23-2

rrectCareCC Spring 2009 | Volume 23 | Issue 2

National Commission on Correctional Health Care1145 W. Diversey Parkway, Chicago, IL 60614

Evidence-Based Nursing Practice

The Time Is Right!

Holistic Health Care OffersPromise of Positive Outcomes

DOC-University Pharmacy Project

National Conference Preview

The magazine of the National Commission on Correctional Health CareT

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National Conference on Correctional Health CareOctober 1721, 2009 Orlando

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For more information, email [email protected], call 773-880-1460 or visit www.ncchc.org.

Orlando NatConfAd CC FP.indd 1 5/5/09 5:02:04 PM

10

CareCorrectCare is published quarterly by the National Commission on Correctional Health Care, a not-for-pro t organization whose mission is to improve the quality of health care in our nations jails, prisons and juvenile con nement facilities.

NCCHC is supported by the leading national organizations representing the elds of health, law and corrections.

BOARD OF DIRECTORSJoseph V. Penn, MD, CCHP (Chair)

American Academy of Child & Adolescent PsychiatryNina Dozoretz, RHIA, CCHP (Chair-Elect)

American Health Information Management AssociationRobert E. Morris, MD, CCHP (Immediate Past Chair)

Society for Adolescent MedicineThomas J. Fagan, PhD (Secretary)American Psychological AssociationNancy B. White, LPC (Treasurer)American Counseling Association

Edward A. Harrison, CCHP (President)National Commission on Correctional Health Care

Carl C. Bell, MD, CCHPNational Medical Association

Patricia Blair, JDAmerican Bar Association

Kleanthe Caruso, MSN, CCHPAmerican Nurses Association

Robert Cohen, MDAmerican Public Health Association

Eileen Couture, DO, CCHPAmerican College of Emergency Physicians

Charles A. FasanoJohn Howard Association

Kevin Fiscella, MDAmerican Society of Addiction Medicine

Robert J. Gogats, MANational Association of County & City Health Of cials

Robert L. Hilton, RPh, CCHPAmerican Pharmacists Association

Renee Kanan, MDAmerican College of PhysiciansJoRene Kerns, BSN, CCHP

American Correctional Health Services AssociationDouglas A. Mack, MD, CCHP

American Association of Public Health PhysiciansNicholas S. Makrides, DMDAmerican Dental Association

Edwin I. Megargee, PhD, CCHPInternational Association for Correctional and Forensic Psychology

Charles A. Meyer, Jr., MD, CCHP-AAmerican Academy of Psychiatry & the Law

Eugene A. Migliaccio, DrPHAmerican College of Healthcare Executives

Ronald C. Moomaw, DOAmerican College of Neuropsychiatrists

Peter C. Ober, PA-C, CCHPAmerican Academy of Physician Assistants

Peter E. Perroncello, MS, CCHPAmerican Jail Association

George J. Pramstaller, DO, CCHPAmerican Osteopathic AssociationPatricia N. Reams, MD, CCHPAmerican Academy of Pediatrics

Judith Robbins, LCSW, CCHP-ANational Association of Social Workers

Sheriff B.J. RobertsNational Sheriffs Association

David W. Roush, PhDNational Juvenile Detention Association

Jayne Russell, MEd, CCHP-AAcademy of Correctional Health Professionals

Ronald M. Shansky, MDSociety of Correctional Physicians

Alvin J. Thompson, MDAmerican Medical Association

Ana Viamonte Ros, MDAssociation of State and Territorial Health Of cials

Barbara A. Wakeen, RD, CCHPAmerican Dietetic Association

Henry C. Weinstein, MDAmerican Psychiatric Association

Ronald Wiborg, MBANational Association of Counties

Representative Appointment PendingNational District Attorneys Association

Copyright 2009 National Commission on Correctional Health Care. Statements of fact and opinion are the responsibility of the authors alone and do not necessarily

re ect the opinions of this publication, NCCHC or its supporting organizations.NCCHC assumes no responsibility for products or services advertised. We invite

letters of support or criticism or correction of facts, which will be printed as spaceallows. Articles without designated authorship may be reprinted in whole or in

part provided attribution is given to NCCHC.

Send correspondence to editor Jaime ShimkusNCCHC, 1145 W. Diversey Pkwy, Chicago, IL 60614

Phone: 773-880-1460; Fax: 773-880-2424E-mail: [email protected]; Web: www.ncchc.org

Features 3 CDC Issues H1N1 Influenza

Guidelines for Corrections

6 National Conference Preview

7 Legal Affairs: Beware of the Specialists Recommendations

10 Evidence-Based Nursing Practice: The Time Is Right!

14 Holistic Care Offers Promise of Positive Health Outcomes

16 DOC-University Rx Project Yields Big Savingsand Awardin Rhode Island

18 Force Feeding for Hunger Strikes

Departments 2 NCCHC News

4 News Watch

8 Clinical News Brief: Earlier ART Yields Better Outcomes

21 Journal Preview: Brief Negotiation Interviewing Lowers HIV Risk, Increases Testing

22 Spotlight on the Standards: Medication Services

23 Juvenile Voice: Nutritional Issues

24 CCHP Page

25 Field Notes

27 Classified Ads and Ad Index

28 Standards Q&A

Orlando NatConfAd CC FP.indd 1 5/5/09 5:02:04 PM

Spring 2009 | Volume 23 | Issue 2

22Spring 2009 CorrectCare www.ncchc.org

Survey Findings Will Help to Bridge Gaps in Pandemic Flu AssistanceAs always, NCCHC is at the forefront in helping correc-tional facilities to provide high quality health care services.A current concern for many facilities is how to properly prepare for and respond to an influenza pandemic. Of greatimportance is collaboration with county and state healthdepartments, which should have the resources to help cor-rectional facilities before and during such an event.

As part of a nationwide effort to improve those relation-ships, NCCHC recently conducted a survey in cooperationwith the National Association of County and City HealthOfficials and the Association of State and Territorial HealthOfficials (both are NCCHC supporting organizations). Wesent an e-mail survey to the health administrators of all NCCHC-accredited facilities asking about health depart-ment help in preparing for and responding to a possibleH1N1 flu outbreak, as well as satisfaction with the level of support they received.

The results will be tabulated in July. The findings, which we will share with our constituents, will enable NACCHO and ASTHO to guide their own members in working more effectively with correctional facilities.

Professionals Find Value in NCCHC EducationEven in these dicey economic times, savvy correctionalhealth professionalsand the administrators who approvetheir budgetsknow a good deal when they see one. Thats why they came out in droves to the Updates inCorrectional Health Care conference in April. It didnt hurtthat the meeting was held in fabulous Las Vegas! But thereal reason for the strong attendance, which was on parwith the previous year, was because of its intentional focuson presentations designed to help you meet the fiscal and human resources challenges of these times. With 55 ses-sions on a broad range of topics and plenty of quality time for networking, this meeting was a sure bet!

Facilities Look to NCCHC for HelpWhen things go awry, correctional facilitieseven those that are not accreditedturn to NCCHC for assistance. For example, in Wisconsin, two deaths at a county jail prompt-ed the sheriff to bring in NCCHC for an independentconsultation. Our report detailed 27 recommendations for improvement and the jail staff is now busy with implemen-tation, starting with the big issues, such as increasing phy-sician hours and improving communication between thecounty and the contract management firm that provideshealth services.

For those facilities that have undertaken the effort to meet the NCCHC health services standards and invite a team of surveyors to measure compliance, there is a strongsense of pride and accomplishment in become accred-ited. In Virginia, the Albemarle-Charlottesville Regional Jailrecently received initial accreditation. Although the jailshealth officials say that, for the most part, they only had to tweak their policies, the efforts bring great benefits on many fronts. Overall, it reflects positively on the facility,said superintendent Col. Ronald Matthews. It also shows the inmates that the jail cares about their well-being, and it improves staff morale.

news

June 26 Accreditation committee meeting

July 10-11 Medical Director Boot Camp, Seattle

July 12-13 Correctional Mental Health Seminar, Seattle

August 22 CCHP examination, multiple regional sites

October 17-21 National Conference on Correctional Health Care, Orlando

November 20 Accreditation committee meeting

For the complete list of CCHP exams, including the regional exam sites see www.ncchc.org/cchp.

of eventsoaCaalendar

The National Commission on Correctional Health Carehas no membership or dues. NCCHC does not require any affiliation to be considered for accreditation, cer-tification or employment as a consultant or surveyor, or to serve on committees or the board of directors. NCCHC staff and spouses are not allowed to acceptgifts or consulting fees from those we accredit or cer-tify. NCCHC is impartial, unbiased and expert. Anddedicated only to recognizing and fostering improve-ments to the field of correctional health care.

