Is Intake Screening Getting the Job Done?

The words Get it Done on a stopwatch or timer to encourage you to complete or finish a task or job

In June I wrote a post about intake screening and how difficult it can be to obtain a full and accurate picture of an inmate’s health status. In spite of the difficulties of the time, place and people involved, a nurse armed with information can still make good decisions about the plan of care for each inmate coming into the facility. One type of information that is useful is knowing the health characteristics of the population served.

The health characteristics of 759 inmates being received into the state correctional system in New York were recently reported in the Journal of Correctional Health Care (July 2015). The data about inmates’ medical conditions was obtained from chart review and information about health behaviors (smoking, etc.) came from individual interviews. There were nearly as many women as men included in the sample (387 men and 372 women). The average age was 35.6 years for women and 33.9 years for men. Eighty percent of the population had less than or equal to a high school education/GED. Given just these findings what are the implications for the nursing plan of care?

One conclusion that can be drawn is that health literacy is likely to be an issue. This means assessing what an individual knows already about a particular health issue and then starting from that point when providing information. Second, this population already has well established behaviors (smoking, sexual practices, use of illegal substances, and other risk taking) but may not yet have experienced the health consequences. Use of motivational interviewing will be a valuable tool to assess a patient’s readiness for change and select behavior change strategies most likely to influence the patient.

The population of men in the New York state prison study was predominately non-Hispanic Black and Hispanic. The majority of women were either non-Hispanic Black or non-Hispanic White. This characteristic will vary from region to region and type of facility. The racial and cultural characteristics of the population being received at the facility are important to know because they are also associated with disease prevalence. For example, Blacks are more likely to experience premature death from cardiovascular disease, while control of hypertension is poorest among Mexican-Americans according to the most recent report from the CDC on health disparities.

Respiratory conditions were the most prevalent chronic disease diagnosed in this population of inmates at admission to prison. Respiratory conditions include asthma, COPD and emphysema and were present among 34% of the newly admitted inmates. A history of smoking and obesity significantly correlated with respiratory diseases.

Cardiovascular conditions, including hypertension, atherosclerosis and heart disease were diagnosed in 17.4% of this population. Obesity was significantly associated with cardiovascular disease and diabetes. Sexually transmitted disease was diagnosed in 16.4% of the population. Women had a higher prevalence of chronic disease than men, particularly greater incidence of diabetes and STDs. It is not clear whether this is because women are more likely to access health care or are more susceptible to certain diseases. Age (40 years of age and older) was also correlated with higher risk for diabetes and cardiovascular disease.

Chronic disease was more prevalent in this inmate population than rates for the same disease in the general community. Rates for respiratory disease among the general community are estimated to be 19% compared to this prison population with a prevalence rate of 34%. Diabetes rates were 2.4% in the community among adults the same average age as the prison population. The rate of diabetes among prisoners was 4.9%. HIV disease was 3.5% among newly admitted prisoners while in the same average age group in the general community the HIV rate was less than half of one percent.

The results of this study done in the New York system are similar to those reported by the CDC a year ago. The CDC study looked at the chronic diseases reported by over 100,000 inmates in 606 state, federal and local correctional facilities in the U.S.

What does all this mean to correctional nurses? It is difficult to elicit a full and accurate history from an inmate during intake screening; especially if we are rushed, there are many screenings still to get done and the setting challenges privacy in sharing of medical information. By knowing that 3 of every 10 inmates screened is likely to have chronic respiratory disease helps me evaluate carefully the answers I am getting about the inmate’s medical history and emphasizes the importance of my skill assessing the respiratory system. The same is true for the other common chronic conditions. This doesn’t mean that the other areas of the health appraisal aren’t important, they are. It means that if diseases like diabetes, STDs, respiratory disease and HIV are not identified at about the same frequency as the rates reported for correctional populations then the screening methods should be examined for possible improvement. We all know that early identification of disease means treatment can be initiated that is less costly and burdensome than the emergence of an urgent or emergent medical crisis.

Are the rates of chronic disease tracked at your facility? If so, how do they compare to the rates reported for the New York state correctional system? How do the rates for chronic disease among inmates at your facility compare to the general community? Are there implications of these findings for correctional nursing that go beyond what has been discussed here? Please share your thoughts by replying in the comments section of this post.

For more about the nursing implications of caring for patients with chronic diseases in the correctional setting and the disease burden of this population see the Essentials of Correctional Nursing, especially the first and sixth chapters. Order a copy directly from the publisher or from Amazon today!

Bai, J.R., Befus, M., Mukherjee, D.V., Lowy, F.D., Larson, E.L. (2015) Prevalence and Predictors of Chronic Health Conditions of Inmates Newly Admitted to Maximum Security Prisons. Journal of Correctional Health Care, 21 (3) 255-264

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Medication Reconciliation

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

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

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

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

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

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

When Inmates Arrive at a Facility

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

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

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

When Inmates Return From Offsite care

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

When Inmates Are Followed in Chronic Care Clinic

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

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

When Medications Are Missing

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

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

Other questions to help narrow down the problem are:

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

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

Easing the Burden of Medication Reconciliation

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

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

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

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

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

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Intake Health Screening: Truth or Consequences?

