August 2014 Correctional Health Care News Round-Up (podcast)

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cnt-podcast_cover_art-1400x1400Correctional nurse experts, Mari Knight and Kathy Wild, join Lorry to discuss the latest news in our specialty.

Prison EHRs Improve Coordination of Care

A study was published in the Health and Human Rights Journal about the implementation of electronic health records (EHR) across 12 jails in New York City between 2008 and 2011. This study highlights an interesting use of the EHR – that of using it as a tool to monitor human rights among the patients. In particular, they were interested in violent injuries and mental health stressors. The report highlighted the fear inmates have in revealing their healthcare needs. The report noted that “Patients in jail often avoid care because they fear their information will not be confidential.” Panelists did not find this to be true in the patient populations they have been involved with. The study talked about how aggregate data from the electronic health record system was used to look for vulnerability points such as patterns of injuries in various facilities. This isn’t something that would be readily available through a paper system. They are also using the system to track vulnerabilities such as traumatic brain injury and complex case management. One of the areas they found difficult was integrating mental health care into the EHR. Mental health documentation can sometimes defy categorization with large amounts of narrative notes and free-text assessments. However, expanding visit type options and structured data elements helped. As to human rights and vulnerabilities, they were able to track levels and locations of self-harming incidents and found that adolescence, serious mental illness, and solitary confinement were highly associated with self-harm in their jail system.

Alabama Prisons Face TB Outbreak

The Alabama prison system is reporting an outbreak of tuberculosis. Infection management in the confined spaces of our overcrowded prison system is a continuing issue. The Alabama Department of Public Health is reporting nine active cases of TB so far this year while they have only had 5 cases on average in past years. They are looking to contain their active cases to their designated healthcare facility at St. Clair, which is a fairly common practice. The article affirms what we already know as correctional practitioners – rates of TB are higher behind bars than in the general population. Panelists debate whether there may be increasing TB rates in other systems and how far reaching this concern could be.

Get the Nonviolent Mentally Ill Out of Our Prisons 

Besides infectious diseases, mental illness is of high concern for our patient population, as we discussed with our first story on capturing mental health documentation and trending. This third story is an op-ed from the Salt Lake Tribune advocating community treatment rather than incarceration for the nonviolent mentally ill. The author suggests that a major constraint is the lack of treatment services for addiction and mental health issues. Panelists agree that we need more resources for both violent and nonviolent mentally ill inmates.

Illinois Prison Hospice Offers Care and Redemption 

Ending on the upbeat, there is encouragement in news of the hospice program in the Illinois prison system. The article quotes Edgar Barens, whose documentary on a prison hospice program in Iowa was nominated for an Academy Award, as saying that working as an inmate volunteer in a prison hospice can be transformational but that only 20 of the 75 known prison hospice programs have inmate volunteers. This number seems low and panelists hope more prison hospice programs will include inmate workers.

What’s Bugging You? Lice Identification and Treatment

baboon grooming another closeup isolated on blackDuring a jail intake for a homeless man brought in for vagrancy, a nurse sees some tiny insects flying about his clothing and he is scratching at them as she interviews him. She is concerned that an infestation may result and initiates a protocol for lice which involves shampooing and showering with the insecticide permethrin and a special laundering process for all clothing. Was this the right action?

Correctional nurses need to be aware of various infestations as a high percentage of inmates in some locales are prone to head, body, and pubic lice. Once these little hitchhikers enter a facility they can spread by direct physical contact or through sharing of personal items like clothing, bedding, or towels. Was this patient infected with lice? Let’s look at some information about these little critters.

Do lice fly?

Lice remain on a person’s hair or clothing and wander to the skin to blood feed once or more often each day. They have tiny straw-like mouthparts – similar to those of mosquitoes – that they use to suck blood from skin capillaries. They’re unable to burrow into the skin. Lice never develop wings, so they cannot fly.  They’re also incapable of jumping. So, this patient did not have lice.

Lice cause itching

Lice may cause an allergic reaction that can cause itching. For head lice, the itching tends to be mild and temporary.  Body lice tend to cause far more itching, and even make the infested person feel ‘lousy’. Public lice tend to cause much itching in the affected area.  This patient’s itching may be caused by the insect in question but further investigation is needed.

Lice are not very common

Lice are not nearly as prevalent as is generally believed, and other creatures and objects on a person are frequently mistaken for lice.  Other insects include fleas, ticks, mites and bedbugs. None of these insects have wings, though. The homeless man in our case may merely have gnats or fruit flies about his person.

Lice are relatively tiny – as small as a poppy seed and as large as a sesame seed. A screener must have good eyesight, be close enough to see the creature, use a magnifying lens, and some expertise to identify lice; distinguishing them from other insects. In fact, other kinds of insects and even bits of debris are frequently mistaken to be lice. As in this case, misdiagnosis and unnecessary treatment can be frequent.

