The Power of Appearance

fotolia_120043070_xsMeet Jerry, a new registered nurse in on-the-job training who will begin shadowing you next week to learn to how to conduct sick call. She asks you what she should be thinking about in preparation for this role. You respond by saying that how she does in sick call will establish her competence and clinical authority in the eyes of the inmate population and to prepare for an onslaught of sick call requests as everyone seeks to meet and test her skill.

All patients, not just inmates, assess a nurse’s visual appearance to form an opinion about their confidence and professionalism within the first few seconds of an encounter. In correctional nursing, the inmate’s best opportunity to make this assessment will be during a sick call encounter. Since inmates have no choice in who provides their nursing care they are naturally interested whenever someone new joins the nursing staff.

The traditional white uniform was first established by Florence Nightingale in the early 1900’s to distinguish nurses from lay persons who attended the sick at the time and raise nursing to a respectable profession characterized by caring, compassion and clinical competence. Even though the white uniform has given way to more comfortable and durable clothing it still is the strongest association identified by the public between professionalism and nursing.

The correctional facility you work at has no dress code policy for health care staff. The security staff are provided navy blue uniforms with badges and other insignia detailing their name and position within the organization. Health care staff are simply advised to dress in clean and comfortable clothes appropriate for work in the facility.  In considering what advice to give Jerry in preparation for next week you reflect on your past experience at the facility about staff who were able to establish their authority, confidence and nursing competence early in their correctional nursing career. What advice will you give her as a result of this reflection?

Patients want to know that the person caring for them has the credentials to do so. In fact, some state boards of nursing require that registered nurses be identified clearly by name and credential. Nurses who are accountable for their practice introduce themselves to the patient at the beginning of the encounter. Nurses who do not want inmates to know their name or credential will be unable to establish the trust necessary to obtain important information from the patient about their condition and risk poor care outcomes. Jerry has been issued a name tag but keeps it in her pocket and only shows it when asked.

Staff who dress in a more formal, uniform style are considered significantly more skilled and knowledgeable by patients than those dressed like they were ready for the gym, rooting for the local team or sporting funny sayings. While individual self-expression in attire isn’t prohibited by the facility, it took longer and was more challenging for these staff to prove their competence and skill and project authority when it was necessary. Jerry seems to prefer a t-shirt and scrub pants for work attire.

Some of the staff have taken to wearing polo shirts which have embroidered their credential as a certified correctional health professional on the front. Others wear colored scrubs which fit properly and can be layered based upon working temperatures. Staff who wear patterned or cartooned scrub tops have sometimes been coached if it made them appear too informal, approachable or friendly with inmates and their professional authority was challenged. You note that another aspect of projecting professionalism and respect for the patient and others is wearing clothes that are clean, neat and fit properly.

As you talk with Jerry about creating first impressions she laments that it is all a charade-people should judge her on her actions not her appearance. While you agree with her that there is a lot more to a person than just the visual impression created by the first few seconds, it is however, a vital opportunity, not to be squandered. When you ask her if she wants to see the pilot of the plane she just got on, in sweats. She looks at you a second and gulps. You go on to say “That may be the only information you have about the competence of the pilot flying you across country. The pilot’s appearance is important to you to feel safe and trust that the flight will go according to your expectations. Your patient is the same way, dressing professionally helps them have confidence in your ability and trust that you will take care of them appropriately.”

Jerry shows up Monday morning confident that with your ongoing help and advice she will do well learning how to do sick call like a pro. fotolia_119206347_xs

Do you have a different viewpoint about the impact of the nurse’s appearance in establishing professional authority in the nurse patient relationship? If so please share your views by relpying in the comments section of this post. For more on professionalism in correctional nursing see Chapter 19 in the Essentials of Correctional Nursing. Order a copy directly from the publisher or from Amazon today!

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Emergency Triage and the ESI

Emergency Concept Vector Illustration

This spring, a correctional facility I visit regularly, implemented a new triage system as part of the facility’s emergency response plan. It’s called the Emergency Severity Index (ESI) and has been recommended by the American College of Emergency Physicians (ACEP) and the Emergency Nurses Association (ENA) since 2010. Since then, more and more hospital emergency departments have been implementing use of the ESI. In the Essentials of Correctional Nursing we recommended that correctional facilities use the same triage categories as those used by emergency service providers in the local community. If the ESI is being used in your community maybe it’s time to consider incorporating it into your facility’s emergency response system.

