Correctional Nursing: How to Improve the Practice Environment

Nursing background concept

The first examination of the qualities of professional practice in correctional nursing was done recently in Ontario, Canada. Conclusions from the surveys and interviews of 297 nurses and nurse managers were that the work environment was characterized as understaffed with significant role overload. These nurses also reported limited access to resources, significant autonomy but limited control over practice and experienced significantly higher levels of emotional abuse, conflict and bullying than nurses in other studies. The source of emotional abuse, conflict and bullying most often originated from custody staff followed by other nursing staff (Almost et.al. 2013a). These results support earlier publications about the practice challenges in correctional nursing including limited access to resources and education (Flanagan and Flanagan 2001, Maroney 2005, Smith 2005) , pressure to conform to the values of the custodial subculture (Holmes 2005), and challenges to clinical decision making authority (Smith 2005, Weiskopf 2005).

Reasons to improve the quality of the work environment include the ability to attract and retain nurses, increased productivity, improved organizational performance and better patient outcomes (Almost et.al 2013a, Sherman & Pross 2010, Dall et.al 2009, Needleman et.al 2006). Focusing on improving the professional work environment yields significant results even in the absence of increased staffing (Flynn et.al 2012, Aiken et.al. 2011, Friese et.al. 2008).

The following paragraphs discuss five factors in work environments that can be modified or enhanced to support professional nursing practice.

  1. Control over practice
    • Accurate interpretation and clarification of the state nurse practice act and its guidance in job descriptions, work assignments and policies and procedures (Knox, West, Pinney & Blair 2014, White & O’Sullivan 2012). Workplace directives should also incorporate or reference relevant aspects of the ANA standards of professional practice for correctional nurses (Knox & Schoenly 2014).
    • Work flow should be examined so that barriers to effective practice can be eliminated including system gaps that increase work complexity and work that is not related to patient care (Knox, West, Pinney & Blair 2014, Ebright 2010, Schoenly 2013). An example of the former is locating supplies used for nursing treatments in multiple locations. An example of the later is when nurses are expected to gather and report data on service volume or for quality assurance audits (number of sick call visits, number of clinic appointments, and number of incomplete MARs etc.).
    • Increase nursing participation on committees such as pharmacy and therapeutics, morbidity and mortality review, mental health, utilization review, and medical administration (Aiken et. al. 2011, Flynn et. al. 2012, Almost et.al. 2013a). Staff meetings also should be reviewed to see if meaningful two way dialogue can be increased to involve nurses in identification and early resolution of practice problems.
    • Consider assignment models that emphasize use of nursing process and clinical judgment rather than task completion; where registered nurses provide a greater proportion of direct care themselves while actively supervising care delegated to others (Corrazini et.al 2013a; MacMurdo, Thorpe & Morgan 2013). Staffing takes thoughtful preparation and legacy staffing practices may no longer work as complexity in health care delivery increases (Knox, West, Pinney & Blair 2013, Ebright 2010, MacMurdo, Thorpe & Morgan 2013).
  2. Autonomy in clinical practice
    • Considered one of the hallmarks of correctional nursing it is also an Achilles heel in the absence of appropriate clinical guidelines and support in their use (ANA 2013, Smith 2013, Smith 2005). Protocols should be based upon nursing process and coordination of care rather than reaching a medical diagnoses and rushing to treatment conclusions.
    • Nurses must be appropriately qualified and experienced in assessment and clinical reasoning as well as skilled in surveillance related to the variety of clinical situations encountered in the correctional setting to use protocols.
    • Provide access to information and tools that enhances recognition of clinical patterns and deviations necessary for good clinical judgment (Ebright 2010).
    • Assist nurses to prioritize and coordinate care with daily briefings, debriefings, huddles and work flow tracking to provide real time information about the availability and assignments of other members of the health care team (including primary care and mental health staff).
  3. Positive workplace relationships
    • Establish clear expectations for a respectful workplace in policy, procedure and other written directive. These instructions should define behaviors consistent and inconsistent with professional behavior in the workplace; describe what to do in the presence of unprofessional behavior and how to report these incidents (Almost et.al. 2013a).
    • Joint meetings and interdisciplinary training can be the vehicle to demonstrate support for the goals of both health care and custody (Almost et.al. 2013a, Weiskopf 2005).
    • Nurses may benefit from additional development in the area of conflict resolution because they have such a prominent role negotiating coordination of patient care with custody operations (Schoenly 2013, Weiskopf 2005).
    • Increase communication about patient care between registered nurses and LPN/LVNs (Corrazini et. al. 2013).
  4. Support education and certification
    • Orientation also needs to be tailored to the needs of each individual based upon education, licensure and an assessment of competency (Knox, West, Pinney & Blair 2014; Shelton, Weiskopf & Nicholson 2010). The ANA scope and standards of professional practice should also be incorporated into new employee orientation so that nurses develop institution specific skills consistent with the expectation of the professional discipline (Knox & Schoenly 2014).
    • Mentoring and coaching of new employees should be emphasized in development of expertise in clinical reasoning (Schoenly 2013, Ebright 2010).
    • Use creative, simple approaches to continuing education including self-study, reflective exercises, on-line web based seminars, facilitated case review and discussion, and a journal club (Almost et.al. 2013b, Schoenly 2013). Staff with superior knowledge and skill in a subject area can be asked to assist in developing relevant continuing education material (Knox, West, Pinney & Blair 2014).
    • Certification in correctional nursing is available through both the American Corrections Association and the National Commission on Correctional Health Care. These exams are offered regionally and can be administered at the place of employment if there are enough people taking the exam.
  5. Adequate resources
    • Includes staffing, equipment and supplies as well as access to leadership. Examining the work of first line managers may reveal sources of role overload (scheduling, meetings, payroll data gathering etc.) that impede their availability to line staff and can be reassigned to increase the availability of clinical leadership to line staff(Almost et.al. 2013a).
    • Review legacy staffing practices and work flow to identify opportunities to adjust assignments that result in more appropriate or effective use of existing resources (Knox, West, Pinney & Blair 2013, Ebright 2010).
    • Involve nurses in evaluation of equipment and technology decisions to prevent acquisition of products that complicate rather than improve delivery of patient care (Ebright 2010). For example decisions about how patient specific prescriptions were packaged have impacted timeliness and accuracy of medication administration in some correctional facilities because the packaging was cumbersome and time consuming for nurses to use.