NCCHC Supports Global Principles for Socially Responsible Associations & NonprofitsNCCHC has always been committed to operating in a socially responsible manner.Now, weve made that commitment in writing. NCCHC is proud to be a signa-tory of the Global Principles for Socially Responsible Associations & Nonprofits.A goal of the Global Summit for Social Responsibility convened in 2008 by the American Society of Association Executives and the Center for Association Leadership, the principles promote sustainable development and good corpo-rate citizenship among members of the association community. They are basedon universally accepted principles established by the United Nations Global Compact. The Global Principles also help create a network of associations, non-profits, industry partners and other associates to provide a forum for learning and exchange of ideas and best practices. Learn more at www.asaecenter.org/Forms/SocialResponsibilityPrinciples.

33www.ncchc.org Spring 2009 CorrectCare

Guidance for correctional facilities on novel influenzaA virus (H1N1, initially known as swine flu) wasissued May 24 by the Centers for Disease Control and Prevention. The recommendations aim to ensure con-tinuation of essential public health services and protectionof the health and safety of inmates, staff and visitors. Thedocument is labeled interim to highlight the fact thatrecommendations may need to be revised as more informa-tion becomes available.

Corrections-specific guidance was deemed necessarybecause of the special risks and considerations thatthese institutions pose. For instance, options for isolationor removal of ill inmates are limited. Also, it is essential tomaintain an adequate workforce on site at all times.

The guidance focuses on general preventive measures,reducing the risk of introducing the virus into the facility, rapid detection of infected persons, and management andisolation of identified cases. A summary of key points that pertain to corrections follows. A number of recommenda-tions refer to other CDC guidance documents, all of which are posted at the CDCs H1N1 Web site.

Risk Reduction Visitors who had an influenza-like illness (ILI) in the

previous 7 days or who still have symptoms 7 days after theillness began should not be permitted to enter the facility. Inmates and potential visitors should be informed of this.

Staff with ILI should stay home (or be sent home if they develop symptoms on site) and remain at home for 7days or until 24 hours after symptoms resolve, whichever islonger.

If ILI is present, cancel internal group gatherings andstagger group meals and other activities to provide morepersonal space between individuals. Consider temporarilysuspending or modifying visitation programs.

Rapid Detection of Cases Instruct inmates and staff to report symptoms of ILI to

the facility health care professional at the first sign of illness. Evaluate incoming inmates and isolate those who dis-

play symptoms of ILI. (See the CDCs interim guidance onidentifying and caring for patients with-H1N1 infection.)

Consider daily temperature checks in units where ILI cases are identified.

Conduct testing of some persons with ILI to determine what viruses are circulating at the institution.

Management and Isolation of Cases Health care staff should follow CDC guidance on infec-

tion control for the care of patients with confirmed or sus-pected H1N1 virus infection.

Refer to CDC interim guidance on the use of face masks and respirators to reduce H1N1 virus transmission.

Influenza antiviral chemoprophylaxis may be given to inmates and health care staff in accordance with current

recommendations to reduce transmission. (See separateguidance document on use of antiviral agents.)

Actively monitor the number, severity and location of cases of ILI.

Separate inmates with ILI from others by placing them in individual cells when possible. Consider separating cellmates of sick inmates for 48 hours for observation.

Provide care of inmates with ILI, including scheduledtemperature checks and access to increased fluids, and anti-viral treatment when indicated. (See guidance on antiviral agents.) Also provide tissue, a plastic bag for disposal of used tissues and alcohol-based hand sanitizers.

Restrict movements of inmates with ILI within the facil-ity and restrict inmates from leaving or transferring betweenfacilities during the 7 days after onset of symptoms or until24 hours after symptoms resolve, whichever is longer, unlessnecessary for medical care, infection control or lack of isola-tion space.

If multiple inmates become ill with the H1N1 virus,establish an area specifically for these patients. Do not have them circulating in other parts of the facility. Designate staff to care for these patients only, and limit these staff mem-bers movement to different parts of the facility. (See Using Antiviral Medications to Control Influenza Outbreaks in Institutions.)

Personal items (e.g., linens, dishes) of those who are sick do not need to be cleaned separately, but they should not be shared without thorough washing. Linens should be washed using laundry soap and tumbled dry on a hot set-ting. Persons who handle laundry should avoid hugging itbefore washing it, and should wash their hands with soap and water or alcohol-based hand sanitizer immediately afterhandling it.

Assess and treat as appropriate soon-to-be releasedinmates with ILI or other flu symptoms and make directlinkages to community resources to ensure proper isolation and access to medical care.

Health care providers should identify and address the special health needs of persons at high risk for complica-tions from infection with H1N1 virus. These include thegroups typically at high risk for seasonal flu complications,such as the elderly, pregnant women, patients with chronic medical conditions and those who are immunocompro-mised. (See guidance specific to these populations.)

Other RecommendationsRecommendations on general preventive measures andworkforce protection are generic in that they would applyto any health care setting, discussing topics such as hygiene practices and vaccinations.

Finally, .non-English speaking inmates should be giveneducational materials and information that they can under-stand. If possible, provide a translator when evaluating and treating persons with symptoms. The CDC H1N1 Web siteoffers materials in Spanish and other languages.

To nd the latest CDC

recommendations

for corrections, visit

www.cdc.gov/h1n1u.

Click on Guidance,

then scroll down to

Clinician Guidance for

Speci c Audiences.

CDC Issues H1N1 Influenza Guidance forCorrections and Detention Facilities


Tel: 267/927-5000Fax: 267/927-5007

watch17% of New Jail Inmates Have Serious Mental IllnessA study of more than 20,000 people entering jail found that nearly 17% of have serious mental illness, says a recentreport from the Council of State Governments and Policy Research Associates. Serious mental illness was foundamong 31% of women and 14.5% of males, a particu-larly troubling finding given the growth in the female jailpopulation and the lack of research on the reasons for thisoverrepresentation. Overall, these estimates are three to six times higher than in the general population, and indicatethat as many as 2 million bookings of people with serious mental illnesses may occur each year. The study is the most

accurate accounting on the subject in more than 20 years.Source: http://consensusproject.org/updates/features/prevannouncement

PBS Highlights Woes of Releasees With Mental IllnessIn 2005, the PBS series Frontline aired The New Asylums,a riveting documentary on mental illness in Ohios prisons (and winner of NCCHCs 2005 Award of Excellence inCommunication). In a follow-up, the same two filmmakers have produced The Released, which examines what hap-pens to the seriously mentally ill when they leave prison and why their recidivism rates are so high. According toprogram information, more than 350,000 prisoners withmental illnesses will be released to the community this year. Typically, they are given a bus ticket, $75 and two weeksworth of medication. Within 18 months, nearly two-thirdsare rearrested. The program, which aired April 28, may beviewed online, along with supplemental material such asstory updates, a profile of a successful model for residentialtreatment in the community and a discussion board withdozens of thoughtful comments.Learn more: www.pbs.org/wgbh/pages/frontline/released

Hepatitis A, B Rates Down Sharply; Hep C PlateausRecommendations for childhood vaccination against HAV and HBV appear to have dramatically reduced infections,with rates in 2007 the lowest ever recorded, according toa report from the CDCs National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention. Acute hepatitis Aincidence declined 92% from 1995 to 2007, from 12.0 to 1.0case per 100,000 population. Acute hepatitis B incidencedeclined 82% from 1990 to 2007, from 8.5 cases 1.5 casesper 100,000 population. Declines occurred in all age groups but were greatest among children younger than 15. Higherrates of HBV remain in adults, particularly males aged 30-44,reflecting the need to vaccinate adults at risk for HBV.

Following a peak in 1992, incidence of acute hepatitis C declined, primarily among injection-drug users and possiblybecause of changes in IDU behavior and practices. Since 2003, however, rates have plateaued. In 2007, as in previousyears, the majority of HCV cases occurred among adults,and injection-drug use was the most common risk factor.

