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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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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Medication Reconciliation

Fotolia_85555232_XSAn inmate approaches you at morning med line and asks for his medication. When he gives you his name and identification number you are unable to find a corresponding Medication Administration Record (MAR) and there is no medication with his name on it in the drawer. This is the psych step down unit so he is probably correct to expect to have medication. When asked he tells you that he arrived on the unit last evening from 3E, the acute psych unit. You tell him that there is no medication for him on the cart and that you will contact the pharmacy and will get back to him later that morning. You are thinking that his medication is still in the med cart on 3E and will call the nurse on the unit as soon as you get back to the clinic.

Does this example sound familiar? How many times are you approached to administer a medication and it is not there? It could be because the inmate was just admitted to the facility or just saw the provider and the medication hasn’t been received from the pharmacy. It could be that the inmate was transferred from one unit to another and his or her medication was not transferred to the new location. Maybe the inmate just returned from an off-site procedure and the provider hasn’t reviewed the specialist’s recommendations.

Each admission, provider visit, transfer or change in level of care is an opportunity for omission, duplication, dosing errors, drug-drug interactions and drug-disease interactions to occur and with it the potential for an adverse patient outcome. Almost half of all medication errors in the general health care community occur because medication is not reconciled adequately when there is a handoff in responsibility for the patient’s care and 20% of these result in harm to the patient. Transitions in the responsibility for an inmate’s health care have the same risk. Medication reconciliation prevents mistakes in patient care.

The Institute for Healthcare Improvement and the Joint Commission recommend reconciling medication whenever there is a change in the patient’s setting, condition, provider or level of care required. In corrections medication reconciliation is done when inmates at admission report taking medication prescribed by providers in the community. These medications will need orders to continue or the inmate’s treatment modified by the provider at the correctional facility assuming responsibility for the patient’s care. Medication reconciliation also takes place when an inmate returns to the facility after receiving specialty care in the community, upon admission and discharge from infirmary or another type of inpatient care and whenever their primary care provider changes. There are only three simple steps involved in reconciliation. These are:

  1. Verify the name, dosage, time and route of the medication (s) taken or recommended.
  2. Clarify the appropriateness of the medication and dosing.
  3. Reconcile and document any changes between what is reported or recommended.

The following paragraphs discuss how medication reconciliation is done at several key points in correctional health care.

When Inmates Arrive at a Facility

Intake screening routinely includes an inquiry into what medications an inmate is taking. Sometimes this question is only briefly discussed. However, if an inmate reports recent hospitalization or receipt of health care in an ambulatory care setting it would be a good idea to inquire again about what medications may have been recommended or prescribed. The same is recommended if an inmate reports having a chronic condition. It may be that they are not currently taking medication because they can’t afford it or were unable to obtain the medication for another reason. Inquiry about medications should also include the inmate’s use of over-the-counter or other alternative treatments.

Offenders arriving at a facility from the community, especially jails and juvenile facilities, may have medications on their person and sometimes, family will bring in medications after learning their family member has been detained. It is best practice to verify that the medication received is the same as that on the label. There are several excellent sites for verification of drugs including Drugs.com, Pillbox, and Epocrates.com. Once verified, document the name of the medication, dose, and frequency, date of filling, quantity remaining, physician, pharmacy and prescription number.

Whether it is the inmate’s report or the inmate has brought in their own medication the prescription must next be verified with the pharmacy or community prescriber. Once this is done, notify the institution provider who will determine if the medication should be started urgently so there is no lapse in treatment or if the patient should wait until seen for evaluation.

When Inmates Return From Offsite care

Medication should also be reconciled whenever a patient returns to the facility from a hospitalization or specialty care. The clinical summary or recommendations by the offsite provider should accompany the patient, if not, the nurse should obtain this information right away. Recommendations from off-site specialists or hospital discharge instructions should be reviewed as soon as possible by the nurse and provider in order to continue the patient’s care. When clinical recommendations from off-site care are missed or not followed up on needed treatment is delayed and the patient’s health may deteriorate.

When Inmates Are Followed in Chronic Care Clinic

Chronic care patients are another group that require nursing attentiveness to medication reconciliation including:

  • Evaluating whether the patient is actually taking it as ordered.
  • Following up whenever the medication or the patient is not available and if so, getting scheduled doses to the patient promptly. Also helping the patient to request refills and reorders in time may be necessary so doses are not missed. Also account for the whereabouts of each no show so that medication can be provided as scheduled.
  • Coaching the patient about what to discuss with their provider if they want to make a change or are having side effects. Often patients who want to change or discontinue prescribed treatment will refuse single doses or not pick up their KOP medications. Each of these lapses should be discussed, the patient coached about the next steps to take and the provider notified as well.

