Page 8 • DNA Reporter August, September, October 2017 Nocturnist Coverage for Correctional Medicine: An Innovative Approach to 24/7 Real Time Medical Care Access for the Incarcerated Patient Kristopher T. Starr, JD, MSN, APRN, CNP, FNP-C, CEN, CPEN Kris is a graduate of Widener University School of Law as well as University of Delaware’s Bachelors and Masters in Science Nursing programs. He obtained is Post Master’s Certificate as a Family Nurse Practitioner in 2014. Kris has obtained several certifications to include: Mediator- Delaware Superior Kristopher T. Starr Court/Delaware Court Chancery, Certified Family Nurse Practitioner, Board Certified Emergency Nurse, and is a Board Certified Pediatric Emergency Nurse. He is an Advanced Trauma Life Support and Neonatal STABLE program provider. Kris is also an instructor for Basic Cardiac Life Support, Advanced Cardiac Life Support, Pediatric Advanced Life Support, the Emergency Nurse Pediatric Course, and Trauma Nursing Core Course. Kris has 17 years plus of legal experience and 21 years of nursing experience. In addition to law and nursing experience, he also has 28 years of experience with the Hockessin Fire Company. He currently holds several positions in areas of law, healthcare, fire and education. He currently is the Nocturnist for Connections Community Support Program who is the responsible medical vendor for Department of Correction healthcare. As the Nocturnist he is responsible for the medical care after hours throughout our state’s correctional facilities. Kris can be reached by email at kstarr@ connectionscsp.org Many hospitals have found their patient care volume and the acuity of patients that are admitted outside of bankers hours (9 am- 5 pm) require just the same level of care, if not more, than those required by patients seen during traditional daylight working hours. For these and many other quantifiable reasons, the nocturnist medical provider role came into being. In a 2008 survey, only 6% of hospitals had physician staff who identified as nocturnist providers (Butterfield, 2008). By 2012, 55% of physician hospitalist groups had on site medical providers at night and that number has grown to 81% in 2014 (Kowalczyk, 2016). Admission volumes, overnight clinical condition changes, patient safety, and other factors have made the nocturnist or “nocturnalist” an essential provider of hospital based medicine. So, why not take the data developed in the inpatient arena over the last nine years and apply it to the correctional care area? In Delaware, there are nine Department of Correction facilities that house inmates 24/7. Four of these facilities are considered Level V or maximum security facilities. Howard R. Young Correctional Institution and James T. Vaughn Correctional Center are male facilities located in New Castle County, Delaware. Baylor Women’s Correctional Institute, the state’s only women’s facility is also located in New Castle County. While Kent County does not have any Level V facilities, Sussex County has one Level V facility, Sussex Correctional Institution. Each level V facility houses an infirmary or a small medical inpatient unit that resembles a hospital-based close observation unit. These infirmaries house patients who are generally too ill for general population placement, but do not meet criteria of an inpatient acute-care or progressive care hospital admission. After reviewing various utilization indicators, which included cost variance, nightly emergency and non-emergency transports, emergency department admissions, infirmary admissions, new intakes, call provider usage, call coverage vs. available providers and other indicators, an innovative plan was developed to provide the type of nocturnal hospitalist care provided in many inpatient institutions and translate that care into the correctional medical setting. Nocturnist care partly grew out of the concerns of having providers, who had put in a full day of work, being awoken at night to deal with patient clinical concerns or admissions, while facing the daunting task of having to put in another full day of work the following day after overnight call (Kowalczyk, 2016). This pattern follows a very traditional rotating night call pattern, which many providers are familiar with. Also impacting this call pattern are the number of available providers who might share or distribute the call schedule among the facilities that require coverage. Traditionally, no one looked forward to their “call week” or worse “call weeks.” Even financial incentives sometimes pale against the spectra of lost sleep for multiple days in a row. To measure against these many concerns, nocturnist coverage provides real-time, unimpeded coverage on the off-hours for the facilities requiring provider coverage. More importantly, inmates receive realtime care access and clinical care decisions from a provider who is not burdened by the prospect of other clinical duties facing them the next day, and the provider is not being awoken in the middle of the night. Delaware correctional facilities routinely house approximately 6500 inmates daily. Many of these inmates have chronic medical conditionssome of which require real time assessment and intervention, have episodic medical needs that occur at all hours, experience urgent or emergent medical problems, are brought into the intake facilities from law enforcement agencies at all hours and require intake screenings and the prescribing of routine medications taken at home, or are discharged from health care facilities and require admission to correctional infirmaries for 23 hour observation. Instead of having five to seven different providers