Thanksgiving

Graphic typographic montage illustration of the word Thanksgiving composed of associated terms and defining words in neutral tones. A pair of autumn leaves completes this dramatic, inspirational design.

This week we celebrate Thanksgiving, an American holiday to give thanks for the abundance of the previous year and the fall harvest. Many, but not all of us, get together with family and friends to enjoy a meal and the company of others as fall turns to winter. Some of us will be working, sharing the holiday with our colleagues and patients. No matter what specific plans we each have for the holiday, it is a time of reflection, to identify and give voice to that for which we are thankful.

Lorry, Gayle and I are thankful for you, the readers of the Essentials of Correctional Nursing. Lorry wrote the first post almost five years ago just as we finished editing, our text, The Essentials of Correctional Nursing. We have posted a new blog nearly every week since then. We are grateful to Gayle for joining our blogging adventure this past year and enjoy her take on issues in correctional nursing.

Our purpose in writing the blog is to amplify the material included in the book and to further explore new and recurrent issues in correctional nursing practice. Our most frequently viewed posts address the subjects of delegation, certification in correctional nursing, vital signs, withdrawal, spiritual distress, the ANA Scope and standards of professional practice, and evidence-based practice. As we look back over our files we are thankful for the opportunity the blog has given us to explore subjects in depth.

Day by day, week by week, year by year our readership has grown. We average over 150 hits on the blog every day and have had over 300 hits on some days. Our readership is from all over the world and we have benefited from our contact with correctional nurses from all across the globe. We have more than 200 regular subscribers on email, over 4,000 on Twitter and more than 700 on Facebook. Thank you for your interest and support for the Essentials of Correctional Nursing.

We published The Essentials of Correctional Nursing in 2012, along with eight contributing authors, to reflect the distinguishing features and practices of this specialty in the field of nursing. In doing so we benefited from the support of many colleagues who peer reviewed the manuscript and offered insight about issues in correctional nursing. The text has since been recommended as a resource applicants use to study for certification in correctional nursing. Lorry also has written a series of posts on this blog about how to study for the certification exam and her own journey becoming certified. We are grateful for the growing legion of nurses who are certified in correctional nursing; you are the voice of the profession! If you are not yet certified, perhaps this could be your goal for the new year. It is easier than you think and there are many benefits.

At the end of every year Lorry and I discuss how we are doing with the blog and decide whether to continue and if so, what subjects we are going to tackle in the coming year. This year we decided that with other opportunities and commitments, it is time to move on and no longer will post on the Essentials of Correctional Nursing blog. However we are maintaining the site and the collection of 220 or so posts as a continuing resource for correctional nurses. Next week’s post will be the last and includes a table of contents so that each of our previous posts can be easily accessed from this page!

We continue to support correctional nursing practice through our writing, consulting, and speaking. Here are some helpful links to other correctional nurse resources that we support and endorse:

CorrectionalNurse.Net Blog

Correctional Nursing Today Podcast

CorrectCare Magazine

The Essentials of Correctional Nursing can be ordered directly from the publisher or from Amazon today!  Lorry and I, or any of the contributing authors, are always glad to sign and personalize your copy of the text.

Have a safe and grateful holiday!

Photo credit: © gdarts- Fotolia.com

More Circles in Your Practice

cqi-circle-fotolia

Last week’s post reflected on how the nursing process and SOAPIE documentation are circular processes in correctional nursing practice.  This week, a third circular process that is part of every correctional nurse’s tool bag is considered. This is Continuous Quality Improvement (CQI), known to most correctional health care professionals in both positive and negative ways.

The goal of CQI is to improve quality of care and build efficiency into processes and procedures. An article I read recently described the feelings of many family practice providers about CQI as “the mere mention of the words quality improvement can evoke dread in the minds of many physicians” and I would add nurses also.  Often CQI is mistakenly thought of as more work ;focusing on problems and not solutions. However, if you look at CQI as what you do every day to make things better, it takes on a new light. For example when your washing machine stops working, you evaluate the problem, look at what went wrong and fix it. If the machine still does not work, you examine and try again. Out of all this you put in place practices or changes that will prevent the washer from having the same problem again. That is CQI. No matter if you work in a small jail or a large prison system – it only takes ONE person to improve the effectiveness of health care delivery.

