Improving productivity of sick call

SchokoladeProductivity of nursing sick call was the subject of last week’s post. Meeting the basic principles of access to care and the right to a clinical judgment requires keeping up with sick call demand. When nurses and managers allow requests for health care attention to go unattended for more than a day they are ignoring these principles and their failure to act puts patients at risk of harm. Sometimes it is hard to picture the cumulative effect of not keeping up with sick call demand. An example of not keeping up with productivity requirements is depicted humorously in the chocolate factory scene on the I Love Lucy show.

How many patients should a proficient registered nurse be able to see in sick call in an hour? This is an important question to consider because sick call must be appropriately staffed to meet demand. Also because sick call is not performed in other settings nurses do not have experience from other settings to inform their own performance expectations. Ten experienced correctional nurses responded to this question. Collectively they have nearly 300 years of experience providing health care in the correctional setting and equally represent jails and prisons of all sizes, in every part of the country. The consensus was on average, seven patients per nurse per hour. Remember this is an average and not an absolute. Factors that contribute to variation from this average include gender (more time is required to see women), health status (patients with complex health problems vs simple concerns), whether requests are triaged first (when not triaged first, all patients are seen even those with scheduling or administrative issues), and location (privacy and availability of equipment or supplies).

Seven patients per hour equates to 8.5 minutes per patient. Referring to the example from last week one nurse could expect to spend three hours each day seeing an average of 21 patients who have requested health care attention for problems that require a nursing assessment. There is also an average of 13 urgent walk-ins that require another couple hours of nursing time. If sick call is taking longer than this or there is a back log, critical examination of the process should identify prospects for improved productivity. Here are some suggestions from our experienced nurse colleagues.

Build competency: It takes time to develop nursing sick call skill. A newly hired nurse may see an average of three or four patients an hour and so staffing should take this into consideration. It is reasonable to expect nurses to have a fund of knowledge sufficient to conduct a focused head to toe assessment but they are not likely to have developed these practice skills in a high volume, primary care setting. An approach to building these competencies is to establish a teaching/mentoring relationship with an experienced nurse (or nurse practitioner) and see patients together. Another approach is to team a nurse with a provider and run sick call and primary care clinic concurrently. This later suggestion may require more elaboration but the idea is that the nurse has more assistance and collaboration available when addressing patient needs so that the number of encounters necessary to address a problem can be reduced.

Eliminate waiting: Ask for help to eliminate time lost waiting between patients. At one facility the nurses didn’t schedule patients for sick call on the facility’s automated scheduling system assuming that it only applied to provider appointments. As a result inmates were brought to sick call only when there was a gap in the provider’s schedule. The numbers of patients seen in sick call each day increased when the nurses started scheduling sick call appointments because waiting time had been eliminated. Collaborating with custody staff may yield other ideas to reduce waiting time especially since sick call competes with other activities they are responsible for overseeing.

Manage time during the clinical encounter: Multi-tasking is a key to managing time during the clinical encounter. Taking the patient’s history and description of the subjective complaint while collecting objective data (taking vital signs, inspecting the area, palpating etc.) is one example. Another is to have the equipment and supplies needed for sick call with you. Stopping the interaction to go across the hall to get a dressing or over the counter medication are time wasters. It is really a waste of time to see patients in a non-clinical setting (cell side or on a tier) since another appointment will be necessary if privacy is compromised, an unclothed exam is needed or a treatment must be given. In other words, handle each request once; don’t generate more encounters because the assessment is incomplete.

Manage the patient: Nurses complain that inmates put in multiple sick call requests, often involving the same problem. The reality is that the primary means to access health care is via sick call. Some systems have looked at the kinds of things that inmates are requesting and considered whether they could be handled through another avenue. Examples of other avenues that have been developed include making over the counter medications more readily available (in the housing unit or on canteen), automatic refills of prescription medication, appointment request forms for the optometrist, mailing lab and radiology results back to the patient, and the list goes on and on. Limiting patients to one request per sick call visit only generates more requests; it is more efficient to address multiple complaints at one encounter. An effective way to manage “frequent flyers” is to schedule appointments with some regularity so that they don’t have to rely solely on sick call requests.

Manage complexity: Several of the experts emphasized the importance of triage in sorting out patients with complex needs and making these the first to be seen. Seeing complex patients early in the day means that there is more time get referrals or additional clinical work accomplished so that their needs are addressed proactively. Explaining this approach of triaging and seeing the complex patients first can also enlist custody staff assistance as necessary. Another approach is to consider group appointments for common problems. I have seen this used at a work camp during a round of winter colds and flu when a quick assessment, patient education and supportive treatment were perfectly appropriate to use in a group setting as long as patients were given the option of a more private encounter.