Conclusion: Attention to the work environment of nurses (control over nursing practice, autonomy without isolation, positive working relationships, support for education and specialty certification, and adequate resources) has a profound effect on nursing practice, the ability to recruit and retain nursing personnel and on patient outcomes. More resources about work environments that support professional nursing practice can be found at the sites listed in the resources section below.

What do you think can be done to improve the professional practice work environment for correctional nurses? Are there resources or solutions not discussed here that should be? Please share your opinions by responding in the comments section of this post.

For more on correctional nursing read our book, the Essentials of Correctional Nursing. Order your copy directly from the publisher. Use promotional code AF1209 for $15 off and free shipping.

Resources

 

References

Aiken, L.H., Cimiotti, J.P., Sloane, D.M., Smith, H.L., Flynn, L., Neff, D.F. (2011) Effects of nurse staffing and nurse education on patient deaths in hospitals with different nurse work environments. Medical Care 49(12): 1047-1053.

Almost, J., Doran, D., Ogilvie, L., Miller, C., Kennedy, S., Timmings, C., Rose, D.N., Squires, M., Lee, C., Bookey-Bassett, S. (2013a) Exploring work-life issues in provincial corrections settings. Journal of Forensic Nursing 9:1

Almost, J., Gifford, W.A., Doran, D., Ogilvie, L., Miller, C., Rose, D.N., Squires, M. (2013 b) Correctional nursing: a study protocol to develop an educational intervention to optimize nursing practice in a unique context. Implementation Science 8:71

American Nurses Association. (2013) Correctional Nursing: Scope and Standards of Practice. Silver Spring, MD: Nursebooks.org

Corrazzini, K.N.; Anderson, R.A.; Mueller, C.; Hunt-McKinney, S.; Day, L.; Porter, K. (2013). Understanding RN and LPN Patterns of Practice in Nursing Homes. Journal of Nursing Regulation. 4(1); 14-18.

Dall, T.M., Chen, Y.J., Seifert, R.F., Maddox, P.J., Hogan, P.F. (2009). The economic value of professional nursing. Medical Care 47 (1):97-104.

Ebright, P.R. (2010). The complex work of RNs: Implications for a healthy work environment. Online Journal of Issues in Nursing. 15(1).

Flanagan, N. & Flanagan, T. (2001) Correctional nurses’ perceptions of their role, training requirements and prisoner health care needs. The Journal of Correctional Health Care 8:67-85.

Flynn, L., Liang, Y., Dickson, G., Xie, M., Suh, D.C. (2012) Nurse’s practice environments, error interception practices, and inpatient medication errors. The Journal of Nursing Scholarship. 44(2):180-186.

Friese, C.R., Lake, E.T., Aiken, L.H., Silber, J.H., Sochalski, J. (2008) Hospital nurse practice environments and outcomes for surgical oncology patients. Health Services Research. 43(4): 1145-1162.

Holmes, D. (2005) Governing the captives: Forensic psychiatric nursing in corrections. Perspectives in Psychiatric Care 41(1):3-13.

Knox, C.M., Schoenly, L. (2014) Correctional nursing: A new scope and standards of practice. Correct Care, 28 (1) 12-14.

Knox, C.M., West, K., Pinney, B., Blair, P. (2014) Work environments that support professional nursing practice. Presentation at Spring Conference on Correctional Health Care, National Commission on Correctional Health Care. April 8, 2014. Nashville, TN.

MacMurdo, V., Thorpe, G., & Morgan, R. (2013) Partners in practice: Engaging front-line nursing staff as change agents. Presentation at Custody & Caring, 13th Biennial International Conference on the Nurse’s Role in the criminal Justice System. October 2-4, 2013. Saskatoon, SK.

Maroney, M.K. (2005) Caring and custody: Two faces of the same reality. Journal of Correctional Health Care. 11:157-169.

Needleman, J., Buerhaus, P.I., Stewart, M., Zelevinsky, K. Matke, S. (2006) Nurse staffing in hospitals: Is there a business case for quality? Health Affairs. 25(1):204-211.

Shelton, D., Weiskopf, C., Nicholson, M. (2010). Correctional Nursing Competency Development in the Connecticut Correctional Managed Health Care Program. Journal of Correctional Health Care. 16 (4). 38-47.

Sherman, R. & Pross, E. (2010) Growing future nurse leaders to build and sustain healthy work environments. Online Journal of Issues in Nursing. 15(1).