Skinny Fighting LiarLast week I reviewed a letter responding to a complaint from an inmate’s wife that her husband was not receiving proper care for a back injury received when he was apprehended. The response starts like this “During intake screening on February 10, 2016 the inmate denied recent injury or hospitalizations. He also denied any past history of injury. Upon examination there were no signs or symptoms of injury to his back.”

How many times had you had something similar happen- an inmate seems to be healthy and denies any medical or mental health issues at intake, then a few hours, days or weeks later complains about a particular health issue alleging that it either happened just before incarceration or has been long standing? I have seen this happen lots of times. The letter above reminded me once again how inaccurate and unreliable health information obtained at intake can be. Some nurses I work with actually took a retrospective look at the accuracy of health information collected at intake compared to information obtained by asking the same questions a week later.  What were the findings? Well, it was surprising how much more information the inmate was able to provide.

What do you think are some of the reasons that information taken during intake screening differs from that obtained later? These are some of the reasons that nurses give when asked this question:

  1. Inmates are unreliable or untruthful. If you think about your experience with patients in emergency nursing, urgent care and to some extent ambulatory care settings you would probably agree that they didn’t always tell the whole truth either. Inmates really aren’t different in this regard. It is unrealistic to expect patients to tell you the whole truth when you are asking screening questions.
  2. Inmates are affected by drugs or alcohol and not aware of other health problems they may have, like infected teeth or other sources of pain. Jail nurses cite this as a reason more often. This is because the detainee arrives at the facility directly from the community. It’s always wise for the nurse to be mindful that they have not witnessed the inmate or their environment in the minutes, hours or days prior to intake screening and the inmate may not be able tell us that the headache they have, for example, is a subdural hematoma from a fight that happened on the transport bus an hour ago.
  3. Inmates are manipulative and distort the truth for secondary gain. Yes, they do. If I imagine myself in the same situation, I would too. If what I tell the nurse about my health gets me a preferable setting, with more access to visitation or a lower custody housing assignment, or protection from other inmates then I would answer intake screening questions in a way that is likely to result in my desired outcome. It doesn’t matter if the nurse has that kind of decision making power or not; if the inmate believes the nurse can influence these things they will answer accordingly.

Realizing that an inmate may not have answered the health screening questions fully will protect you from coming to clinical judgements and decisions that are based upon incomplete or inaccurate information. Other reasons for inaccurate intake screening information include:

  • An environment that is not conducive to sharing personal health information. This could be because other inmates can overhear the interview or that correctional officers are nearby. At one jail I visited, intake screening took place with a nurse sitting at a computer behind an elevated counter. The inmate was standing below, speaking to the nurse through a Plexiglas screen. Other inmates were standing about five feet away and officers were everywhere. This was equivalent to giving your health history by megaphone at a football game. No thanks!
  • Failure to communicate effectively. This could be because of cultural or language differences or disability. Health information is a complicated subject. If English is not the inmate’s primary language, the accuracy of screening information collected using English is not going to be as accurate as that collected in the inmate’s native language. The same is true of those who are deaf or hard of hearing. Considering cultural practices regarding health care will also yield richer information than when these are disregarded. Lastly, an uninterested and hardened nurse is not going to elicit personal health information very well from a patient in any setting, not just inmates in the correctional setting.
  • Health care is really not a priority at intake. This is true for the inmate as well as the facility. When an inmate arrives at a jail it is usually because they have just been arrested. Again, when I imagine myself in those shoes, I would be more concerned about when or if I could make bail, how to make contact with my family or someone who can help me and the immediate consequences of my arrest. My health care is not very important until I begin to feel bad. Being asked a bunch of questions about my health status and history is really an annoyance, especially if I believe I won’t be in jail very long. Prisons or detention facilities are different, but still at intake, health care is not likely to be as important as other things, such as housing, access to property, contact with family, and safety for most detainees. Later when these other concerns have been addressed, aspects of health care become more important.

So what does a correctional nurse do about this?

  1. Remember that intake screening is for the purpose of safety. It is to make the best determination possible about care or treatment that an inmate will need for the next few days. Establishing medical support for detoxification, arranging for an inmate to continue important medications and addressing trauma are the primary things to get done. It is not the best time to expect a complete history and physical.
  2. Think of every subsequent health care encounter as another opportunity to add meaningful information to the inmate’s health record. What was documented at intake may no longer be as accurate. Inmates are usually not very sophisticated about health care and may not know or remember what is important to tell their health care provider about. You can model this in your interaction with inmates and can also coach them in preparation for their primary care appointment. View each encounter as adding a chapter to a patient’s book rather than a battle over what the inmate gets or not.
  3. Take an objective look at what intake screening is like from the inmate’s perspective. Go out to booking or the intake area and observe the process. What is the experience like? Identify the things that may be barriers to giving information during health screening and see if anything can be changed to improve the process. Not all of the barriers can be eliminated but just knowing what they are gives a good picture of the things that make intake screening vulnerable to inaccuracy. This information can be used to identify inmates or the kinds of situations which might benefit from scheduled follow up.