Contingency planning: No day is ever the same as the next. The number of sick call requests received each day varies and sometimes there will be events that cause the number of requests to skyrocket (e.g. after a disturbance, norovirus or other outbreak, new provider or nurse). A suggested practice is to check in at the half way point; if the number of patients needing to be seen is going to exceed the time available then a backup plan needs to go into effect immediately to prevent backlog. This may mean reassigning staff or re-deploying staff (and mangers and providers) to ensure that all patients are seen timely. Sick call is not a task that gets marked off a list but is instead a dynamic and complex human process that requires attention and commitment to satisfactory completion every day.

 

How does the consensus of an average of seven patients an hour sit with your experience? What advice do you have for nurses who want sick call to become more efficient? Please share your opinion and advice by responding in the comments section of this post. There is much more on the subject of Sick Call written by Sue Smith in Chapter 15 of the Essentials for Correctional Nursing. Order your copy directly from the publisher. Use promotional code AF1209 for $15 off and free shipping.

Be safe this holiday season!

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Considering productivity in sick call

mature female nurseNurses at a medium security male facility have asked you to help them get a handle on nurse sick call. They don’t know what is wrong but are burdened by the number of sick call requests that they get every day. There are times during the week when inmates are not seen within the facility’s definition of timeliness. The average number written requests for health care attention that the nurses receive each day is 42. Approximately half of these involve physical symptoms that require a nursing assessment no later than the next day. The nurses see on average 26 patients each day; but only half of these are nursing assessments scheduled from triage of the written request. The other half are urgent walk-ins. There is a backlog of 30 patients who have yet to be assessed by a nurse.

What do the numbers tell: What is your first impression about how nurse sick call is being handled? Looking at the average statistics a backlog can be predicted. If an average of 21 patients each day have concerns that involve physical symptoms then the nurses will need to see that many patients every day to keep up. In this example the nurses are only seeing about 13 patients scheduled from triage of the written request each day so every day eight patients are added to the backlog. To catch up the nurses need to see more than 21 patients a day until the backlog is eliminated.

Underlying principles of sick call: Nursing sick call is considered one of the signature practices defining the specialty of correctional nursing. There are two legal principles underlying nursing sick call. The first is that inmates have daily, unimpeded access to health care. The second is that inmates are entitled to a professional clinical judgment regarding their health concerns. Simply put, inmates can request health care attention every day and their concerns must be addressed in a responsive, timely and clinically appropriate manner (Smith 2013). The failure to see patients, as in the example above, is a violation of these underlying legal principles and puts patients at risk of harm.

What gets measured gets done: Sometimes the never ending onslaught of requests for health care attention can overwhelm nursing staff and becomes a morale and staff retention issue in addition to a legal or risk management problem. Having performance benchmarks for nursing sick call can be helpful in identifying when practices deviate from the norm, considering root causes and developing solutions to improve performance. Based upon your experience how many patients can a proficient nurse see in sick call in an hour? What advice would you give to a nurse who wanted to become more efficient at sick call? Please share your opinion and advice by responding in the comments section of this post.

Next week’s post will include the consensus from nursing colleagues about how many patients nurses can see in an hour of sick call as well as their advice about how to manage sick call efficiently.

There is much more on the subject of Sick Call written by Sue Smith in Chapter 15 of the Essentials for Correctional Nursing. Order your copy directly from the publisher. Use promotional code AF1209 for $15 off and free shipping.

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Pustules, Furuncles and Petechia, Oh My!

human skin anatomy cross sectionI just spent a week at a correctional facility and while there was privileged to observe several nurses conducting sick call. I came away from these experiences appreciating that this process has become one of the signature practices of the correctional nursing specialty. Sue Smith referred to sick call when done well as “a thing of beauty” in her chapter on the subject in the Essential of Correctional Nursing (page 304). Reflecting on the experience of being with these sick call nurses over the week it occurred to me just how many patients were seen because of skin problems. Complaints included toenail fungus, dry skin, contact dermatitis and acne. Sound familiar? Most nursing protocols for problems related to the skin almost presume a diagnosis first. Here are some examples of these types of protocols: ectoparasite infestation, urticaria, dermatitis, candidiasis infection, bacterial infection, fungal infection, boils, jock itch, warts etc. In order to select the correct protocol the nurse should perform a more general skin assessment first. A thorough assessment and objective description of the condition also should accompany any referral to a primary care provider for more definitive diagnosis and treatment of those conditions not covered by a nursing protocol or that do not respond to nursing intervention.

Subjective description: The following subjects should be covered while gathering information from the patient about a skin problem.