What is the Emergency Severity Index or ESI?

The ESI guides nurses’ in the evaluation of patient acuity and the resources that will be needed to treat the patient. Acuity is defined as the stability of a patient’s vital functions and the potential threat to life, limb or organ. Resources are defined as the number of resources to stabilize and initiate treatment. The result is a triage decision that stratifies patients’ need for emergency treatment into five levels of urgency. It was developed by a group of emergency nurses, physicians, managers, educators and researchers in collaboration with the Agency for Healthcare Research and Quality (AHRQ) who continue to update the tool and related training material.

How does it work?

The ESI is an algorithm that incorporates only four questions and the answers lead to a triage conclusion. The four questions are:

  • Does the patient require immediate life-saving intervention? If so the patient is triaged as ESI level 1. No further triage is necessary and life saving measures are initiated immediately. Life saving measures are those which secure an airway, maintain breathing, support circulation or address a major change in level of consciousness. If the answer is no then go to the next question.
  • Can the patient wait to be seen medically? Three criteria are used to make this determination.
    1. Is it a condition that could deteriorate quickly or for which treatment is time-critical?
    2. Is the patient confused, lethargic or disoriented?
    3. Is the patient in severe pain or distress?

A yes answer to any of the above means that the patient cannot wait and so is triaged as ESI level 2. No further triage evaluation is necessary and the nurse’s focus shifts to ensuring prompt initiation of treatment. If the patient does not need to be seen urgently then proceed to the next question.

  • How many different resources are needed to address the patient’s chief complaint? The nurse uses their experience to predict how many different kinds of interventions will be necessary to diagnose and treat the patient. Resources are those beyond basic first aid, point of care testing and medications. Diagnostic tests, procedures, consults, and inpatient admission are considered resources.

If more than two different resources will be needed (i.e. lab and an EKG) the patient is triaged ESI level 3. If one resource will be needed (i.e. x rays) the patient is triaged ESI level 4. If no resources will be needed (i.e. injury dressed, ice applied and medication administered) the patient is triaged ESI level 5. These level determinations may be altered by the presence of abnormal vital signs, which is considered next.

  • Does the patient have abnormal vital signs? Any patient with an elevated heart rate, increased respirations or a low oxygen saturation rate should be reconsidered for ESI level 2 and seen urgently.

What are the advantages of using the ESI?

The ESI has been found to be more accurate than other triage systems because it is simple and reduces subjectivity. One benefit is that it identifies patients in need of immediate attention more rapidly than other methods. The ESI can help prioritize clinical staff attention and resources and it facilitates communication about patient acuity more effectively. It also has been used as the foundation for facility policy and procedure. The jail referred to at the beginning of this post has since drafted policy and procedure setting timeframes for response to each of the ESI levels. By keeping track of emergencies by ESI level the data can be used to determine if practices could be improved with targeted training or enhanced resources. Finally, the AHRQ maintains a website on the ESI that includes an implementation handbook that can be downloaded for free. There are also DVDs that include lectures and case studies that can be used to support training in use of the ESI. There is no charge for these materials but they must be requested from the site.

How easy and reliable is it?

The ESI has been found to be an easy, reliable and valid measure of patient acuity and resource need in multiple hospital settings and comparison groups. If you want to try it out, use your experience to determine the ESI rating for the patients in these four examples which come from the training material provided at the AHRQ site:

  1. A 58-year-old male complains of left lower-quadrant abdominal pain for 3 days. He denies nausea, vomiting, or diarrhea. No change in appetite. past medical history HTN. Vital signs: T 100°F, RR 18, HR 80, BP 140/72, SpO2 98%. Pain 5/10.
  2. An 18-year-old female is brought to medical because her cell mate found her lethargic and “not acting right”. The patient has a history of depression. On exam, you notice multiple superficial lacerations to both wrists. Her respiratory rate is 10, and her SpO2 on room air is 86 percent.
  3. A 72-year-old male fell and hit his head in the cell. He is awake, alert, and oriented and remembers the fall. He has a past medical history of atrial fibrillation and is on multiple medications, including warfarin. His vital signs are within normal limits.
  4. “I have had a cold for a few days, and today I started wheezing. I need a breathing treatment,” reports a 39-year-old female with a history of asthma. T 98°F, RR 22, HR 88, BP 130/80, SpO2 99%, No meds, no allergies.