Are there reasons that you think make intake health screening inaccurate or unreliable that are not mentioned in this post? What advice would you give others to improve the accuracy or reliability of intake health screening?

For more about the art and science of intake health screening refer to Chapter 14 about Health Screening in the Essentials of Correctional Nursing. You can order a copy directly from the publisher or from Amazon today.

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Intake Health Screening-Making the most out of this brief encounter

Rear view of nurse assisting man while working at reception desk in hospital


Receiving or intake health screening is done whenever someone is brought to a jail or prison for admission. These individuals are being detained for any number of reasons including having been arrested for an alleged illegal activity, involved in an altercation or other suspicious activity that the police were called for, having been tried, found guilty and sentenced to serve a term of incarceration, having violated conditions of parole or probation, or are being deported for being in the country illegally or are being transported by the Federal Marshall.

Persons may be held in custody for only a brief time (hours) or for very long periods of time (life). The length of time people generally spend in jail is considerably less than in prison. Therefore, jails have very high rates of turnover and intake health screening is a very high volume activity. Furthermore, people admitted to jail have been in the community immediately before, perhaps living in conditions that were a risk to their health and wellbeing or they may have been injured during the arrest or while in police detention. The volume of people admitted to prisons is not as great but because they have been in custody for a while their condition may have deteriorated if it was not identified or treated at facilities which held the person previously. Because of the potential to miss identifying a serious medical or mental health condition and delay necessary treatment, intake receiving screening is also a considered a risk prone process.

Chart audit of intake health screening is one way to monitor the quality and effectiveness of the process. I just finished an audit of 25 charts using these three questions.

  1. Were conditions that warranted referral to a provider identified?
  2. Were patients seen timely by a provider when referred?
  3. Were records of previous care requested when the patient reported ongoing or recent treatment?

Several problem practices were identified that would be good to review further so that corrections can be put in place. I have seen these same problems with intake screening before and so wanted to share them with you to see if your experience is similar and if you have found ways to improve? The following paragraphs describe these findings and suggest possible corrective action.

  1. Practices that reduce the likelihood of identifying a medical or mental health condition that should be referred include:
  • Not collecting serial assessments when abnormal results are found initially. There are many things that can cause elevated blood pressure, including stress, agitation and withdrawal. The same with pulse, blood glucose and peak flow readings. Repeating tests that were abnormal at the end of the assessment or having the inmate wait a bit to reassess adds important information. Results that don’t improve or worsen need to be followed up and a nurse cannot depend on the next person down the line to pick it up. Consideration should be given to removing the barriers that get in the way of obtaining serial assessment data at intake screening.
  • Not inquiring further to yes answers or when the patient reports a medical or mental health condition. For example, if the patient says that they have seizures follow up questions should elicit a description of the type of seizure, when the last one took place, how often they happen and what treatment did the patient receive. Another example was a woman who reported in response to the social history questions that she had been forced to have sex and did not feel safe living at home. Maybe the nurse expected the social worker to pick up on this later but the absence of any additional inquiry or explanation on the part of the nurse indicated that this information was ignored in considering possible health problems. Developing question prompts may help nurses follow up on positive answers.
  • Not going further to establish rapport with patients who give minimal answers or deny obvious problems. An example I see frequently is a patient who denies alcohol or drug use when either their current condition or history of arrest suggest it is likely untrue. A follow-up question or statement to challenge the answer in a non-threatening manner may yield better information. Receiving screening is a dialogue not just rote fact finding using a standardized questionnaire. When the patient’s answer is no to every question you have to consider if language or some other barrier is effecting the patient’s disclosure. Here are some techniques that build rapport during intake screening:
      • Professional appearance of the nurse
      • Focus on the patient
      • Have a neutral or friendly facial expression
      • Allow silence so the patient can reflect and respond
      • Eye contact that is neither too much or not enough
      • Ask questions without reading verbatim
      • Avoid use of leading or biased questions
      • Avoid body language that is perceived as superior or judgmental
      • Do not be distracted, preoccupied or rushed
      • The setting provides privacy

2. Practices impacting timely referrals to providers include:

  • Not following up when nurses make urgent or priority referrals to a provider to make sure the patient is seen timely. We all get busy during the shift and it may be that something is preventing the provider from seeing the patient within the timeframe the nurse requested. Or it may be that the communication about the patient’s priority was missed. The person making the referral bears responsibility to follow-up to make sure that it is accomplished or an acceptable alternative put in place. This is the sixth step in the nursing process; evaluation and revision of the plan of care.
  • Not ensuring that patients are seen by a provider promptly when they return to the facility after diversion to the emergency room. When the ED clears an arrestee for jail it simply means that their condition is not urgent enough to require further monitoring in the ED or admission to the hospital. It does not mean the person was medically cleared and therefore intake health screening is not necessary. Instead information from the ED should be collected and reviewed by the nurse, other intake screening data collected and the patient referred promptly to a provider. If not immediately, the provider should see these patients no more than a couple hours of their return to jail and the nurse should follow up to ensure that this takes place.

