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

 

What are these eight rights anyway?

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

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

Health Care Advances

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

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

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

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

The Important Three

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

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

Spread the Word about the 8

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

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

Photo credit:  Yahoo Images

 

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Medication Reconciliation

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

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

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

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

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

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

When Inmates Arrive at a Facility

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

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

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

When Inmates Return From Offsite care

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

When Inmates Are Followed in Chronic Care Clinic

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

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

When Medications Are Missing

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

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

Other questions to help narrow down the problem are:

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

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

Easing the Burden of Medication Reconciliation

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

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

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

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

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

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Med Line Tips

Simple expressionist image of people with their hands in the air

Medication line can be daunting for nurses new to the correctional setting. The American Nurses Association Scope and Standards of Professional Practice describe medication administration as a defining feature of correctional nursing and make the point that while the methods of nursing in this setting may differ, the standards of practice remain the same (2013). The correctional nurse may administer medication to a line of 200 or more inmates who gather two, three or four times a day. In addition, the nurse may run med line from a medication cart stationed near the dining hall or by the rec yard or to roll the cart from housing unit to housing unit. Clearly this is not like how medication administration is done in most other clinics, emergency rooms, hospitals or nursing homes. Here are some tips from a previous post by Lorry to make running med line go more smoothly:

  1. Make sure the medication cart or area is stocked with the things you are likely to need including:
  • Patient medications
  • Medication administration records (MARS)
  • Pen, highlighter and notepad
  • Current drug reference book
  • Calculator
  • Pill crusher and packets if needed
  • Pill cups
  • Water and drinking cups
  • Waste receptacle
  • Keys needed to access the medication room, cart, and narcotics container

 2. Take these steps before med line:

  • Scan the MARS for any new medication orders, any new patients, that each MAR indicates whether the patient has allergies and if so, what the allergy is.
  • Check to see that any new medications are available (in the cart or medication room) and if not where it is in the process of getting dispensed and delivered.
  • If there are any medications, you are unfamiliar with check the drug reference.
  • Make any calculations you need to administer the correct dose.
  • Clean the surfaces of the cart and make sure that the water receptacle is washed and ready for use.
  • Perform hand hygiene.

3. Follow the steps each time at med line:

  • Following the same steps is called habituation and helps you not forget a step, if distracted. When you are consistent in practicing this way it is also easier to manage inmate behavior.
  • Use two forms of identification to ensure it is the right patient. Do not rely on your visual memory of what the patient looks like.
  • Locate the MAR corresponding to the patient’s name and identification.
  • Scan the MAR for medications due.
  • Locate the medication and check the medication name, dose, time and route against the MAR.
  • Put the medication in a cup.
  • Repeat for each medication that is due.
  • State the name of each medication to the patient as you prepare to put it into the cup. If it is a new medication confirm that the patient knows its purpose, major side effects or precautions.
  • Recheck the MAR and medications in the cup.
  • Ask the patient if they have any questions about the medications.
  • Watch the patient take the medication, watch for palming and check the patient’s oral cavity for cheeking. Beware of any distractions at this point; diversion is likely.
  • Have the patient put the medicine cup into the waste before leaving the medication cart or window.

When med lines are too long: Sometimes nurses are pressured to abandon the rights of medication administration (right patient, right medication, right dose etc.) in the interest of speed because there are too many inmates to medicate in the time available.  Here are some options to manage this problem without abandoning your accuracy and jeopardizing the patient’s safety.

  • Create a separate time and line for certain medications, like insulin, or those that have tight dosing schedules or certain groups of patients like those just starting a new medication, those on mental health medications etc.
  • Suggest establishing a self-administration program if one does not exist.
  • Deliver KOP medication in another line.
  • Spread patients who are on once daily dosing out among several med lines rather than all in one.
  • Collaborate with providers to reduce the volume of prescriptions and dosing. Can a medication be provided once a day rather than twice? Are there prescriptions that could be eliminated, treated with over the counter preparations, or delivered in long lasting form?
  • Suggest using the commissary or some way to provide over the counter medications other than med line.

What tips would you give to new nurses about passing medication in the correctional setting?  What solutions have you found for the problem of long med lines? Please share your tips and solutions with other correctional nurses by replying in the comments field of this post.

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

References not hyperlinked in the blog post:

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

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Continuity of medication and solving problems unique to the correctional setting

preso FATMany of the issues that nurses confront in the correctional setting while advocating for patients and their treatment are because health care is not the main goal, the burden of disease is great, and the population is transient with high turnover among inmates.

Problems with medications that arise from the setting: The most common problem in this category are inmates who do not show up to take medication at the prescribed time. While patients have a right not to take a medication in the correctional setting the patient must communicate this to the nurse by stating their refusal. The mere absence of a patient is not a refusal but a “no show” instead. There are many reasons why an inmate doesn’t appear to take their medication; it could be that they are at an appointment, in court or attending a program. It could also be that they have been moved to another part of the correctional facility or transferred to another institution entirely. It could be that no officer has let the inmate out of the cell or the housing unit. The nursing action to a “no show” is to follow up to find out where the inmate is and determine if the dose can be given later. Repeated instances of “no shows” need to be reported to the supervisor so that a systemic correction can be ma

Another problem is having the wrong medication delivered. Because there are so many inmates and they may have very similar names the pharmacy may dispense the wrong medication or staff may incorrectly identify the patient’s and put their medication in the wrong place in the med room or on the cart. This is one of the reasons for insisting upon two forms of identification and checking the medication against the MAR. When inmates have similar names, use of capital letters, color coding or some other way to easily distinguish one from the other is a practical solution.