Answers: 

  1. ESI level 3: Two or more resources. Abdominal pain in a 58-year-old male will require two or more resources. At a minimum, he will need labs and an abdominal CT.
  2. ESI level 1: Requires immediate lifesaving intervention. The patient’s respiratory rate, oxygen saturation, and inability to protect her own airway indicate the need for immediate endotracheal intubation.
  3. ESI level 2: High risk. Patients taking warfarin who fall are at high risk of internal bleeding. Although the patients’ vital signs are within normal limits and he shows no signs of a head injury, he needs a prompt evaluation and a head CT.
  4. ESI level 4: One resource. This patient only needs a nebulizer treatment for her wheezing. No labs or x-ray should be necessary because the patient does not have a fever.

How did you do? Was it easy to use? There are hundreds of case examples included in the ESI training materials which is a great resource for correctional nurses. There also is a chapter devoted to evaluating competency in the use of the ESI tool.

This blog post is dedicated to bringing down to earth, practical resources and advice for nurses who practice in correctional settings. The ESI is described here because it is increasingly being used by emergency departments in the United States and may be used in your community. If so, you may want to consider using it at your facility as well. If you use the ESI at your facility, please share your experience by replying in the comments section of this post.

For more on this subject read Chapters 16 in the Essentials of Correctional Nursing. Order a copy directly from the publisher or from Amazon today!

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Top Educational and Skill Needs of Correctional Nurses

TRAINING Vector Radial Tag CloudThe most recent issue of CorrectCare, a quarterly publication by the National Commission on Correctional Health Care (NCCHC) included an article by Sue Smith MSN, RN, CCHP-RN reporting the results of a recent survey of nursing leaders about the educational and skill needs of correctional nurses. I have reprinted it here so that you can consider the results in light of your own experience and educational needs. Please take a minute to think about your own answers to each of the five survey questions that were used and compare your opinions to those of others who responded.

Nurse Leader Survey Sheds Light on Nurses’ Top Educational and Skill Needs

by Sue Smith, MSN, RN, CCHP-RN

The Nursing Advisory Council is a stakeholder group that advises the NCCHC multidisciplinary education committee on the continuing education needs of correctional nurses and assists the NCCHC lead nurse planner in assessing continuing education for correctional nurses and evaluating the quality and effectiveness of the continuing education. The council consists of nine nurse members who represent a wide variety of roles and settings, including staff nurses, nurse managers/administrators, nurse educators and advanced practice nurses who work in jails, prisons, governmental agencies and private correctional health care agencies.

In 2015, the Nursing Advisory Council developed a needs assessment survey directed at nursing leaders, including nurse managers and nurse administrators. The survey questions were determined by consensus and consisted of five primary questions:

  1. How much time should be allotted for training a first-time correctional nurse before working independently?
  2. What are the three most important topics for orientation/training of correctional nurses?
  3. What is the single most important piece of knowledge for a correctional nurse to have?
  4. What is the single most important skill for a correctional nurse to have?
  5. What RN/LPN-LVN ratio are you using at your facility? What is the rationale for this ratio?

The survey questions were distributed via SurveyMonkey to nurses who self-identified as nurse managers or nurse administrators at NCCHC educational conferences. The survey was available to the target audience for two weeks. In total, 273 responses were received; a small number of responses were discarded that did not address one or more of the questions. The collected results were analyzed by the lead nurse planner using simple data reduction techniques.

1. How much time should be allotted for training a first-time correctional nurse before the nurse is allowed to work independently? (233 responses)

Less than 2 weeks         18%

2-4 weeks                        14%

5-8 weeks                   49%

9-12 weeks                       8%

3-5 months                      8%

6-12 months                    3%

2. What are the three most important topics for orientation/training of correctional nurses?

     Safety/Security (134)

Inmate manipulation, Safety of self and others

Security issues and procedures, Collaboration with security staff, Contraband

Infection control

     Nursing Practice (129)

Health/physical assessment skills, Emergency response, Sick call procedures, Documentation

Medication issues including administration, verification, pharmacology and competence

Triage/screening, Mental health, including assessment, referrals, suicide prevention, substance abuse