3. Not requesting health records of recent or ongoing treatment at intake may delay initiation of appropriate medical or mental health care. Examples of conditions where the previous treatment record should be requested include HIV disease, seizure disorder, heart disease and other acute or chronic conditions. Nurses are in the best position to get prior records; the patient is right there and can sign the consent forms and the nurse knows how to navigate the local health community. These records can be very important to the provider’s decisions about treatment. Many times the reason given for not requesting records is that the patient will be gone before the record arrives or that the patient’s information is so vague that tracking down the provider isn’t efficient use of time. Examining barriers to requesting previous records should be explored and efforts to eliminate or develop sources to get the information made. Making specific arrangements for transfer of information with specific providers who see a majority of the same population may reduce the time it takes to get information. Examples would be the state prison system and jails, major community based providers of indigent care, and the mental health system in the state or county. With the advent of electronic records, the timeliness to request and receive information is vastly improved.

Conclusion: Intake health screening is an activity unique to jails and prisons, that involves nurses’ collection and review of information about the health of every person admitted to the facility and nursing decisions about patients’ immediate needs for medical attention, ongoing treatment and protection from harm. It is a high risk, problem-prone aspect of correctional health care and should be regularly reviewed by the Quality Improvement Program and studied to identify opportunities to improve practices. This blog post described the findings from a chart audit that used just three criteria and only took a couple hours to complete. Six areas of possible improvement in nursing practice were identified. Further study to identify and eliminate barriers to best practices is the next step to an improved intake process.

What are the most common problems you have identified when monitoring the nurses’ role in intake or receiving screening? What barriers were addressed which improved intake screening practices? Please share your answers to these two questions by replying responding in the comments section of this post.

For more about the nurse’s role in intake or receiving screening see Chapter 14 Health Screening in our book the Essentials of Correctional Nursing. Order a copy directly from the publisher or from Amazon today!

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Identifying Prescription Drug Misuse and Abuse

piatto di farmaci e drogaOne of my first mentors in correctional health care described prisons and jails as functioning like a city or town with many of the same characteristics as the surrounding community. I still think that is a good description. So we can expect trends identified in the larger community to eventually transcend the walls of the correctional facility in some way. One of these trends is the growing problem of prescription drug misuse and abuse.

According to a 2010 survey done by the Substance Abuse and Mental Health Services Administration more Americans over age 12 are taking prescription medications for non-medical purposes. These medications include pain relievers, tranquilizers, stimulants, sedatives and psychotherapeutic drugs. More than half of those said that they obtained the drug from a friend or relative for no cost. More than half the teens surveyed in another study obtained prescription drugs for non-medical purposes from the family medicine cabinet (Kirchner et. al., 2014).

The Centers for Disease Control and Prevention (CDC) reports that visits to Emergency Rooms (ER) increased 114% from 2004 to 2011. The majority of this increase is due to misuse or abuse of pharmaceuticals. In 2011 half of the admissions to the ER were related to prescription drug misuse or abuse. Of these admissions, one third involved medications used to treat anxiety or insomnia and another third were opioid analgesics (2014).

Deaths by poisoning or drug overdose have been the leading cause of injury in the United States since 2008. Overdose deaths have increased five-fold since 1980 (Kirchner et. al., 2014). In 2010 among deaths related to overdose with prescription drugs 75 % involved opioid analgesics and 35 % involved benzodiazepines. The number of overdose deaths from opioid analgesics is now greater than those of deaths from heroin and cocaine combined (CDC 2014).

All of this is to say that detainees arriving at our jails and prisons are likely to have recently misused or abused prescription drugs. Thorough, routine and non-judgmental inquiry about recent drug use during reception health screening is essential to identify individuals who will need to be managed medically during withdrawal. These questions should solicit the name of the drug, the usual dose; the route used, frequency, date and time of the last dose. Other questions include previous withdrawal symptoms and whether hospitalization was necessary (Laffan 2013).

The characteristics of people who overdosed with prescription drugs include:

  • Middle age
  • Male
  • White, Native American or Alaska Native
  • Rural community
  • History of chronic pain
  • History of mental health disorder
  • History of substance abuse
  • Have multiple health care providers or inconsistent providers
  • Taking multiple prescriptions (DHHS, 2013).

These are not listed as a definitive means to diagnose prescription drug abuse but instead to point out how many of our inmates have these same characteristics and are at risk of adverse consequences from this behavior.

When inmates are identified who will need assistance with detoxification the nurse’s next step is to contact a provider. Monitoring and management of withdrawal from prescription drug abuse should be initiated by a provider according to protocols established by the facility medical director. Nurses should not be expected to use standing orders to initiate detoxification (NCCHC 2014). For more about drug withdrawal in the correctional setting read Chapter 5 in the Essentials of Correctional Nursing. Order your copy directly from the publisher. Use promotional code AF1209 for $15 off and free shipping.