The report states that ongoing HBV vaccination pro-grams and increased vaccination of adults with risk fac-tors will eventually eliminate domestic HBV transmission. Further prevention of HBV and HCV relies on identifyingand preventing transmission in hospital and other healthcare settings. HCV prevention also relies on identifying andcounseling uninfected persons at risk about ways to protectthemselves. Public health management of persons with chronic HBV or HCV infection will help prevent transmis-sion to susceptible persons, and their medical management will reduce secondary effects of chronic liver disease.Source: MMWR Surveillance Summaries, May 22; www.cdc.gov/mmwr/mmwr_ss.html

Call toll-free 1.866.932.7185or visit us on the web at www.CHPnow.com

Delivering Quality OutcomesDiscover how Correctional Health Partners can support you in balancing clinical demand with available resources in your correctional system. Contact us today, and allow us to demonstrate how our expertise in developing services, skills, and collaborative relationships can bring substantial value to you.

Innovative cost containment services

Claims processing

Prior authorization and utilization management

Reporting and analysis

Provider network development

Care management and coordination

Pharmacy management, including formulary development

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We Deliver:

Meeting ChallengesColorado-based Correctional Health Partners (CHP) is proud to announce that it has increased its services to include the Oregon Department of Corrections. CHP is a clinically enhanced TPA with the expertise to effectively address and manage the unique challenges inherent in the delivery of healthcare services to correctional facilities. Our proven cost-containment systems have successfully increased the efciency, managed the costs, and allowed for the highest quality of care for our clients.

The strong working relationship we have with CHP is unmatched in my experience with contract agencies. Their staff is highly skilled, motivated, and experienced in managing a healthcare system. They are consummate professionals who demonstrate their commitment to us and ultimately the taxpayers. It is a true partnership in managing healthcare for the offender population.

Joan Shoemaker Director of Clinical Services, Colorado Department of Corrections

1515 Arapahoe Street Suite 300, Tower 1 Denver, Colorado 80202 1.866.932.7185 phone www.chpnow.com



CONFERENCE LEARNING OBJECTIVES

ing quality y off c cara e, accccess toto c caare, fif nanancnciaal mananaagegemmemem ntt andn workforce develoopment

Identify major h heae lth hhh care, reeseseara chh a and policcy y issisissusuese faccining inincacarccereraata ed individuals, includidingng inffecectiouus s ddises asseses, menttntalal ii i llllllnnenn ss, susubstatancn e ababa useand special needs (e.g.,., w wommenenss issssueu s, juuvenilee hheaeaaealtltltth,h, g gereriaai trtriccs,s, d disisababbility)y)

Demonstrate increasedd unundedersr tatandndining g ofof sskiills s nenecececessarryy too b bbetetteter maam nanageg common medical, dentall a andnd psyyychhc olologogicalal p problemmmms s founnnd dd inn c cororreectc ioonnal settings

Describe legal, ethical and d adadministratitiveve i issssues and deded vevelolop soluluttions forthe correctional setting

October 17-21Disneys Coronado Springs Resort

National Conference onCorrectional Health Care

Building Health Care Systems That WorkToTodad y, ccosost-t-t-effeffefefecctivve,e, evidencncce-e bab sed systems are the building blocks for transformation of correctctioionaal hehealalthth ccarare. TTheh NN Naational Conference gives you the blueprints to under-sts annd,d develop, immplpleement t anand d immpprove such systems. In this high-intensity environ-mentpacked d wiwithth lece tutututures,,s ppaannelle s, workshops, posters, exhibits and networkingyou will gain the knnowowleedgdggee anandd skillllss toot reshape not only your institutions health services, but also the well-bebeining g ofoff y yoour paap tit eents and the community at large.

For even greater benefitt, attendndd t thhe preconference seminars to reinforce the founda-tions of your r knknowo ledge. The ccoonfeererencnce proper begins Sunday evening with the ExhibitHall Openiingg R Reecepe tion, wheerree ccoolllleaeaguguese mingle and take a first look at the wealth of producu ts andd sservices on dissplplplayay..

CONTINUING EDUCATIONUpUpUpUp t tto o 323222 h h ours of CE credit may be earned d inn eeacchh cacatetegogory bbebeb lollow.w TThiihis ss mammm ximum number includes crrede its offfered d aatt prpreeccconononfferenccce seminars. See the Preliminary Program orcoonfffferrereene cececece WW Web site for details

CCCCHHHP Nurse Physician PsPsyycchhoh logist Social Worker General

Register by August 28 for significant early-bird savings! And see the Preliminary

Program for other money-saving tips.

BUILDING BLOCKS FOR SUCCESS D Discocover the latetest ttooo ls aaaanndndd t ttttecece hnhniqiques fofor r mamakikingn heaealtth h seserrvices delelivi erymomorere costt-effectiveve

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D Devvelelopop strtratategegiei s foor memeete ing naatitionoonalal statandndndndara dsdsdss i i in nnn thththe midst ofof bubudget ccutuu sannd sts afaffifingng s shoortrtagges

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SESSIONS WITH SUBSTANCEImmmmerse yoururseesellf in 3 days of programming and over 1000 edducationall sessioonsnsns, each designed to provide cururrereentn i innfforor--mmatition on subjectss impmporo tant to our field. Hereree ss a saamppm lilil ngng::

A Assurini g Nursing g SkSkills Through Competency yy DeeDevevelolopmpmenent Beyonond Diagnossiis: The Soul of the Psychopathh Chestst Pain: Gete tinngg to the Heart of the Matteteerr Efffecctitivev Corrrectioonns Crisis Intervention Training Esssentials of Corrrrectional Juvenile Health Care Excited Deliriuum m aand Sudden In-Custody DeathManan gementt o oof Hypertension and Diabetees MMMananaga ing the e DiDiD fff icult Patient MMMRRSAA: The SSupererbbuug g of Corrections PPandeemim c PPreppararedednness Plans SSeizuureres:s: E Effffecectitivveve Treatment and CCost MMaM nanagementnt WWWriteee I I IIttt RRiRight: Reduce Your Lawsuit RRisisk byby I Impm ror vinng Youururr Documentation

The Coronado Springs Resort evokes the legendary cultures of Mexico and the Southwest amid Mayan architectural flourishes. Amenities include a large outdoor poor (with waterslides and waterfalls), whirlpool, childrens pool, full-service res-taurant, food court, health club, laundry facilities, business center and game room. Also enjoy complimentary transportation to Walt Disney World sites.

NOT TO BE MISSED! Special interest discussion groups Speaker Q&A sessions Opening ceremony and keynote Educational poster display Exhibit hall networking breaks Exhibit hall raffles NCCHC bookstore Orlando attractions

FOR MORE INFORMATIONViViV sisitt ththe e NaNaatit ononnala Conference Web site for detailed informa-titiononon, , inninnclclududininng registration fees and policies, a schedule of sesessssioi nsns, , thththe e Preliminary Program and online registration. Or cacall us to reqeqqqueueu st Preliminary Program by mail.

www.ncchc.org 773-880-1460


by Robert P. Vogt, JD, CCHP

As a rule of thumb, courts prefer to leave the prac-tice of medicine to those who are educated and trained in the medical field. Courts will generallynot attempt to second-guess licensed physicians as to thepropriety of a particular course of medical treatment fora given prisoner-patient. Medical professionals are not required to pro-vide proper medical treatment toprisoners, but rather they must pro-vide medical treatment that reflects professional judgment, practice orstandards. The treatment decisions of medical professionals are given defer-ence by the courts unless no mini-mally competent professional wouldhave so responded under those cir-cumstances.

The cases also hold that the Constitution is not a medical code mandating that specific medical treatment must be provided to an inmate. Inmatesdo not have a constitutional right to demand a particulartype of medical treatment nor do they have the right to demand that treatment is provided by a particular type of specialist. Physicians do not violate the Constitution when, in the exercise of their professional judgment, they refuse to implement a prisoners requested course of treatment.

Furthermore, because the practice of medicine remains an art, judges recognize that [T]here is not one properway to practice medicine in a prison, but rather a range of acceptable courses based on the prevailing standards in the field. Because several acceptable courses of treatment may exist to address the same condition, deliberate indifference does not arise simply because two physicians hold different opinions on how to properly treat a condition.

Enter the SpecialistWhile these principles are fairly well-established, the law becomes murky when a specialist comes into the mix. Inthe eyes of the judiciary, a specialist often stands on a differ-ent footing and the willingness of the courts to defer to the correctional physician is much less.