Nurses who work in hospitals and other major health care settings have the advantage of quick access to the pharmacy for stat or urgent orders. Correctional nurses most often work in facilities that do not have an on-site pharmacy and in fact may use a mail order pharmacy located miles away. And yet there are times when an inmate arrives or an incident happens and a medication is needed quickly. Many of these types of situations can be anticipated (anaphylaxis, for example and medication epinephrine) and the medication stocked at the facility. Imagine though, an inmate arrives who is on the newest HIV medication and no other medication is a clinically appropriate substitution. It doesn’t make sense to stock some of every medication just in case there is a need. Instead, most facilities have made arrangements with a local pharmacy with 24 hour – seven day a week service to provide medications that cannot be obtained timely from the regular dispensing pharmacy. The nurse will be the one responsible for contacting the pharmacy and making arrangements for delivery once the provider has given the medication order. Correctional facilities without access to a backup pharmacy to fill urgent and stat orders jeopardize the health and safety of inmates.

Problems with medications arising from the burden of disease: Inmates as a population are sicker than the general community. There are many studies which have demonstrated the burden of disease among correctional populations. The majority take prescription medications, not only for one or more chronic medical diseases but often for a mental health disorder as well. Polypharmacy is a problem in correctional settings. The impact on nurses is an explosion of inmates on med line or who need KOP meds delivered, lengthy MARS that need to be transcribed and kept updated, and an increasingly complex patient care situation that can produce adverse events. Also the patients themselves, in this case, inmates, expect providers to treat conditions that many of us who live in the community would either not experience, ignore or treat ourselves without use of prescription medication. Because patients in correctional facilities see different providers, medications may be prescribed by one without being aware of what else the patient is receiving. A solution to this is to bring patients on multiple medications to the attention of the medical director or senior medical professional for review. These are patients perhaps better assigned to see one provider and for medical and mental health providers to collaborate when making treatment decisions. These are also patients whose treatment would benefit from pharmacy consultation.

Because of the presence of so many mentally ill persons in prisons and jails nurses are also likely to be involved in administration of involuntary medication to patients. State law and other aspects of law will govern the use of involuntary medication in your facility and you need to familiarize yourself with these requirements; hopefully your facility will have a policy and procedure. Many patients who have gone through the process of having an involuntary medication order put in place are very cooperative with the process. Medication may also be administered involuntarily in a psychiatric emergency; again, be familiar with your facility’s policies and practice as well as state law so that you are prepared if this becomes necessary.

Problems with medications arising from inmate movement: Missing medications are a huge problem, especially in large jails and prisons with multiple locations where medications are administered. If an inmate is moved from housing block A to D block, and a different medication cart is used for these two housing units, the nurse administering medication in block D isn’t going to have the inmate’s medication when it is time to administer it, unless the nurses are informed that the inmate has been moved before the next med administration and someone moves the medication from one cart to another. In this same scenario, if the inmate takes the medication KOP, it gets put into his property when he is moved and he cannot access it until the property is inventoried and returned to him. Solutions to this problem center on improving the timeliness of notification by custody to health care and nursing accountability to put the medication in the new location. For KOP a solution is to ensure prompt processing of property or providing a way for the inmate to bring the medication with them to the new location.

The problem of transfers is even more profound when an inmate is transferred from one correctional jurisdiction to another, from a county jail to a state prison and visa versa, from one county jail to another or one prison to another, from a jail to the Marshall’s Service to a series of jails for brief stays while being transported across country to another correctional facility. Nurses play a key role in providing a written transfer summary that includes a list of the inmate’s medical problems, the medications they are taking, recent labs and pending appointments. When this is not done it may be because the nursing staff did not receive timely notice of the transfer. If you receive an inmate from another facility who reports that they were taking medication it is best to contact the facility to verify the information and follow up until you succeed in receiving it.

Discharges is another problem area. When inmates return to the community, it is a well-established standard that they receive a supply of medication sufficient to ensure continued treatment until they are seen by a provider in the community. Again lack of timely notice that the inmate is being discharged is the culprit. Solutions to this problem are to work with classification officers to anticipate the probable discharge date. Inmates can also be good sources of information about probable discharge dates and provide information about the resources they use for health care while in the community. Some jails initiate discharge planning at the time of intake and provide inmates with information about how to obtain bridge medication until they see a community provider. Most facilities have processes in place to let inmates take the medication already dispensed, to provide a container of especially prepared discharged medication or for the inmate to go to a local pharmacy to pick up medication prescribed by the provider at the correctional facility within a couple days of discharge. The nurse’s role usually is to ensure the discharge prescription has been written, the patient has their medication upon release or has been provided with information about how to obtain the medication from a community pharmacy.

Managing and monitoring continuity of medication

One of the most important factors affecting patients’ willingness to follow the treatment plan is whether their symptoms are relieved and new ones not experienced (Ehret et al. 2013, Mills et al. 2011). If patients don’t feel better, they are not going to continue following treatment recommendations. Increasing adherence to prescribed medication has greater impact on health outcomes than any other specific form of medical treatment (Brown & Russell 2011, Sabaté 2003). Monitoring patients closely for symptom response, addressing side effects promptly and eliminating barriers and other reasons for medication discontinuity increase the likelihood of treatment success (Vellegan et al. a. & b. 2010). These three interventions are within correctional nurses’ independent scope of practice and can therefore be implemented without provider orders.

Specific steps correctional nurses can take to support the patient’s continuity of care in medication treatment are to:

  1. Notify custody staff of patients whose medication requires:
    • Dietary restrictions or a special diet for patients with diabetes or those taking MAO inhibitors for example.
    • Work restrictions such as not driving or using machinery when a patient is taking medication that causes sedation.
    • Canteen restrictions when for example a patient’s salt intake or carbohydrates must be limited.
    • Housing restrictions such as a lower bunk for a patient taking medication that causes dizziness or medically supervised housing for patients on medication that needs close monitoring (rehydration for example)
    • Environmental precautions: such as limiting exposure for patient’s taking heat or light sensitive medication.
  2. Schedule Follow up appointments with:
    • Nursing to check adherence by review of the MAR or the patient’s own medication if on KOP, to collect serial data such as blood pressure, weight, blood glucose and to find out from the patient if they are feeling better (intended effects) or experiencing side effects (unintended effects). Patients with poor adherence should be seen weekly while those with better adherence can be seen monthly or quarterly.
    • The patient’s provider(s) to review labs, discuss progress, symptom relief, side effects, adherence and adjust prescribed treatment as necessary. Provider appointments should be scheduled to coincide with the availability to lab and other monitoring measures as well in time to see the patient to re-order medication.
  3. Schedule lab and other monitoring measures to coincide with and take place in advance so that the data is available for review and discussion with the patient at provider appointments. Be familiar with common lab work recommended for medications you are responsible for providing to patients and help providers remember to order these when appropriate.