Schoenly, L. (2013) Management and Leadership. In Schoenly, L., & Knox, C. (Ed.) Essentials of Correctional Nursing. New York: Springer.

Smith, S. (2013) Nursing Sick Call. In Schoenly, L., & Knox, C. (Ed.) Essentials of Correctional Nursing. New York: Springer.

Smith, S. (2005) Stepping through the looking glass: Professional autonomy in correctional nursing. Corrections Today 67(1):54-56.

Weiskopf, C.S. (2005) Nurse’s experience of caring for inmate patients. Journal of Advanced Nursing 49(4):336-343.

White, K. & O’Sullivan, A. (2012). The Essential Guide to Nursing Practice: Applying ANAs Scope and Standards in Practice and Education. American Nurses Association. Silver Springs, MD: Nursebooks.org.

Photo credit: © Kheng Guan Toh – Fotolia.com

 

Minimizing liability in correctional nursing

Overburdened doctor at the hospital in the stressLitigation has been a major catalyst in the reform of the criminal justice system, including the delivery of health care. Correctional nurses can expect to be involved in litigation involving health care during their professional career in this specialty practice area. Being familiar with the legal system particular to correctional health care, regulations and other information about the nurse practice act, as well as the profession’s code of ethics assist nurses in steering through the liability landscape (Moore 2013).

I recently reviewed an article describing a study of nurses practice insurance claims. What really caught my attention was that correctional health was one of the specialty areas included in the analysis. The results were very interesting and are summarized here.

CNA HealthPro and Nurses Service Organization (NSO) analyzed nurses professional liability claims which had been closed between 2006 and 2010 to identify patterns or trends in liability and to make recommendations to both minimize exposure and promote patient safety (Benton & Flynn 2013). This analysis included 516 liability claims and another 1,127 claims for defense against allegations made to regulatory boards. Finally, a survey was conducted of 1,617 nurses who had experienced a liability claim loss between 2006 and 2010 and a random matched sample of nurses who had never had a claim to identify demographic and workplace factors that affect risk exposure. The analysis was limited to registered nurses (RNs) and licensed practical or vocational nurses (LPN/LVN). Please note that a similar analysis was completed in 2012 for advanced registered nurse practitioners (ARNPs) and can be obtained at their website.

Professional liability claims involving nurses in correctional health care are a small proportion of total closed claims and the average indemnity cost in this field was less than the average for all claims. The table below depicts how nurses’ liability in correctional health compares to other practice specialties in terms of closed claim experience.

Nursing specialty % of closed claims Average paid indemnity
Correctional health 3.1 $144,701
Obstetrics 10.3 $382,353
Behavioral health 1.7 $151,944
Adult med/surg 40.1 $143,969
Emergent/urgent care 9.7 $141,832
Community health/hospice 8.9 $138,452
Gerontology 18 $100,294
Overall 100 $161,501

Claims involving scope of practice, assessment and monitoring had the highest average indemnity payments consistent with the significant effects these aspects of practice have on patient safety. Closed claims regarding nursing care or treatment were more prevalent but had a lower average payout. The work profile survey showed that lower indemnity payments were associated with nurses who reported more continuing education, working in an organization that had a policy for disclosing errors and who were comfortable asking managers for help.

The risk control recommendations made as a result of the analysis are similar to those made by Jacqueline Moore in Chapter Three of the Essentials of Correctional Nursing. The recommendations from both these sources are consolidated here:

1. Make sure your individual practice is consistent with the state nurse practice act and the organization’s policies and procedures.

  • Request and review a copy of the nurse practice act from the state regulatory board.
  • Review your organization’s policies and procedures regularly.
  • If the organization’s policy and procedure differ from the state nurse practice act bring this to the attention of your manager. Until clarified follow the directive which is the most restrictive. In other words, the organization can limit your practice in the work setting but cannot assign responsibilities that are broader than the nurse practice act.
  • Know the steps you are to take within your organization if you are given an assignment outside the lawful scope of practice or your personal competence to perform.
  • Do not accept assignments that you are not competent to perform.

2. Ensure communication is professional, accurate, respectful, inclusive, complete, appropriate and timely.

  • Determine the patient’s primary language or communication preferences and arrange translation or other accommodations to ensure the patient understands and agrees with the plan of care.
  • Exchange key information whenever responsibility for the patient is transferred from one caregiver to another or from one setting to another.
  • Do not criticize a provider in the presence of a patient or in documentation in the health record.

3. Maintain clinical competencies relevant to the needs of the population served and standards of practice for correctional nursing.

  • Attend relevant classes, in-service and continuing education. Maintain copies of certificates or other evidence of attendance.
  • Participate in peer review and reflective practice exercises.
  • Subscribe to journals, websites and other means to stay up to date with the literature that pertains to correctional nursing such as this blog post and Correctional Nurse.net.
  • Join professional organizations such as the American Nurses Association, the International Association of Forensic Nurses, the American Correctional Health Services Association, the Academy of Correctional Health Professionals, and the American Corrections Association.

4. Nurses are in the prime position to prevent harm to the patient and are expected to advocate for the patient’s wellbeing.

  • Invoke the chain of command as necessary to focus attention on the patient’s status or when there is a change in condition.
  • Ensure timely attention to patient needs and implementation of the plan of care.
  • Persist in communication and follow-up regarding the patient until a satisfactory resolution is achieved.
  • Address communication issues that deter use of the chain of command including identification of individuals who ignore, bully, retaliate or intimidate when chain of command is accessed.