Centers for Disease Control and Prevention. (2014) Prescription Drug Overdose in the United States: Fact Sheet. Accessed at

Kirschner, N., Ginsburg, J., Sulmasy, L. S., (2014) Prescription Drug Abuse: Executive Summary of a Policy Position from the American College of Physicians. Annals of Internal Medicine 160 (3).

Laffan, S. (2013) Alcohol and Drug Withdrawal in Schoenly, L. & Knox, C.M. (ed.) Essentials of Correctional Nursing, pp. 81- 96, (New York: Springer Publishing Company LLC).

National Commission on Correctional Health Care. (Prisons and Jails 20014). Standards for Health Services. National Commission on Correctional Health Care.

U.S. Department of Health and Human Services (DHHS), Behavioral Health Coordinating Committee, Prescription Drug Abuse Subcommittee, (2013) Addressing Prescription Drug Abuse in the United States: Current Activities and Future Opportunities. Accessed at

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Clinical Communication with Patients who are Deaf or Hard of Hearing

abstract human face 3d illustrationIt is 1 o’clock Saturday morning and the police have just arrived with a middle aged man to book into jail for an assault that took place in the city an hour ago. He has abrasions on his face, neck and hands; he is observant and seems compliant with the officers’ instructions. Custody staff complete booking and he is brought to medical for intake health screening. The officer tells the nurse that the man is deaf. The nurse writes on a notepad “Can you read and write?” The detainee nods his head affirmatively. The nurse puts the intake screening form in front of the detainee and points to each question on the form. The detainee nods his head in a “no” gesture to each of the screening questions. The nurse takes vital signs, examines the abrasions, applies a bactericidal ointment and then observes the detainee while he is changing into the jail uniform. His deafness and abrasions are noted; no other problems are identified by the nurse and the detainee is given a handbook that explains how to access health care when he is released to housing.

Did this nursing encounter meet the standard of care for persons in correctional settings who are deaf or hard of hearing?

The components of receiving screening defined by the American Corrections Association (ACA) and the National Commission on Correctional Health Care (NCCHC) are that a screening form is used to inquire about the status of each detainee’s health and that reception personnel observe the detainee’s condition for signs of illness or injury before making decisions about disposition. NCCHC also states in the discussion of the standard that “Receiving screening is conducted using a form and language fully understood by the inmate, who may not speak English or may have a physical (e.g., speech, hearing, sight) or mental disability” (2014, page 72). The nurse modified how the receiving screening data was collected when the detainee indicated that he could read and write. Literally interpreted the accreditation standards were met. But were best practices used to screen for potential emergency situations, treating illness or continuing prescribed medication?

The Americans with Disabilities Act passed in 1990 establishes specific requirements that apply to persons who are deaf or hard of hearing in correctional settings. These include:

  • Giving primary consideration to providing the aid or service requested by the person with the hearing disability.
  • Communication aids and services may not be denied except when a particular aid or service would result in an undue burden or a fundamental change in the nature of the law enforcement services being provided.
  • Only the head of the agency or his or her designee can make the determination that a particular aid or service would cause an undue burden or a fundamental change in the nature of the law enforcement services being provided.
  • Not charging for communication aids or services provided.
  • Providing effective, accurate, and impartial interpreters when needed.

In this case the nurse did not inquire about the type of communication aid or service the detainee preferred but instead only asked if the detainee could read and write. Relying on writing or pointing to items is effective communication for brief and relatively simple face-to-face conversations. Having the detainee fill out the health history portion of the intake screening form may be appropriate if he is literate enough in medical terminology. While many who are deaf and hard of hearing indicate the ability to read lips nurses need to be cognizant that only about 30% of what is said can be accurately interpreted (Shuler et. al., 2013). If the detainee indicates he has any medical or mental health problems, is seeing a provider in the community or is taking medication the nurse will have to use a more interactive and accurate communication method. These include:

Sign language interpreters: There are several kinds of sign language, including American Sign Language (ASL) and Signed English. When arranging for an interpreter be sure to ask what form of sign language the detainee uses.

Oral and cued speech interpreters: Some individuals have been trained in lip reading and with assistance from an interpreter can understand spoken words fairly well.

Transcription services: Many people who are deaf or hard of hearing are not trained in either sign language or speech reading. There are several types of devices that allow a person who is deaf or hard of hearing to communicate by typing. These include Computer Assisted Real-time Transcription (CART) and text telephone (TTY or TTD).

Video services: use high speed internet and wireless connections to link a camera or videophone that transmits sign language to an interpreter who conveys the message verbally to the hearing person.

Each state defines the education and training required to be considered a qualified interpreter and may also require certification. Since the ADA requires that interpreters in correctional settings be effective, accurate, and impartial special care should be taken in arranging for interpreters. Using staff who “know sign language” or family members to interpret may not meet these criteria. Further the nurse needs to document in the detainee health record what effort was made to inquire about communication preferences, arrangements made to provide assistance and if an interpreter is used document their name, certification or qualification and contact information.