  •      Duration: Is the onset sudden or gradual? Previous episodes or is this the first? Has the condition been persistent or does it fluctuate over time?
  •      Location: Where is it located? Where did it start? Has it spread and if so where?
  •      Provoking or relieving factors: What brought it on, makes it worse and makes it better?
  •      Associated symptoms: Itching, tenderness, bleeding, discharge, generalized or systemic symptoms of fever, pain, malaise?
  •      Response to treatment: What treatment has the patient tried and what was the result? Be sure to include consideration of prescription, over the counter and complementary (herbal, etc.) interventions.

The patient’s medical history and family history may be relevant (chronic or immunosuppressive disease, skin cancer etc.). Other areas to consider in gathering the patient’s subjective data include environmental exposures (work, leisure activity etc.); alcohol, drug and tobacco use, allergies and recent travel. Equipment for a dermatological exam: In terms of the tools of the trade, dermatologists recommend having a magnifying glass and measuring device available. Another recommendation is to ensure adequate lighting. Natural light is best; a hard thing to come by in some correctional facilities. If relying on artificial light, a high intensity, incandescent light is best. In addition a handheld light is helpful to provide lighting from the side when assessing a lesion. Finally, you have to have sufficient privacy for the examination and since the assessment will involve palpation, the hands need to be clean and for the patient’s sake warm. It is always best to tell the patient that you are going to touch them, where and why before you do. This is especially true for patients who have a history of having been traumatized or abused. Examination: The first step is to just look at the patient; do they seem well or ill? Is there any evidence of systemic illness (vital signs, flushing, jaundice, etc.). The next steps are to visually inspect and then palpate the lesion or effected area. Inspection includes the noting the following characteristics:

  • Location – is the lesion or effected area related to sexual contact, exposure to sun or other environmental conditions (chemicals etc.); is it in an area of friction or pressure from clothing, does it involve mucous membranes or areas of perspiration.
  • Number and Distribution – How many? How are they arranged?
Terminology Description
Annular Circular pattern
Confluent Merged or run together
Discrete Separated and distinct from each other
Generalized Scattered over an area
Grouped Clustered in multiples
Linear Line or snakelike shape
Polycyclic Concentric circles like a bull’s eye
Zosteriform Along a nerve root
  •  Characteristics – Size (measure the longest side first). Describe the color and any variation in coloring, including any areas of inflammation. Note whether edges are clearly defined and if the shape is regular or irregular.

Next palpate the affected area for tenderness and warmth. Palpate the lesion to determine where it is located within the three layers of skin (epidermis, dermis, subcutaneous tissue), how thick the lesion is and its consistency (hard, soft, firm, fluctuant). When pressure is applied does the color change or does it break down or bleed easily. Examine regional lymph nodes for tenderness or inflammation. The purpose of inspection and palpation is to obtain an accurate and objective description of the skin problem. There is a vast vocabulary of terms to describe skin conditions. A few of the most common are listed here. A great glossary of dermatological terms can be found at the American Academy of Dermatology.

Type of lesion Description
Atrophic Thin, wrinkled skin
Crust, scab Dried serum, blood or pus
Excoriation Hollowed out or linear area covered by a crust. Caused by scratching, rubbing or picking.
Lichenification Skin thickening
Macule, patch Flat, circumscribed, discolored spot. Macule less than 1 cm (ex. freckle). Patch is larger than 1 cm.
Nodule, papule Solid, palpable lesion. Nodule if greater than 1 cm, papule smaller than 1 cm in diameter.
Petechia, ecchymosis, purpura Extravasation of blood into skin. Petechia are less than 2 mm, ecchymosis larger than 2 mm. Pupura are confluent lesions.
Plaque Well defined plateau above the surface of the skin. As seen in psoriasis or eczema.
Pustule Superficial, elevated lesion containing pus.
Scales Dead skin that flakes or is built up
Scar Fibrous tissue formed after a skin injury
Vesicle, bulla or blister Circumscribed, bump containing clear fluid. Vesicle less than 5mm. Bulla or blister larger than 5 mm.
Wheal Transient, irregular, elevated, indurated, changeable lesion caused by local edema.

Documentation: Once you have taken the patient’s history, collected subjective information about the chief complaint and examined the patient review your documentation of findings to ensure that it is complete. A good description of the lesion will be important in comparing whether the patient’s condition is improving or getting worse with recommended treatment. A focused assessment of a skin condition assists in clinical decisions about which nursing protocol to use and/or the urgency of a provider referral. The key parts of an assessment include:

  • Presenting symptoms
  • History of the complaint
  • Examination
    • Location and size
    • Number and distribution
    • Characteristics of the lesion
  • Documentation of findings

For more about nursing assessment and sick call in the correctional setting go to our book, Essentials for Correctional Nursing. It is the only text published about the unique experience of correctional nursing practice. Order your copy directly from the publisher. Use promotional code AF1209 to receive a $15 discount and free shipping.  By the way, the title of this post, Pustules, Furuncles and Petechia, Oh My! is a riff on the Wizard of Oz, a holiday favorite of mine. Here is a clip from the movie. Enjoy!