It is important to note that, presumably, a correctionalphysician sends an inmate to see a specialist because the correctional physician recognizes the need for the special-ists assistance. The correctional physician is unable to treatthe inmates particular problem and reaches out for helpfrom a professional whom the correctional physician recog-nizes as having expertise in that area. If the specialist exam-ines the inmate and issues treatment recommendations that are subsequently ignored by the correctional physician, a heightened level of judicial scrutiny may result.

A review of the cases in this area reveals that the courts struggle with reconciling how a correctional physician canrefuse to implement the recommendations of the special-ist to whom the correctional physician turned for help inthe first place. The judges look for evidence that a physi-cian may have deliberately ignored the express orders of a specialist for reasons unrelated to the medical needs of the

prisoner.In such a circumstance,

the courts generally donot decide that the cor-rectional physician wasdeliberately indifferent in choosing not to follow the specialists advice. Instead, the courts simply determine that there isenough of a question thatthe issue should be leftfor a jury to resolve. As

described by one court, An inference of deliberate indif-ference may arise when prison officials refuse to follow an youtside specialists orders or recommendations.

The case of Gil v. Reed is perhaps the leading decision indthis area. In Gil, the inmate suffered from a rectal prolapseland was referred by the prison physician to a surgeon spe-cialist. Surgery was performed and the inmates surgeonspecialist specifically instructed the prison medical staff not to provide certain pain relievers because of their constipat-ing effect. Nonetheless, on three occasions after receiving these instructions, the prison physician ordered the inmateto be given the very medication that the specialist had warned against. This was done even though nonconstipat-ing alternative pain relievers were available.

Under these circumstances, the Gil court could not make lsense of the prison physicians refusal to follow the special-ists instruction and ruled that a jury should decide if theprison physician acted with deliberate indifference.

Conscious Decision or Blanket Denial?In addressing inmate claims that a correctional physicianwas deliberately indifferent by refusing to follow a special-ists recommendations, the courts try to assess whether the refusal reflected a conscious decision to try a differentcourse of medical treatment or a simple blanket denial. Theformer is not sufficient to establish deliberate indifference, while the latter may show that the physician knew of and disregarded an excessive risk to inmate safety.

Provided that the decision reflects a course of treatmentbased on the prevailing standards in the field, the courts

affairs

Beware of the Specialists Recommendations

continued on page 8


may still defer to the correctional physicians judgment. Asone court explained, What we have here is not deliber-ate indifference to a serious medical need, but a deliberatedecision by a doctor to treat a medical need in a particularmanner.

In one case, for example, the court sustained a correc-tional physicians decision to provide an inmate with some,but not all, of the specialist-recommended medications.The physicians decision was based on his belief that some of the recommended medications were duplicative of others. Similarly, in another case, the court upheld a correc-tional physicians decision to forgo a specialists recommen-dation to obtain an MRI. Here, the physician relied on hisown multiple clinical examinations of the inmate, and thefindings of an x-ray, as guiding his course of treatment.

Electing to forgo the recommendations of a specialistpresents liability risks and should be done only after carefulconsideration. Inmates often feel that they are legally enti-tled to a specialists recommendations even though appro-priate alternatives are available. To help reduce any potentialexposure, a correctional physician opting not to implement a specialists recommendation should document the basisfor his medical judgment and outline the alternative courseof treatment that will be provided.

Robert P. Vogt, JD, CCHP, is a partner in Weldon-Linne & Vogt, a Chicago-based law firm that defends health profes-sionals and institutions in Illinois, Indiana and Wisconsin. Contact him at [email protected].

Specialist p (continued from page 7)

HIV-infected adults in a resource-limited setting are morelikely to survive if they start antiretroviral therapy beforetheir immune systems are severely compromised, accordingto a randomized clinical trial in Haiti. In an interim review, an independent data and safety monitoring board foundoverwhelming statistically significant evidence that start-ing ART at CD4+ T cell counts between 200 and 350 cells/mm3 improves survival compared with deferring treat-ment until the count drops below 200 cells/mm3. The trial sponsor, the National Institute of Allergy and Infectious Diseases (part of the National Institutes of Health), heeded the boards recommendation to end the trial immediately.Study participants who have fewer than 350 CD4+ T cells/mm3 will be offered ART.

The clinical trial began in 2005 and enrolled 816 adultswith early HIV disease and CD4+ T cell counts from 200 to 350 cells/mm3. Half of the participants began ART withintwo weeks of enrollment; for the others treatment began when their counts dropped below 200 cells/mm3 or theywere diagnosed with AIDS. This deferred treatment is thestandard of care in Haiti and in keeping with World HealthOrganization guidelines. The first-line treatment regimenconsisted of zidovudine, lamivudine and efavirenz.

At the time of the interim review, the standard of care group had nearly 4 times as many deaths as the early treat-ment group (23 vs. 6, respectively). Also, participants who began the study without TB infection were twice as likely todevelop TB in the standard of care group (36) compared tothe early treatment group (18).

The investigators say this finding may change the stan-dard of care in dozens of countries where ART is initiatedonly when CD4+ T cell counts drop below 200 cells/mm3. In the United States, the Department of Health and Human Services has established a count of 350 CD4+ T cells/mm3 as an indication for initiation of therapy. However, the studyfinding also underscores the importance of identifying HIVinfections earlier and starting ART earlier.Source: NIH News; www.nih.gov/news/health/jun2009/niaid-08a.htm

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Earlier ART Yields Better Outcomes

DRUG INTERACTIONSEfavirenz: Efavirenz has been shown in vivo to induce CYP3A. Other compounds that are substrates of CYP3A mayhave decreased plasma concentrations when coadministered with efavirenz. In vitro studies have demonstratedthat efavirenz inhibits 2C9, 2C19, and 3A4 isozymes in the range of observed efavirenz plasma concentrations.Coadministration of efavirenz with drugs primarily metabolized by these isozymes may result in altered plasmaconcentrations of the coadministered drug. Therefore, appropriate dose adjustments may be necessary for thesedrugs. Drugs that induce CYP3A activity (eg, phenobarbital, rifampin, rifabutin) would be expected to increase theclearance of efavirenz resulting in lowered plasma concentrations.Emtricitabine and Tenofovir DF: Since emtricitabine and tenofovir are primarily eliminated by the kidneys,coadministration of ATRIPLA (efavirenz 600 mg /emtricitabine 200 mg/tenofovir disoproxil fumarate 300 mg) withdrugs that reduce renal function or compete for active tubular secretion may increase serum concentrations ofemtricitabine, tenofovir, and/or other renally eliminated drugs. Some examples include, but are not limited to,acyclovir, adefovir dipivoxil, cidofovir, ganciclovir, valacyclovir, and valganciclovir.Coadministration of tenofovir DF and didanosine should be undertaken with caution and patients receiving thiscombination should be monitored closely for didanosine-associated adverse reactions. Didanosine should bediscontinued in patients who develop didanosine-associated adverse reactions. Suppression of CD4+ cell countshas been observed in patients receiving tenofovir DF with didanosine 400 mg daily. Atazanavir andlopinavir/ritonavir have been shown to increase tenofovir concentrations. ATRIPLA should be discontinued inpatients who develop tenofovir-associated adverse reactions. Coadministration of atazanavir with ATRIPLA is notrecommended. There are insufficient data to support dosing recommendations for atazanavir, with or withoutritonavir in combination with ATRIPLA.Efavirenz, Emtricitabine and Tenofovir DF: Other important drug interaction information for ATRIPLA issummarized below. The drug interactions described are based on studies conducted with efavirenz, emtricitabineor tenofovir DF as individual agents or are potential drug interactions; no drug interaction studies have beenconducted using ATRIPLA. The list includes potentially significant interactions, but are not all inclusive.Established and Other Potentially Significant Drug Interactions*: Alteration in Dose or Regimen May BeRecommended Based on Drug Interaction Studies or Predicted InteractionAntiretroviral agents: Protease Inhibitors Atazanavir:rr atazanavir concentration, tenofovir concentration.Coadministration of atazanavir with ATRIPLA is not recommended. Coadministration of atazanavir with eitherefavirenz or tenofovir DF decreases plasma concentrations of atazanavir. The combined effect of efavirenz plustenofovir DF on atazanavir plasma concentrations is not known. Also, atazanavir has been shown to increasetenofovir concentrations. There are insufficient data to support dosing recommendations for atazanavir oratazanavir/ritonavir in combination with ATRIPLA. Fosamprenavir calcium:amprenavir concentration. Fosamprenavir(unboosted): Appropriate doses of fosamprenavir and ATRIPLA with respect to safety and efficacy have not beenestablished. Fosamprenavir/ritonavir: An additional 100 mg/day (300 mg total) of ritonavir is recommended whenATRIPLA is administered with fosamprenavir/ritonavir once daily. No change in the ritonavir dose is required whenATRIPLA is administered with fosamprenavir plus ritonavir twice daily. Indinavir:indinavir concentration. The optimaldose of indinavir, when given in combination with efavirenz, is not known. Increasing the indinavir dose to 1000 mgevery 8 hours does not compensate for the increased indinavir metabolism due to efavirenz.Lopinavir/ritonavir:lopinavir concentration,tenofovir concentration. A dose increase of lopinavir/ritonavir to600/150 mg (3 tablets) twice daily may be considered when used in combination with efavirenz in treatment-experienced patients where decreased susceptibility to lopinavir is clinically suspected (by treatment history orlaboratory evidence). Patients should be monitored for tenofovir-associated adverse reactions. ATRIPLAshould be discontinued in patients who develop tenofovir-associated adverse reactions. Ritonavir:ritonavirconcentration,efavirenz concentration. When ritonavir 500 mg every 12 hours was coadministered with efavirenz600 mg once daily, the combination was associated with a higher frequency of adverse clinical experiences (eg,dizziness, nausea, paresthesia) and laboratory abnormalities (elevated liver enzymes). Monitoring of liver enzymes isrecommended when ATRIPLA is used in combination with ritonavir. Saquinavir:saquinavir concentration. Should notbe used as sole protease inhibitor in combination with ATRIPLA.NRTI Didanosine:didanosine concentration. Higher didanosine concentrations could potentiate didanosine-associated adverse reactions, including pancreatitis, and neuropathy. In adults weighing >60 kg, the didanosinedose should be reduced to 250 mg if coadministered with ATRIPLA. Data are not available to recommend adose adjustment of didanosine for patients weighing