Special needs, Discharge planning

     Professional Practice (52)

Professional boundaries

Neutrality, Firm, fair and consistent

Compassion; patient advocacy; balance of advocacy vs. safety

Emphasis on patient care, Autonomy

     Legal/Constitutional Issues (37)

Access to care, Deliberate indifference, Policies and procedures, Licensure/scope of practice

Standing orders, Patient confidentiality, Standards/guidelines

     Miscellaneous (15)

Time management, Critical thinking, Ethics, Electronic medical records

Unique practice environment, Clinic operations, Limitations and restrictions on care provision

3. What is the single most important piece of knowledge for a correctional nurse to have?

     Professional Nursing Practice Skills (108)

Assessment skill, Professional boundaries

Able to see inmates as patients, quality care, respect, patient advocacy, compassion, nonjudgmental attitude, uses nursing process, appropriate follow-up

Critical thinking skills, previous clinical experience, good judgment, know where to find the answer

Emergency skills including recognition of critical patients, proper CPR, trauma evaluation, emergent care

     Safety/Security (74):  Don’t let guard down, how to get help, staying calm, situational awareness, infection control

     Correctional Nursing Practice (16): Unique practice, understand population served, understand environment and facility culture, how to navigate security/medical issues, role of health care in corrections, concept of firm, fair  and consistent

      Legal Issues (16): Policies and procedures, inmate rights, scope of practice

     Communication/Collaboration (15): Manner, effective communication, with advanced providers and DON/HSA, with security, knowledge of chain of command, SBAR technique, professional communication, who and when to call for help

     Clinical Nursing Knowledge (9): Pathophysiology, medications, current on clinical guidelines, proficiency on treatments

     Mental Health (9): Inmates, staff

     Manipulation (7): Inmate-patient behavior

     Miscellaneous (2): Computer skills, preventive health care

4. What is the single most important skill for a correctional nurse to have?

     Assessment Skills (111)

Physical, mental health, health, rapid

Interviewing skills

     Interpersonal Skills (46): Good listener, nonjudgmental, honest, able to handle manipulation, objectivity, professional behavior, boundary setting, able to get along with others, assertiveness, respect, conflict resolution skills, ethics, flexibility, diligence

     Critical Thinking Skills (33): Accuracy, think and perform under pressure, good judgment, confidence, problem-solving

     Communication (33): Written (including documentation), verbal with staff and inmates, therapeutic.

     Clinical Skills (25)

Evidence-based medicine, clinical knowledge, nursing process, CPR, codes, first responder

Triage/prioritization of care

     Personal Skills/Attributes (21)

Observational skills, including awareness of surroundings

Organizational/time-management skills

Autonomy, Self-motivated learner

5. What is the ratio of RNs to LPNs/LVNs at your facility? (268 responses)

Overall average – 3 (RNs) : 4 (LPN/LVNs)

Most frequently occurring ratio – 1 : 1

27 respondents reported all RN staff.

A few respondents reported use of nursing assistants, medical assistants, medication aides and paramedics in addition to or instead of licensed nurses.

103 (38%) did not give information or a ratio could not be determined from the information given.

6. Which of the following best describes the correctional setting where you work? (236 responses)

 Jail                                                                 45%

Prison facility                                                    19%

State DOC/agency                                            17%

Federal agency                                                   8%

Juvenile detention/confinement facility      6%

Private corporation                                           5%

Other*                                                                 12%

* immigration facility, inpatient acute correctional facility, consultants, tribal jails

Discussion

Total responses were 273. However, not all respondents answered every question and it was necessary to discard a number of unusable responses. Simple arithmetic averages were calculated for questions 1, 5 and 6. Qualitative data received in response to questions 2, 3 and 4 were analyzed and separated into broad categories. The number in parentheses beside each category indicates the number of responses in that category.

There is some overlap in the information requested by questions 2, 3 and 4. This was anticipated by the Nurse Advisory Council, but we felt that there would be enough variation in the responses and/or response rates to ensure that the information gleaned from the survey would be useful. The data analysis does indicate that the weight, or importance, of the topics listed varies between each question. Additionally, there was some variation in the specific topics suggested by respondents.

The information gleaned from this survey is consistent with the results of the general needs assessment survey completed in 2014. The Nurse Advisory Council has been using, and will continue to use, the information collected by these two needs assessment surveys to plan continuing education for correctional nurses who attend NCCHC educational conferences.