When in doubt – don’t treat

Treating everyone who enters a facility is not a good idea; nor is it cost effective. Treatment focused just on those infested is consistent with sound medical practice.  It can also dramatically save time and precious funds; while reducing the risk of lawsuit. The standard medications used in prisons for delousing contain the insecticides permethrin and pyrethrins. These have become less effective as resistance is becoming widespread.

When positive lice identification is confirmed, treatment can be ordered as follows:

  • Head lice can be treated with one or two 10-minute applications of a pediculicide.
  • Body lice usually require no treatment to the person. Instead, a person with body lice should bathe and change into prison-issued clothing. The infested clothing should be disinsected by proper laundering, or disposed of.  If body lice are detected on the body hairs of a person, a full-body treatment with a pediculicide is needed.
  • Pubic lice would necessitate treatment to the affected area only.

Ongoing prevention measures for lice include frequent (at least weekly) laundering of clothing and linens, and early recognition and treatment of genuine infestations.  The Federal Bureau of Prisons Lice and Scabies Protocol of March 2011 recommends the following actions:

  • Be sure laundry temperatures are set to at least 130 degrees Fahrenheit to kill lice and their eggs on linens and clothing. Use a hot cycle for drying, as well.
  • Educate inmates about lice and how to get treatment if they observe lice. The FBOP Protocol includes inmate education handouts that might be helpful.
  • Inmates should not be transferred to other facilities until 24 hours after initiation of treatment.  If moved before the 2nd treatment application (7 days), communication and continuation of treatment should be provided.

How are you managing lice, bedbugs, fleas, and ticks in your facility? Share your thoughts in the comments section of this post.

Photo Credit: © Sascha Burkard – Fotolia.com

Hand Hygiene Challenges for Correctional Nurses

What exciting thing can be said about washing your hands? Even before becoming nurses, we heard this admonishment as youngsters in households across the fruited plain. Our Infection Control 101 lecture started with: Hand washing is the single most important infection control principle we have.

Infection is rampant in most correctional facilities. Our work settings were created for purposes other than healthcare and hold a population with known propensity for a variety of infectious conditions.

Yet, with all this knowledge and all this evidence before us, handwashing frequency is abysmally below standard requirement. I couldn’t find a study of handwashing in correctional settings, but a multihospital study cited by the CDC found only 36-59% of health care workers washing their hands where and when they should.

Nurse leaders from the Mayo clinic suggest that what we really need is not more knowledge but a culture change and environmental accommodations to improve hand washing frequency. In an article in the November, 2011 issue of Nursing2011, authors Johnson, Kachler, and SIska offer the following interventions to improve hand washing:

• Keep it simple: Create simple message about hand hygiene, using protective equipment and cleaning clinical equipment. Find resources on the CDC site.

• Place hand-hygiene products where they are needed: Like at the door of the nurse’s station, the medication room, and clinic rooms used for patient care.

• Integrate hand hygiene into the workflow: Make it easy and convenient. Keep hand sanitizer locked in the medication or treatment cart for use when delivering care in the housing unit.

• Role model: Medical, nursing and administrative leaders should ‘walk the talk’ on hand hygiene and other infection control responsibilities.

But wait, correctional nurses encounter many unique barriers to increasing hand hygiene practices. Here are some of our challenges according to Joseph Bick, a correctional physician:

• Many areas in which clinical care is provided lack hand washing stations. Our facilities were not designed for health care practices.

• Soap and soap dispensers are valuable commodities and may be stolen by inmates

• Alcohol based hand washes burn with a clear flame and may raise concerns with custody staff.

An additional peculiarity of the correctional setting is our patient population’s propensity to take advantage of available resource for their benefit. To wit, inmates have been known to drink alcohol-based hand sanitizer. A recent event landed 4 inmates in the emergency room in Shelby County, AL. []. Although the CDC has not officially supported alcohol-free hand sanitizers, they are growing in popularity in school and correctional settings.

Are you using alcohol-free hand sanitizers? How are you making it easier to “Wash Your Hands!” in your clinical setting? Share your experiences in the comments section.

Here’s a fun video from Jefferson Hospital about hand hygiene:

Photo Credit: © asiln – Fotolia.com

June News Round-Up (Podcast)

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Regular panelist, Sue Smith, MSN, RN, CCHP-RN, and guest panelist Sue Lane, RN, CCHP, join host Lorry Schoenly in a discussion of recent infection outbreaks in the news this month. Our first story comes from Oklahoma, where the State Department of Corrections reports the need to make contact with about 60 former inmates who are believed to have had contact with two inmates found to have active TB at one of the correctional facilities in the state.

In the Oklahoma article, the physician interviewed stated that TB is so controlled in the US public that medical professionals now often miss the signs. Our next news story involves an even less prevalent infectious disease – leprosy. This story comes from Minnesota, where the department of health reports an inmate with likely leprosy – now more commonly referred to as Hansen’s disease – was not managed appropriately and continued in general population for a couple months before being isolated. The inmate is Burmese and had spent a significant amount of time in a Thailand refugee camp. Have either of you had experience with Hansen’s disease in the correctional setting?