Kathy Page, a colleague of ours, summed this subject up in a quote from the Essentials of Correctional Nursing “During the years reviewing malpractice cases that took place in correctional settings, most of the litigation was due to nurses not advocating for the patient, resulting in a delay in treatment. This includes nurses being judgmental in their charting (e.g. “malingering, drug seeking”), resulting in lack of access to care. Also, nurses’ failure to follow the provider’s orders for medications and treatments resulted in withholding or lack of care” (page 53).

In publishing the results of this claims analysis, the authors suggest that nurses be inspired to examine their practice to identify the recommendations for change most likely to reduce liability risk using this self-assessment tool developed as part of the full report.

Are these the results you expected? What recommendations do you have to reduce liability for nursing practice in the correctional setting? Please share your thoughts by replying in the comments section of this post.

For more on correctional nursing read our book, the Essentials of Correctional Nursing. Order your copy directly from the publisher. Use promotional code AF1209 for $15 off and free shipping.

References

Benton, J.H. & Flynn, J. (2013) Identifying and minimizing risk exposures affecting nursing practice to enhance patient safety. Journal of nursing Regulation 3(4):4-9.

Moore, J. (2013) Legal considerations in correctional nursing in Schoenly, L. and Knox, C.M. (eds.) Essentials of Correctional Nursing. New York, NY: Springer Publishing.

 

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Alcohol Withdrawal: Special Issues

Danger signEven with an effective screening process, a solid treatment plan, and regular monitoring, patients withdrawing from alcohol can be in danger. Seizures and Delirium Tremens (DTs) can derail an otherwise effective withdrawal program. That is why it is also important to consider patient safety when making management decisions.

Safe Housing

Withdrawing patients are prone to falls and injury. Decreased liver functioning from long alcohol use causes increased bleeding tendencies that lead to hematoma formation, making head injury dangerous. Hallucinations and delirium can lead to erratic behavior and friction with officers and other inmates. Officers need to be aware of any inmates they are monitoring who are withdrawing. Those with potential for confusion, agitation, seizures, or delirium should be housed in the most protective manner possible.

Complicating Circumstances

Chronic conditions and past injuries can make alcohol withdrawal even more perilous than usual. According to Federal Bureau of Prison guidelines, withdrawing patients who have any of these additional conditions should have even close monitoring and additional safety precautions.

  • Cardiac Conditions: Sympathetic hyperactivity, common as high levels of alcohol are withdrawn, can agitate a weakened heart. A slower taper of benzodiazepine therapy is recommended for this group of patients.
  • Elderly: Older alcoholics may not show the usual signs of sympathetic hyperactivity so they may progress to severe withdrawal symptoms without any warning. Higher levels of chronic diseases and greater use of prescription drugs in this patient population increases chances of co-morbid complications and drug interactions. Aging causes decreased drug metabolism that can affect the adjustment of medications during the treatment tapering process.
  • History of Traumatic Brain Injury (TBI): Past brain injury increases the likelihood of seizures or DTs.
  • Liver or Kidney Disease: Chronic liver or kidney disease leads to poor metabolism of medication that requires closer monitoring as treatments are tapered.
  • Pre-existing Psychiatric Conditions: Alcohol can ameliorate psychiatric conditions. Mental illness symptoms may re-emerge once alcohol is no longer in the system. Severe depression, in particular, can lead to attempts at self-harm and suicide. Another reason for close monitoring.
  • Pregnant Inmates: Pregnancy complicates the withdrawal process by adding a second patient. Coordination of alcohol withdrawal with an obstetrical specialist is highly recommended, especially if there is also concern about drug use. Many correctional settings are not equipped or staffed to manage complex situations so transfer to an acute care facility is often the best option.
  • Seizure Disorders: A history of seizure disorders or already being under medical management for seizures increases the potential for withdrawal seizures. This history should be considered when tapering from benzodiazepine treatment. A slower taper is recommended for these patients.

How do you handle alcohol withdrawal for patients with these additional considerations? Share your tips in the comments section of this post.

To read more about alcohol and drug withdrawal in the correctional setting see Chapter 5 in the Essentials of Correctional Nursing. The text can be ordered directly from the publisher and if you use Promo Code AF1402 the price is discounted by $15 off and shipping is free.

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Alcohol Withdrawal: Keeping Tabs

AlkoholsuchtWithdrawing from alcohol may be a common experience behind bars but it can never be taken lightly. Withdrawing patients need ongoing monitoring until they are through the risky period – at least the first three to five days. So, once you have screened for alcohol withdrawal and set a treatment plan in motion, you need to regularly check-in with withdrawing inmates to assess the progression of symptoms.

Know the Score

Both the Federal Bureau of Prisons Clinical Practice Guideline for Detoxification of Chemically Dependent Inmates and the NCCHC Alcohol Detoxification Guideline recommend the use of the Clinical Institute Withdrawal Assessment of Alcohol Scale, Revised (CIWA-Ar) for ongoing symptom monitoring and management during alcohol withdrawal (A copy of the CIWA-Ar can be found in the FBOP Guidelines).