assume weekly call coverage to cover these nine institutions, for 14 days every month, one nocturnist covers all nine facilities and the four infirmaries. The correctional nocturnist generally works from 8 pm to 8 am. Typically, the nocturnist receives a call directly from the institution. A nurse in medical will relay the problem, chief complaint, history of present illness/injury, pertinent physical findings, current vital signs, and any further assessment data. The nocturnist logs into the medical record and assesses the current and prior medical history, allergies, current medications, and any current or prior treatment course, including diagnostics such as lab work, radiographs, and electrocardiograms WESTMINSTER VILLAGE Seeking a place to be for “FUN IN THE SUN?” A place to work where you can enjoy your work day? Westminster Village is the place to be! Visit our new TCU unit and newly renovated Health Center! Seeking FT Resident Services Manager For Assisted Living Registered Nurses for LTC www.wvdover.org (302) 744-3600 PHONE (302) 744-3520 FAX firstname.lastname@example.org (EKGs). Nursing can perform real time tests including EKGs, Point of Care labs, and other assessments, scan and securely send this data to the nocturnist, which grants a more complete clinical picture for further medical decision making. The nocturnist then gives an assessment and plan to the nursing staff and enters a real time treatment note, complete with scheduled medications and treatment orders, into the clinical electronic health record of the inmate to avoid the sometimes confusing and error prone nature of verbal orders. Having the real time interaction with the provider, complete with contemporaneous care orders, medications, and documentation closes the clinical continuity loop and provides the oncoming day providers an accurate look at what occurred overnight, what care decisions were made and the medical decision-making behind them. Furthermore, the inmate received a provider encounter with a clinical assessment and documented care plan that granted the inmate virtual access to a trained clinician in the wee hours. In the correctional care environment, this engaged program equates to virtual 24/7 provider access and care. Translating the nocturnist from the hospital setting to the correctional setting is not without its own set of barriers and precautions. But, when considering the correctional care environment and the challenges that lie in staffing correctional medical centers, providing reasonable clinical care and provider access to inmates in a timely, efficacious, safe and cost-effective manner, all while appreciating the competing needs of the correctional system, the cost of care provision, and the Constitutionally mandated nature of health care provision to the incarcerated population, the utility, feasibility, and justification for a nocturnist care provider is easily demonstrated. There are several benchmark indicators that might score the value of the nocturnist to the correctional care system. While the provision of this level of service might not fit neatly into a revenue based valuation (i.e., RVU/patient), there are other indicators that may lend themselves to measurement in the near and intermediate terms to attach valuation. Included among these indicators are benchmarks such as: • Number of emergency/non-emergency transports • Emergency department admissions • Patients seen • Medications ordered • Intakes performed • Infirmary admissions • Total call volume/day/week • Grievance rates • Cost variance based on cost indicators (traditional call/nocturnist call) Among the intangible or non-value quantified indicators to program success include quality of life (QoL) reported by providers based on call requirements, recruitment and retention of providers on the basis of call requirements, correctional officer overtime as a measurement of off-hour utilization, and reduction in workload by day providers. In summary, the implementation of a nocturnist clinical care provider in the correctional setting represents an ambitious undertaking to address the lack of real-time clinical care provision to incarcerated individuals during the overnight hours. This bold and thoughtful program balances the competing concerns of timely care provision to a vulnerable population, staffing resources and allocation, work-life balance, and the need to implement a 24-7 care model in a challenging clinical environment. References Butterfield, S. (2008, December). Physicians of the night. ACP Hospitalist. Retrieved at https://acphospitalist.org/ archives/2008/12/cover.htm Kowalczyk, L. (2016, July 4). The doctors who only come out at night. The Boston Globe. Retrieved at https://www.bostonglobe.com/lifestyle/healthwellness/2016/07/04/hospitals-increasingly-turningnocturnists/lfTgilEc7guOCbHGbfNr1K/story.html