References and Resources:

  1. Adult Decision Support Tools: Integumentary Assessment (2014). Remote Nursing Certified Practice. CRNBC Publication 743 at https://www.crnbc.ca/Standards/CertifiedPractice/Documents/RemotePractice/743IntegumentaryAssessmentAdultDST.pdf
  2. American Academy of Dermatology at https://www.aad.org/education/basic-dermatology-curriculum
  3. Hess, C.T. (2008) Practice points: Performing a skin assessment. Advances in Skin & Wound Care: The Journal for Prevention and Healing 21(8): 392-394.
  4. Jail Medicine by Jeffrey Keller at http://www.jailmedicine.com/. Select dermatology from the categories section for several blog posts on dermatology issues in the correctional setting.
  5. Johannsen, L.L. (2005) Skin Assessment. Dermatology Nursing 17 (2): 165-166.
  6. Pullen, R.L. (2007) Assessing Skin Lesions. Nursing 2007 (8): 44-45
  7. Tidy, C. (2014) Dermatological History and Examination. PatientPlus at https://www.patient.co.uk/print/2041

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Nursing Sick Call Part 4: Using Data to Drive Improvement

?????????????????????????????????????????????Sick call is the primary way to access health care during incarceration and lays the foundation for meeting inmates’ constitutional rights to adequate health care. Sick call must be timely, clinically appropriate and responsive to the health needs of inmates making requests for care. Sick call is a high-risk, high-volume and frequently problem-prone aspect of the health care program and should be monitored as part of the continuous quality improvement process used at the facility.

1. Set thresholds: This is the first step in monitoring any aspect of health care. By keeping track of the volume and timeliness of sick call it is possible to set norms for each step in the process. So for example if a unit receives and triages an average of 50 sick call requests each day starts to receive 90 requests a day will know to investigate the reason for this deviation from the norm. It could be that there is a new nurse assigned to sick call or there is an infectious disease process like influenza being transmitted or perhaps the nurse isn’t being responsive to the inmates’ concerns and they are submitting additional requests in the hope of a referral. When inmates are concerned about violence on the unit (such as an impending riot) one sign is an increase in use of sick call. Noting average utilization rates is one way to identify potential problems when the rate is greater or smaller than the norm.In addition to average rates of sick call, activity goals or standards for performance should be set to compare actual performance to the goal or desired level of performance. An easy example of a threshold is that 100% of all requests for sick call attention will be reviewed by a nurse and triaged within 24 hours of the request being received.  Another threshold is that 100% of all requests that have a symptom based complaint will be seen by a nurse in a face-to-face encounter within 48 hours of the request being received. These are compliance indicators for NCCHC’s essential standard on access to care (E-07) so a threshold of 100% is preferred. Another example is that all nursing sick call encounters will document that patient education was provided. In this case the threshold may be less than 100% and represent a goal to be attained by the nursing staff. A final example where a threshold less than 100% might be set is patient satisfaction.

2. Identify problems or opportunities for improvement: Efficient, effective and clinically responsive services are goals of quality health care. The table below outlines aspects of sick call that are monitored against established thresholds to evaluate how well the program meets CQI goals.

CQI Goal

Aspect of Sick Call Monitored Method of review
Efficiency TimelinessFlow through (including referrals)Communication Chart reviewSick call logs
Effectiveness Use of nursing processCompetencyClinical decision making Chart reviewObservation

Responsive

Flow through (including referrals)Patient outcomesPatient satisfaction

Chart review

Sick call logs

Patient survey

Connected to this post are three audit tools that were developed to monitor the quality of sick call. Click on the link set up below for each tool. The link will open another page then click on the link on that page and the audit tool will open up. Perhaps one or more of these tools can be adapted for use at your site.

Some facilities also keep a log to monitor timeliness of sick call and referral care. Many times logs are put in place because the facility has a history of not providing timely access to care and an external tracking tool is found to be necessary. Entries on the log record the date and time the request is received, triaged, and the face-to- face encounter takes place. Also recorded is the nature of the request, the diagnosis, and the disposition. If the disposition is referral to a clinician the date the appointment is requested as well as the actual date the appointment occurs is recorded. Fortunately with automation of scheduling and health records systems these logs take less work to maintain. Deviations from established timeframes and failure to provide timely care can be identified and remedied quickly if when the sick call log is reviewed daily.

3. Improve sick call services: Problems with access to care or opportunities to improve sick call services are easy to identify if the services are regularly audited and input from staff involved in delivering the service sought out. Nursing staff meetings should regularly include review and discussion of sick call and the results of CQI audits. The ideas staff have about how to fix a problem or make sick call better are critical to achieving solutions that are practical and sustainable.

