Page 6 • DNA Reporter August, September, October 2017 Identifying Sepsis to Improve Patient Outcomes in the Correctional Environment Amy Fierro, BSN, RN Amy earned her Bachelors of Science in Nursing degree from Eastern University. She has a wealth of experience in healthcare including 20 years of emergency room experience, 7 years as Director of Clinical Operations in Outpatient Surgery, 10 years of experience in emergency medical service, and is also Amy Fierro a wilderness first responder instructor. Amy started her correctional healthcare journey as the Director of Nursing at Baylor Women’s Corrections Facility in New Castle County, Delaware. She is now the Health Services Administrator at Baylor and is responsible for coordinating the medical, mental health and dental care of 400 plus patients under her care. Amy can be reached by email at afierro@ connectionscsp.org Did you know the DNA Reporter goes to all registered nurses in Delaware for free? Arthur L. Davis Publishing does a great job of contacting advertisers, who support the publication of our newsletter. Without Arthur L. Davis Publishing and advertising support, DNA would not be able to provide the newsletter to all the nurses in Delaware. Now that you know that, did you know receiving the DNA Reporter does not automatically provide membership to the Delaware Nurses Association? DNA needs you! The Delaware Nurses Association works for the nursing profession as a whole in Delaware. Without the financial and volunteer support of our members, our work would not be possible. Even if you cannot give your time, your membership dollars work for you and your profession both at the state and national levels. The DNA works hard to bring the voice of nursing to Legislative Hall, advocate for the profession on regulatory committees, protect the nurse practice act, and provide educational programs that support your required continuing nursing education. At the national level, the American Nurses Association lobbies, advocates and educates about the nursing profession to national legislators/regulators, supports continuing education and provides a unified nationwide network for the voice of nurses. Now is the time! Now is the time to join your state nurses association! Visit www.denurses.org to join or call (302) 733-5880. According to the National Institute of General Medical Sciences (2017), sepsis is a life threatening condition affecting more than one million patients annually and up to 50% of patients could die as a result. In a recent article by Sepsis Alliance (2016) the cost of sepsis in the United States has reached an astounding billion dollars. In the world of nursing, in every work environment including the correctional setting, sepsis will be an encountered diagnosis. When dealing with sepsis, it is important to understand how it is defined, who is at risk, signs and symptoms, how it can be masked in the correctional environment, and educational initiatives that can be implemented to bring awareness to this devastating costly illness. The National Institute of General Medical Sciences (2017) defines sepsis as a severe infection, most often the result of bacteria entering the blood stream which causes a severe immune response to occur. As a result, the body tries to fight the infection with overwhelming immune responses which can cause inflammation, blood clots, and leaky vessels (National Institute of General Medical Sciences, 2017). One the most disturbing realities is how rapid this can occur, putting patients in a life threatening situation before they realize what is happening. This can be especially alarming for those who are new to the correctional environment and placed in general population where they are not under the watchful eye of trained medical personnel 24 hours a day. For this reason, it is important to know who is at risk, prior to security placement so early intervention can occur. Anyone can encounter a diagnosis of sepsis, but it is important to note that some patients are more at risk than others. According to the Centers for Disease Control and Prevention (CDC) (2016) those who have weakened immune systems, chronic medical conditions, and those over the age of 65 years old are at increased risk of getting sepsis. The National Institute of General Medical Sciences (2017) stated those with specific chronic illnesses like diabetes, AIDS, cancer, and liver or kidney disease are more at risk. Infants and children are also at risk, especially if any of the above is already present. Children who are less than one year old and have an improperly treated infection are also at risk (Centers for Disease Control and Prevention, 2016). It is imperative medical staff are aware of the signs and symptoms of sepsis to aid in quick intervention. According to the CDC (2016), it is a mixture of signs and symptoms most often starting with signs and symptoms of infection such as: fever, pain, clammy skin, confusion, shortness of breath, diarrhea, vomiting, and a high heart rate. The National Institute of General Medical Sciences (2017) also added chills, rapid breathing, rash, and disorientation to the list of possibilities. The problem with all of these is that they all mimic other health conditions which can lead healthcare providers in a different direction of diagnosis and treatment. In the correctional environment there are additional circumstances that healthcare providers and nurses must take into account when looking at the