August, September, October 2017 DNA Reporter • Page 9 Publication and APA Guidelines William Campbell, Ed.D, RN, Co-Managing Editor for the DNA Reporter So you want to be an author? Writing an article on a topic of healthcare importance for publication is part of being a professional. Nursing is a profession and as such by definition we must each be involved in research (original or literature), writing, presenting, or in some way disseminating that information for the improvement of our profession and fellow professionals. The dissemination of knowledge to strengthen the profession and improve patient outcomes began over 150 years ago. Florence Nightingale conducted research on how to improve patient outcomes with new improved nursing interventions in the 1850’s and published those best practices in 1859/60 in Notes on Nursing. The same were taught at St. Thomas’s Training School for Nurses. Many of those best practices, like hand washing, became traditions as well as Evidence Based Practice (EBP) and are still used today. Now it is your turn to write on what you know best and share it with your fellow Delaware nurses. If you have an idea for a theme, or wish to volunteer as a Guest Editor, or as an author, contact Sarah at the DNA Office. The DNA Reporter is a great place to start your publication history, or to continue it. We would love to hear from you. Here is some information about the process, roles and responsibilities, and APA to help you get started. The DNA Reporter is the official publication of the Delaware Nurses Association and is published quarterly. It is mailed free to all nurses in Delaware who have their addresses on file with the Delaware Nurses Association (DNA) and our publisher. For each issue a theme is selected by the DNA Board of Directors and/or the Co-Managing Editors. A volunteer Guest Editor is then sought for that issue. The Guest Editor must be a member of DNA and have expertise within that theme. He/She agrees to serve as the Guest Editor, to select 5 authors with expertise to write articles under that theme, to electronically communicate with the authors, to review the articles (first peer review), suggest revisions, and forward the articles to the Co- Managing Editors. The Co-Managing Editors, Dr. William Campbell and Dr. Karen Panunto (along with the DNA President or a 3rd member of the Communications Committee) will do the second peer review. The Guest Editor also writes an article (300- 500 words) to introduce the topic, the articles, and the authors, provides a bio, and a photo. The 5 authors should be members of DNA, but it is not required. They must be nurses, or if a nonnurse author is selected then they must co-author with a nurse. The authors will write an original article, not previously published, of about 1000 words. The author and Guest Editor will confirm that the article fits the theme of the issue. The articles must be written in a professional formal style, double spaced, 12 point and Times New Roman font. The articles must use APA 6th edition throughout, have in-text citations, and a reference page. The DNA Reporter strives to maintain its high level of quality. Therefore these guidelines must be strictly enforced and articles not meeting these guidelines cannot be accepted for publication. Each article is peer reviewed by the Guest Editor first, then by the Co-Managing Editors, and returned to the authors with suggested revisions. Once revisions are approved and/or corrections made by the author, the revised article goes back to the Editors for a final review before being forwarded to the publisher. With this multi-level peer review the DNA Reporter works to maintain the high quality, readability, and accuracy of each article and each issue. If the author is using large quotes, graphs or diagrams from another source, or any copyrighted material it is the author’s responsibility to obtain, in writing, permission to use. Each author also writes a brief bio including name with credentials, education, experience, positions, contact information (work email and phone number), and a head and shoulders PR photo. Unsolicited manuscripts are also welcome. If interested please see the submission guidelines always found in the blue shaded information box usually located on page 2 or 3 of each issue. Deadlines for each issue are set by our publisher and must be adhered to strictly due to their other scheduled publications. Therefore earlier deadlines are set for the authors and Guest Editor and must also be followed strictly. There is no flexibility in the final deadline. The most difficult part of writing any article especially if you have not been an author for a professional nursing publication previously is correctly using APA. The best APA reference or self help book is the APA 6th edition Publication Manual available at most bookstores, libraries, or online for purchase or use. If unsure of the proper APA consult the Manual. There are also online programs and aids including some computer software. Many of these contain errors. The computer software is very problematic due to the cookies and formatting that it locks into the citation which will not allow the editors or publisher to make corrections if and when needed. Only the original author can make corrections and even then it is often incorrect. Authors should refrain from using these programs. The use of APA for crediting sources used in the Reporter is mandatory and falls into 2 types: the intext citation and the reference listings. Each has its unique formatting. While it looks complicated and can be over whelming most of the time it involves 2 sources: either journals/books or online references. Each of these also has its unique format. Examples for these types are provided here for your use. For other sources, such as government documents, check the APA Publication Manual, 2010, 6th edition, for clear guidelines and examples. In-text citation from a source that is quoted (with the exact words and they must be in quotation marks): … (author, date, page number of quote) or for example (Jones, 2014, p. 12). Other methods of breaking up this info are possible – see the Manual. In-text citation for data, numbers, specific info, not a word-for-word quote, but paraphrased; not from the author’s head or general knowledge, but from some other source (“the author had to pull it Publication and APA Guidelines continued on page 11
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