Sue Smith, MSN, RN, CCHP-RN, is a correctional nurse educator. She serves as lead nurse planner for NCCHC educational activities and directs the NCCHC Nursing Advisory Council. Contact her at nsuesmith48@yahoo.com.

How similar were your answers to the survey results? Do the results confirm your priorities for correctional nurses’ professional development and continuing education? Please share your comments with others who follow this blog by responding in the comments section of this post.

For more on this subject read Chapters 17 and 19 in the Essentials of Correctional Nursing. Order a copy directly from the publisher or from Amazon today!

Photo credit: @ treenabeena– Fotolia.com

Stewardship involves the health care team

The last two posts have been about the challenge we all face in preventing the development of antibiotic resistance and treating those who have antibiotic resistant diseases. In today’s world of antibiotic resistant diseases, we all are guided to be vigilant when the plan of care contains antibiotic therapy. Providers have an important role in antibiotic stewardship and so does the rest of the corrections health team, including the nursing staff, the pharmacy, laboratory and clerical staff to ensure our patients receive the community standard of care with regard to treating infectious disease. This post highlights the U.S. Department of Justice, Bureau of Prisons’ development of guidelines for antibiotic stewardship in correctional health care.

Clinical practice guidelines

In 2013, the Bureau of Prisons (BOP) published Antimicrobial Stewardship Guidance. The BOP is the first correctional health care system to develop and make available to the public a written plan to address prevention and treatment of antibiotic resistant disease. Since then other systems have used it as the basis to develop their own guidelines on the use of antibiotics.  The BOP guidelines provide information about:

  • diagnosing and identifying infections
  • understanding lab values,
  • therapy selections,
  • multi-drug resistant organisms
  • national guidelines for treatment.
  • to communication, competencies and training.

Strategies of the BOP Program

The BOP guidance is based upon four strategies:

  • Education for all staff about appropriate use of antimicrobial agents
  • Formulary management with varying degrees of restriction in the use of antibiotics
  • Prior approval programs for antibiotic medications not on the formulary
  • Converting patients from broad to narrow spectrum antibiotic therapy.

Communication, communication, communication

Communication, is at the heart of success in promoting antibiotic stewardship.  The BOP guidelines stress that patient satisfaction is influenced more by communication, than by whether or not the patient receives an antibiotic. Communication is used to validate the patient’s illness, help them understand the disease as well as the treatment options. Sometimes antibiotics are warranted and sometime they are not and we use communication to help the patient understand the treatment recommended for their illness.  Communication practices recommended by the BOP include:

  • Choosing terminology–using the diagnosis name instead of referring an illness as “just a virus” validates the patient’s symptoms. They will be more willing to participate in the treatment plan when they know you care about what is happening to them. No matter how mild or severe, all illnesses are important to the patient.
  • Offering symptomatic relief—it takes sensitivity when talking about a condition that is a virus or other illness that does not require use of antibiotics. Provide information about symptomatic relief such as over the counter medications, showers, hydration, gargles and warm or cold packs. In addition to talking with the patient provide a handout to reinforce the information.
  • Discuss expectations for the course of illness and possible medication side effects—none of us hears everything the provider tells us at a visit. Our patients benefit from knowing what to report, what improvements looks like and when to report worsening symptoms. Patients should receive information about their illness, treatment or self-care options, what to expect and when to seek medical attention from nursing staff and others at every subsequent patient interaction.

Good communication provides the means to engage patients in the recommended and most appropriate treatment regime.

Nursing competencies and training

Infectious disease is a large group of illness and a challenge in maintaining a current knowledge base. In corrections health, we become more proficient in the most common diseases that our patients have. To assist us we have tools, such as standard protocols for MRSA and skin infections, pneumonia, tuberculosis, sepsis, gynecological infections, urinary infections and sexual transmitted diseases. Just keeping up with the laboratory tests and newly developed antibiotics can be a daily learning experience.