When Medications Are Missing

When patients come to the pill cart or widow expecting to receive medication and there is either no medication or MAR asking the patient a few questions as listed below will narrow down where the medication may be located:

  • when was the last dose received (this indicates there is an active prescription and will help determine the urgency for resolution)?
  • If the inmate says that he or she haven’t had any medication yet, ask when they saw the provider who ordered it? (maybe the prescription has not been dispensed yet or it has arrived but hasn’t been unpacked and put away).

Other questions to help narrow down the problem are:

  • if they have been moved recently from another part of the facility (medication and MAR were not transferred).
  • when did they arrive at the facility or were transferred from another (check the transfer sheet, medications and MAR were not transferred).
  • is it a prescription brought in from the community (may be stored elsewhere)?
  • if they have gone by any other names (may be filed elsewhere).

Based upon the answers to these question you may instruct the patient to wait (i.e. “It was just written last night and hasn’t been filled yet, please check back tomorrow.”) or tell the patient that you will look for it and administer it at by at least the next pill call. If you are not able to resolve the problem promptly be sure to assess the patient to determine if the provider should be contacted. Allowing patients to miss medication, even if somebody else is responsible, is equivalent to not providing treatment that is ordered and can be a serious violation of a patient’s constitutional rights in the correctional setting, much less exacerbate their medical condition.

Easing the Burden of Medication Reconciliation

Other recommendations to ease the burden of medication reconciliation from the Institute for Healthcare Improvement are:

  1. Identify responsibilities for medication reconciliation such as standardizing where information about current medications is located, specifying who is responsible for gathering information about medications and when medication reconciliation is to take place, establishing a time frame for resolution of variances and standardizing documentation of medication variance and resolution.
  2. Use standardized forms to ensure that information about medications is elicited and documented.
  3. Establish explicit time frames for when medication is to be reconciled and variances resolved such as within 24 hours of admission, within four hours of identification of variance in high risk medications (antihypertensives, anti seizure, antibiotics, etc.), at every primary care visit.
  4. Educate patients about their medications and their role in reconciliation at every transition in care.

When do you obtain information about the medications a patient takes and how do you verify the patient’s information? Do you provide patients with a list of the medications they take? What is the patient’s role in medication reconciliation at your facility?

If you wish to comment, offer advice about medication reconciliation in correctional health care please do so by responding in the comments section of this post.

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

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Contraband: Health or Security Issue? Part III

This month the Essentials of Correctional Nursing blog welcomes Gayle F. Burrow RN, BSN, MPH, CCHP-RN, Correctional Health Care Consultant from Portland, OR, to the blogging team. Gayle will share insights from her many years of jail nursing experience in a regular monthly rotation with ECN bloggers Catherine Knox and Lorry Schoenly.

The daily work in corrections health, whether a jail, prison or juvenile facility, easily becomes routine. Concerns for personal safety and facility security can fade as reliance is placed on standard operating procedures, custody colleagues, and our own growing familiarity with the criminal justice system. When this happens our safety can be threatened a couple ways. For correctional nurses, this can happen when someone becomes overfamiliar with a patient or when an inmate has been able to manipulate a staff member to bring drugs into the facility.

A news item reporting that a correctional staff member has assisted an inmate to escape from a facility can lead to a reaction like “How in the world could this happen?” Unfortunately, it does happen; even with good orientation, teamwork and communications.  Inmates have persuasive skills that they learned on the streets and staff member may be going through a difficult, vulnerable life situation. This can be a dangerous combination.

Objects and Relationship Contraband

The book “Games Criminal Play” was helpful to me when I entered the correctional nursing specialty many years ago. Although published in the 1980’s, the principles for dealing with inmate manipulation are timeless and remain helpful today. One key principle is that criminals have a manipulation process so subtle that victims rarely realize what is happening until it is too late. That is why it is important for us to be ever-vigilant in avoiding manipulation traps in our nurse-patient interactions. Here are some actual examples of inappropriate staff activities:

  • Forming a relationship while in the jail leading to the patient moving in with the staff member after release
  • Living with a drug dealer and passing on information to inmates
  • Putting money on an inmates books
  • Not reporting when a family member is in custody

Professionalism and Boundaries

Maintaining professional boundaries with patients is safe practice. Contraband can include not only sharp objects but also information, money and personal relationships. By being a skilled health practitioner, sensitive team member and grounded in yourself, you can deliver good health care while avoiding contraband participation.