What problem areas do you experience with medication treatment that you believe are unique to the correctional setting? Do you have solutions to any of these problems that haven’t been discussed in this post? Please share your comments by replying in the comments section of this post.

For more about supporting medication treatment and continuity of care see Chapter 6 Chronic Conditions and Chapter 12 Mental Health in our book the Essentials of Correctional Nursing. Order a copy directly from the publisher or from Amazon today!

References

Brown, M. T. & Bussell, J.K. (2011) Medication adherenace: WHO cares? Mayo Clinic Proceedings 86 (4) 304-314.

Ehret, M.J., Barta, W., Maruca, A., et al. (2013) Medication adherence among female inmates with bipolar disorder: results from a randomized controlled trail. Psychological Services, 10 (1), 106-114.

Mills, A., Lathlean, J., Forrester, A., Van Veenhuyzen, W. & Gray, R. (2011) Prisoners’ experiences of antipsychotic medication: influences on adherence. The Journal of Forensic Psychiatry & Psychology, 22 (1) 110-125.

Sabaté, E., ed. (2003) Adherence to Long Term Therapies: Evidence for Action. Geneva Switzerland: World Health Organization. Accessed January 24, 2015 at http://www.who.int/chp/knowledge/publications/adherence_report/en/

Velligan, D.I., Weiden, P.J., Sajatovic, M. et al. (2010 a.) Assessment of adherence problems in patients with serious and persistent mental illness: recommendations from the Expert Consensus Guidelines. Journal of Psychiatric Practice, 16 (1) 34-45.

Velligan, D.I., Weiden, P.J., Sajatovic, M. et al. (2010 b.) Strategies for addressing adherence problems in patients with serious and persistent mental illness: recommendations from the Expert Consensus Guidelines. Journal of Psychiatric Practice, 16 (5) 306-324.

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Knowledge Resources for Medication Management

ReadingThe American Nurses Association statement on the scope of practice for correctional nurses requires that nurses be knowledgeable of the medications administered, including dosages, side effects, contraindications and allergies. Nurses also must be able to teach and coach patients so that they know what medications they are taking, the correct dose and frequency (2013). Many more drugs have been developed to effectively treat a wider variety of conditions in the last several decades and new drug formulations established which reduce treatment time, improve adherence and reduce the burden of side effects. With the proliferation of treatment choices available to prescribers today, the scope of knowledge required of nurses has expanded as well.

The types of health problems presented by our patients during incarceration is very broad therefore correctional nurses must maintain more expansive knowledge about the drugs likely to be prescribed than nurses who specialize their practice to a certain acuity (e.g., critical care) or particular health problem (e.g., kidney dialysis). It is impossible to memorize all this information so what references should a nurse use to aid their knowledge about medications these days? What are the drug references that you use?

A couple years ago another nurse and I were talking about a patient and one of the drugs that had been prescribed. I went in search of the big red text from the American Hospital Formulary Service. He turned to the computer and typed the drug’s name into Wikipedia and before I left the room he had the information we were looking for.  The problem is that anyone can contribute information to Wikipedia and so the accuracy and completeness of drug information on this site has been examined. Drug information on Wikipedia relies most heavily on news articles and commercial websites rather than evidence-based material and the information, especially that which is safety related is not reliably updated (Koppen, Phillips & Papageorgiou 2015).

Nurses in one survey in the U.S. favored using the Physician’s Drug Reference (PDR) or a text written especially for nurses like Lippincott’s Nursing Drug Handbook (Gettig 2007). In another survey nurses reported that, other than the PDR, they relied most on other colleagues in the workplace. The problem with relying on co-workers for information about drugs is that the individual may not be available or authoritative on the subject. Access to information and ease of use were the most important factors in nurses’ choice of drug information resources so that quick and concise answers could be obtained (Ndosi & Newell 2010). As drug information has become more available in electronic format it can be more quickly accessed and is becoming a more reliable reference for busy correctional nurses.

The following is a list of drug references and applications that are available on line and can be obtained for free:

National Library of Medicine has three databases that are useful for nurses in medication management. The first is the Drug Information Portal which provides information on 53,000 drugs from government agencies and scientific journals. The second is Drugs, Herbs and Supplements providing information for patients about the purpose of drugs, correct dosages, side effects and potential interactions with dietary supplements and herbal remedies. Last is a database designed for use in emergencies and developed to help identify unlabeled pills called Pillbox.

Epocrates is one of the most widely used and highly recommended drug references. In addition to drug information the basic package which is free has a dose calculator, drug-drug interaction checker which includes OTC medication and a pill identification program. For an annual fee the program can be upgraded to access medical information, diagnostic information, a medical dictionary and infectious disease guidelines.

Medscape Mobile is a combination medical reference and drug database. In addition to clinical reference for 8,000 drugs, herbals and supplements it includes a robust drug-drug interaction checker and a dosage calculator.

A final resource that should be available at every correctional facility is the telephone number for the poison control center. This is a national hotline number (1 800 222-1212) which connects to the nearest poison control center. Most poison exposures can be treated locally if contact is made with a poison control center because they are staffed 24 hours seven days a week by health care professionals with special training. The facility should also stock a supply of antidotes for various types of poison. A consensus guideline published in the Annals of Emergency Medicine (2009) recommended stocking 12 antidotes available for immediate use in treatment (2009). Since then several poison control centers have lists on-line of recommended antidotes to have on hand.

Availability of antidotes is a decision that should be made by the facility medical director in consultation with the supplying pharmacy. Usually they are stored with other emergency medications. Nurses should be familiar with each antidote stocked at the facility for use in medical emergency care. Here is a link to a list of common drugs and antidotes that nurses should know about.