patient as a whole. The patient population in corrections has additional risk factors such as homelessness, intravenous drug abuse, and little or no healthcare prior to entry. Some patients enter corrections in withdrawal, which can mask the signs and symptoms of sepsis, making early intervention very challenging while others have untreated chronic medical conditions, coupled with breaks in the skin from injuries or drug abuse. Breaks in the skin combined with unsanitary living conditions and lack of proper hygiene can contribute to a perfect storm of sepsis risk. Patients who are labeled as a “pain seeker” could easily be dismissed, missing key signs and symptoms if they are not looked at as a whole. Nurses who provide nonjudgmental care, collect an accurate and complete health history, and perform a proper head to toe assessment will decrease the chances of missing this life-threatening illness. Nationwide, this population is at increased risk. In addition to proper nursing care, there are several educational initiatives that could be implemented to improve patient outcomes in the correctional environment based on the research and current practice. First, the author witnessed sepsis awareness first hand in a local hospital recently as evidence by screensavers running sepsis education on workstation computers as well as posters strategically placed throughout the unit. This was one hospital’s way of bringing awareness to all staff as well as family members and patients. Some correctional environments have implemented targeted nursing protocols to help identify patients who look critically ill for unknown reasons (Shelton, 2015). These protocols assist nursing in collecting subjective and objective data, performing an assessment, and implementing an immediate plan of action which includes preparing the patient for transport to an emergency facility (Shelton, 2015). Nursing protocols are important for nursing staff in corrections because they practice with a great deal of autonomy, providing care often after hours or on the weekends when providers are on call. In 2015, the Prehospital Early Sepsis Detection (PRECEP) scoring tool was evaluated (Bayor et al., 2015). This tool looked specifically at prehospital scoring that is fast and effective utilizing commonly collected information such as: blood pressure, temperature, heart rate, respirations, oxygen saturation, blood glucose level, and the Glascow Coma Scale (Bayor et al., 2015). Another prehospital scoring system known as the quick sequential organ failure assessment (qSOFA) uses three simple indicators: systolic blood pressure less than 100 mmHg (1 point), respiratory rate greater than 22 (1 point), and an altered Glascow Coma Scale less than 15 (1 point) (Seymour, Liu, & Iwashyna, 2016). If a patient scores a two or three they should be prepared for emergency transport to a higher level of care. Scoring systems such as these could be implemented in any prehospital environment such as the correctional environment and could save lives by identifying and implementing care sooner. These scoring systems coupled with nursing protocols could escalate the care of the patient, leading to improved patient outcomes in an already compromised population. According to Sepsis Alliance (2016) sepsis is the most expensive illness to treat in the United States. The National Institute of General Medical Sciences (2017) reported care most often happens in intensive care units and consists of, but not limited to: laboratory work, x-rays or radiology scans, oxygen, intravenous fluids, intravenous antibiotics, mechanical ventilation, kidney dialysis, other medications such as vasopressors or corticosteroids, and possible surgery. Bringing awareness to this topic and educating the public about this costly condition can change the outcomes for many including when patients seek help, how healthcare workers identify early warning signs, and the measures that should be implemented to treat sepsis. Research is ongoing and continues to provide us with recommendations for best practices in the identification and treatment of sepsis. References Bayor, O., Schwarzkopf, D., Stumme, C., Stacke, A., Hartog, C. S., Hohenstein, C., et al. (2015). An early warning scoring system to identify septic patients in the prehopsital setting: The PRESEP score. Academic Emergency Medicine, 868-871. Centers for Disease Control and Prevention. (2016). Sepsis Fact Sheet. Retrieved from Centers for Disease Control and Prevention: https://www.cdc.gov/sepsis/pdfs/ sepsis-fact-sheet.pdf National Institute of General Medical Sciences. (2017, January). Sepsis Fact Sheet. Retrieved from National Institute of General Medical Sciences: https://www. nigms.nih.gov/education/pages/factsheet_sepsis.aspx Sepsis Alliance. (2016, June 30). Sepsis Alliance: Suspect Sepsis. Save Lives. Retrieved from Sepsis Alliance News New U.S.Government Report Reveals Annual Cost of Hospital Treatment of Sepsis Has Grown by .4 Billion: http://www.sepsis.org/sepsis-alliance-news/ new-u-s-government-report-reveals-annual-cost-ofhospital-treatment-of-sepsis-has-grown-by-3-4-billion/ Seymour, C. W., Liu, V. X., & Iwashyna, T. J. (2016). Assessment of clinical criteria for sepsis for the third international concensus definitions for sepsis and septic shock (sepsis-3) . JAMA, 762-774. Shelton, S. (2015, February 24). Looks Critically Ill (Don’t Know Why). Retrieved from DOC Health Services Nursing Treatment Protocols: https://www.oregon.gov/ doc/OPS/HESVC/docs/protocols/Emergency_protocols/ Looks%20Critically%20Ill%202015.pdf