The detainee in this example was scheduled to be seen by a nurse the following day to review the intake screening information and complete the history portion of the initial health assessment. Correctional staff at booking inquired about the detainee’s communication preferences and had noted in the classification system that he used American Sign Language (ASL). The nurse was aware of this and made arrangements for the presence of a qualified interpreter at the nursing encounter the next day. The ADA does not require that the services of an interpreter be immediately available  at intake for example but that arrangements are made in a reasonable amount of time when they are necessary.

Best practices summary

• Before speaking, get the person’s attention with a wave of the hand or a gentle tap on the shoulder.

• Face the person and do not turn away while speaking.

• Try to converse in a well-lit area.

• Do not cover your mouth or chew gum.

• Minimize background noise and other distractions whenever possible.

• When you are communicating orally, speak slowly and distinctly. Use gestures and facial expressions to reinforce what you are saying.

• Use visual aids when possible, such as pointing to printed information or photos.

• When using an interpreter, look at and speak directly to the deaf person, not to the interpreter.

  • Talk at your normal rate, or slightly slower if you normally speak very fast.
  • Only one person should speak at a time.
  • Use short sentences and simple words (U.S. Department of Justice, Civil Rights Division, Disability Rights January 2006).

It is estimated that up to nine percent of the population has some degree of hearing loss, and this percentage will increase as the population ages. So as correctional nurses, we expect to come into contact with people who are deaf or hard of hearing. In your opinion was the standard of care met in the intake screening and assessment of this detainee’s health status? What are the challenges in providing nursing care for detainees who are deaf or hard of hearing? Please share your opinions and experience by responding in the comments section of this post.

For more on correctional nursing read our book, the Essentials of Correctional Nursing. Order your copy directly from the publisher. Use promotional code AF1209 for $15 off and free shipping.


American Corrections Association. (2010). 2010 Standards Supplement. Alexandria, VA.: American Corrections Association.

National Commission on Correctional Health Care. (Prisons and Jails 20014). Standards for Health Services. National Commission on Correctional Health Care.

Shuler, G.K; Mistler, L.A.; Torrey, K.; Depukat, R. (2013). Bridging communication gaps with the deaf. Nursing 2013 43 (11): 24-30.

U.S. Department of Justice, Civil Rights Division, Disability Rights. (January 2006). Communicating with People Who Are Deaf or Hard of Hearing: ADA Guide for Law Enforcement Officers. Accessed June 16, 2014 at

U.S. Department of Justice, Civil Rights Division, Disability Rights. (October 2003). ADA Business BRIEF: Communicating with People Who Are Deaf or Hard of Hearing in Hospital Settings. Accessed June 16, 2014 at

Photo credit: © koya979 –

Happy New Year: Alcohol Withdrawal

Alkoholflasche in PapiertüteIt is New Year’s Eve and the police have just brought a middle aged man into the booking area on an arrest for drinking while driving. The man is in his 50’s, staggering but attempting to follow the booking officer’s directions. This is his first arrest so there is no history or prior information about him. The booking officer asks you to assess the man and decide if he can be accepted at the jail or if the arresting officer should take the man to the hospital for further assessment and possible treatment.

Use of alcohol is widespread among persons brought to jail.  A third of all inmates booked into jail were drinking at the time of arrest. Almost half of all jail inmates report alcohol use that met the definition for dependence or abuse (Karberg & James 2005).  Access to alcohol is disrupted by detention or incarceration and puts individuals who regularly use alcohol at risk of alcohol withdrawal syndrome. Seventy-four percent of deaths from intoxication took place within the first seven days of admission according to the Bureau of Justice Statistics (Noonan 2010). Identifying inmates at risk of alcohol withdrawal and treating these patients proactively is the most important step in preventing alcohol related death in jail. See a post on this topic at The decision to accept this man into the jail or send him to the local hospital for further evaluation is going to depend upon two things:

  • An assessment of the patient’s condition and
  • The facility’s capacity to provide ongoing monitoring and treatment.

At the initial medical clearance any person presenting with the following should be referred to the hospital:

  • Inability to ambulate without assistance
  • Fever greater than 1010 F
  • Serious trauma or other injury
  • Profound confusion or altered sensorium
  • Tremors
  • Seizure activity
  • Autonomic dysfunction (dilated pupils, pulse greater than 120, blood pressure greater than 120, severe diaphoresis and/or flushing).

If the person does not have any of the conditions described above use of a standardized alcohol consumption assessment tool is recommended in addition to the health screening questions asked at intake (Laffan 2013, Department of Veterans Affairs 2009).  Two recommended tools are the CAGE Alcohol Abuse Assessment Tool which was discussed in a previous post and the Alcohol Use Disorders Identification Test (AUDIT-C). The AUDIT-C tool identifies individuals who are hazardous drinkers or have active alcohol use disorders.   It consists of only three questions: 1. How often do you have a drink containing alcohol?