The BOP guidelines list the following infectious disease competencies for correctional nurses:

  • Understanding culture and sensitivity laboratory report results.
  • Understanding common IV antibiotic dosing, frequencies and regimes.
  • Knowing the signs of improving clinical status that facilitate de-escalation.
  • Understanding the timing of medication dosing and blood sample collection.
  • Knowing the signs/symptoms of common allergic reactions to frequently used medications.
  • Awareness of the facility antibiotic therapy guidelines.
  • Knowing the common side effects and adverse events associated with antimicrobials.
  • Understanding the principles of antibiotic stewardship.

The ups and downs of antibiotics

In 1928, Sir Alexander Fleming, discovered a naturally occurring antiseptic enzyme. He was quoted as saying “one sometimes finds what one is not looking for”. From his work, in six years, penicillin was discovered.  From early to modern history antibiotics have played a major part in wellness and prevention of mortality.  Today, we have new challenges from organisms adapting to medications and not curing illness. Everyone in the health care profession is working to curb this and to ensure all of us receive treatment that HEALS.

Are the infectious disease competencies for correctional nurses recommended by the BOP the ones you would recommend? What additions or changes to this list of competencies would you recommend? Please share your ideas by replying in the comments section of this post.

Read more about the identification and management of infectious diseases in the correctional setting in our book the Essentials of Correctional Nursing. Order a copy directly from the publisher or from Amazon today! 

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Antibiotic Stewardship has Four Rights

stewardship photo

The subject of antibiotic stewardship was touched upon in last week’s post about Superbugs. The goal of these programs is to avoid unnecessary and inappropriate use of antibiotics to prevent development of antibiotic resistant disease organisms. In addition to curing illness, appropriate antibiotic use should also reduce side effects of medications and lower health care costs.

Inpatient settings, such as hospitals and long term care, have had programs in place to monitor the use of antibiotics for some time. In 2009, the Centers for Disease Control and Prevention (CDC), launched the “Get Smart for Health Care Campaign  ” to promote the improved use of antibiotics.  The Joint Commission and the Infectious Disease Society of America (IDSA) have also come out with recommendations, guidelines and tool kits for health care settings to begin their own stewardship programs.

Correctional facilities are also patient care settings

A study by the CDC indicates that 30-50% of antibiotics prescribed in hospitals are unnecessary or inappropriate. How does that translate to corrections health? The article states that overprescribing and mis-prescribing is contributing to the development of antibiotic resistant bacteria and challenges from side effects of antibiotic use. Of all the health care settings, corrections health is probably the most cautious in prescribing medications for patients because our patients come from an “medication dependent culture”, whether legal or illegal.  Many corrections health programs have policies, procedures and clinical protocol to guide the assessment, diagnosis and treatment of the most common antibiotic resistant conditions, such as methicillin resistant staph aureus (MRSA), resistant tuberculosis and gonorrhea. Even with these practices in place, are correctional health care programs able to assert that all antibiotic use is appropriate? Probably not.

The fundamental four rights

The goal of antibiotic stewardship has four points to ensure that patients being treated for infectious conditions receive:

  • the right antibiotic
  • at the right dose
  • at the right time and
  • for the right duration

Most correctional health programs already have in place the components of an antibiotic monitoring system. The existing quality improvement (CQI) program or pharmacy and therapeutics (P & T) committee should include monitoring of appropriate antibiotic use among the subjects reviewed. Staff to lead the effort could include the staff or consulting pharmacist, the medical director or other provider, infectious disease specialist or nurse, or one of the staff responsible for medication administration. By using existing resources and interest, it is possible to initiate antibiotic stewardship at your facility, no matter how large or how small.

Common guidelines to ensure antibiotic stewardship

Practical advice for implementation of antibiotic stewardship include these recommendations from the Infectious Disease Society of America, which can be translated into any setting:

  • Pre-authorization or review of orders for targeted antibiotics with consultation provided about alternatives.
  • If pre-authorization or consultation is not available, after two or three days of treatment review the patient’s response to treatment and adjust treatment accordingly.
  • Conduct a continuous quality improvement study or audit of patient response to treatment with antibiotics to identify areas to target for improvement.
  • Timely diagnostic services, especially for respiratory specimens, aids in the determination of whether antibiotics are necessary.
  • Use of standard protocols for specific diagnoses or syndromes to guide the assessment, treatment and evaluation of the patient’s response to treatment.

Corrections health reflects the community.