What is CQI Anyway?
The National Commission on Correctional Health Care (NCCHC) describes CQI as a pathway to improve health care by identifying problems, implementing and monitoring corrective action and studying its effectiveness. In short, it is a method of continuously examining effectiveness and improving the outcome of care or procedures to deliver service.

There are volumes written about CQI and it can seem very complex but if you think of CQI as a simple process that is done all the time, you will be able to find areas of health care delivery or patient care that can be improved and take steps to find and implement solutions.

A Little History
Even before health care began looking at ways to improve systems, industry had in place methods to look at products that did not work correctly. W. Edwards Deming, PhD., a statistician who revolutionized management theories in Japan and the US, developed the following principles of quality improvement:
• A strong focus on customers—in our case, patients.
• Continuous improvement of all processes.
• Involvement of the entire organization in the pursuit of quality
• Use of data and team knowledge to improve decision making.
In the 1980’s, the Joint Commission set standards for hospital systems to establish a formal program to monitor the delivery of care. The effort to improve the health care provided to patients spread to all health care institutions, hospitals, clinics, care homes and correctional facilities. When the National Commission on Correctional Health Care (NCCHC) developed standards for jails, prisons and juvenile facilities, in the early 1980”s, quality improvement was an essential standard.

Components of CQI
The CQI model requires that you identify the problem area, and your aim or what you want to improve or change. Some common methods for identifying areas for improvement are routine chart reviews by members of the care team, targeted audits to see if forms are completed, referrals made, and labs reviewed. Others might be staff concerns such as equipment not on the emergency cart, missing charts, emergency send outs, or patients not coming to clinic. NCCHC suggests that the areas to study be those that are high-risk, high volume or problem prone aspects of health care. Some program processes to look at are intake, continuity of care through incarceration, emergency care as well as adverse patient events.

Once you have identified the problem area and goal for improvement you bring about the desired changes using the CQI circular model of going through the steps 1. plan 2. do 3. study/check 4. act. Each step is very simple as you can see in the following description:
Plan: Analyze the process, determine what changes would most improve the process, and establish a plan for making the improvement.
Do: Put the changes into motion on a small scale or trial basis.
Check/Study: Check to see whether the change is working.
Act: If the change is working, implement it on a large scale. If the change is not working, refine it or reject it and begin the cycle again.

If you have experience in a quality improvement, you have heard about outcome studies and process studies. If you are new to quality improvement, these two types of studies help to focus quality improvement efforts. An Outcome Study looks at the outcome of a patient’s condition after an intervention has occurred. Examples include: are infections healed with antibiotics, is the A1C in the normal zone, and are chest pain emergency visits reduced when nitroglycerine is kept on person. A Process Study: focuses on procedural or policy oriented issues, such as timeliness of intake screening, physician review of diagnostic results, health assessments completed before day 7 or 14, and TB skin tests read on time.

Documentation and communication of CQI results are extremely important. Each CQI study should be written up and shared with others along with the changes in practice, procedures or training. Most important is to CELEBRATE the successes with staff and be PROUD of the CQI work the team accomplishes.thumbs-up-picture

In summary, the key points of Quality Improvement are:
• It is focused on making processes better.
• The first step is finding key problem areas.
• Identify and prioritize potential change projects. Then use the PDSA cycle to study and implement the change

On reflection of nursing practice, the American Nurses Association, Standards of Correctional Nursing Practice, Standard 10, Quality of Practice, talks about the contributions to quality practice is a responsibility for all of us. One of the competencies is to participate in quality improvement activities with the purpose of improving nursing practice, healthcare delivery and the corrections system.

CQI is a continuous and ongoing part of correctional nursing practice, like the use of the nursing process and SOAPIE documentation discussed in the last week’s post. At the center of each of these processes is the NURSE and the important, skilled and thoughtful care nurses deliver.

Have you participated in CQI projects that improved patient care? We learn from each other so please share with us your successes and examples in the comment section below.

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

Photo Credit: © canbedone- Fotolia.com & © naruedom- Fotolia.com

The Circles in Your Practice

On a busy day and in the midst of patient care we are not always aware that much of our nursing practice care is a continuous process. Whether it is completing sick call, medication administration or counseling a patient, we are always “evaluating”. Nursing practice is circular, in that our patients continually respond to our health interventions and as nurses, we observe and act on that response. nursing-process-grid-11-7-16

The American Nurses Association defines correctional nursing as the “protection, promotion and optimization of health and abilities; prevention of illness and injury; alleviation of suffering through the diagnosis and treatment of human response; advocacy for and delivery of health care to individuals, families, communities and populations under the jurisdiction of the criminal justice system”.