Are there any knowledge resources for nurses in managing medications that are not described here and should be? Please let us know about them by responding in the comments section of this post. For more about the opportunities and challenges in correctional nursing order a copy of our book, Essentials of Correctional Nursing directly from the publisher or from Amazon today!

References

ANA (2013). Correctional Nursing: Scope and Standards of Practice. Silver Springs: American Nurses Association.

Dart, R.C., Borron, S.W., Caravati, E. M., et.al. (2009) Expert consensus guidelines for stocking of antidotes in hospitals that provide emergency care. Annals of Emergency Medicine 54 (3): 386-394.

Gettig, J.P. (2007). Drug information availability and preferences of health care professionals in Illinois: A pilot survey study. Drug Information Journal 42, 263-272.

Koppen, L., Phillips, J., Papageorgiou, R. (2015) Analysis of reference sources used in drug-related Wikipedia articles. Journal of the Medical Library Association 103 (3), 140- 144.

Ndosi, M. & Newell, R. (2010). Medicine information sources used by nurses at the point of care. Journal of Clinical Nursing 19, 2659-2661.

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Communication and medication management

man talking on the phone but does not listen

This week’s post explores the language of medication management. The correct use of terminology enables nurses to communicate accurately and prevents misunderstanding with other nurses, providers and pharmacy staff in the delivery of patient care. Continuing the analogy that working is corrections is like foreign travel it is helpful to speak and understand enough of the local language to find the train station, grocery and rest room and not get these mixed up along the way. The same is true when dealing with medications in correctional health care.

 

Using the correct terminology

The terminology used to describe who does what in the medication delivery system is subtle and often misused. One of the most commonly misused terms I hear used in correctional settings are dispense and administer. Only pharmacists and prescribers (physician, advanced practice nurse, physicians assistant) can dispense medication. To dispense is to remove medication from a stock bottle or container, label and package it for a patient according to a written prescription (the sig). Important steps in this process are to verify that the order is safe (right drug for the problem, correct dosage and route) and to review other medications the patient may be taking to ensure that the new medication does not cause an adverse interaction. Administration of medication is to give medication to a patient as prescribed and then to evaluate or monitor the patient for intended and unintended effects. Medication administration involves correctly carrying out the order as well as assessment of the patient’s response which are fundamental steps of nursing process. Most states allow administration of medication to be delegated by a nurse to unlicensed personnel if they have been trained and are supervised.  Sometimes medication is given to inmates in correctional facilities by other types of personnel including clerical staff, medical technicians, paramedics and correctional officers. The proper term for this is distribution of medication because there is no evaluation that the medication is being given as prescribed and no evaluation of the medication’s effect.

An adequate number and variety of medications must be available at any time at a correctional facility to treat inmate/patients in a timely manner. To accomplish this a correctional facility will have an arrangement with a wholesale drug supplier or pharmacy to dispense and deliver patient specific medications that are prescribed and will keep some medication on hand to use in an emergency or to start treatment immediately. Procurement is the term used when ordering or receiving medication at a correctional facility to be available for use, as prescribed, in the treatment of patients. Medication accountability is a similar term, but broader in scope.  Both state law and the accreditation standards require that there is a system to track, document and account for all medication from the time it is received at the facility until it is administered or delivered to the patient, returned or destroyed. Nurses may be responsible for procurement and accountability of medication at the facility, especially if no pharmacy staff are on site. This is not a role nurses have in traditional health care settings but is common in corrections.

Knowing how and where patients get medication

There are a handful of terms used in correctional settings to describe how inmates receive medication. When inmates receive medication administered directly by a nurse is referred to as directly observed therapy or DOT.  When a package of medication (an envelope, blister card or bottle) is given to an inmate and they are expected to take the medication on their own is referred to as keep on person or KOP medication. Another term is self-administered medication. When inmates receive medication it may be at a “pill call” or “pill line”.  Medication may be delivered “cell side”, through the “cuff port”, at the “pill cart” or “pill window”. Sometimes the vernacular used to describe an activity or place within a correctional facility can be unprofessional or demeaning. Nurses should know what local terms are used as well as their meaning, then make a deliberate decision to use the local language or not.

Selection and availability of drugs

As mentioned in last week’s post, correctional facilities should have a formulary which is a list of the medications that providers can order. The formulary can be “open” meaning virtually any brand of drug is available. A correctional facility that uses a local retail pharmacy to supply medications is more likely to have an open formulary. A “closed” formulary narrows the choices of drugs available in each class (antibiotics, analgesics etc.).  Accreditation standards require that if a particular medication is not on the formulary that there must be a way to request it for a particular patient if needed-this is a “non-formulary” request. Correctional nurses are often involved in helping to fill out and track responses to non-formulary requests so that the medication is received by the patient in a timely manner. It also pays for nurses to be familiar with what drugs are on the formulary so that they can help providers remember what is available when writing orders.

Having a voice in drug selection

Nurses sometimes have representation on the Pharmacy and Therapeutics Committee (P & T) where decisions about what drugs are on the formulary are made. Nursing input is very important in drug selection especially to avoid decisions that result consume unnecessary time during pill line (such as pill splitting or crushing) or present safety issues in the correctional setting (potential misuse or error). If you have a chance to serve on this committee I hope you will jump on the invitation. Even if you do not have a spot on the committee be sure to voice your opinion about the selection of drugs available for treatment at your facility.

Use of generic vs. brand names

One of the most important decisions and practices in medication delivery is how particular medications are referred to. At your facility is the brand or trade name of the drug used or is the generic or chemical name used? In a comment on last week’s post a nurse said that some nurses organize medications in the cart by using the generic name and other nurses put the medication in by brand name. That means that you have to look in at least two places on the cart for a particular medication! Deciding on and then using one or the other saves a lot of time.  It really is preferable to use the generic name since the brand or trade name changes.