After discussing two serious issues – Tuberculosis and Leprosy, we end on a lighter note – inmate creative uses of antibiotic ointment. A research study reported at the annual APIC conference this month found that inmates are using antibiotic ointment for other purposes such as dry skin, lip balm, hair grease and shaving. The researcher and current APIC president suggest this practice may contribute to antimicrobial resistance. and we need more education and awareness. What are your thoughts on this research and how does it compare to what you have seen in your own practices.

Infectious Disease Management Resources

Centers for Disease Control. Health Providers and TB Program Materials By Topic
Centers for Disease Control. Regional Training and Consultation Centers
Federal Bureau of Prisons Clinical Practice Guidelines: Management of Methicillin-Resistant Staphylococcus Aureas (MRSA) infections

 

New Latent TB Regimen from CDC: Good News for Correctional Nurses

            The Centers for Disease Control and Prevention (CDC) announced recommendations for a new treatment option for latent tuberculosis infection (LTBI) this past week.  These recommendations are welcome news for correctional nurses challenged with managing LTBI treatment for their inmate population. Correctional nurses are in contact with a significant portion of the more than 11 million people in the US who are infected with the TB bacterium (4% of the population). Reports clock the incarcerated TB infection rate in US prisons at least 4 times higher. This rate is escalated further in under-developed countries. Improving behind-bars treatment of LTBI can significantly improve public health, in addition to the immediate benefit of decreasing infection transmission to inmates and corrections staff.

The current medication regimen for LTBI treatment is onerous, especially in secure settings. Treatments can last for 9 months and require daily doses of one or more mediations. The serious nature of tuberculosis makes this treatment most often given by direct observation, requiring the patient to be transported to the medical unit daily and observed taking the medication. The new guidelines still require DOT administration, but now the medication is only needed once weekly for 12 weeks for most patients with LTBI. This is a much more efficient regimen for the correctional setting.

New CDC Recommended Treatment for LTBI

  • Isoniazid (INH) and rifapentine (RPT) – a long acting rifamycin-class antibiotic
  • Once weekly in direct-observation dosing for 12 weeks
  • Monthly clinical appointments for side effects and physical assessment

Patients Inappropriate for this Regimen

  • HIV-infected patients receiving antiretroviral treatment
  •  Pregnant women
  • Patient with LTBI and presumed INH or RIF resistant
  • Children under 2 years

The CDC is currently collaborating with the Infectious Diseases Society of America and the American Thoracic Society to update their guidelines to include these recommendations. In addition, it is likely that the Federal Bureau of Prisons (FBOP) will include these significant changes in the next update of their January, 2010 Clinical Practice Guidelines.

2012 will be a good year to re-evaluate and revamp your TB clinical processes. How will these new guidelines change your practice as a correctional nurse?

 

Photo credit: George Kubica/CDC

Correctional Nurses Keep Infection Under Control

Recent news that there are big issues with MRSA(methicillin-resistant Staphylococcus aureus) in some Illinois Prisons got me thinking about how observant correctional nurses can have a great impact on reducing the incidence and spread of this deadly infection in inmate community, thereby protecting custody staff, as well. I am not familiar with the healthcare staffing patterns in IL Prisons, however, many facilities have a designated infection control (IC) nurse who focuses on prevention, containment and treatment of infections in the inmate community. Here are some of the key activities of an infection control nurse in corrections.

Education to Prevent Outbreaks MRSA%20Image

One of the main ways infection outbreaks are prevented is through continuous education of the inmates and custody staff about methods to decrease the spread of infection (Frequent Handwashing!!!). Inmate workers such as porters, kitchen help, and laundry workers need special education in methods to decrease infection spread. The generally low literacy levels of the inmate population require simple and practical instruction methods.

Environmental Scanning

IC nurses regularly round throughout the facility specifically checking for any conditions that might indicate an infection issue. From the temperature of the water in the laundry area to the location of raw foods in the kitchen, the nurse is looking for opportunities to prevent disease spread. Shower stall mold, empty soap dispensers and even leaks resulting in stagnant water are areas of concern. Custody staff are less likely to be attuned to the health implications of these issues. An alert nurse, working in conjunction with custody peers, can improve health conditions.

Inmate Assessment and Early Treatment

IC nurses focus on intake assessments which determine any potential infections which might be brought into the inmate community by new arrivals. Evaluations for TB, skin infections, and H1N1 or other flu symptoms take place at intake. Those with high potential for these conditions are isolated from the general population until definitive diagnosis can take place. These nurses are also often involved in the ongoing treatment of chronic infections such as HIV and hepatitis, by managing the Infectious Diseases clinics with the ID physician specialist.

Reporting and Responding

Most states have health departments which manage the public health and require reporting of any potential outbreak or pandemic situations. An IC nurse can be the key point person with the health department and initiate immediate action in the event of a potential outbreak. It appears that there was lack of communication with the health department in the IL situation cited above. Immediate response to a potential outbreak through containment and treatment can prevent further spread.

How do you keep the spread of infection under control? Share your tips in the comments section of this post.