The Nursing Process

The American Nurses Association published the Correctional Nursing: Scope and Standards of Practice in 2013. The goals of the scope and standards are to:

  • inform nurses and others about correctional nursing practice
  • guide nurse’s day-to-day practice and resolve conflicts
  • develop policy and procedure and other governance of professional practice
  • reflect on professional practice and plan improvement.

There are 16 standards of nursing practice with the first six delineating the steps in the nursing process. These six elements of the nursing process are circular as well as inter-related to each other.

  • Assessment is data collection about the patient’s health condition. Nurses use all their skills and senses to identify changes in a patient condition. By observing the patient, interviewing the patient, completing the physical examination, collection history information and reviewing of the patient’s health records an assessment is formulated.
  • Diagnosis is the nurse’s analysis of the data gathered and identification of the patient’s problem which results in the nursing diagnosis. The nurse also validates the diagnosis with the patient.
  • Outcomes Identification focuses the nursing diagnosis on the needs of the patient. The goal of nursing care is for the patient to achieve an improved level of functioning that is realistic to attain. Using the SMART technique, an acronym for setting goals that are specific, measureable, attainable, and realistic and time bound, assists in developing the outcome statement.
  • Planning  for the nursing interventions that will achieve the outcomes identified for the patient is the next step. These plans are specific to each patient and focuses on achievable outcomes. Planning, rather than reacting or practicing by rote, is more effective in reaching the goals of patient care.
  • Implementation are the action steps the nurse follows in carrying out the plan of care. Implementation may be one or more nursing intervention steps, and may take place over hours, weeks or months depending on the patient’s condition. Implementation requires the nurse to delegate care to subordinate personnel and communicate with colleagues to achieve completion of the patient’s plan of care.
  • Evaluation occurs all along during the nursing process. It is both the end and the beginning in the continuous process of care that is delivered to the patient. Documenting the patient’s response to interventions, evaluating their effectiveness and the outcomes achieved leads to modification or revision in the plan for care.  This illustrates how each step is fundamental to the circular process of nursing practice.

The nursing process is an integral part of every patient encounter. Expert nurses move through these steps fluidly without stopping to focus solely on each component. Nurses are attentive to their patient’s response to care provided all along the continuum from illness to wellness.

The Patient Plan & Documentation

The S.O.A.P method of documenting patient care is common in most correctional settings and is used as the main communication method in the patient’s health record. In the literature, two additional elements in SOAP charting are recommended; these are Intervention and Evaluation. These two additional elements of documentation align with the nursing process just discussed and support charting of continuous patient care.

  • S-Subjective: reports what the patient says
  • O-Objective: records what the nurse observes
  • A-Analysis: identifies a nursing diagnosis
  • P-Plan: describes nursing interventions
  • I-Implementation: records how those actions were carried out
  • E-Evaluation: reports the actual patient response and outcome.

This systematic approach to detailing patient care keeps us goal orientated and focused on how the patient is progressing in the treatment plan. With an eye toward always evaluating or “continuing” to evaluate a patient’s response to treatment, the nurse is ready to intervene to prevent an exacerbation of illness or unexpected response to treatment.

When nurses respond to requests for care, complete sick call assessments, administer medications and call patients up to check on how they are doing, it is part of the circular pathway of continually evaluating how our patients are or are not responding to care.

Next weeks’ blog topic will explore a third “circular” area of nursing practice, which is the Continuous Quality Improvement Process. Can you think of more circular processes in your nursing practice or insight into the continual evaluation process in nursing care? We would like to know your thoughts about the nursing process and SOAPIE process. Share in the comment section at the end of this post. We like to hear from you.

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

 

Photo Credit: American Nurses Association NSPS’10_Fig 4. Nursing Process Standards.

Remembering Meaningful Milestones

ncchc-40th-celebrationThe National Commission on Correctional Health Care (NCCHC) held its national conference in Las Vegas last week (October 24th through the 26th).  For the over 1600 attendees, it was a recognition of the profession of correctional health care and the path from the beginning to present day.

40 Years of Educational Offerings

For 40 years, NCCHC has been offering educational opportunities during four educational sessions each year. Edward Harrison CCHP, former NCCHC president was at this conference to bestow some awards and meet friends. His words reflect some of the highlights accomplished along the way.

