Receiving or intake health screening is done whenever someone is brought to a jail or prison for admission. These individuals are being detained for any number of reasons including having been arrested for an alleged illegal activity, involved in an altercation or other suspicious activity that the police were called for, having been tried, found guilty and sentenced to serve a term of incarceration, having violated conditions of parole or probation, or are being deported for being in the country illegally or are being transported by the Federal Marshall.
Persons may be held in custody for only a brief time (hours) or for very long periods of time (life). The length of time people generally spend in jail is considerably less than in prison. Therefore, jails have very high rates of turnover and intake health screening is a very high volume activity. Furthermore, people admitted to jail have been in the community immediately before, perhaps living in conditions that were a risk to their health and wellbeing or they may have been injured during the arrest or while in police detention. The volume of people admitted to prisons is not as great but because they have been in custody for a while their condition may have deteriorated if it was not identified or treated at facilities which held the person previously. Because of the potential to miss identifying a serious medical or mental health condition and delay necessary treatment, intake receiving screening is also a considered a risk prone process.
Chart audit of intake health screening is one way to monitor the quality and effectiveness of the process. I just finished an audit of 25 charts using these three questions.
- Were conditions that warranted referral to a provider identified?
- Were patients seen timely by a provider when referred?
- Were records of previous care requested when the patient reported ongoing or recent treatment?
Several problem practices were identified that would be good to review further so that corrections can be put in place. I have seen these same problems with intake screening before and so wanted to share them with you to see if your experience is similar and if you have found ways to improve? The following paragraphs describe these findings and suggest possible corrective action.
- Practices that reduce the likelihood of identifying a medical or mental health condition that should be referred include:
- Not collecting serial assessments when abnormal results are found initially. There are many things that can cause elevated blood pressure, including stress, agitation and withdrawal. The same with pulse, blood glucose and peak flow readings. Repeating tests that were abnormal at the end of the assessment or having the inmate wait a bit to reassess adds important information. Results that don’t improve or worsen need to be followed up and a nurse cannot depend on the next person down the line to pick it up. Consideration should be given to removing the barriers that get in the way of obtaining serial assessment data at intake screening.
- Not inquiring further to yes answers or when the patient reports a medical or mental health condition. For example, if the patient says that they have seizures follow up questions should elicit a description of the type of seizure, when the last one took place, how often they happen and what treatment did the patient receive. Another example was a woman who reported in response to the social history questions that she had been forced to have sex and did not feel safe living at home. Maybe the nurse expected the social worker to pick up on this later but the absence of any additional inquiry or explanation on the part of the nurse indicated that this information was ignored in considering possible health problems. Developing question prompts may help nurses follow up on positive answers.
- Not going further to establish rapport with patients who give minimal answers or deny obvious problems. An example I see frequently is a patient who denies alcohol or drug use when either their current condition or history of arrest suggest it is likely untrue. A follow-up question or statement to challenge the answer in a non-threatening manner may yield better information. Receiving screening is a dialogue not just rote fact finding using a standardized questionnaire. When the patient’s answer is no to every question you have to consider if language or some other barrier is effecting the patient’s disclosure. Here are some techniques that build rapport during intake screening:
- Professional appearance of the nurse
- Focus on the patient
- Have a neutral or friendly facial expression
- Allow silence so the patient can reflect and respond
- Eye contact that is neither too much or not enough
- Ask questions without reading verbatim
- Avoid use of leading or biased questions
- Avoid body language that is perceived as superior or judgmental
- Do not be distracted, preoccupied or rushed
- The setting provides privacy
2. Practices impacting timely referrals to providers include:
- Not following up when nurses make urgent or priority referrals to a provider to make sure the patient is seen timely. We all get busy during the shift and it may be that something is preventing the provider from seeing the patient within the timeframe the nurse requested. Or it may be that the communication about the patient’s priority was missed. The person making the referral bears responsibility to follow-up to make sure that it is accomplished or an acceptable alternative put in place. This is the sixth step in the nursing process; evaluation and revision of the plan of care.
- Not ensuring that patients are seen by a provider promptly when they return to the facility after diversion to the emergency room. When the ED clears an arrestee for jail it simply means that their condition is not urgent enough to require further monitoring in the ED or admission to the hospital. It does not mean the person was medically cleared and therefore intake health screening is not necessary. Instead information from the ED should be collected and reviewed by the nurse, other intake screening data collected and the patient referred promptly to a provider. If not immediately, the provider should see these patients no more than a couple hours of their return to jail and the nurse should follow up to ensure that this takes place.
3. Not requesting health records of recent or ongoing treatment at intake may delay initiation of appropriate medical or mental health care. Examples of conditions where the previous treatment record should be requested include HIV disease, seizure disorder, heart disease and other acute or chronic conditions. Nurses are in the best position to get prior records; the patient is right there and can sign the consent forms and the nurse knows how to navigate the local health community. These records can be very important to the provider’s decisions about treatment. Many times the reason given for not requesting records is that the patient will be gone before the record arrives or that the patient’s information is so vague that tracking down the provider isn’t efficient use of time. Examining barriers to requesting previous records should be explored and efforts to eliminate or develop sources to get the information made. Making specific arrangements for transfer of information with specific providers who see a majority of the same population may reduce the time it takes to get information. Examples would be the state prison system and jails, major community based providers of indigent care, and the mental health system in the state or county. With the advent of electronic records, the timeliness to request and receive information is vastly improved.
Conclusion: Intake health screening is an activity unique to jails and prisons, that involves nurses’ collection and review of information about the health of every person admitted to the facility and nursing decisions about patients’ immediate needs for medical attention, ongoing treatment and protection from harm. It is a high risk, problem-prone aspect of correctional health care and should be regularly reviewed by the Quality Improvement Program and studied to identify opportunities to improve practices. This blog post described the findings from a chart audit that used just three criteria and only took a couple hours to complete. Six areas of possible improvement in nursing practice were identified. Further study to identify and eliminate barriers to best practices is the next step to an improved intake process.
What are the most common problems you have identified when monitoring the nurses’ role in intake or receiving screening? What barriers were addressed which improved intake screening practices? Please share your answers to these two questions by replying responding in the comments section of this post.
For more about the nurse’s role in intake or receiving screening see Chapter 14 Health Screening in our book the Essentials of Correctional Nursing. Order a copy directly from the publisher or from Amazon today!
Photo credit: © Tyler Olson – Fotolia.com