This quick-to-use tool has been validated in many settings and assesses vital signs and withdrawal symptoms in 10 categories:

  • Nausea/Vomiting
  • Tremors
  • Anxiety
  • Agitation
  • Paroxysmal Sweats
  • Orientation and Clouding of Sensorium
  • Tactile Disturbances
  • Auditory Disturbances
  • Visual Disturbances
  • Headache

A score is calculated by summing the scale number for each of the 10 categories. The highest obtainable score is 67 and most protocols consider a score greater than 15 to need increased attention and medical treatment. For example, the NCCHC Alcohol Detoxification Guidelines recommends this categorization of patients based on a CIWA-Ar Score:

  • Low Risk: Asymptomatic or minimal symptoms (CIWA-Ar score less than 10)
  • Moderate Risk: A history of significant alcohol withdrawal syndrome and history of medical and psychiatric conditions (CIWA-Ar 10-15)
  • High Risk: History of severe alcohol withdrawal syndrome including seizures, delirum tremens, and suicidal ideations (CISA-Ar greater than 15)

Using the Data

Using risk categories can determine the level of attention given to withdrawing patients. For example, low risk patients may be evaluated every 8 hours while moderate and high risk patients may need hourly assessments and intervention until symptoms subside.

Regularly assessing withdrawing patients along a continuum of these ten symptoms provides objective data that can be used to guide treatment with benzodiazepines. The FBOP guidelines establish a treatment protocol based on the CIWA-Ar score:

CIWA Treatment

The Assessment Challenge of CIWA-Ar

Although the CIWA-Ar rating system is practical and can be completed in a few minutes, it requires practice and consistency among raters. Let’s take the scoring for agitation as an example. Here are the directions on the Scoring Tool:

Rate on a Scale of 0-7

  • 0 = No Activity
  • 1 = Somewhat Normal Activity
  • 4 = Moderately fidgety and restless
  • 7 = Constantly paces or thrashes about

The directions indicate that you can rate this category anywhere from 0-7 and provides low, middle, and high score examples. One nurse may determine that the patient is slightly more than moderately fidgety and restless; rating the patient as a 5. The next shift nurse may see the same restlessness as slightly under moderate and rate the patient a 4. In reality, the patient may be escalating in agitation and is really on the way to a 7. With a spread of scores in both the FBOP and NCCHC guidelines of less than 10 to over 15 encompassing risk ranges, a couple points difference in nurse evaluations can mean missing increased withdrawal symptoms or overmedicating receding symptoms.

Meeting the Challenge

In the high-stakes process of managing alcohol withdrawal, assessment variability using the CIWA-Ar tool must be minimized. This can be accomplished in several ways:

  • Orient every nurse specifically to the tool including the use of case presentations to be sure the directions can be correctly applied.
  • Use actual withdrawal situations to determine inter-rater reliability of the use of the tool. Have more than one nurse independently score a withdrawing patient and then have them compare their findings.
  • Consider only using the defined scores on the tool. For example, in the agitation category the only scores possible would be 0,1,4,7. This could eliminate some of the variability among raters.
  • Consider instructing assessors to err on the side of higher scores as the greater risk is in not treating withdrawal and closer monitoring is a safer outcome.

Successful alcohol withdrawal in the criminal justice system requires a thoughtful coordinated effort involving many team members. Ongoing monitoring of withdrawing patients is a major part of this effort. How are you monitoring your withdrawing patients? If you use the CIWA-Ar Tool, how do you confirm proper use? Share your thoughts in the comments section of this post.

To read more about alcohol and drug withdrawal in the correctional setting see Chapter 5 in the Essentials of Correctional Nursing. The text can be ordered directly from the publisher and if you use Promo Code AF1402 the price is discounted by $15 off and shipping is free.

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Alcohol Withdrawal: What’s the Plan?

What is your plan ?Alcohol withdrawal is a fact of life in our patient population. You are likely screening for it on intake and hopefully using a standard evaluation tool like those described in a prior post. Once you see an incoming patient is at risk for withdrawal, what is your plan?

Location, Location, Location

Withdrawing patients need to be located where they will not get lost in the system. Some facilities have the capacity to keep potentially withdrawing patients in an Infirmary or Special Needs Unit where they are directly monitored. Other facilities only place symptomatic patients in the infirmary and keep potentially withdrawing patients in a specific housing unit. If they develop symptoms they are transferred to a higher level of observation or treatment. The key principle is to have a designated place for potentially withdrawing inmates where officers and other staff are aware of what signs and symptoms indicate alcohol withdrawal.

Get the Timing Down

If you know when your patient last had a drink or can estimate it based on entry into the facility, you can have some idea of when withdrawal symptoms will peak. Of course, timing is individualized based on many factors such as the patient’s liver health and long-term nature of the alcoholism. However, generally, withdrawal from alcohol progresses to completion over 5 days with the greatest degree of symptoms in the first 24-36 hours. Without intervention, though, withdrawal can lead to delirium tremens at about 3-5 days from the last drink. This condition is serious and can lead to hallucinations, electrolyte imbalances, unconsciousness, and death. Even ‘frequent-flyer’ alcoholics with a known history of uncomplicated withdrawals in your facility should be watched closely and treated for withdrawal. A phenomena called ‘alcohol withdrawal kindling’  can emerge where progressive withdrawal episodes increase in neurotoxic intensity. This means your ‘regular’ withdrawing patient may not progress as mildly this time around.