  1. Never
  2. Monthly or less
  3. 2-4 times a month
  4. 2-3 times a week
  5. 4 or more times a week

2. How many drinks of alcohol do you have in a typical day?

  • 1 or 2
  • 3 or 4
  • 5 or 6
  • 7 to 9
  • 10 or more

3. How often do you have six or more drinks on one occasion?

  • Never
  • Less than monthly
  • Monthly
  • Weekly
  • Daily or almost daily

Each answer is scored; an answer of “a” equals zero points and an answer of “e” equals 4 points for a possible total points of 12.  Men who score 4 and women who score 3 or more are considered hazardous drinkers with active alcohol use disorders (Bush et al. 1998, Department of Veterans Affairs 2009). These individuals will likely experience withdrawal symptoms that need to be monitored and treated medically. Inmates who are pregnant, have other chronic medical problems, or give a history of delirium tremens or seizures upon withdrawal are more at risk of morbidity and mortality associated with alcohol withdrawal. A provider should be contacted immediately to initiate and manage the care of these patients during incarceration. The table below describes the symptoms and nursing care required by patients undergoing alcohol withdrawal. Facilities without the capacity to provide 24 hour monitoring and availability of on-call provider consultation should be prepared to refer detainees to the hospital for required monitoring and care. Good clinical oversight, thoughtfully prepared protocols and trained staff are sufficient to manage inmates with minor and moderate withdrawal symptoms.

Condition Symptoms Nursing actions
Minor withdrawal
  •   Nausea
  •   Sleeplessness
  •   Night sweats
  •   Anxiety
  •   Irritability
  •   BP = 140/90
  •   Mild tremor
  •   Disturbance in vision, hearing or sensation.
  •    Symptom monitoring (CIWA –AR) q 4 hours
  •   Encourage fluid intake (8-10 glasses daily)
  •   Medication for anxiety or agitation
  •   Provider ordered medications
Moderate withdrawal
  •   Inability to concentrate
  •   Forgetfulness
  •   Numbness of hands or feet,
  •   Severe agitation or anxiety
  •   Tremors
  •   Disturbance in vision, hearing or sensation
  •  Admit for inpatient care
  •   Vital signs q 4 hours
  •   CIWA-AR q 4 hours
  •   Oral fluids (10-12 glasses daily)
  •   Provider ordered medications
Severe withdrawal
  •   Hallucinations or  delusions
  •   Profound confusion or altered sensorium
  •   Autonomic dysfunction
  •   (dilated pupils, fever, pulse greater than   120, diastolic BP greater than 110, severe diaphoresis or flushing)
  •   Seizure activity
  •  CIWA-AR greater than 15
  •   Emergency transport to the hospital
  •   Notify provider immediately

The Clinical Institute Withdrawal Assessment-Alcohol Revised (CIWA-AR) is a nationally recognized tool for monitoring alcohol withdrawal (Bayard et al. 2004).  The use of a standardized tool provides a consistent basis for serial evaluations of withdrawal symptom and can serve as the source for protocols that define treatment orders and timeframes for contacting a provider or referring for offsite care (Laffan 2013). On assessment of the inmate in the case example above the nurse found that the patient was at risk of withdrawal symptoms but he did not have any complicating medical conditions and so was cleared for booking. After completing the initial screening exam the nurse put him on the facility’s alcohol withdrawal protocol that included medically supervised housing and a treatment plan concurrent with the suggestions in the table above. What do you do at your facility to recognize and treat alcohol withdrawal? Share your thoughts in the comments section of this post. For more about alcohol withdrawal read Chapter 5 in the Essentials of Correctional Nursing. Order your copy directly from the publisher. Use promotional code AF1209 for $15 off and free shipping.  References Bayard, M., McIntyre, J., Hill, K.R., (2004) Alcohol withdrawal Syndrome. American Family Physician, 69 (6) 1443-1450. Bush, K., Kivlahan, D.R., McDonell, M.B., Fihn, F.B., Bradley, K.A. (1998) The AUDIT alcohol consumption questions (AUDIT-C): an effective brief screening test for problem drinking. Ambulatory Care Quality Improvement Project (ACQUIP). Alcohol Use Disorders Identification Test. Archives of Internal Medicine 158 (16) 1789-95. Department of Veterans Affairs. (2009) Management of Substance Use Disorder. Accessed 12/230/2013 at Karberg, J.C. & James, D.J. (2005) Substance Dependence, Abuse and Treatment of Jail Inmates, 2002. Bureau of Justice Statistics, Special Report (NCJ 209588). US Department of Justice, Office of Justice Programs. Accessed 12/30/2013 at Laffan, S. (2013) Alcohol and Drug Withdrawal in Schoenly, L. & Knox, C.M. (ed.) Essentials of Correctional Nursing, pp. 81- 96, (New York: Springer Publishing Company LLC). Noonan, M. (2010) Mortality in Local Jails, 2000-2007. Bureau of Justice Statistics, Special Report, US Department of Justice, Office of Justice Programs. Accessed 12/30/2013 at Photo credit: © artenot

Assessing the Mentally Ill Patient: Part 3

Last week we had just finished an assessment of a young man with agitated, restless behavior. These are some of the key findings from our assessment of the patient:

Does not respond to questions or requests in a  coherent way.