Correctional health care is consistent with and supportive of health care in the community. With statistics like 23,000 deaths per year in the US from antibiotic resistance, stewardship and oversight of antibiotic use has become the community norm.  The safety of our patients and in essence the community, requires that we attend to the appropriate use of antibiotics in the correctional health care setting as well.

If your facility has an antibiotic oversight or stewardship program, please share your experience with us by replying in the comment section of this article.  Next week will examine the Bureau of Prisons’ antibiotics stewardship program and the role of nursing!

 

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Superbugs are not only in your garden!

superbugsDo you find bugs in your yard and garden that are eating your plants, roots, grass and eliminating flowers? Have you tried pesticides only to find the bugs come back stronger by becoming pesticide resistant? Our bodies are the same as plant life in the garden.  The ready availability and use of antibiotics to treat illnesses has resulted in emerging infectious diseases that are resistant to known treatment modalities.

News is Full of Superbug Warning

There are more and more articles in the community papers, TV news shows and health care literature about the challenges to cure health conditions that are caused by medication resistant organisms. The most recent story  warned that in the US this new “nightmare superbug” is a strain of e-coli.  They used the words “alarming development and terrifying”.  Other frequently discussed antibiotic resistant infections have been for tuberculosis, gonorrhea, and skin infections. Some parts of the world are trying to get a handle on resistant strains of malaria.

Corrections Health Responses

In recent years, corrections health programs have developed guidelines and procedures for skin infections and tuberculosis.  They vary with the program and include prevention, identification, treatment and follow up care.  The level of isolation or protection and the use of an antibiotic regime is set by the medical directors and pharmacists.  Custody and health staff have become accustomed to being taught about preventing contagious disease and are skilled in using standard precautions, wearing gloves, respecting wounds that are bandaged and reporting concerns to medical.  Having sanitizing gel and gloves available around the facilities is the norm now instead of the exception.

Precautions to Consider

The picture of superbugs really encompasses a world view as changes in how we live and the treatments we receive for illness has contributed to more organisms being resistant to current therapies.  We normally focus on our facilities, however, some of the recommendations to help slow down the emerging resistant diseases encourages us to take a larger world view of public health. The United Kingdom recently published a multi-nation review of how to tackle the problem of drug resistant organisms infections. The report outlines steps that should be taken by each of us individually and as leaders in health care at our facility to curb the tide of emerging “superbugs”.

  • Raise awareness of the threat of inappropriate antibiotic use.
  • Improved hygiene to safeguard against infections.
  • Less unnecessary microbial use in agriculture, aided by improved transparency by retailers and food producers.
  • Better monitoring of drug resistance.
  • Development of both diagnostics to cut unnecessary antibiotic use and improved vaccines and alternatives.

Another recent article about superbugs described a woman in Pennsylvania diagnosed with drug resistant e-coli and noted the specialized diagnostic and therapeutic resources necessary to treat her. The article also described how new the information about emerging drug resistant disease is and the lack of coordinated and widely disseminated research.  So not only do we all need to keep abreast of the infectious disease that are arriving in our facilities, but bring awareness of the need for specialized education and training in infectious disease prevention.

Main Warning

We have heard for years about the dangers of antibiotic resistant diseases and have developed procedures and protocols in monitoring and treatment. The most frequently stated practice change is to have antibiotic stewardship programs to curb the inappropriate use of antibiotics. Many of our patients coming into custody have a history of frequent antibiotic use and want us to give them antibiotics for many of their ailments. We need to provide patients with education about appropriate antibiotic use; we also need to ensure staff are knowledgeable and that the practice guidelines are based upon the most current evidence.  To address resistance in gardening we now treat superbugs with beneficial insects like green lacewings, ladybugs and praying mantis so lets do the same in health care with appropriate antibiotic use and stewardship. That way we may affect the predictions that millions of people may become ill from “superbug infections” by year 2050.

What are you doing to help curb antibiotic use in your place of work? Do you have any special patient teaching tips or resources you would like to share with us? If you do please put your sharing in the comment sections below.  We all can learn from each other.

 

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What are these eight rights anyway?

The picture posted with this column of a nurse on her way to give medications gives rise to many thoughtsNurse Medication Picture and memories. For me, it brings memories of my early years in nursing practice.  We wore white uniforms, white shoes, white nylons and white caps.  . I remember learning how to safely and accurately administer medications through each of the steps from the physician’s order to setting up medications, to administration and documentation. I also remember how much emphasis was placed on giving the right patient the right medications. Like the nurse in the picture, medication rounds were done using a tray holding medication in cups and small cards with the patient information and medication on them.