The Plan-Do-Study-Act Cycle is a simple four step method to make changes that will correct or improve sick call. The first step is to select from among several possibilities one change to try out. Next pilot the change to see if it makes a difference. The pilot should be small in scale so it is quick and easy to accomplish. For example if the nurses think their productivity could be improved if all the equipment needed for sick call were in one place, a small test of change would be to outfit one room and then see if the nurses using that room for sick call are more efficient. The third step is to study the effect of the change by reviewing the results. In the example about the equipment being in one place the evaluation could be the time it takes a nurse to see five patients compared to others or how many patients are seen in an hour of sick call. Staff input at this stage is very important too. One question to ask at this stage is what has been learned about sick call as a result of the pilot. The fourth step is to take action based upon what was learned from the pilot that tested the change. If no improvement was noted or it proves impractical select another solution to test out through the cycle. If an improvement is achieved begin to incorporate what was learned on a wider basis and continue to monitor the outcomes of the change through the PDSA cycle.

How is data used to improve sick call at your facility? Nurses involved in sick call should also collect and monitor the data that drives improvement in access to care. Do the nurses at your facility discuss sick call at staff meetings to find ways to correct problems or make improvements? Do you have a sick call audit tool that you would like to share with other correctional nurses? Please share your resources and experience by responding in the comments section of this post.

For more on nursing sick call and access to care read Chapter 15 in the Essentials of Correctional Nursing. Order your copy directly from the publisher. Use promotional code AF1209 for $15 off and free shipping.

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Nursing Sick Call Part 3: Use and Misuse of Protocols

Diagram of ideal careProtocols are used by nurses in sick call to evaluate patients’ health care complaints. Protocols describe the steps to be taken in collecting the subjective and objective findings, the factors that lead to a diagnostic conclusion and the resulting actions taken to address the problem. Nursing actions driven by protocol may include treatment that a person would do for themselves if they were living in the community, simple first aid, health education or advice about self-care, and/ or referral to a provider. Protocols also exist for nurses to use in responding to medical emergencies. These protocols are more extensive than those used in sick call. Protocols discussed in this post are limited to those used to address non-urgent health care complaints.

The use of protocols by nurses is not in lieu of provider based care but to facilitate patient access to needed health care. Patient care is enhanced when the protocols involve the patient in self-care and support collaboration between clinicians in the management of a patient’s health status. In the Oregon Department of Corrections, for example, 80% of patient concerns can be addressed during the sick call visit. Every nursing sick call visit should provide information about the patient that is considered useful in the next clinical encounter.

Requirements for the use of protocols: The National Commission on Correctional health Care (NCCHC) provides detailed guidance about the requirements for use of nursing protocols in standard E-11 (2014). The first requirement is that the protocols are developed by the nursing administrator and responsible physician. The physician is responsible for ensuring that the protocols guide clinically necessary medical care and the nurse administrator is responsible for ensuring that nurses are allowed by law to perform the scope of work described in the protocol and that nurses are trained and competent to use the protocols. A note here is that this collaboration should include a discussion of the underlying philosophy and approach to patient care to build understanding of what each profession can contribute to patient access. Protocols are not intended to make nurses into physicians and must be written to remain consistent with the scope of nursing practice while at the same time supporting the patient to access appropriate, timely and responsive health care.

A good place to start is to review the state nurse practice act to determine if there is any guidance regarding practice that is specific to the correctional setting or the use of protocols in any setting. Another important consideration is the differentiation in state law or regulation between the scope of practice for an RN and an LPN. In some states the nurse practice act may prohibit LPNs from performing sick call and in other states there may be limitations or additional supervisory requirements.

Another requirement of the standard is that the program must demonstrate that each nurse has been trained initially in the use of protocols, annually each nurse must demonstrate knowledge and competency in the use of protocol, and training is provided whenever the protocols are revised or new protocol introduced. In addition the protocols are to be reviewed and approved for use each year by the nurse administrator and responsible physician. The annual review and resulting revisions should be based upon the results of:

  • continuous quality improvement studies,
  • clinical performance reviews and competency evaluations,
  • adverse patient events or near misses, and
  • evidence- based practice recommendations from the literature.

Misuse of protocols: The most recent issue of CorrectCare has an article by Tracey Titus, a nurse and the NCCHC accreditation manager that discusses the misuse of nursing assessment protocols. She points out that the correctional environment sometimes lends itself to the misuse of nursing protocols. The following paragraphs are some of the ways that nursing protocols can become misused in correctional healthcare.