August, September, October 2017 DNA Reporter • Page 7 Caring for the Aging Inmate Theawna Trisvan, MSN, RN, CCHP Theawna earned her Bachelor’s and Masters of Science in Nursing degrees from Wesley College in Dover, DE. She became a Certified Correctional Health Professional (CCHP) in June of 2015. In the past, she has worked in various healthcare settings such as long term care, home healthcare, and as a clinical instructor for Polytech and Wesley Theawna Trisvan College. Theawna’s correctional healthcare experience included working at James T. Vaughn Correctional Center from 2012 to 2015 in the infirmary, chronic care, and continuous quality improvement areas. Currently, she is a correctional statewide nurse educator for Connections Community Support Programs. Theawna’s responsibilities include educating new staff on correctional healthcare, performing annual skills with staff, support site leadership, among many other duties. Theawna has a passion for continuing education and sharing her knowledge with others. She feels it’s important the community is aware of correctional healthcare and the effects it has on our society today. Theawna can be reached via email at ttrisvan@connectionscsp. org and at her office at 302-634-0434. A special population in the correctional setting is the aging inmate. Caring for aging inmates has been a major concern for correctional staff due to the rapid growth of this population. According to the U.S. Justice Department’s Bureau of Justice Statistics, the U.S. prison population has grown from just over 319,000 in 1980 to nearly 1.5 million in 2005 (Abner, 2006). The fastest growing population is the aging inmate who can cost an average of ,000 year and more for advanced chronic conditions (Williams et al., 2012). The correctional system was designed for the purpose of carrying out the sentences of inmates rather than serving as a provider of nursing home level care, which alludes to a vulnerable and least prepared population (Porporino, 2014). Mandatory minimum sentences, three strikes rules, and truth-insentencing laws established in recent decades are keeping more inmates in prison for longer periods of time (Abner, 2006). Per Delaware Department of Correction (DDOC) A-01 policy, all offenders shall have access to healthcare for all their medical, dental, and mental needs. Correctional staff struggle with finding ways to remain true to the purpose of overseeing inmate sentences while seeking ways to deliver elder care in a cost-effective and humane manner (Bayer, Falkowski, Magnuson, Masters, & Potter, 2016). Aging inmates suffer from an array of diseases due to predisposing risk factors, prison overcrowding, prior substance abuse, poor lifestyle choices, mental health disorders, and the accumulation of stress. Dr. David Thomas from the Department of Surgery at Nova Southeastern University stated, “Inmates appeared to be physically and medically older than their actual age” (Abner, 2006, p. 9). The Bureau of Justice Statistics uses 55 as the definition of a geriatric inmate (Williams et al., 2012). Aging can affect cardiovascular, neuromotor, and cognitive systems which cause gradual decline in individuals (Hawkes, Manselle, & Woollacott, 2014). “The stress of incarceration including lack of support systems and a lack of trust in fellow inmates leads to chronically stressful and debilitating environments” (Abner, 2006, p. 9 ). Elderly inmates who suffer from a chronic illness are enrolled in a chronic care clinic and followed by nurses, providers, clinical pharmacist, and other specialties as needed. Per DDOC policy E-12, offenders are identified and enrolled in the appropriate chronic care clinic and shall be seen every 90 days or sooner as needed. Chronic care clinics include, but are not limited to: diabetes, hypertension, seizure, arthritis, hyperlipidemia, respiratory, cardiovascular, and cancer diagnosis. Older inmates nationwide have a higher burden of three chronic medical conditions such as hypertension, diabetes, and pulmonary disease than younger prisoners and older non-prisoners (Williams et al., 2012). It is common for them to suffer from many comorbities and be enrolled in more than one clinic. The correctional facilities follow the community standards for managing chronic conditions and ensure patients have a treatment plan designed specific to their needs. The treatment plan includes medication regimen, chronic condition status, patient goals, referrals for additional care, and any new findings during the visit. Specialty care services also available include: dialysis, optometry, podiatry, infectious disease specialists, nutrition, hospice care, obstetrics and gynecology, physical therapy, and radiology and laboratory services. Other issues correctional staff face is the increasing need for medical equipment such as canes, walkers, wheelchairs, oxygen, continuous positive airway pressure machines, hearing aids, assistive devices, air mattresses, handicap access, and the list continues to grow. Special consideration for housing must be balanced with the needs of security. Elderly inmates can still have visual/hearing impairments, pressure ulcers, and dementia, be taken advantage of by other inmates, and be at risk for falls, plus many other health safety hazards. The three most common geriatric syndromes in older inmates are vision and hearing