Years later, the safety of administering medications was outlined in the Five Rights of Medication Administration.  I cannot tell from the literature when these became formalized but when I returned to school in the mid 1980’s, the Five Rights were prominent in nursing practice, risk management and patient safety.

Health Care Advances

As the body of knowledge for nursing practice evolves, we continuously improve our practice to assure our patients receive the highest level of care with an emphasis on patient safety and error reduction. Because of this, three more rights have been added to the body of knowledge for medication administration, making a total of eight rights.

In corrections settings, medication administration is completed by a variety of job classifications. No matter who gives medications to patients, they must be qualified and trained in medication administration and follow the Eight Rights, as described below:

  1. Right Patient: check the name on the medication administration record (MAR), use two identifiers; ask patient to identify themselves, check name &/or picture on ID wrist band or badge.
  2. Right Medication: check the order, select medication, compare to the order, check the MAR, and then check the medication against the MAR before giving to the patient. If it is a new medication does the patient know what it is for and are there any allergies that would contradict giving it.
  3. Right Dose: check the order or the MAR, confirm the appropriateness of the dose, for medications with high risk consequences from dosing errors have someone double check the calculation.
  4. Right Route: check the order and MAR, confirm the route is the correct for that medication and dose, confirm that the patient can receive it by the ordered route.
  5. Right Time: check frequency the medication is to be given on the MAR and the time is correct for this dose, confirm when the last dose was given.
  6. Right Documentation: document administration AFTER giving the medication, document the route, time and other specifics such as site, if injectable, lab value, pain scale or other data as appropriate.
  7. Right Reason: confirm the rationale for the ordered medication; why is it prescribed, does the patient know why they are taking this medication. If they have been taking it for long is its continued use justified?
  8. Right Response: has the drug had its desired effect, does the patient verbalize improvement in symptoms, and does the patient think there is a need for an adjustment in the medication?  Document your monitoring of the patient for intended and unintended effects.

Adapted from Bonsall, L. M. (2011). 8 rights of medication administration. Retrieved June 17, 2016 from http://www.nursingcenter.com/ncblog/may-2011/8-rights-of-medication-administration

The Important Three

When you examine the new three rights closely, their importance becomes clear and explains why they are included as best practices:

  • Right Documentation:  We hear from our legal representatives, instructors, managers and peers, that “if it was not documented, it was not done”. No excuses can make up for a patient receiving double dose of medications when it was not documented or a provider changing a medication when they thought a patient was not taking the medication. Besides accurate and timely documentation of medications administered, this right also includes the accurate documentation of the order on the MAR.
  • Right Reason: When taking off orders or preparing to administer a medication, knowing why the patient is taking a medication is the foundation for patient education and evaluating the effects of the treatment. This is especially important when a particular medication, such as gabapentin, may be ordered to address one of several different conditions (seizure, nerve pain, restless leg syndrome etc.). Information in the patient’s chart will often clarify why this medication is being ordered; if not, consult the provider so that you know what the patient can expect from the treatment.
  • Right Response: We cannot effectively teach a patient about a certain medication and the desired effects of treatment if we do not know the drug ourselves.  Knowing about medications is a continual learning process, which grows day by day.  Make a habit of learning about new drugs each day.  This information can be found in the drug reference books kept in the medication room, by talking with providers, consult with the pharmacist, discussing medications at shift or team reports and exchanging information with team members.  See also a previous post that describes all of the online drug references that are available without charge.

Spread the Word about the 8

Even though these additional best practices have been discussed in the literature and have been topics in nursing education for several years, I still hear nurses refer to the Five Rights. They are called rights because they are not a request or desire—but a RIGHT. Each one of the eight rights is fundamental to nursing practice and when used together better promote patient care and enhance safety. By following these steps, nurses promote wellness and identify and prevent harm to our patients. What do the eight rights of medication administration mean to you?  How has understanding the eight rights in your practice, improved your patients care?  Share your experiences and challenges with medication administration in the comment section below.

Read more about correctional nursing in our book the Essentials of Correctional Nursing. Order a copy directly from the publisher or from Amazon today!

Photo credit:  Yahoo Images

 

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