health care personnel face.

And yes, I’ve had people ask why I’m not working as a “real nurse”, and why am I working with “those people”.  My response was unswerving: that I’ve chosen to work with a microcosm of our county population that is sicker due to lack of consistent medical and mental health care.  They, like us, need and deserve health care.  This has led to some interesting conversations, I assure you.  Corrections Health is Public Health at its best. Once you enter the field, it’s easy to get hooked, and longevity in this elite field is common.  You either hate it and leave, or you love it and stay.   To this day, the years I worked with jail inmates are the highlight of my 42 year nursing career.

Do you have an uplifting story to share about your correctional nurse experience? Send your thoughts to lorry@correctionalnurse.net

Photo Credit: © Michael Flippo – Fotolia.com

Diabetic Self Care in Corrections (Podcast Episode 91)

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cnt-podcast_cover_art-1400x1400Kelly Ranson, MSN, PHN, CCHP, Chief Nurse Executive at Kern Valley State Prison in Delano, CA joins Lorry to discuss implementing diabetic self-care at her facility. Kelly recently graduated from the California State University MSN program. This project was part of her graduate studies.

Tips for Making Change Happen

It is not easy to change practice in traditional clinical settings but there are added barriers to health care innovations in a correctional setting. Kelly provides a real-life perspective on how she went about initiating her diabetic self-care project.

  • Pick something you are passionate about. It will keep you motivated when the going gets rough. Kelly has a personal connection with diabetes in her own family as well as having a graduate school class project requirement related to chronic diseases.
  • Seize an opportunity when it comes along, no matter the original reason. Kelly took advantage of an institutional decision for inmates to carry glucometers that originated as a staff work-reduction action.
  • Research the evidence to support the change you want to make. Kelly researched national diabetes standards but also included World Health Organization information for 3rd world countries as the prison environment has many similarities.
  • Consider what the facility leadership is interested in and link to that. Kelly connected the innovation with fiscal savings in reducing late-stage diabetes health care costs.
  • Consider the down-side of the innovation and make accommodations. Kelly and the Warden disassembled the glucometers and lancets to determine if they could be used to create a weapon.
  • Start it as a trial. Administration may be willing to trial a change knowing that it can be pulled back if unsurmountable difficulties arise.
  • Be a hero on the patient side and the taxpayer side. Kelly linked improving patient care to reducing costs to gain management engagement.
  • Include some of the nay-sayers into the implementation team. Kelly involved the nurses who were skeptical about the success of the program with lifer inmates. They became the champions of the program through their early involvement.
  • Involve the patient population early on. Kelly and her team met with the inmate advisory group and got their support before implementation.

Nursing News

AAP Updates Measles Recommendations

The recent measles outbreak is the largest in the US since the vaccine became universally available. The American Academy of Pediatrics recently released updated measles guidelines in response to this national outbreak. Of importance for correctional practice is the recommendation for vaccination of unvaccinated adults born after 1957 who have not had the disease. If you are in an outbreak state, your facility may be considering measles vaccination in the near future.

Fatal Smoking Risks May Be Higher Than Thought

A study recently published in the New England Journal of Medicine found 17% more fatalities caused by smoking than originally noted in an examination of five large databases of over 180,000 fatalities. Twenty one common diseases are associated with cigarette smoking but previously unrecognized smoking-related deaths were discovered. Some interesting findings from this study were that death from infection was 2.3 times higher in smokers and cirrhosis of the liver was 3.1 times higher. The good news is that the elevated risks decrease over time if a smoker quits. So, the move to smoke-free correctional facilities is definitely a positive health move for our patients.

No Evidence to Support Dietary Fat Recommendations

A new meta-analysis of 6 dietary trials involving over 2000 participants was published in OpenHeart, an imprint of the British Medical Journal in partnership with the British Cardiovascular Society. Turns out those dietary guidelines we’ve been using to teach our patients and guide medical diets are not evidence-based. In fact, there is no data to support the recommendations to keep dietary fat less than 30% and saturated fats less than 10%. In this age of evidence-based medicine, it is interesting that so much of our practice is built on a shaky foundation.

What is your take on these news items? Share your thoughts in the comments section of this post.

Botulism and Prison Brew

PotatoSeveral inmates from the same housing unit have come to nursing sick call with complaints of feeling generally unwell, blurred vision, and some difficulty breathing. Since they are all from the same unit an infectious condition is considered. This is flu season so it could be the flu virus….but maybe something else?

Ours is a clever patient population. When confined in a secure setting with little in the way of resources, they are able to manufacture a wide array of items for personal use or barter on the prison underground market.

Homemade alcohol is one such commodity and is fairly common in the US prison system. Local names for prison alcohol products include hooch, pruno, juice, buck, chalk, brew, raisin jack, and jump. The brew is most often made from fermented fruit but any food source will work.

The Centers for Disease Control (CDC) reported on five outbreaks of deadly botulism from prison hooch in the Arizona, California, and Utah prison systems. Although the botulism bacteria can be introduced through any fresh food item, potato peels were identified as the source in several of the CDC investigated outbreaks. Botulism is caused by a toxin produced when a bacteria commonly found in soil is placed in an oxygen-deprived environment – like the closed containers used for DIY alcohol production. The toxin is produced during the fermentation process if no heat is applied to kill the bacteria.

Signs that Trouble is Brewing

Correctional nurses must be aware of the symptoms for botulism if their patients have a propensity to create their own moonshine.

It is important to act on early signs of botulism as the nerve paralysis caused by the bacterial toxin can quickly move to the respiratory muscles and lead to death. Often the first signs involve the eyes with double vision, blurred vision, or drooping eyelids. Slurred speech and dry mouth can follow along with general muscle weakness and difficulty swallowing. Botulism can quickly progress to respiratory failure.

Poisoning from botulism toxins through prison hooch can happen in a few hours or take up to 10 days to appear. A medical evaluation of symptoms is necessary to rule out other possible causes of progressing paralysis. Information about the potential of drinking homemade alcohol is important for a quick diagnosis and response. Question the patient and housing officers in a suspicious situation.

So, if home-brewing is a popular hobby at your facility, be particularly alert for signs of botulism poisoning among those who make and partake of this beverage. It may seem like a harmless way to keep the prisoners peaceful and preoccupied – but it also has potential to brew up some trouble.

Do inmates in your facility create their own drinking alcohol? Share your experiences in the comments section of this post.

Some material for this post was originally published for my health care column over at CorrectionsOne.Com.

Photo Credit: © gekaskr – Fotolia.com