by Lorry Schoenly, PhD, RN, CCHP

Judging from the response to a recent NCCHC con-ference session, interest is growing for application of evidence-based nursing practice (EBNP) in correctionalhealth care. Speaker Susan Laffan, RN, CCHP-A, considersJJthis a perfect time to apply the evidence-based approach to nursing care. The trend toward evidence-based practice is growing in the nursing profession, says Laffan, a consultantbased in Toms River, NJ. Our, clinical practice should reston solid research evidence where possible.

In fact, the origins of the modern nursing professionin the 1800s with Florence Nightingale included seeds of EBNP. In her 1861 landmark book, Notes on Nursing, shegstates, The most important practical lesson that can be given to nurses is to teach them what to observehow toobservewhat symptoms indicate improvementwhich are of nonewhich are the evidence of neglectand what kind of neglect.

What Is EBNP?Evidence-based nursing practice involves the use of the most credible and up-to-date research to guide patientcare. This way of practicing stresses the use of protocols and procedures that are based on research and other objec-tive information, rather than ritual, opinion or the way wehave always done it. A 1992 survey of staff nurses regardingthe sources of knowledge used to guide practice revealed

that most relied on nursing school, workplace sources,physicians and intuition. Although enthusiastic about usingresearch evidence as a basis for practice, nurses can bebewildered by how to do so.

EBNP brings many potential advantages, including moreeffective practice, greater confidence in decision-making and better patient outcomes. Sara Jo Brown, PhD, RN,author of Evidence-Based Nursing: The Research-Practice Connection, a nursing textbook, sees a bright future fornnursing practice built on a strong foundation of credible evidence.

Nursing is science and artsort of like yin and yangthat are complementary opposites within a greater whole,Brown says. Many nurses have strong nursing art knowl-edge and skills but have not incorporated the use of science into their practice. Effective practice needs both. The cor-rectional nursing specialty can undoubtedly help inmatesachieve better health outcomes by turning more often toresearch evidence as a basis for practice.

Key Steps to EBNPPracticing nurses need not conduct an actual researchstudy to determine effective interventions. Fortunately, that is neither desirable nor advocated by EBNP specialists. Instead, EBNP focuses on using the wide array of publishedresearch to determine application to practice. Here are thekey steps to the practice of evidence-based nursing.

EBNP stresses the

use of protocols and

procedures that are

based on research

and other objective

information, rather

than ritual, opinion

or the way we have

always done it.

Evidence-BasedNursing Practice

The Time Is Right!


Identify a specific patient problem or situation that is inneed of a better approach

Systematically search for research evidence that could be used to address the issue

Appraise the validity of the research evidence, and its rel-evance and applicability to your population and setting

Integrate the research evidence with site information that might influence management of the issue

Thoughtfully implement the evidence-based practice decision

Evaluate the outcome of the decision

Locating and Assessing EvidenceThe isolated nature of correctional nursing practice once made it difficult to find clinical research. Without easyaccess to a medical library or hospital resources, correc-tional nurses could be frustrated in attempts to locateanswers to clinical challenges. In the last decade, however,the advent of the Internet, with its an increasing variety of search engines and online resources, has eliminated barriersto acquiring information. Now there are many Internet sitesdedicated to serving as health care data repositories, with some specific to nursing.

Thus, the Internet is a great first stop on the road toimplementing EBNP. The table above lists some of the mostfruitful sites. Of course, traditional sources such as universityand medical libraries are also helpful, if available.

The fastest road to EBNP is locating evidence-based clini-cal guidelines already developed by a reliable entity. In this case, there is no need to go back to the original studiesithas already been done for you. The next most helpful is apublished systematic research review. Here, the author has studied the array of research in a particular area and synthe-sized the information and often the degree of confidence in the findings. The last choice would be to review individual published studies. This, of course, requires a greater under-standing of research principles to determine if the findings are applicable in your setting.

Many organizations that produce evidence-based guide-lines rate the strength of the evidence in support of each of the recommendations that make up the guideline. Thetable at right is an abbreviated version of one of these ratingsystems. The strongest evidence classification for a recom-mendation is 1A and the weakest is 4.

Where to StartBrown suggests starting with clinical issues that arent cur-rently being handled well. Nursing issues with patient groups that are high volume, consume a significant amount of time or are not achieving good outcomes are good places to start, she says. These issues often are identifiedthrough the continuous quality improvement program. A quality deficit generates an opportunity to pursue better patient outcomes. The standard of care, the nursing inter-ventions, should be based on available research.

EBN Example: Pressure Ulcer PreventionPressure ulcer prevention is an example of a thorny cor-rectional nursing issue that could be improved by adoptingevidence-based interventions. The first step is to identify the populations that are developing pressure ulcers in yoursetting. Then, search the literature for research evidence relevant to your population. Look first for evidence-basedclinical practice guidelines produced by respected organi-

continued on page 12

Web Site Location CommentNational Guideline Clearinghouse www.guideline.gov A resource from the Agency for Healthcare Research and Quality,

U.S. Department of Health and Human Services

Cochrane Collaboration www.cochrane.org Produces systematic reviews of health care interventions

Joanna Briggs Institute www.joannabriggs.edu.au Research review database on nursing and other health care topics

Registered Nurses Association of Ontario

www.rnao.org RNAO Nursing Best Practice Guidelines on a variety of topics

Source: Evidence-Based Nursing: The Research-Practice Connection, S. J. Brown, 2009n

Agency for Healthcare Research and Quality (AHRQ) Levels of Evidence

Type of Evidence Rating

Meta-analysis of multiple well-designed controlled studies 1A

Well-designed randomized controlled trials 1

Well-designed nonrandomized controlled trials(quasi-experimental studies)

2

Observational studies with controls Retrospective studies Interrupted time studies Case-control studies Cohort studies with controls

3

Observational studies without controls Cohort studies without controls Case series

4


zations. If you cannot find one, then look for a systematicresearch review about the issue. Carefully consider all of thekeywords that might lead to information about pressureulcer prevention and management. Search words couldinclude wound care, pressure ulcer, decubiti and woundhealing. The box at left outlines search findings from theWeb sites listed on page 11.