How medication is packaged

Various terms are used to describe how medication is packaged. Some nurses came into the profession when most medication was administered out of “bulk stock”. This refers to taking one dose for a particular patient out of a bulk container of the drug. Some correctional systems prefer to use bulk stock for psychotropic drugs because of cost, frequent prescription change and high patient turnover. To improve patient safety most state pharmacy laws prohibit medication administration systems that rely solely on “bulk stock” and have developed “patient specific packaging” that is in “unit dose”.  Patient specific packaging is a medication that has been prepared and dispensed by a pharmacist in a container or package that is labeled with the patient’s name, start and stop date, the medication dose, route and frequency, as well as prescriber and pharmacy names. Many correctional systems will provide discharge medication packaged in this way with a child proof cap. When medication is packaged in unit dose each dose of medication is packaged individually. An example of unit dose are the plastic or paper packets or aspirin or acetaminophen. Unit dose packaging may be labeled with the individual patient name as described in patient specific packaging above or it may not be labeled and used like “bulk stock” with single doses provided to multiple patients. An example of the later would be single doses of medication used for immediate treatment such as an antihistamine. Finally some correctional facilities allow inmates or their families to bring in an inmate’s medication that they were taking in the community. This is referred to as patient owned or personal medications. The medication and prescription must be verified before accepting it into the facility and accountability for proper use must be assured. Usually several types of packaging is used in correctional facilities. How many different kinds of packaging and what terms are used at your facility?

Preventing miscommunication

Even when we speak the same language communication can be misunderstood. Errors in communication occur in oral and written communication about medications sometimes resulting in adverse consequences for the patient. The Joint Commission, U.S. Food and Drug Administration (FDA) and the Institute for Safe Medication Practices (ISMP) have each promoted practices that reduce errors in medication management. One example is that QD is often misunderstood as QID resulting in four times the intended daily dose. The opposite is also true but the patient would receive a much lower dose than was intended therapeutically.   Either can have disastrous consequences. The IMSP and FDA have listed medication abbreviations that are frequently misunderstood and have developed brochures, posters, a slide set and a video about how to avoid these errors. The health care program at your facility should have a list of approved abbreviations and may also have adopted a list of error prone abbreviations to avoid using. If not the IMSP website is a recommended resource.

Have you had a funny or sobering experience with the language used in medication management at your facility? Do you have any terms unique to medication delivery in the correctional setting you would like to contribute to our glossary? Do you favor use of generic or brand names and why? Please comment by responding in the comments section of this post.

For more about the opportunities and challenges in correctional nursing order a copy of our book, Essentials of Correctional Nursing directly from the publisher or from Amazon today!

 

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An overview of medication management in correctional settings

Isolated, whitespace, copyspace.

The roles and responsibilities of correctional nurses for medication management are broader in scope than other practice settings. In health care settings many other professional and support personnel contribute to delivery of patient care.  However in correctional facilities nurses are relied upon to deliver care without the availability of these other types of personnel. The result is that correctional nurses often work in professional isolation and may feel like they are in a foreign country (Muse, 2012). I think traveling in a foreign country is a good analogy for correctional nursing. Doing this well involves preparation by learning something about the sights to see, building skill using a little of the language, familiarizing yourself with the rules, particularly which side of the road people drive on and finding out how to avoid being robbed or harmed in some way. The thrill of correctional nursing, like the thrill of foreign travel, comes when you realize how much you are enjoying it, especially the independence of professional nursing practice in this field. This post is the first part of a guidebook for your journey managing medication in correctional settings.

State law, rule and regulation

State law serves as the basis for nearly all of the practices and procedures involved in medication management. Most nurses are familiar with the nurse practice act in their state. If not, this is the place to start by reviewing it for definitions and references to medication. The nurse practice act will be especially helpful in describing the training and supervision requirements if non-licensed personnel, such as nursing assistants, administer medication at the correctional facility.

The pharmacy practice act is the most important resource to review. These laws will define how to obtain, store, dispense and account for medication which are often the responsibility of nurses when there is no pharmacist on site.  Even if there is a pharmacist at the facility, being familiar with the law that governs their practice is helpful in understanding the recommendations pharmacists make about drug storage, packaging of medications and accountability.

The medical practice act provides important information about how a physician’s order for medication is lawfully carried out. The medical practice act also has information about how medical assistants and paramedics work as well as the requirements for training and supervision which need to be followed if these personnel are involved in medication management.

This is not interesting reading but it does provide information that nurses can use in determining the responsibilities of personnel for medication management. It also provides definitions and terminology to accurately communicate with the pharmacy that provides medication to the facility and with providers about implementation of orders. Finally it provides nurses a basis to knowledgably resist inappropriate requests from custody and other personnel not familiar with health care laws to carry out tasks that are inconsistent with state law.

Accreditation standards

The National Commission on Correctional Health Care (NCCHC) and the American Correctional Association (ACA) are organizations which accredit correctional facilities for providing services and programs consistent with national standards. The standards are also used by most correctional facilities in developing policy and practices even if accreditation is not sought. Both organizations have standards related to medication management which are summarized in Figure 1. This list is a handy description of all the moving parts and pieces of medication management in correctional settings and nurses are involved in all of these components. This list can be used to review how medication management is handled at a facility and identify areas that may need attention.

Figure 1:   Standards for medication management in correctional facilities
NCCHC ACA
Applicable standards C-05, D-01, D-02 4-4378, 4-4379
1. Facility operates in compliance with state and federal laws regarding medications. Similar
2. There is a formulary and method to obtain non-formulary medication. Similar
3. Policy and procedures address how to procure, receive and account, dispense, distribute, store, administer and dispose medication. Similar
4. Medications are under control of appropriate staff and accounted for. Secure storage and perpetual inventory of controlled substances, syringes and needles.
5. Medication is only prescribed as clinically indicated after provider evaluation. Similar
6. Providers are notified of medication needing renewal prior to expiration. Similar
7. Staff are properly trained to administer or distribute medication. Similar
8. Inmates do not prepare, dispense, or administer medications. Self-carry medication programs are allowed.
9. There are no outdated, discontinued, or recalled medications at the facility.
10. If there is no on-site pharmacist, a consulting pharmacist is available for advice and makes inspections of the facility’s medication program at least quarterly.