  • Correctional health care providers were caregivers for AIDS patients before the disease had a name and before many in community health care settings overcame their fear of the disease.
  • Although decades ago telemedicine was widely promoted throughout the country, it advanced in correctional health settings more so than in many community environments.
  • Treating sexually transmitted and other infectious diseases in the community often relies on the interventions provided patients in the correctional system .
  • Correctional systems picked up the slack when community mental health programs lost their funding.
  • Health care for all, regardless of one’s ability to pay, was the established practice in corrections 30 years before the Patient Protection and Affordable Care Act.

During the conference the foundation of correctional health and the early leaders were recognized.  To add to our recognitions, nothing is more noteworthy than our next celebrated milestone.

Estelle vs Gamble- 40 Years Ago

The 40 year milestone of this court case, which is considered the basis for correctional healthcare, forces us to reflect on the advancement of quality care that today is provided across the country to all our detainees. This court case forced everyone to look at care in the jails and prisons across the country and build health care delivery systems that were comprised of qualified health professionals, identified illness, treated disease and prevented harm and suffering.

Estelle vs Gamble is a case brought forward by a prisoner in Texas in 1976. Even though the state “lost” the case, the decisions by the courts provided the foundation for care of all prisoners and the basis of deliberate indifference. During initial orientation, each new employee in correctional health care hears about Estelle vs Gamble and learns that detainees have:

  • The right to access health care in all settings.
  • The right to a professional medical opinion
  • The right to the care that is ordered.

The first standard in the NCCHC’s Accreditation Standards is “Access to Care”. The discussion states that “this standard intends to ensure that inmates have access to care to meet their serious health needs and is the principle on which all National Commission on Correctional Health Care standards are based. It is also the basic principle established by the U.S. Supreme Court in the 1976 landmark case Estelle v. Gamble.” (A-01, 2014 standards, page 3)

Remembering the foundations of correctional health, will provide us with a vision that expands the quality of health care and integrates us into the communities in which we practice.

Certified Correctional Health Professional (CCHP) for 25 Years

The third celebration was to honor the 25 years that the special certification for correctional health professional has been in place. Before 1991, a group of correctional health leaders, worked to develop a test that would reflect the unique challenges and foundation upon which correctional health is practiced across the country. Other health care specialties already had in place specific  certifications, such as ICU nurses, emergency nurses, IV nurses and some mental health specialties. These certifications recognize the knowledge base and competencies required in a specific field or specialty area of practice.

The first CCHP exam was in 1991 and was a take home exam with multiple choice and essay questions. At the conference, we honored 17 CCHP’s who completed the test in 1991 and are still certified today.

As the years have progressed, the test has expanded to a proctored exam at various conferences and sites.  Also other exams for specialties within correctional health have been developed. After you obtain your CCHP certification you may add to your credentials by taking a specialty exam. These include the CCHP-RN, CCHP-Physician, CCHP-Mental Health and CCHP-Advanced.  Achieving professional certification is the surest way to demonstrate that you have the qualifications and expertise to meet the challenges of delivering correctional health care in any setting.

As we go through our daily work, it is good to take time to reflect on how we achieved this proud and important professional career, and all the people who came before us and showed the dedication and leadership to improve care and show us the way.

Do have a reflection on the history of correctional health care that you would like to share? Please reply in the comments sections of this post.

Read more about legal foundations of correctional health care and the professional organizations that support correctional nursing in our book the Essentials of Correctional Nursing. Order a copy directly from the publisher or from Amazon today!

Photo Credit: NCCHC,org, education and conferences link

FLU-Give it a Shot!

flu-shot-photoOctober is a busy month for health professionals. We celebrate Breast Cancer Awareness Month, Mental Health Awareness Week, Dental Hygiene Month, Chiropractic Health Month, Pharmacist Month, Domestic Violence Awareness Month, Health Literacy Month and Patient Centered Care Awareness Month.

There are more awareness areas to be celebrated.  However, one is missing from the list.  It is special to October as it is the month that flu season begins and we all should be planning flu clinics and getting our own flu vaccines.

Recently the Centers for Disease Control and Prevention’s (CDC) Advisory Committee on Immunization and Practices (ACIP) adopted recommendations for the 2016-2017 flu season. This year two changes are noteworthy. The first is that the live, attenuated influenza vaccine (LAIV) has been found to be ineffective and will be unavailable this year. The second is that they have eliminated the egg allergy limitations of the past.