With search results in hand, decide which guidelines or study review results are most applicable to your situation.Then, working with administrative and medical leadership, determine which practices to incorporate into site policy and procedure for pressure ulcer prevention and care.Involvement of all clinical staff in the process encouragesstaff development and speeds adoption of new practice. Finally, patient outcomes should be tracked over time.

This is just one example of the myriad of correctional nursing issues that could benefit from applying evidenceavailable from research taking place in the nursing commu-nity. The time is right to enhance the quality of care for ourinmate-patients through EBNP.

Lorry Schoenly, PhD, RN, CCHP, is a clinical education man-ager with Correctional Medical Services and is based in Pennsylvania. Contact her at [email protected]. She also hosts an Internet site dedicated to increasing awareness of correctional nursing practice: www.correctionalnurse.net. Follow her on Twitter: lorryschoenly.

Evidence-Based Nursing g (continued from page 11)

Correctional Medical Services (CMS), is the nation's largestprivate provider of contract healthcare services to correctionalfacilities. As a ProfessionalHealthcare provider, You have options,We have opportunities!

We are currently seeking Physicians to fill the following positions:

Medical Directors, Staff Physicians,Psychiatrists and Dentistsin Delaware, Arkansas, Maine, Missouri,Indiana, Maryland and NewMexico.

For more information please contact:DeeThandi, Physician Recruiter

Phone: 800-893-2118 Fax: 866-303-2728Email: [email protected] EOE/AAP/DTR

You haveOPTIONS!We haveOPPORTUNITIES!

Different andMaking a Difference

Physicians

Pressure Ulcer Search ResultsNational Guideline ClearinghouseCurrent evidence-based pressure ulcer guidelines from ... Hartford Institute for Geriatric Nursing Registered Nurses Association of Ontario National Collaborating Centre for Nursing Support Also older guidelines

Cochrane CollaborationResearch reviews on ... Surface support for pressure ulcer prevention Repositioning for pressure ulcer prevention Wound cleansing for pressure ulcers Much more

Joanna Briggs InstituteBest practice guidelines in PDF format: Pressure Ulcers: Prevention of Pressure Related Damage Pressure Ulcers: Management of Pressure Related Tissue Damage

Registered Nurses Association of OntarioRNAO Best Practice Guideline: Risk Assessment and Prevention of Pressure Ulcers

1Tests 050338-201 and HIB 3-107-10-1. 2Jarvis WR. Selected aspects of the socioeconomic impact of nosocomial infections: morbidity, mortality, cost, and prevention. Infection Control and Hospital Epidemiology 1996;17:552-557. 3Study #051120-201. 4Independent Lab Test Time-Kill Study 5 Minutes S. epidermidis ATCC #12228. 52Q06 HPIS data for antimicrobial skin cleansers. The Mlnlycke Health Care, Biogel, Hibiclens and BARRIER names and logos are registered globally to one or more of the Mlnlycke Health Care Group of Companies. Distributed by Mlnlycke Health Care US, LLC, Norcross, Georgia 30092.2009 Mlnlycke Health Care AB. All rights reserved. 1.800.843.8497 www.hibigeebies.com

Guard against MRSA.In prison, the last thingyou need is a break out.

Clean-up with the bene ts:?`Y`Zc\ejb`ccjDIJ81

=XjkXZk`e^#YifX[$jg\Zkildantimicrobial activity


Holistic Care Offers Promise ofPositive Health Outcomes

by Heidi Bale, RN, CCHP, and Jane Grametbaur, RN, CCHP-A

In a society brought up with scientific medicine, holistic medicine is generally perceived as all smoke and mirrors.Although some types of holistic medicine, like acupunc-ture, have become more mainstream recently, many medi-cal professionals regard holistic treatment as ineffective ordownright dangerous.

Although often dismissed as quackery, holistic medicine has roots as far back in history as man has walked the earth.Before the great scientific discoveries of the past century, the ordinary man depended on the tribal priest or healer to provide relief from his ills.

The healer often used herbs, plants and spiritual methods to treat disease. Several botanicals that come to mind aseffective today are the opium poppy, from which we derive morphine, and foxglove, which the ancient herbalist pre-scribed for cardiac problems and from which digitalis waslater extracted.

As the only known antidote to poisoning caused by thedeath cap mushroom, which kills by destroying the liver, the herb milk thistle has great potential for use in treating liverdamage caused by cirrhosis and hepatitis. European doctorsfrequently use milk thistle to treat patients with liver disease and numerous studies have shown it is effective. A numberof other herbs and over-the-counter vitamins, such as thosecontaining omega-3 fatty acids, may be of use in treatingother chronic medical conditions such as arthritis.

The ancient Chinese believed sickness stemmed from the interruption of the flow of energy through the body and developed a system to clear the body of blockages. Weknow this form of energy healing as acupuncture. Some Chinese patients have major surgery with nothing but acu-puncture for anesthesia. After surgery these patients simply get up and walk out of the operating room.

In India, meditation, a religious practice devised to help the practitioner become closer to God, has shown benefits for health. Patients who incorporate meditation into theirdaily activities become calmer and have better controlin stressful situations. With time, practitioners can lowerblood pressure and heart rate, diminishing the need for medication.

Several traditional Native American practices also may be useful as an adjunct with current medical treatment forcardiovascular disease. In addition, Native American com-munity leaders have used medicine men and women andancient traditions to treat drug addiction and alcoholism in at-risk youth. Some traditions and ceremonies, such as thesweat lodge ceremony, have shown promise in treatment of PTSD and drug and alcohol addiction.

Well-Suited to CorrectionsCorrectional medicine traditionally has focused on the con-servative practice of scientific medicine, so it would seem that holistic medicine would have no place in the correc-

tional setting. Yet, in many ways, it is perfectly tailored foruse in correctional populations.

Inmates suffer from varying degrees of anxiety due tothe circumstances of their incarceration and to the stress of living in a correctional setting. Communal housing, disrup-tion of sleep and daily routines, as well as loss of control in day-to-day decisions cause stress, behavioral outbursts and exacerbation of health problems.

Holistic medicine focuses on the treatment of theindividual as a whole, encompassing care for not only thephysical symptoms of illness but also the mental and spiri-tual symptoms. Meditation, relaxation techniques, Reiki, taichi, guided imagery and gardening are methods most com-monly used in corrections today.

A Sampling of Programs In 2003 and 2004, the San Diego County Sheriff s Department instituted a program for psychiatric patientsincarcerated in its facilities. The goals included identifying mental health inmates who did not require care by a psy-chiatrist, treating this population using holistic methods,reducing the number of patients who required treatmentwith mental health medications, increasing the efficacy of time spent with patients by psychiatrists and decreasingwait times for patients in need of psychiatric evaluation.

Specially trained registered nurses identified patients who met the criteria of sleep disturbance, anxiety, substance abuse concerns and depressive symptoms in patients not on psychotropic medications. These patients were referred to mental health clinicians who had completed specialtraining. The patients also received handouts on improvingsleep and reducing stress.

As reported in the July 2006 issue of the Journal of Correctional Health Care, a study to assess program out-acomes found that approximately half of the inmates initiallyseen needed no further follow up after holistic treatment. A small group did require follow-up visits but were man-aged without medication. Approximately 30% of the grouprequired referral to the psychiatrist.

Study findings also showed a significant decrease in the wait time to see a psychiatrist, as well as the time needed by the psychiatrist to evaluate the patient. The more effi-cient use of time by the psychiatrists allowed more time forthe evaluation and care of acutely ill mental health patients.

A number of studies have examined the use of medita-tion in prisons and jails. One of the most recent was com-pleted by a group from Old Dominion University in Virginia and published in the January 2009 issue of the Journal of Correctional Health Care. The researchers hypothesized that ethe use of meditation by inmate populations would be acost-effective way for institutions to deal with problems from insomnia to conflict management. The primary focus of the study was to determine if participation in a struc-tured meditation program would decrease medical symp-toms, emotions and behaviors in a female population.


The study group received training in meditation practicesby trained facilitators. Emphasis was placed on enhancing inner calm and learning to live in the moment, as well as discussion with other study group members and facilita-tors. Results showed that inmates who participated in meditation had fewer sleep problems, fewer problems with angry outbursts, andreduced feelings of stress and anxiety.

In San Francisco,the city and countyjails implemented ameditation program through the SanFrancisco Zen Centerfor a number of years. This class lasted about90 minutes, incorpo-rating tai chi and yoga exercises to quiet themind and body. Thisprogram was directed at women who were incarcerated foralcohol and drug crimes.