  •  Vocalizes words but they are not logically connected to express thought.
  • Increased agitation when interviewed.
  • Appearance of visual & tactile hallucinations.

The patient is not in touch with current reality and has symptoms of abnormal cognitive status. This is the definition of psychosis. Our initial nursing diagnosis is that the patient is at risk of deterioration or injury as a result of a psychotic condition.  The first step in our plan is to place the patient in the inpatient unit, for safety, additional assessment and monitoring. See Chapter 12: Mental Health for more information about the assessment of psychosis including more detail about patients experiencing hallucinations and delusions.

Delirium is characterized by:

  •     Rapid onset or mental status that fluctuates over the course of a day and
  •     Inattention, or difficulty focusing, distractibility or inability to track what is said and
  •     Disorganized thinking, incoherence or an altered level of consciousness (hyper-alert, lethargic, stuporous). 

Another piece of advice for nurses in correctional settings is to always consider medical causes as a possible explanation for psychotic symptoms. The next step is to look at the onset of symptoms and consider whether the patient is likely to be experiencing delirium rather than a psychotic disorder.  It is important to identify delirium early because the underlying medical problem can be treated and the symptoms reversed. Key findings from our patient assessment that suggest delirium are:

  • Condition has deteriorated within the last 24 hours.
  • Not responsive to questions or requests.
  • Increased agitation and hyper-vigilant.

Medical conditions that can cause delirium include:

  • Alcohol or drug withdrawal
  • Drug abuse
  • Electrolyte or other chemical imbalance including metabolic or endocrine diseases
  • Infection
  • Poisons
  • Medications
  • Surgery
  • Other conditions that deprive the brain of oxygen and other nutrients (cardiopulmonary diseases, CNS disease)

The patient denied any history of alcohol or drug use when interviewed during receiving screening. Now that it is 72 hours later, his symptoms and their onset suggest alcohol withdrawal so we further assess the patient using the Clinical Institute Withdrawal Assessment of Alcohol Scale, Revised (CIWA-Ar).  The results of this further evaluation lead us to conclude that this patient is in moderate to severe alcohol withdrawal.  We call the provider with our findings and request treatment orders. The focus of treatment is to prevent seizures and to address fluid and electrolyte imbalances. The plan of care also includes serial assessments to monitor the patient’s status closely and a safe environment to prevent injury.  For more information about the assessment and treatment of alcohol and drug withdrawal see Chapter 5 in the Essentials of Correctional Nursing.

Always remember that psychiatric symptoms, such as psychoses, can be caused by medical conditions.  When identified and treated these symptoms can be completely reversed.  Objective, descriptive assessment, use of standardized screening tools and attention to the possibility of both medical and psychiatric etiology contribute to accurate clinical judgments.

If you haven’t already order your copy of the Essentials of Correctional Nursing directly from the publisher at

Photo Credit: © termis1983

CAGE for Alcohol Withdrawal


Our patients are prone to drug and alcohol misuse so correctional nurses need heightened awareness of withdrawal potential for all who enter their facilities. According to authorities, more than 65% of inmates meet criteria for drug abuse, alcohol dependence, and addiction. There are also significant concerns about deaths while in custody related to drug and alcohol withdrawal. Of the two, alcohol withdrawal has significantly higher concerns but withdrawal from opiates and depressant drugs can also cause problems.


Intake assessment of withdrawal potential is critical for good care. CAGE is a standard evaluation of alcohol intake that can quickly determine if withdrawal is likely. Two positive responses are considered a positive test and indicate further assessment is warranted.


C – Have you ever felt you should cut down on your drinking?

A – Have people annoyed you by criticizing your drinking?

G – Have you ever felt bad or guilty about your drinking?

E – Eye opener: Have you ever had a drink first thing in the morning to steady your nerves or to get rid of a hangover?


Correctional nurse and chapter author Susan Laffan has a list of other questions that should be asked during intake:

  •  Do you currently use any type of alcohol or drugs?
  • If “no”: has the individual used in the past?
  • What type?
  • alcohol: beer/wine/liquor
  • drugs: illegal vs. prescription (dosage)
  • name of each drug
  • route of drug (oral/smoke/inhaled/intravenous)
  • How much/many?
  • How often?
  • Date and time last used?
  • Have you ever had withdrawal symptoms or seizures/“shakes” when alcohol/
  • drug is stopped?
  • Have you ever been hospitalized for medical treatment of withdrawal
  • symptoms?

What do you use to evaluate for alcohol withdrawal potential? Share your tips in the comments section.

Read more about withdrawal detection and management in correctional nursing practice in Chapter 5: Alcohol and Drug Withdrawal from Essentials of Correctional Nursing. Order your copy directly from the publisher.