impairment, incontinence, and falls (Williams et al., 2012). Keeping aging inmates safe is a priority and nursing staff must advocate for patient safety for their overall wellbeing. Some inmates require constant medical attention and can be housed permanently in an infirmary setting due to their high level of acuity. The infirmary manages care for patients under observation for medical or mental health concerns, chronically ill patients, pre and post-operative patients, those on dialysis, and patients who are on hospice. End of life care can be challenging for medical staff due to the correctional setting as a whole. Nursing staff have a key role in overseeing and facilitating care to the aging population in prisons/ jails. From administering medications, assessing patient conditions, providing education, treating wounds, and responding to emergency codes, nurses work to address healthcare needs among the elderly. Correctional nurses have a lot of autonomy and must possess critical thinking skills for dealing with various patient conditions. They must also maintain a non-judgmental attitude and provide a therapeutic environment for patients while still maintaining professional boundaries and following facility rules. Nurses have to remember, although the inmate is considered an elderly patient, they are still considered to be an inmate first. Health promotion in correctional facilities plays a major role in prevention of chronic illness in the aging inmate population. Medical and mental health staff should educate their patients during every patient encounter such as: provider and nursing visits, medication passes, and during the intake/ discharge processes. In some correctional facilities, healthcare staff have developed healthy living classes that teach inmates how to eat a healthy diet, properly manage stress, and prevent and manage chronic illness. Being able to identify inmates who have a high risk for chronic disease and who also have a long sentence, may be beneficial to get an early start on treatment. The future for caring for the elderly inmate poses a challenge for the correctional staff. Ensuring all staff are prepared and educated on the needs for the growing aging population continues to be problematic. Nationwide, correctional staff have requested training in geriatrics, but few geriatrics training programs exist. According to Williams et al. (2012) correctional officers and medical staff must be up-to-date on the aging process, signs and symptoms of health decline, and how to effectively manage chronic disease in elderly inmates. (Williams et al., 2012, p. 1477) also pointed out that healthcare workers and correctional staff training on geriatrics should focus on the following areas: 1. Common normative age associated conditions (vision loss and hearing deficits) 2. Common pathological age associated physical conditions (falls & incontinence) 3. Common clinically diagnosed cognitive conditions (dementia & delirium) 4. The challenges that the conditions may cause. 5. Ways to identify patients who need rapid assessment by a health care provider. Correctional facilities will be faced with more challenges as life expectancy rises and elderly inmates carry out lengthy life sentences. There are many questions and not enough answers at this time for what the future will hold for the aging inmate population. Understanding aging inmate health and healthcare needs will have clinical and public health relevance that will extend beyond the prison walls (Williams, Goodwin, Baillargeon, Ahalt, & Walter, June 2012). In the future, finding effective ways to educate all correctional staff on the vulnerable aging population will be paramount. References Abner, C. (2006). Graying prisons: State face challenges of an aging inmate population. Retrieved from: http://www.csg.org/knowledgecenter/docs/ sn0611GrayingPrisons.pdf Bayer, B., Falkowski, P., Magnuson, T., Masters, J., Potter, J. (2016). Preparing corrections staff for the future: Results of a 2-day training about aging inmates. Journal of Correctional Health Care, 22(2), 118-128. DOI: 10.1177/1078345816634667 Department of Correction Policy Manual (May 2017). Policy number 11-A-01. Retrieved from: http://www.doc. delaware.gov/downloads/policies/policy_11-A-01.pdf Department of Correction Policy Manual (May 2017). Policy number 11-E-12. Retrieved from: http://www.doc. delaware.gov/downloads/policies/policy_11-E-12.pdf Hawkes, T. D., Manselle, W., & Woollacott, M. H. (2014). Cross-sectional comparison of executive attention function in normally aging long-term T’ai Chi, meditation, and aerobic fitness practitioners vs sedentary adults. Journal of Alternative & Complementary Medicine, 20(3), 178-184. doi:10.1089/ acm.2013.0266 Porporino, F. J. (2014). Managing the elderly in corrections. Paper presented at the 2014 International Community Corrections Association Annual Conference, Cleveland, OH. Williams, B. A., Goodwin, J. S., Baillargeon, J., Ahalt, C., & Walter, L. C. (June, 2012). Addressing the aging crisis in U. S. criminal justice health care. Journal of the American Geriatrics Society, 60(6), 1150-1156. doi:10.1111/j.1532-5415.2012.03962.x Williams, B. A., Stern, M. F., Mellow, J., Safer, M., & Greifinger, R. B. (August, 2012). Aging in correctional custody: Setting a policy agenda for older prisoner health care. American Journal of Public Health, 102(8), 1475-1481. doi:10.2105/AJPH.2012.300704
© Copyright May 2018 - Arthur L. Davis Publishing Agency, Inc.