Nursing standards

The American Nurses Association (ANA) has recognized correctional nursing as a specialized field of practice since 1995. The ANA publishes a reference that describes the scope and sets standards for the practice of correctional nurses. With regard to medication management the role and responsibility of correctional nurses is as follows:

  1. To be knowledgeable of medications administered, including dosages, side effects, contraindications and food and drug allergies.
  2. Practices with regard to medication management in the correctional setting meet the same standards as in the community. To do so nurses must be knowledgeable about state practice acts (as suggested earlier in this chapter).
  3. Ensure that patients know what medications they are taking, the correct dosage and potential side effects.
  4. If patients are expected to take medications without supervision the nurse evaluates the patient’s competence to self-manage and takes steps to protect those who are not competent to do so.
  5. Work with custody staff so that patients receive medication in a timely and safe manner (ANA, 2013).

This overview makes me reflect on my first experience with medication management in correctional nursing. I was being oriented to administer medications on the evening shift at a maximum custody men’s prison. A technician rolled a grocery cart filled with stock bottles of all kinds of medication out to me. The cart was full. In giving me the cart he said “You roll this along the tier and stop at every cell. Ask the inmates what meds they want. When you give them the medication then you record it on one of these index cards that has the medication listed at the top.” I remember being shocked and asked the technician why they did it that way. He shrugged his shoulders and went on with his tasks. While this experience is pretty extreme you might use it to review against the ANA nursing standards of practice, the accreditation standards and state law that were reviewed in this post and identify the inconsistencies. Being knowledgeable about the standards and requirements for medication management prevents erosion of professional practice and ultimately protects patients from harm.

Going back to the travel analogy, knowing state law, the national standards for correctional facilities as well as the standards of practice for correctional nurses is like having a guidebook to review the sights to see in place you have selected to travel to. These become a reference point to plan so you can make the most of your time as well as an expectation for what will take place while on your journey.

Is medication management a troublesome area where you practice correctional nursing? Have you looked at the problem through the lens of applicable state law, corrections standards and the nursing practice standards? If so, what have you identified as the problem areas? Please comment by responding in the comments section of this post.

For more about the opportunities and challenges in correctional nursing order a copy of our book, Essentials of Correctional Nursing directly from the publisher or from Amazon today!

 

References

ANA (2013). Correctional Nursing: Scope and Standards of Practice. Silver Springs: American Nurses Association.

Muse, M. (2012). Professional role and responsibility. In C. Schoenly L. & Knox, Essentials of Correctional Nursing (pp. 364-377). New York: Springer.

National Commission on Correctional Health Care. (2014). Standards for Health Services. Chicago: National Commission on Correctional Health Care.

American Correctional Association. Performance Based Standards for Correctional Health Care. Retrieved August 19, 2015 from http://www.aca.org/standards/healthcare/

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Six Challenges Managing Medications that make Correctional Nursing Unique

3d illustration of a corridor

 Medication management is a primary responsibility of nurses working in correctional settings (American Nurses Association (ANA) 2013). The Bureau of Justice Statistics reported that 66% of prisoners and 40% of inmates in jail who had a chronic condition were taking prescription medication. Among inmates with mental illness 27% of those in state prisons, 19% in Federal prisons and 15% in jails reported receiving prescription medication while incarcerated (Bureau of Justice Statistics, 2006). In addition to chronic medical problems and psychiatric disorders, medications are prescribed for inmates who have acute conditions, such as urinary tract infection as well as to provide symptom relief for minor illnesses and discomfort such as headache, constipation or seasonal allergies. As much as 80% of the population at a correctional facility may be taking medication for one or more of these reasons.

Medication management is identified as one of the features of correctional nursing that distinguishes it as a specialized field. Nurses who are new to the correctional setting are often unprepared for the scope and breadth of their role and responsibilities for managing medication delivery and yet they must meet the same standards for delivery of medication as in the community (ANA 2013).These challenges define what is unique about correctional nursing practice with regard to medications.

I started making a list of the challenges correctional nurses deal with in managing medication delivery. When the list became almost a full page long I sat back and thought about what similarities there were between the items and the following groupings came together.