At the Hampshire County House of Correction in Massachusetts, inmates have been trained to practice Reiki on each other. Reiki is a Japanese technique for relaxationin which practitioners use their hands in positions over the patients body to sense energy centers, or chi. With intu-ition and training, the practitioners unblock trapped energy,thereby releasing stress, easing withdrawal symptoms and smoothing out emotions. Students are taught to practiceReiki on themselves before mastering higher levels andtending to other inmates.

In 2006, San Quentin State Prison in California estab-lished a gardening program for inmates through the InsightPrison Project, a not-for-profit organization that aims to provide unique rehabilitation programs for the prison. Participants were taught to cultivate plants and gardenson the grounds of the prison. As they learned to nurtureflowers and vegetables, these men also learned to nurturepositive responses to negative emotions and interactions. This program sought to plant responsibility, teamwork andappreciation through mindful gardening. Prison officialshope to expand this program, which now operates inde-pendently as the Insight Garden Project.

Insight Prison Project also offers a mindful meditation program. Increasingly popular in recent years, mindfulmeditation requires no special skills or training and instead simply focuses on being in the present and allowing the practitioner to let various thoughts surface while meditat-ing. This form of meditation honors all belief systems andbackgrounds and can be performed anywhere.

As more correctional facilities see the benefit of usingholistic treatment as an adjunct to scientific practices, we canexpect to see more innovative and creative solutions to med-ical and psychiatric issues. For instance, the San BernardinoCounty, CA, jail recently purchased a Wii play station byNintendo for use in treatment of mental health patients.

We added the Wii program to our mental health group sessions in an effort to engage more of our seriously men-tally ill patients, says health services administrator Kathy Wild, RN, MPA, CCHP. We looked at the recent increase inthe use of this equipment for nursing home residents and were impressed with the results. We do this group several

times a week and include the mental healthclinicians and our nurses during the sessions.This engages the patient with the staff. We are very impressed with the results weve seen so far. Inmates who rarely come out of their cells look forward to using the system and often are seenlaughing and talking with staff during the courseof the group.

Significant BenefitsWhether it is through yoga, guided imagery (aform of guided meditation), tai chi, gardening orother means, the reduction of stress and anxietyis proven to reduce pain, improve sleep quality,calm emotions and produce a sense of well-

being. This, in turn, decreases the need for expensive medi-cations and reduces behav-ioral outbursts and assaultson staff. Giventhe escalatingcosts of healthcare and thedifficulties inrecruiting staff,the potentialbenefits of holistic care aresignificant.

With a littleimagination and innova-tion, staff canblend holisticcare withconventional medical treat-ment. The endresult will ben-efit both the

patient and the health care system by decreasing exacerba-tions of chronic illness, teaching patients new methods of coping with pain and anxiety, and providing patients with self-care practices that will last a lifetime.

Heidi Bale, RN, CCHP, is health services coordinator for the Washington State Department of Corrections, Raymond, WA. Jane Grametbaur, RN, CCHP-A, is the principal of Grametbaur & Associates Legal Nurse Consultants, Riverside, CA. To contact the authors about this article, send an e-mail to [email protected].

An inmate at the San Bernardino County jail engages with a Wii program. (photo courtesy of SBSD/Kathy Wild)

Tony and Willie center themselves at Insight Prison Projects Integrative Health Yoga and Meditation class. (photo courtesy of IPP/James Fox)


Saving an estimated $12 million over the course of a seven-year program is sweet enough. It was the cherry on top when the Pharmacy Benefit Management Institute honored the collaboration that produced thosesavings with its 2009 Rx Benefit Award, which recognizesinnovation in pharmacy management.

The initiative is a joint effort between the Rhode Island Department of Corrections and the University of RhodeIslands College of Pharmacy.In its award announcement,PBMI said the two entities arepioneering a new higher educa-tion/state agency managementmodel. This is the first time theinstitute has honored a collabo-ration involving a university or college and a state agency.

Since its inception in 2002, the collaborative managementmodel has enabled RIDOC toreduce medication waste bynearly 75% and to hold the trend line on expendituresdespite significant drug costinflation and increases in theinmate population.

Our 2009 award recipients have differentiated themselves from industry norms with creative new approaches, saidDana Felthouse, president of PBMI, which helps health care benefit executives work with pharmacy benefit managers and other pharmacy professionals to design prescription drug benefit programs.Another hallmark of the winners is a passion for collabora-tion among stakeholders. The solutions are programs thatdemonstrate success in improving pharmaceutical healthcare, as well as curbing costs.

Then and NowThe situation was not so rosy 10 years ago, when theDepartment of Corrections operated an on-site pharmacystaffed with state employees, says Joseph Marocco, MPA,CCHP, RIDOCs associate director of health care services. Itwas difficult to recruit and retain staff for several reasons,including a national shortage of pharmacists and correc-tional salaries that did not match those in the community.To try to keep up with the growing demands of a growinginmate population, contract pharmacists were often used,at a hefty cost.

To remedy those problems, in 2000 RIDOC decided tooutsource pharmacy services. Although that was a definite improvement, the prison systems health administratorswanted to get a better handle on overall pharmacy man-agement. We wanted to make sure we were looking at the

whole picture: our formulary, who was on what meds and why, cost analysis and cost-saving measures, plus reportingon all of this, Marocco explains.

Again they turned to outside expertise. After a competi-tive bidding process, the agency awarded URIs College of Pharmacy a three-year, $454,000 contract in 2002 to man-age its pharmacy program using pharmacy benefit manage-ment strategies. The new approach was a success, and the

two organizations are now in the midst of afour-year, $682,000 con-tract.

Today, pharmacyservices are managedjointly by the College of Pharmacys HealthcareUtilization ManagementCenter and RIDOCmedical staff. The col-lege provides an on-sitepharmacy manager andextensive data analysis,reporting, clinical sup-port and managementresources. Pharmacy stu-dents assist with muchof the data analysis.Prescription fulfillment is done via contract withCPS (Contract Pharmacy Services Inc.) using an

electronic pharmacy order system.The results speak for themselves. RIDOCs daily popula-

tion averages 3,800 inmates and annual admissions are 18,000 per year. Based on pharmaceutical trend data, thesystems medication costs had been projected to be $13.7 million from 2003 through 2006, but its actual costs were $8.8 million. Total overall savings have climbed to $12million as the program has matured, according to E. Paul Larrat, associate dean of the College of Pharmacy andHUMC codirector, along with Rita Marcoux, an assistant professor of pharmacy research.

This is an impressive feat given the growth in inmatenumbers, the changing demographics and health problems among the patient population, and rising drug prices, saysMarocco.

Rx for QualityRIDOC relies on the college pharmacy experts and students for medication quality review, says medical director MichaelPoshkus, MD, CCHP. This includes help with quality assur-ance programs and review of medication use as well as anymedication errors that may occur.

Poshkus appreciates having pharmacy experts to consultwhenever we have a question about ordering medica-

DOC-University Rx Project Yields Big Savingsand Awardin Rhode Island

Displaying the 2009 Rx Benefit Award are Matt Coty, URI pharmacy student, and Rita Marcoux, URI assistant professor of pharmacy research. Also present (L-R): student Brian Touhey; Michael Poshkus, RIDOC medical director; E. Paul Larrat, associate dean, URI College of Pharmacy; Joseph Marocco, RIDOC associate director of health care services; and Larry Myerson, the URI on-site pharmacy man-ager. (photo credit: URI/Michael Salerno)


tions and what would be the most cost-effective meansto provide pharmaceuticals to our patient population. Healso values the work of the students. Their projects involvereviewing our utilization of different drugs and helping uscome up with protocols that allow us to better utilize medi-cations for our populations.

Marocco adds that the program has improved hisdepartments relationship with the state Board of Pharmacy by helping the board understand the complexities of cor-rectional pharmacy care. Its not a nursing home; its not a hospital; its not an ambulatory care center. Its a little bit of everything.

Larrat says it is unusual to apply pharmacy benefit man-agement strategies to a group like RIDOC. One of the things that has impressed me ... is the team atmosphere.We were very welcomed by the medical team a few years back. Thats helped with access to information and our abil-ity to educate the staff about pharmaceutical care, which hopefully filters down to better care and treatment of the inmates.