Maintain the Protocol

Alcohol withdrawal is both a common and risky medical condition for the inmate-patient population. Therefore, it is important to have a standard protocol for treatment. A standard protocol establishes consistent and appropriate practices for all staff members and provides a safeguard in those situations where practitioners may be unfamiliar with the standard of care. The Federal Bureau of Prisons Clinical Practice Guideline for Detoxification of Chemically Dependent Inmates is a good place to start in determining necessary elements of a plan of care. Here are some important management principles that should be a part of any correctional alcohol withdrawal protocol:

When to Seek Provider Orders: If a patient is deemed a medium or high risk of alcohol withdrawal at intake, most protocols stipulate a provider evaluation and prescriptive therapy. Low risk patients may be put on a monitoring protocol and advanced to provider oversight if symptoms emerge. Many of the protocol treatments described in this post require a provider order but can be part of a protocol list to speed treatment ordering and avoid omissions.

Patient Evaluation: Withdrawal protocols should spell out how often patient evaluations should take place, with increasing evaluation frequency if severity progresses. Low risk patients, for example, may require three-times-a-day evaluation while high risk patients may require every two hour evaluations for a specific time period.

Benzodiazepine Therapy: A cornerstone of alcohol withdrawal management is the use of benzodiazepines to reduce the excitability of the nervous system that has been shocked by the loss of alcohol. This tranquilizing effect can relieve withdrawal symptoms such as insomnia, muscle spasms, involuntary movement disorders, anxiety, and convulsions. While some correctional providers recommend long-acting options, such as Valium, as they have the ability to self-taper over time, the FBOP guidelines recommends Ativan, a shorter-acting option. The point is to have benzodiazepine therapy as part of the protocol with specific guidelines at to timing and dose. This may end up being based on the facility medical director’s preference and comfort level. Having a consistant program for benzodiazepine therapy spelled out in a protocol eliminates variability and helps both nurses and providers maintain the program.

Vitamin Therapy: Many who are alcohol dependent are poorly nourished and frequently thiamine deficient. Thiamine replacement therapy is recommended as a part of a withdrawal protocol along with a multivitamin.

Symptom Management: Common withdrawal symptoms should be addressed on the protocol with standard treatment options. Many symptoms of alcohol withdrawal are reduced through benzodiazepine administration but other common side effects such as headache, nausea, and vomiting may need additional comfort measures such as pain relievers or anti-emetics. Having these options addressed on a protocol and then prescribed by a provider at the time of protocol initiation is efficient.

Nutrition and Hydration:Don’t forget the need for quality food and water during withdrawal. This point, in itself, may indicate a need for a special housing assignment for withdrawing inmates. Most chronic alcoholics are undernourished and can become dehydrated during withdrawal. This can lead to eleyctrolyte abnormalities and hypoglycemia. Encouraging eating and drinking is important. Some settings even have electrolyte replacement drinks available for use by patients in withdrawal. Many protocols include checking fingerstick blood glucose daily on high risk patients.

Know When to Hold ‘Em – Know When to Ship Them

Many, if not most, of our patients withdrawing from alcohol can be treated safely behind the perimeter, but some can’t. Knowing when a patient needs to be moved to a higher level of care is crucial. Generally, seizures, hallucinations, or hemodynamic instability are all indications of a need for acute care monitoring and treatment. Be sure to have indications for emergency transport spelled out in your alcohol withdrawal protocol.

What is your plan for managing alcohol withdrawal in your setting? Share your tips in the comments section of this post.

Other Alcohol Withdrawal Resources

Drug and Alcohol Withdrawal Clinical Practice Guidelines – NSW

World Health Organization Management of Alcohol Withdrawal Recommendations

To read more about alcohol and drug withdrawal in the correctional setting see Chapter 5 in the Essentials of Correctional Nursing. The text can be ordered directly from the publisher and if you use Promo Code AF1402 the price is discounted by $15 off and shipping is free.

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Alcohol Withdrawal: Do You Know the Signs?

AlkoholismusAlcohol withdrawal is the most serious of substance withdrawal situations. Do you know the signs of this condition? Most everyone working in a jail for even a short time is aware of the substantial use of alcohol by those detained for criminal activity or other law violations. Indeed, many of these law violations are a result of alcohol overuse such as DUI, traffic violations, and personal injury due to car crashes. As many as 85% of inmates are substance involved in some way. One study of data from the Arrestee Drug Abuse Monitoring Program (ADAM) estimates 1.2 million arrestees were alcohol dependent in 1997.

BOLO!

Be on the lookout for alcohol withdrawal in all your jail patients. Universal screening for alcohol withdrawal is recommended by the National Commission on Correctional Health Care (NCCHC) in their Alcohol Detoxification Guideline. They recommend that every intake screening include the following:

  • An explanation of why alcohol screening is taking place – to identify those who need treatment for withdrawal
  • Questions about the type, amount, frequency, duration of use, and withdrawal history
  • Immediate medical evaluation for a positive history of heavy and regular alcohol use.

NCCHC guidelines also recommend the use of a standard screening tool such as the Simple Screening Instrument for Substance Abuse (SSI-SA). This list of questions is indeed simple and less cumbersome than many alternatives. An advantage of this tool is that is can be used for either drugs or alcohol. The patient’s answers to 16 yes/no questions are then scored along a continuum of degree of risk for abuse.

Another highly-credible alcohol screening tool is CAGE, discussed in a prior blog post. CAGE is even shorter than the SSI-SA and is specific to alcohol intake. Two positive responses are considered a positive test and indicate further assessment is warranted.