  1. Professional isolation: Health care delivery in correctional facilities is often a very small part of the overall operation. In many cases nurses are expected to deliver services in independently and without advice from other health care providers. Nurses recently commented on CorrectionalNurse.net, Lorry’s other website that double checking dosages of high risk medications is a challenge when there is only one health care person on duty. One solution is to have the inmate confirm that the dose corresponded with what he or she understands it should be. Dispensing, drug packaging, storage inventory and disposal of medications are all subjects governed by state pharmacy laws and regulations. Unless there is a pharmacist on staff, correctional nurses need to be familiar with and ensure their practices comply with these requirements, in addition to the nursing regulations, when managing medication in the correctional setting.
  2. Security: Maintaining security is a primary focus of correctional facilities. This includes accounting for the presence and activities of each inmate throughout the day, ensuring that only authorized persons and products enter and exit the facility, and that contraband does not enter, is not otherwise obtained or manufactured. The most obvious example of a unique responsibility for correctional nurses is counting needles and syringes and accounting for each use. Others are ensuring access to inmates when medication is due (even on lockdown) and protecting patient confidentiality (not having medication lines that serve to identify the mentally ill or those with HIV disease for ridicule or extortion by others). Sometimes a facility will determine that for security reasons, not clinical, that all medication must be floated on water or even worse, crushed, impacting patient adherence, the time it takes to administer medication and in some cases the therapeutic effectiveness of the drug. Nurses need to confer with security on an ongoing basis so that security practices that compromise the therapeutic value of prescribed treatment are not put in place.
  3. Safety: The safety of inmates, staff and the general community is the other primary focus of correctional facilities. For correctional nurses this includes ensuring the safety of themselves and patients as well. A significant aspect of medication delivery is managing inmate behavior. This includes consistent practices for patient identification (two-part identification), checking that inmates don’t cheek or palm medication, providing privacy at the medication window or cart (prevent crowding). Often an officer will be assigned to escort the nurse or mange the medication line. Nurses need to engage the cooperation and assistance of this officer and be alert to their own behavior so that medication administration is conducted in a safe and efficient manner. The patient safety aspects are ensuring the cleanliness and hygiene of the medication delivery area to prevent transmission of infectious disease and monitoring conditions so that side effects from medications that make patients heat or light sensitive are prevented.
  4. Expanded role: Unless a correctional facility is large and has a number of specialized programs the health care program is likely to be staffed pretty simply without the support services nurses are used to in other health care settings such as pharmacy technicians, IV teams, respiratory therapists, inventory clerks and so forth. Nurses in correctional facilities routinely perform these roles instead and if there is assistance the nurse is responsible for their assignments and supervision. Nurses order medication from the pharmacy, arrange for refills and renewals, check for outdated drugs, receive, inventory and store medications and arrange for medication to be returned or properly destroyed. Nurse initiate treatment for patients via nursing standardized protocols that involve providing the patient with medication to treat the illness or manage symptoms. Nurses are the primary health care professional responsible to ensure that patients do receive medication as ordered and are expected to monitor patient adherence and solve problems with medication availability. Correctional nurses also assess the patient’s ability to manage their own medication if the facility has a self-medication or “Keep on Person” (KOP) program and to provide education or other assistance to support the inmates in providing their own care.
  5. Greater volume and scope: Because correctional nurses are responsible for the health needs of the entire population housed at one or more facilities they are generalists in nursing practice not specialists. Medications may be administered by a nurse or other personnel supervised by the nurse so that the inmate is directly observed when taking medication. Inmates may also be provided with a supply of medication by a nurse to take by themselves in a KOP or self- carry program. Nurses may also take medication to administer to patients in restraints, seclusion or housed in a high security setting for disciplinary or protective reasons. Nurses may give some medication under rules that allow for involuntary administration to patients with mental illness. In some correctional facilities nurses may be expected to use PICC lines or other specialized equipment or procedures to administer medication. The volume of medication administered by a nurse in the correctional setting exceeds that in any other setting. One difference is that most patients on pill line would be responsible for taking these medications by themselves or with the assistance of family in their own home.
  6. Timeliness: Medication delivery and administration must take place in coordination with all of the other activities that compete for the time and availability of inmates. In one facility I recently visited medication administration was halted on a unit until the canteen delivery was finished. The nurse was stranded in the corridor for twenty minutes until canteen was over. When the nurse insisted that medications be administered and canteen delivery wait the inmates complained bitterly. This is just one example of the competition for time. These time pressures can affect the therapeutic effectiveness of the drug if given too close or far apart. If inmates go to work or court before nursing staff are on duty inmates may miss important doses. The volume of medication to be given can impact timeliness; if there are too many medications a nurse may feel pressure to short cut or abandon the five rights resulting in increased patient risk.

So what are your thoughts about the uniqueness of medication management in correctional nursing practice? What have I forgotten or you would describe differently? Is there anything discussed here that you disagree with because it is not unique to correctional nursing. Share your thoughts in the comments section of this post.

Are you interested in knowing more about this nursing specialty? If so, see our book, Essentials of Correctional Nursing. Order your copy directly from the publisher or from Amazon today!

 

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References:

American Nurses Association (2013) Correctional Nursing: Scope and standards of professional practice. American Nurses Association. Silver Springs, MD.

James, D.J. & Glaze, L.E. (2006) Mental Health Problems of Prison and Jail Inmates. U.S. Department of Justice, Officer of Justice Programs, Bureau of Justice Statistics. Accessed 6.16.2015 at http://www.bjs.gov/content/pub/pdf/mhppji.pdf

Maruschak, L. M., Berzofsky, M., & Unangst J (2015) Medical Problems of State and Federal Prisoners and Jail Inmates, 2011-12. U.S. Department of Justice, Officer of Justice Programs, Bureau of Justice Statistics. Accessed 6.16.2015 at http://www.bjs.gov/content/pub/pdf/mpsfpji1112.pdf

Preventing diversion of prescription drugs in prison and jail

esnifar

Last week’s post described the epidemic of prescription drug abuse in the United States and the impact on the nation’s jails and prisons. This week we return to the same subject but focus on the problem of prescription drug diversion during incarceration. There are many more medications available and appropriate to be used in treatment today than when I started in nursing 40 years ago. Just to illustrate there were an average of 13 prescriptions written in 2011 for every person in the United States. At one of the jails I am familiar with an average of 24 prescriptions per inmate are filled each month.

Most correctional facilities allow some medications to be taken by inmates on their own as directed by the provider. This is usually called a “self-carry” or “keep on person” program. Virtually all facilities also require that certain medication be administered to inmates. These medications usually have potential for misuse (narcotics) or are medication regimes that require close monitoring (TB prophylaxis). The volume of medications handled daily in correctional facilities is substantial.

Nearly 85% of incarcerated adults in the United States have a substance use disorder and four out of five crimes committed by youth involve substance abuse (National Center on Addiction and Substance Abuse 2010, 2004). Some misuse of prescription drugs takes place simply because access to illegal drugs is so greatly limited during incarceration. Incarceration also brings other discomforts such as insomnia, pain, anxiety and boredom. Inmates may request medication from health care staff; they may also simply take or trade for someone else’s medication in an effort to alleviate problems like these. As correctional health care professionals we all have experience with patients who feign an illness or symptom to get a prescription for a preferred medication. Prescription medication has a value in prison or jail that is greater than in the general community (Phillips 2014).

Diversion and misuse of prescription medication is as much a clinical problem as a custodial one. If patients are bullied or coerced into giving up needed medication their condition may deteriorate. The provider may prescribe higher doses or additional intervention to treat a condition that appears unimproved when instead the patient was not treated effectively in the first place. In addition inmates who take someone else’s medication are not monitored clinically and expose themselves to potential for adverse reaction or other injury.