1. Protocols do not substitute for primary care encounters: Protocols sometimes go beyond the knowledge and skills of the nursing staff perhaps in the mistaken belief that nursing sick call takes place in order to reduce the workload of physicians, nurse practitioners and physician’s assistants. Nurses do not have the same diagnostic acumen and clinical skills as a primary care provider. Protocols are most appropriate to treat problems that in the community people take care of themselves and to determine the urgency of referrals for problems that need to be seen by a primary care provider. A best practice is to schedule a providers’ clinic at the same time as nursing sick call so that the nurse can confer regarding patients whose problem exceeds the scope of the protocols.

2. Protocols do not substitute for good security practices: At the other extreme sometimes sick call is used to control access to things that can be as effectively managed by good security practices. A couple examples are dispensing and supervising use of dental floss or determining if an inmate should be authorized to receive a second pair of long underwear. This is a waste of nursing time and burdens the efficiency of sick call and sick patients have to wait longer to have their needs addressed. Clinical errors are made when sick call is overcrowded and rushed increasing the risk of adverse patient care events.

3. Protocols cannot cover every problem: In my early experience we wrote protocols for many, many different conditions. A year later when the protocols were reviewed we discovered that the nurses really needed only a few. Furthermore the nurses had no way of remembering the details of so many different protocols. In our re-write we focused only on the most common complaints (e.g. pain, skin conditions, minor trauma and HEENT complaints) and have since only gradually added additional protocols based upon actual utilization data.

4. Unqualified personnel cannot use protocols: Many systems find themselves with legacy staffing patterns and assignments that require health care and other personnel to work outside their lawful scope. Because of a lack of clinical oversight state practice acts may not have been consulted when the assignments were originally made. Do not assume that because certain personnel have been performing sick call that the practice is allowable or has been grandfathered in. Most systems work through this situation by rearranging assignments to better match the qualifications of existing staff.

5. Untrained or incompetent personnel cannot use protocols: There are very few if any other nursing settings that use protocols to manage initial requests for health care attention. Therefore nurses do not bring to corrections experience in this area and must be trained. Some nurses even after initial training are not able to demonstrate sufficient competency. Placing a nurse who is not competent in sick call undermines the nurse’s potential for eventual success and puts patients in harm’s way. Instead an individual performance improvement plan must be developed and coaching, monitoring and supervision provided for a reasonable period of time.

6. Protocols are not standing orders: Standing orders are written orders that specify the same course of treatment for each patient with a certain condition. Historically standing orders have been overused in correctional health care as a way to treat inmates when physician time was inadequate. Protocols differ from standing orders in that the action taken by a nurse to address the patient’s complaint is individualized based upon an assessment of the condition. For example every patient’s headache should not be treated the same way nor should every diabetic be on the same sliding scale for insulin. Standing orders are appropriately used for preventive care, such as immunizations and for diagnostic preparation.

How well do the protocols work at your facility? Are there too many or not enough? What kind of training did you receive in order to conduct nursing sick call? If you could make a change in nursing sick call what would it be? Please provide your thoughts and experience in the comments section of this post.

For more on nursing sick call and access to care read Chapter 15 in the Essentials of Correctional Nursing. Order your copy directly from the publisher. Use promotional code AF1209 for $15 off and free shipping.

 

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Nursing Sick Call Part 2: Pitfalls with the Face- to- Face Encounter

NSPS'10_Fig 4  Nursing Process  StdsLast week’s post on nursing sick call emphasized the importance of receiving and responding in a timely and clinically appropriate manner. Each request must be triaged within 24 hours of receipt. When the request describes a clinical symptom it must be assessed in a face- to- face encounter. Obviously if the symptom is of an emergent nature the assessment must take place immediately. Examples of requests that are potentially life threatening and should be assessed immediately include statements regarding suicide or hopelessness, cardiac or respiratory distress and trauma.

However most requests received via sick call are not of an emergent nature. Patients with non-urgent clinical symptoms need to be evaluated within 48 hours from time the request was received and this timeframe can extend to 72 hours on weekends. Non-urgent health care attention is requested most often for symptoms relating to pain, skin conditions and HEENT problems. Nurses should expect to be very familiar with the assessment, evaluation and treatment of multiple conditions that manifest in these symptoms. Correctional nursing expert, Jessica Lee, as well the National Commission on Correctional Health Care (NCCHC) recommend staff with the most skill and experience in assessment be responsible for sick call.

The face-to- face encounter involves the six components of nursing process defined in the American Nurses Association (ANA) standards for correctional nursing practice (2013). These inter-related components are depicted in the diagram at the top of this post as assessment, diagnosis, outcomes identification, planning, implementation and evaluation. For a description of how the nursing process is used during nursing sick call see Chapter 15 in the Essentials of Correctional Nursing.

What are the pitfalls for nurses in the face-to-face encounter? In thirty years’ experience as a correctional nurse, manager and consultant I have observed thousands of nurses in sick call encounters and reviewed their documentation. Some of these nurses were definitely experts, others were new to the process, and many were competently performing these skills. The following are the problems and pitfalls most often seen with the face-to-face nursing encounter.