The World Health Organization (WHO) recommends use of AUDIT – the Alcohol Use Disorders Identification Test. This tool was developed and extensively evaluated in a variety of settings, making it a credible screening option.

Whatever tool you use, it is important to consistently screen every incoming patient.

Expect Under-Estimation

There are many reasons your patients may under-estimate their alcohol involvement. First of all, if alcohol use could be a contributor to the activity that resulted in detainment, your patient may not want to emphasize use. Then, trust might be lacking in the nurse-patient relationship that will limit full disclosure. Finally, people generally under-estimate poor habits while over-estimating good behaviors. For all these reasons, some seasoned jail nurses mentally double the estimated drinking reported on intake. Although that might be extreme, expecting under-estimation can help you better predict withdrawal potential.

Assume It Is Present

Alcohol withdrawal should be top-of-mind when screening those entering the criminal justice system. Besides screening tool results, NCCHC guidelines also recommend that immediate medical evaluation be sought for observable symptoms of current alcohol use such as alcohol on the breath, unsteady gait, or confusion.

Withdrawal from alcohol causes increased excitability in the nervous system leading to the following manifestations:

  • Nausea and/or vomiting
  • Tremors, tremulousness, or agitation
  • Confusion
  • Unsteadiness or lack of coordination

Any of these symptoms should indicate a deeper evaluation of alcohol withdrawal potential.

How do you screen for potential alcohol withdrawal in your setting? Share your thoughts in the comments section of this post.

To read more about alcohol and drug withdrawal in the correctional setting see Chapter 5 in the Essentials of Correctional Nursing. The text can be ordered directly from the publisher and if you use Promo Code AF1402 the price is discounted by $15 off and shipping is free.

Photo Credit: © Jörg Lantelme – Fotolia.com

Preventing diversion of prescription drugs in prison and jail

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Last week’s post described the epidemic of prescription drug abuse in the United States and the impact on the nation’s jails and prisons. This week we return to the same subject but focus on the problem of prescription drug diversion during incarceration. There are many more medications available and appropriate to be used in treatment today than when I started in nursing 40 years ago. Just to illustrate there were an average of 13 prescriptions written in 2011 for every person in the United States. At one of the jails I am familiar with an average of 24 prescriptions per inmate are filled each month.

Most correctional facilities allow some medications to be taken by inmates on their own as directed by the provider. This is usually called a “self-carry” or “keep on person” program. Virtually all facilities also require that certain medication be administered to inmates. These medications usually have potential for misuse (narcotics) or are medication regimes that require close monitoring (TB prophylaxis). The volume of medications handled daily in correctional facilities is substantial.

Nearly 85% of incarcerated adults in the United States have a substance use disorder and four out of five crimes committed by youth involve substance abuse (National Center on Addiction and Substance Abuse 2010, 2004). Some misuse of prescription drugs takes place simply because access to illegal drugs is so greatly limited during incarceration. Incarceration also brings other discomforts such as insomnia, pain, anxiety and boredom. Inmates may request medication from health care staff; they may also simply take or trade for someone else’s medication in an effort to alleviate problems like these. As correctional health care professionals we all have experience with patients who feign an illness or symptom to get a prescription for a preferred medication. Prescription medication has a value in prison or jail that is greater than in the general community (Phillips 2014).

Diversion and misuse of prescription medication is as much a clinical problem as a custodial one. If patients are bullied or coerced into giving up needed medication their condition may deteriorate. The provider may prescribe higher doses or additional intervention to treat a condition that appears unimproved when instead the patient was not treated effectively in the first place. In addition inmates who take someone else’s medication are not monitored clinically and expose themselves to potential for adverse reaction or other injury.

Methods to prevent or mitigate diversion

  1. Formulary controls: Often the first reaction to counter diversion is to ban prescription of the drug in the first place. The problem with this approach is that once a particular drug is banned another becomes the drug of choice for misuse. Secondly there are appropriate clinical indications for these medications and not allowing their use is to deny medically necessary care. It is possible to designate a particular drug as a non-formulary item that requires additional rationale and review before it can be issued. An example of this is that many facilities have made bupropion a non-formulary anti-depressant and thus limited its use (Phillips 2012). It is also possible to designate a certain housing location with greater supervision and control for patients receiving drugs at high risk for diversion. For example some facilities require patients to be admitted to the infirmary in order to receive treatment with an opiate analgesic.
  2. Choice of preparation: Another action is to administer the drug in a way that limits the possibility of diversion. Choices include ordering the drug in a liquid, aerosol or injectable preparation or that the tablet be “crushed and floated” (Bicknell et.al. 2011). Challenges are that these methods are either more expensive or time consuming to administer. A policy to “crush and float” an entire class of drugs (i.e. psychotropics) is not advised since the effectiveness and safety of some medications may be altered. Nurses expose themselves to liability if they “crush and float” medications against manufacturer advice (Phillips 2012).
  3. Increased multidisciplinary communication: Communication between providers, nurses and custody staff about prescription drug abuse generally and the importance of each method used to minimize diversion will reinforce the roles of each (Phillips 2014). Both correctional officers and nurses have responsibilities to ensure that inmates take medications as prescribed. These include maintaining orderliness during medication administration, monitoring ingestion, observing individual inmates for intended and unintended effects of medication. Correctional officers should be invited to provide information about behavior that suggests coercion by others or diversion. Providers and nurses may ask correctional officers about their observations of an inmate’s behavior to help with diagnosis or clinical monitoring. Random cell searches by correctional staff and periodic review of adherence by nursing staff are very helpful in identifying inmates who are diverting medication. Recently a facility changed their procedure for medication administration to include checking an inmate’s hands as well as their mouth before leaving the medication area. This change was made after discussion with an inmate who was found trading medication. The provider asked the inmate how he managed to get the medication and he gladly demonstrated his sleight of hand. It was an educational experience for all the staff and improved the methods used to control diversion at the facility.
  4. Caring for patients: Proactive identification and preventive treatment of inmates withdrawing from use of illicit drugs is an important first step in reducing diversion. This includes programming and targeted education to build alternative coping skills and recovery (Phillips 2012).Indications that a patient may be “at risk” of diverting prescribed medication include:
  • Requesting a particular drug by name before describing symptoms
  • Objective data about the patient’s condition is inconsistent with the description of symptoms
  • Refusal or non-adherence with other drugs prescribed for the condition
  • Claiming allergies or side effects to other possible drugs without being able to provide specific detail
  • Not remembering or being able to pronounce drugs other than the preferred drug
  • Threatening or other signs of excessive distress when the requested drug is not prescribed (Phillips 2012, 2014).