To read more about the area of safety for the nurse and patient in correctional settings see Chapter 4 sections on contraband, medical contraband and professional boundaries in the Essentials of Correctional Nursing. You can order a copy directly from the publisher or from Amazon today!

Contraband-Health or Security Issue? Part II

This month the Essentials of Correctional Nursing blog welcomes Gayle F. Burrow RN, BSN, MPH, CCHP-RN, Correctional Health Care Consultant from Portland, OR, to the blogging team. Gayle will share insights from her many years of jail nursing experience in a regular monthly rotation with ECN bloggers Catherine Knox and Lorry Schoenly.

The most common examples of contraband we think of are guns, knives (shanks), sharpened toothbrushes, hording medications, and homemade ropes.  When inmates attempt to hide contraband in their body, things can go awry. Here are a few examples:

  • A swallowed balloon of drugs leaks.
  • Eyebrow pencil mistakenly inserted into the urethra instead of the vagina.
  • A swallowed ring lodges in the intestine.
  • Wrapped razor blades cut into the bowel.
  • A wad of money or hidden jewelry causes a vaginal infection.
  • Horded medication traded to another inmate causes an allergic reaction.

Inmates know that bringing in or making unauthorized items is against the rules, so they do not want to tell anyone because they know they will receive discipline. They have read the inmate handbook about the rules inside the facility. Also, they do not want to give up their important possessions because this is the same way they kept valuables when living on the streets.

Patient Awareness

Health staff provide services in chronic disease management, evaluating care requests and medication management and emergency response.  The challenge is to find ways to make patients aware of contraband. This can be done by incorporating information into everyday nursing practice.  Some areas of nursing practice where the topic of the dangers of contraband can be discussed are:

  • At intake or booking, incorporate a statement of awareness that having unauthorized items on your person can have health consequences.
  • During health assessments or nursing sick call evaluations, take the time to mention that contraband is a health issue and we want to prevent any harmful consequences.
  • Posters or videos can be developed to bring awareness of the possible health consequences of some types of contraband.
  • Work with corrections or custody to expand the statements in the inmate handbook to include some health information about the trauma or illness from contraband.

Staff Awareness

Staff also need reminders to be continually aware of the medical implications of contraband. Here are some ways to keep contraband in the forefront of correctional health care activities:

  • Staff meeting or in-service discussing the types of contraband have effects on the health of our patients. Such things as pelvic infections, drug overdoses, perforated bowels, bowel obstructions, rectal bleeding, stomach problems, drug overdoses, trauma or injury can be emergencies from hidden objects.
  • Review contraband situations that have occurred in the facility and complete a Continuous Quality Improvement study to see what could be implemented to target areas for improvement. Use the plan, do, study, act cycle and information from NCCHC to evaluate ways to identify and improve care in this area.
  • Review procedures for sharps and controlled substances in medical. Reinforce the safety aspects of these important procedures.
  • Look at the orientation program to make sure it covers safety from both a custody and health perspective.
  • Work with custody to be a part of their procedures to identify and eliminate risk in the institution. Things that health should be notified about are finding stashes of medications, drugs found in housing areas, and finding things for suicide attempt.
  • Identify the difference when a provider finds a contraband item during a physical examination and when custody asks medical to perform a body cavity search. One is a consented exam and one is asked to do a forensic procedure only performed by personnel trained in this procedure. Body cavity searches are usually completed at the local emergency room by trained staff.  Guidance on the topic may assist in making decisions
  • Use a staff meeting or in-service time to outline the physical assessment skills necessary to identify contraband. Some system are the gastro intestinal system, pelvic area, rectal function, and signs and symptoms of infection.
  • Invite a custody representative to a staff meeting or in-service session to review contraband, what it is and what are examples found in the facility. Sometimes it is a rope, tattoo gun, sharp shank or maybe it is a cute wallet made from gum wrappers.  This increased awareness can change practices and result in discussions about projects or supplies in use by medical.