2016-2017 Changes

  • Flu Mist is Out-With no significant effectiveness found with the live virus vaccine, this year children’s immunization recommendations are for intermuscular doses only. Basically, children under 9 years of age will require one injection, children 6months to 8 years old will require two doses of the vaccine, unless they have received intermuscular injections in the past. Everyone 9 years of age and older, require only one dose of the 2016-2017 flu vaccine.
  • Egg Allergy Recommendations-These recommendations have changed a lot from prior years and the ACIP has listed the changes on their website. In summary, patients should still be observed for 15 minutes after the vaccine just in case there is a reaction. If a person has a history of a severe allergy to eggs, a medical provider should monitor their vaccinations. 

Nurses Responsibilities in Herd Immunity: Since corrections health is community health in many ways, nurses have a very important role during flu season and that begins with getting vaccinated. In the world of patient safety, a term called “Herd Immunity” is referred to as a means of stopping the spread of diseases. It also be called community immunity and describes protection from a contagious disease with community wide vaccination. The goal is prevention and containment of the disease. The concept is for the chain of infection to be interrupted by those vaccinated thus stopping the spread of disease to a susceptible host.

18 States have Mandates: In taking a leadership role in disease prevention, 18 states no longer allow health professionals to make a personal choice in obtaining an influenza vaccine. These laws are based on the hospital or facility type at this time. Since corrections facilities have a very fragile and vulnerable population, the same mandate should apply to personnel who work in these facilities as well.  Use this link to research the vaccination laws being published by the CDC.

Prevention is the Key: As nurses, we incorporate prevention into all our patient care activities and treatments. Key prevention tips include:

  • Wash your hands frequently and effectively.
  • Avoid close contact with those who show signs and symptoms of illness.
  • Stay home from work when you are sick.
  • Cover your mouth and nose when coughing or sneezing.
  • Avoid touching your eyes, nose or mouth.
  • Practice good health habits to stay healthy yourself.
  • Obtain flu vaccines for yourself and your family.

Outbreaks: In our corrections facilities, we do not have the luxury of isolating people in their homes or controlling their activities. However, there are processes we can plan for before an outbreak occurs or put in place if an outbreak occurs in your facility.

  • Educate the population about flu season and what they can do to reduce their risk.
  • Work with the local health department or pharmacist for a supply of flu vaccine. The supply this year is supposed to be adequate.
  • Monitor for outbreaks and track them. Work with custody to group ill inmates together, reduce movement, and limit visiting and other things to reduce transmission.
  • If ill patients have to go to court, institute droplet precautions by issuing a mask. Use a gown and gloves if necessary. Sometimes I have seen video court used with ill inmates or court delayed.
  • Administer antiviral treatment for those most vulnerable such as the elderly, chronically ill, immune compromised, pregnant or have acute medical conditions.
  • Consider vaccines for the entire population. Whether a jail or prison, every flu vaccine you administer, reduces the spread of disease in the community when they are released or have visitors.
  • Remember custody in your vaccination program. They want to stay healthy and not spread disease just like health staff.

Remember that vaccination is a community effort. Nurses’ commitment to vaccination best practices is critical to staying healthy and saving patient lives this influenza season. GIVE IT A SHOT

What is the influenza immunization policy in your institution? What practices are part of your plan to reduce the spread of disease? What happens when your facility has a flu outbreak? We enjoy hearing about your experience so please reply in the comment section.

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! 

Photo Credit: http://www.U.S.fotolia.com/ https://www.fotolia.com/id/120105499

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! 

Photo Credit: http://www.U.S.fotolia.com/#100153097/healing

 

Antibiotic Stewardship has Four Rights

stewardship photo

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

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

Correctional facilities are also patient care settings

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

The fundamental four rights

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

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

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

Common guidelines to ensure antibiotic stewardship

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

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

Corrections health reflects the community.

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

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

 

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Superbugs are not only in your garden!

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

News is Full of Superbug Warning

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

Corrections Health Responses

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

Precautions to Consider

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

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

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

Main Warning

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

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

 

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What are these eight rights anyway?

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

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

Health Care Advances

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

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

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

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

The Important Three

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

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

Spread the Word about the 8

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

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

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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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