Delays: Evaluations that take place long after the request has been submitted place the nurse in a difficult spot. The patient is frustrated because of the delay and may be disrespectful; the condition may have gotten worse and the patient already been seen in an emergency or the condition grown more complex and require a referral when it could have been treated by the nurse if seen earlier. Imagine how you would react if it took three days to receive one dose of aspirin or ibuprofen for a headache. When inmates experience failures in access the response is often to flood the system with requests and soon the nurses can’t keep up. Stay on top of requests so that there are no delays and the volume will be more manageable. There are no defensible reasons for delaying access to care; it is a constitutional requirement.

Incomplete assessment: Nursing assessment involves the collection of both subjective and objective information that is relevant to the patient’s reason for requesting health care attention. The subjective assessment includes asking sufficient questions about the problem to determine additional data to be gathered during the objective exam, diagnostic testing and chart review. Failing to physically examine the patient to adequately verify and amplify subjective information is a common error in nursing sick call. Examples are sick call encounters have incomplete vital signs recorded or dental complaints that do not include an examination of the oral cavity and neck but just a referral to the dental department. This may be because of inexperience, fear or concern about touching inmates or trivializing patient complaints. Nursing assessments should be conducted and documented so that the clinical information contributes to the next provider’s assessment whether it is a provider appointment or the next sick call visit.

Inadequate patient involvement: Involving the patient in each encounter is a sure way to reduce unnecessary requests for health care attention and submission of a grievance both of which take additional time to respond to. This is not to say that a nurse should give the patient what they want. Instead it means to ask for the patient’s input about the outcome they desire and then to provide an explanation of findings, recommended plan and the rationale that takes into account the patient’s input. Involving the patient demonstrates respect and helps build the therapeutic relationship; it also gives useful clues that can help motivate the patient in their own care. If the patient doesn’t understand then another explanation may be useful especially if the patient has low health literacy. The nurse may schedule the patient back for a follow up appointment to go over the information again or to check on the patient’s symptoms. If the patient doesn’t agree with the plan the nurse should reconsider their findings or make a referral for higher level care.

Poor clinical decision making: Making clinical decisions is a skill built by thoughtful reflection on practice while gaining experience. As experience increases diagnostic conclusions are drawn more quickly by patterns recognition rather than the more deliberate process of gathering and analyzing data. The downside to pattern recognition is that the nurse’s conclusions are prone to bias based upon personal experience and cultural socialization. Two common errors in diagnostic reasoning are premature closure (coming to a conclusion before sufficient data is gathered) and confirmation bias (only seeing data that matches our conclusion and ignoring data that doesn’t). See two previous posts about how to build and hone clinical decision making skills.

Inefficient use of resources: Time, space and equipment are the resources nurses use during sick call. Examples of inefficient use of resources include conducting the face-to-face encounter in an area where the nurse cannot properly examine the patient, using a blood pressure cuff that is the wrong size or not calibrated, having to go to another area to get supplies or equipment to complete the examination, not having the chart available or not referring to the chart for data on the patient’s recent health care. See a previous post about safe practices for nurse sick call. Nurses should be able to elicit the health history at the same time observe the patient and gather objective physical assessment data. Like playing the drums the face-to-face encounter takes practice. Nurses develop these skills when they are provided support, coaching and feedback. Face-to-face encounters which are incomplete or inadequate also waste provider resources if an unnecessary referral is made or the information about why the provider appointment is needed is incomplete.

What are the challenges you experience in completing timely, responsive and clinically appropriate face-to-face encounters with patients who have symptom based requests for health care attention? Please provide your thoughts and experience in the comments section of this post.

For more on nursing sick call and access to care read Chapter 15 in the Essentials of Correctional Nursing. Order your copy directly from the publisher. Use promotional code AF1209 for $15 off and free shipping.

References

 American Nurses Association. (2013). Correctional nursing scope and standards of practice. Silver Spring, MD: American Nurses Association.

Knox, C & Shelton, S. (2006). Sick Call. In Clinical Practice in Correctional Medicine (2nd ed.). Philadelphia: Mosby Elsevier.

LaMarre, M. (2006). Chapter 28: Nursing role and practice in correctional facilities. In M. Puisis (Ed), Clinicsl Practice in Correctional Medicine (2nd ed.). Philadelphia: Mosby Elsevier.

National Commission on Correctional Health Care. (2008). Standards for Health Services in Prisons. Chicago: NCCHC.

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Nursing Sick Call Part 1: Receiving and Responding to Requests for Care

PRIGIONIERONursing sick call has been described as the signature practice defining the specialty of correctional nursing. There is no experience quite like sick call in any other area of nursing practice. Nursing sick call is considered the backbone of health care delivery in correctional settings because it is the primary way inmates can access health care during incarceration. In a recent interview Jessica Lee, Vice President for Nursing Support at Corizon commented that sick call is a barometer of the quality of the entire health care program in a correctional facility.