The nurse should be observant for these behaviors when seeing patients in sick call, nurse clinics or during medication administration, document the findings in the inmate’s health record and inform the patient’s prescribing provider. This information is more helpful to the treating provider when it is descriptive rather than judgmental. Nurses should also discuss with patients the potential for victimization when taking medication, the adverse outcomes of prescription drug abuse as well as steps to protect the inmate. This discussion is most effective if it is specific to the patient, the drug and their behavior rather than more general information.

Medications with high diversion value in the correctional setting

Click on this link to a table Common Prescription Medications- Use and Misuse which lists the prescription medications that are commonly misused or abused by inmates. The table also lists the purpose each drug is usually prescribed for as well as the reason for its misuse. During administration or when working with patients to self-administer these drugs nurses should be hyper-vigilant for possible diversion. Please remember though that any prescription medication can be misused if there is a belief that the drug will produce some desired effect.

Conclusion:

What have you learned about diversion of prescribed medications at your correctional facility that has not been discussed here? Are there methods to prevent diversion not discussed here that should be? Please share your opinions and experience by responding in the comments section of this post.

Anthony Tamburello, MD, FAPA, Statewide Associate Director of Psychiatry,  Rutgers University Correctional Health Care in New Jersey provided much of this information in a continuing education presentation for nurses and was willing to share it for use in this post. Also correctional physicians in the United Kingdom have published Safer Prescribing in Prisons: Guidance for Clinicians a thoughtful and well organized on-line resource. For more on correctional nursing read our book, the Essentials of Correctional Nursing. Order your copy directly from the publisher. Use promotional code AF1209 for $15 off and free shipping.

Resources:

Bicknell, M., Brew, I., Cooke, C., Duncall, H., Palmer, J., Robinson, J. (2011) Safer Prescribing in Prisons: Guidance for Clinicians. Royal College of General Practitioners, Secure Environments Group. Accessed at http://www.rpharms.com/news-story-downloads/prescribinginprison.pdf.

Centers for Disease Control and Prevention. (2014) Prescription Drug Overdose in the United States: Fact Sheet. Accessed at http://www.cdc.gov/homeandrecreationalsafety/overdose/facts.html.

Kirschner, N., Ginsburg, J., Sulmasy, L. S., (2014) Prescription Drug Abuse: Executive Summary of a Policy Position from the American College of Physicians. Annals of Internal Medicine 160 (3).

Laffan, S. (2013) Alcohol and Drug Withdrawal in Schoenly, L. & Knox, C.M. (ed.) Essentials of Correctional Nursing, pp. 81- 96, (New York: Springer Publishing Company LLC).

National Commission on Correctional Health Care. (Prisons and Jails 20014). Standards for Health Services. National Commission on Correctional Health Care.

Phillips, A. (2014) Prescribing in prison: complexities and considerations. Nursing Standard 28 (21): 46-50.

Phillips, D. (2012) Wellbutrin®: Misuse and abuse by incarcerated individuals. Journal of Addiction Nursing, 23: 65-69.

Tamburello, A. (n.d.) Prescription Medication Abuse. Presentation for University Correctional Health Care. Rutgers, The State University of New Jersey. Personal correspondence dated 6/17/2014.

The National Center on Addiction and Substance Abuse at Columbia University. (2010). Behind bars II: Substance abuse and America’s prison population. New York, NY: The National Center on Addiction and Substance Abuse at Columbia University. Retrieved from http://www.casacolumbia.org/addiction-research/reports/substance-abuse-prison-system-2010.

The National Center on Addiction and Substance Abuse at Columbia University. (2010). Criminal neglect: Substance abuse, juvenile justice and the children left behind. New York, NY: The National Center on Addiction and Substance Abuse at Columbia University. Retrieved from http://www.casacolumbia.org/addiction-research/reports/substance-abuse-juvenile-justive-children-left-behind.

U.S. Department of Health and Human Services (DHHS), Behavioral Health Coordinating Committee, Prescription Drug Abuse Subcommittee, (2013) Addressing Prescription Drug Abuse in the United States: Current Activities and Future Opportunities. Accessed at http://www.cdc.gov/HomeandRecreationalSafety/overdose/hhs_rx_abuse.html.

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