Methods to prevent or mitigate diversion

  1. Formulary controls: Often the first reaction to counter diversion is to ban prescription of the drug in the first place. The problem with this approach is that once a particular drug is banned another becomes the drug of choice for misuse. Secondly there are appropriate clinical indications for these medications and not allowing their use is to deny medically necessary care. It is possible to designate a particular drug as a non-formulary item that requires additional rationale and review before it can be issued. An example of this is that many facilities have made bupropion a non-formulary anti-depressant and thus limited its use (Phillips 2012). It is also possible to designate a certain housing location with greater supervision and control for patients receiving drugs at high risk for diversion. For example some facilities require patients to be admitted to the infirmary in order to receive treatment with an opiate analgesic.
  2. Choice of preparation: Another action is to administer the drug in a way that limits the possibility of diversion. Choices include ordering the drug in a liquid, aerosol or injectable preparation or that the tablet be “crushed and floated” (Bicknell et.al. 2011). Challenges are that these methods are either more expensive or time consuming to administer. A policy to “crush and float” an entire class of drugs (i.e. psychotropics) is not advised since the effectiveness and safety of some medications may be altered. Nurses expose themselves to liability if they “crush and float” medications against manufacturer advice (Phillips 2012).
  3. Increased multidisciplinary communication: Communication between providers, nurses and custody staff about prescription drug abuse generally and the importance of each method used to minimize diversion will reinforce the roles of each (Phillips 2014). Both correctional officers and nurses have responsibilities to ensure that inmates take medications as prescribed. These include maintaining orderliness during medication administration, monitoring ingestion, observing individual inmates for intended and unintended effects of medication. Correctional officers should be invited to provide information about behavior that suggests coercion by others or diversion. Providers and nurses may ask correctional officers about their observations of an inmate’s behavior to help with diagnosis or clinical monitoring. Random cell searches by correctional staff and periodic review of adherence by nursing staff are very helpful in identifying inmates who are diverting medication. Recently a facility changed their procedure for medication administration to include checking an inmate’s hands as well as their mouth before leaving the medication area. This change was made after discussion with an inmate who was found trading medication. The provider asked the inmate how he managed to get the medication and he gladly demonstrated his sleight of hand. It was an educational experience for all the staff and improved the methods used to control diversion at the facility.
  4. Caring for patients: Proactive identification and preventive treatment of inmates withdrawing from use of illicit drugs is an important first step in reducing diversion. This includes programming and targeted education to build alternative coping skills and recovery (Phillips 2012).Indications that a patient may be “at risk” of diverting prescribed medication include:
  • Requesting a particular drug by name before describing symptoms
  • Objective data about the patient’s condition is inconsistent with the description of symptoms
  • Refusal or non-adherence with other drugs prescribed for the condition
  • Claiming allergies or side effects to other possible drugs without being able to provide specific detail
  • Not remembering or being able to pronounce drugs other than the preferred drug
  • Threatening or other signs of excessive distress when the requested drug is not prescribed (Phillips 2012, 2014).

The nurse should be observant for these behaviors when seeing patients in sick call, nurse clinics or during medication administration, document the findings in the inmate’s health record and inform the patient’s prescribing provider. This information is more helpful to the treating provider when it is descriptive rather than judgmental. Nurses should also discuss with patients the potential for victimization when taking medication, the adverse outcomes of prescription drug abuse as well as steps to protect the inmate. This discussion is most effective if it is specific to the patient, the drug and their behavior rather than more general information.

Medications with high diversion value in the correctional setting

Click on this link to a table Common Prescription Medications- Use and Misuse which lists the prescription medications that are commonly misused or abused by inmates. The table also lists the purpose each drug is usually prescribed for as well as the reason for its misuse. During administration or when working with patients to self-administer these drugs nurses should be hyper-vigilant for possible diversion. Please remember though that any prescription medication can be misused if there is a belief that the drug will produce some desired effect.

Conclusion:

What have you learned about diversion of prescribed medications at your correctional facility that has not been discussed here? Are there methods to prevent diversion not discussed here that should be? Please share your opinions and experience by responding in the comments section of this post.

Anthony Tamburello, MD, FAPA, Statewide Associate Director of Psychiatry,  Rutgers University Correctional Health Care in New Jersey provided much of this information in a continuing education presentation for nurses and was willing to share it for use in this post. Also correctional physicians in the United Kingdom have published Safer Prescribing in Prisons: Guidance for Clinicians a thoughtful and well organized on-line resource. 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.

Resources:

Bicknell, M., Brew, I., Cooke, C., Duncall, H., Palmer, J., Robinson, J. (2011) Safer Prescribing in Prisons: Guidance for Clinicians. Royal College of General Practitioners, Secure Environments Group. Accessed at http://www.rpharms.com/news-story-downloads/prescribinginprison.pdf.

Centers for Disease Control and Prevention. (2014) Prescription Drug Overdose in the United States: Fact Sheet. Accessed at http://www.cdc.gov/homeandrecreationalsafety/overdose/facts.html.

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.

Phillips, A. (2014) Prescribing in prison: complexities and considerations. Nursing Standard 28 (21): 46-50.

Phillips, D. (2012) Wellbutrin®: Misuse and abuse by incarcerated individuals. Journal of Addiction Nursing, 23: 65-69.

Tamburello, A. (n.d.) Prescription Medication Abuse. Presentation for University Correctional Health Care. Rutgers, The State University of New Jersey. Personal correspondence dated 6/17/2014.

The National Center on Addiction and Substance Abuse at Columbia University. (2010). Behind bars II: Substance abuse and America’s prison population. New York, NY: The National Center on Addiction and Substance Abuse at Columbia University. Retrieved from http://www.casacolumbia.org/addiction-research/reports/substance-abuse-prison-system-2010.

The National Center on Addiction and Substance Abuse at Columbia University. (2010). Criminal neglect: Substance abuse, juvenile justice and the children left behind. New York, NY: The National Center on Addiction and Substance Abuse at Columbia University. Retrieved from http://www.casacolumbia.org/addiction-research/reports/substance-abuse-juvenile-justive-children-left-behind.

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 http://www.cdc.gov/HomeandRecreationalSafety/overdose/hhs_rx_abuse.html.

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