The manner in which inmates make requests for health care attention is the first step in the sick call cycle and the focus of this post. The ability to request health care attention is a fundamental right of persons who are incarcerated. The American Correctional Association (ACA) and the National Commission on Correctional Health Care (NCCHC) both have established standards which require that:

  • requests are received by health care personnel every day,
  • each request is evaluated within 24 hours of receipt and
  • there are no impediments to making requests for health care attention.

Seems pretty simple but compliance requires that correctional officers and nursing staff act in ways that are consistent with these standards in hundreds of encounters and interactions with inmates every day. So access to health care is a high volume, high risk activity in correctional health care. Correctional facilities can protect themselves from adverse patient events and litigation by developing policies, procedures, job descriptions and assignments that meet these standards. In addition it is important to verify that actual practices are consistent with the facilities policies and procedures through supervision and audit of staff performance. The following is a breakdown of the areas that need to be considered to ensure that your facility meets accepted standards for access to care.

Communication: The facility should have one or more ways established for inmates to make requests for health care attention. Inmates must be informed of this process at the time of admission to the facility. Common methods used to request health care attention are by filling out a request slip that is given to a health care provider, signing up on a list, showing up at a particular time, or calling to request an appointment. The next consideration is whether the selected methods are working. Pitfalls to an effective request process include not giving inmates this information at admission, inmates not understanding the process, not having a secure place to put written requests, not picking up written requests every day, forms that are too complicated to fill out, not having sufficient forms, not having access to the sign up list or use of the telephone, lock down or scheduling conflicts, and intimidation of inmates requesting care by other inmates or staff. Nurses should be assigned daily to review and assure that the method(s) used to request care are working. There should be documentation that provides evidence that requests for access to care may be made daily and that there are no impediments. Having the date on each request received, each list of inmate requests, or each walk-in encounter is the kind of documentation that provides this evidence.

Triage: Every request for health care attention must be evaluated within 24 hours of receipt. This evaluation is a form of triage used to determine when and how each request will be handled. Triage is a clinical decision made by licensed health care personnel. Triage requires use of the nursing process to assess the patient, diagnosis the problem, identify the desired outcome, plan and implement intervention(s) to achieve the identified patient outcomes. Simply reading a written sick call slip is not sufficient triage of a request that involves any description of a symptom based complaint. Any inmate submitting a written request for health care attention for a complaint that is symptom based must be evaluated in a face to face encounter within 24 hours of receipt of their request. With other methods for making requests (sign- up, telephone or walk- in) as long as nursing personnel evaluate each request within 24 hours the standards are met. Documentation includes the nurse’s evaluation as well as the date and time the patient was seen. Problems with nursing triage of inmate requests for health care attention include not performing triage seven days a week, not triaging every request received on a daily basis, using inappropriate personnel to perform triage, clinically inadequate triage, trying to talk patients out of needing to be seen, minimizing patient complaints or blaming the patient.

Disposition: The outcome of triage is the disposition or decisions made in response to the patient’s request. Dispositions include treatment, referral, patient education, and advice about self- care. Many times a single request will have more than one disposition decision. In addition to the decision about what is to be done the nurse also decides who will do it and by when. Each of these decisions, including by whom and when, are documented and dated. The nurse should explain the disposition to the patient so that they know what to expect and by when. Every nursing encounter should be considered an opportunity to education that promotes the patient’s engagement in their health care. Pitfalls in the disposition of requests for health care attention include poor clinical decisions, inadequate follow through or handoffs to responsible others, silos between programs and departments that result in disruption of care, and lack of patient understanding or agreement with the plan of care.

Monitoring: When requests for health acre attention are not received and acted upon in a timely, responsive and clinically appropriate manner the efficient operation of the health care program will be in serious jeopardy. Effects of insufficient access are increases in the number of inmate grievances, increases in requests for emergent health care attention and inmates will submit multiple requests for the same problem. Health care programs should track the timeliness, completeness and appropriateness of communication, triage and disposition of health care requests. Other aspects of access to care that should be monitored are the types of requests being made as well as the subject and frequency of multiple requests. This data helps to answer two questions: Is the system to access care working and are the responses clinically appropriate, responsive and timely?

Do the practices in place at your facility meet the standards for access to health care? How does the facility monitor access to health care? What is your role in ensuring that inmates have unimpeded access to health care during incarceration?

For more on nursing sick call and access to care read Chapter 15 in the Essentials of Correctional Nursing. Order your copy directly from the publisher. Use promotional code AF1209 for $15 off and free shipping.

 

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