As a health professional, we have a special relationship with the patients and assist in maintaining their health and overcoming illness. Health staff interview and screen in booking and respond to requests for care and emergencies. We are there as advocates and support. With little in the literature to guide correctional health care in the area of health effects of contraband, we can learn about how to deliver care when things come up.

In the next article will be about a topic that is not easy to discuss. It relates to situations in which custody or health staff contribute to contraband items or comes under the control of an inmates demands.

Share your experiences with contraband in your institutions and share them with us in the comment sections of this post.

For more about correctional nursing practice consult the Essentials of Correctional Nursing. Order a copy directly from the publisher or from Amazon today!

References

Standards for Health Services in Prisons, NCCHC, 2014 edition, Standard P-I-03, Forensic Information, pages 149-150.

Standards for Health Services in Jails, NCCHC, 2014 edition, Standard J-I-03, Forensic Information, pages 149-150.

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Contraband—Health or Security Issue?

This month the Essentials of Correctional Nursing blog welcomes Gayle F. Burrow RN, BSN, MPH, CCHP-RN, Correctional Health Care Consultant from Portland, OR, to the blogging team. Gayle will share insights from her many years of jail nursing experience in a regular monthly rotation with ECN bloggers Catherine Knox and Lorry Schoenly.

Contraband is found frequently in the corrections literature usually with a focus on preventing objects like cell phones, sharp objects and drugs from coming into the institutions at booking or at visiting times. Inmates and their friends and families can be inventive. Drones are becoming a new threat to security. They are dropping packages and weapons into recreation yards. A jail in Ohio has installed body scanners at intake to identify and remove items found in body cavities of those being booked into jail. The officers report, of the four thousand they book annually, they find something every day.

Correctional nurses must understand what constitutes contraband and the damage it can cause. Contraband can consist of weapons, drugs, food, tobacco and even objects that inmates can use to coerce officers into doing their bidding. Contraband can also include medication or medical items that can be harmful if used incorrectly.

Contraband is a Safety Issue

Learning about contraband begins with orientation to the facility and in health orientation. In these sessions new correctional nurses discover:

  • The definition and examples of contraband at this particular facility.
  • Procedures in place to prevent things entering the facility, such as cell phone detectors, body scanners, strip searches, phone detection dogs, housing sweeps, mail inspections and now drone tracking devices.
  • Procedures in place for health staff such as sign out and shift counts for narcotics.
  • The importance of sharps, needles and scissors control and counts.
  • The practices in place during medication rounds to identify and prevent diversion.

Contraband is a Health Issue

Health staff sometimes feel that contraband is a custody responsibility. Nurses often find out about searches or lock down times when heading out on medication rounds or when evaluating a patient in a housing unit. However, contraband can dramatically and quickly affect a person’s health. Health care staff should know about the health effects of contraband and be alert to this unique area of our practice.

In an intake or receiving facility, one common situation is when the arresting officer or custody witnesses someone swallowing baggies of drugs. Sometimes the inmate will become scared and notify the nurse. With a witnessed contraband incident, plans can be made to send the inmate to the hospital for observation and treatment.  It is the unwitnessed situations where harm can occur, such as the collapse of a patient from a leaking baggy or overdose from swallowing drugs. Sharp items can cause stomach or intestinal perforations.

Contraband Risk Reduction

Contraband prevention and identification can become part of everyday patient care practice. Here are some examples of ways to incorporate contraband awareness into clinical practice.

  • Questions included in the booking screening process to identify that contraband is a health issue.
  • Intake evaluation can include discussion of the health problems of hiding objects in body cavities.
  • An evaluation for abdominal pain or even constipation, can include inquiry as to any object swallowed or placed in the rectum.
  • General education during health encounters can elicit information from patients.

Is Contraband a Health or Security Issue?

With the wide variety of contraband brought into a facility, custody has processes in place to locate items with screenings, searches and equipment. Health staff have responsibility for procedures like counts, medication checks, knowing what is on your carts, and locking up sharps and medications. Some items do not cause any health concerns and others can cause death. Since, the safety of the institution is everyone’s responsibility, reviewing the policies and procedures for the facility and health will give guidance.

Next week we will continue to review this complex topic of contraband from a health perspective. It will be interesting to know how your facility handles contraband. Share your experience in the comment section at the end of this article.

To read more about personnel and patient safety in correctional settings in relationship to contraband and other areas, see Chapter 4 of the Essentials of Correctional Nursing. Order a copy directly from the publisher or from Amazon today!

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