Fostering Future PharmacistsBoth Poshkus and Marocco praise the work of the URIpharmacy students and are pleased that the prison setting can serve as a teaching facility for them. Indeed, Marcouxsays PBMI was very excited that we are taking this oppor-tunity to introduce students to a part of pharmacy thatoften, students are not aware of. They are gaining experi-ence that prepares them for jobs that many organizations inthe health care industry are seeking.

Although the students who work on the project do sometimes visit the prison facilities, they spend most of their time on URI campus analyzing data and prescriptiontrends. I reviewed utilization of emergency prescriptions to see where we can maximize the effectiveness of the order-ing system, says Matt Coty, who graduated in May after completing his six-year doctor of pharmacy degree He saysthe program is important because everybody deserves appropriate medications, and they should be treated just asany other individual would be treated.

Brian Touhey, who also graduated in May with a doctor-ate in pharmacy, says he would encourage other pharmacystudents to make this one of their rotations. Part of it wasbeing on campus analyzing the numbers and then cominghere to see it all come to fruition. This helped me not onlywith my clinical judgment, but my personal judgment aswell.... You have to use your professional judgment, yourclinical judgment, put everything else aside and do yourbest for them.

This article was written by CorrectCare editor Jaime Shimkus using information provided by the University of Rhode Island as well as by Joseph Marocco, MPA, CCHP, RIDOCs associate director of health care services.

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A World of Opportunities


by Marc F. Stern, MD, MPH

Whether you think its a step forward or back-ward, the Supreme Court of Washington Staterecently issued a ruling in a case that adds someclarity to how correctional health care physicians shoulddeal with hunger strikers. The events in the case, McNabb v. Department of Corrections (2005) took place in 2004; the scourt heard the case in 2005 and handed down its ruling in2007.

Mr. McNabb arrived in WDOC from jail after being sentenced for starting a fire in which family members were hurt. He had been on a hunger strike for five months andhad lost around 90 pounds upon admission to WDOC; therefore, WDOC began force feeding the patient via nasogastric tube. Shortly after beginning force feeding, the patient volunteered to eat, but brought suit against WDOCclaiming WDOC had violated his right to refuse treatmentunder his right to privacy. He asked the court to declareWDOCs force-feeding policy unconstitutional.

The court concluded that WDOC was correct in forcefeeding Mr. McNabb. In arriving at their decision (which can be viewed at www.courts.wa.gov/opinions/pdf/773599.no1.pdf), the court did not deny that Mr. McNabb has a right to refuse artificial nutrition. However, they felt that the state has a greater interest in force feeding him. Specifically, they wrote:

the court will weigh McNabbs right to refuse artificial means of nutrition and hydration against the existence of five compelling state interests:(1) the maintenance of security and orderlyadministration within the prison system,(2) the preservation of life,(3) the protection of innocent third parties,(4) the prevention of suicide, and(5) the maintenance of the ethical integrity of the medical profession.

This is the first time a court has used this particular set of litmus tests in this combination. However, the componenttests are not new. Indeed, the first test is also known as the Turner Rule. In Turner v. Safley (1987), a case regarding yan inmates right to marry, the U.S. Supreme Court found that the states interest outweighs the inmates interestwhen the state has a legitimate penologic interest to deny the inmates right. So, for example, if the state felt that the inmates hunger strike might spread to other inmates,impairing the states ability to maintain safety and order,then the Turner Rule would be satisfied. Incidentally, the risk of a hunger strike spreading is not just theoretical. Infact, it is what happened in New York DOCS when Mark David Chapman (sentenced in the death of John Lennon) stopped eating in protest. The second through fifth testswere borrowed from another Washington State case(Welfare of Colyer, 1983).r

WDOC Policy Passes MusterIn its decision, the court referred frequently to WDOCsforce-feeding policy, including the fact that the policy was

applicable to this situation and was properly executed byWDOC. Thus the policy itself has now been subject to judi-cial review and has survived. This may provide some guid-ance to other jurisdictions.

As of this writing, the 2007 policy in effect is essentiallythe same as the one reviewed by the court, except that it affords WDOC the authority to obtain clinical data from the patient against his/her will in order to monitor thepatient after force feeding is initiated. Such data includes vital signs, blood tests and urine tests. An updated version of the policy, published in December 2008, extends that authority to the pre-force-feeding period when staff is try-ing to determine whether or not the patients condition is serious enough to begin force feeding. (The policy, no.620.100, is posted at www.doc.wa.gov/policies.)

It is interesting to note that unlike the WDOCs policy on involuntary medication administration for severe men-tal disease (which was upheld by the Supreme Court in the well-known case Washington DOC v. Harper, 1990), rWDOCs forced feeding policy does not include a due pro-cess component. The current court did not take issue with this. They noted and were satisfied that medical staff issued a written determination.

Unsettled QuestionWhether increased authority on the part of correctionalsystems to force feed inmates is a good thing is not asettled question. That, certainly, is an ethical question foreach of us to ponder. However, from a legal standpoint, atleast, not all courts have agreed with the Washington State Supreme Court that prison walls separate citizens fromtheir constitutional rights. At least three state courts have reached an opposite conclusion (California Supreme Court: Thor v. Superior Court, 1993; Georgia Supreme Court: t Zane v. Prevatte, 1982; Florida appeals court: e Singletary v. Costello, o1996; all cited in AELE Monthly Law Journal, Jail & Prisoner lLaw Section, December 2007).

Finally, the reader should carefully note that all the casesdiscussed above concerned inmates who were otherwise in good physical health. In the case of a patient with a severe debilitating or terminal disease they would not, and shouldnot, apply.

This article was reprinted with permission from the Winter 2009 issue of CorrDocs, the quarterly newsletter of the Society of Correctional Physicians. This version has been modified slightly to omit case reference details. CorrDocs is available at the SCP Web site, www.corrdocs.org.

Marc F. Stern, MD, MPH, is a correctional health care con-sultant. At the time this article was written, he was the assis-tant secretary for health services at the Washington State Department of Corrections. To contact him, send an e-mail to [email protected].

Force Feeding for Hunger Strikes

#1prescribed

NRTI backbone

in correctional facilities1

emtricitabine tenofovir disoproxil fumarate

TRUVADA is a once a day backbone for combination therapy in adults with HIV-1

Treaat HIV confidently wwith TRUVADA in

corrrectional facilities

Demonnstrated efficacy and tolerability profile through 3 years in Study 9342

TRUVADA is the only DDHHS-preferred dual NRTI3

TRUVADA or its compoonents have been chosen in long-term clinical triaals with leading PIs1,4-9

Depend on TRUVADA to be your partner with PIs

Safety information: be b drug interactions have been observed between tenofovir DF annd atazanavir or lopinavir/ritonavir. Atazanavir 300 mg should oosted with ritonavir 100 mg and taken with food when administered with TRUVADA. Atazanavir without ritonavvir should not be coadministered with TRUVA navir or lopinavir/ritonavirDA. Patients on atazanplus TRUVADA should be monitored for tenofovir-associated adverse reactions. TRUVADA shhould be discontinued in patients who dev ed adverse reactions.elop tenofovir-associate 2

Indications and usage2

TRUVADA, a combination of EMTRIVA (emtricitabine) and VIREAD(tenofovir disoproxil fumarate), is indicated in combination with otherantiretroviral agents (such as non-nucleoside reverse transcriptase inhibitors or protease inhibitors) for the treatment of HIV-1 infection in adults. Thefollowing points should be considered when initiating therapy with TRUVADA for the treatment of HIV-1 infection: It is not recommended that TRUVADA be used as a component of a triple

nucleoside regimen TRUVADA should not be coadministered with ATRIPLA (efavirenz

600 mg/emtricitabine 200 mg/tenofovir disoproxil fumarate 300 mg), EMTRIVA, VIREAD, or lamivudine -containing products*

In treatment -experienced patients, the use of TRUVADA should be guided by laboratory testing and treatment history

WARNINGSLactic acidosis and severe hepatomegaly with steatosis, including fatal cases,have been reported with the use of nucleoside analogs, including VIREAD, acomponent of TRUVADA, in combination with other antiretrovirals.TRUVADA is not approved for the treatment of chronic hepatitis B virus (HBV) infection, and the safety and efficacy of TRUVADA have not beenestablished in patients coinfected with HBV and HIV-1. Severe acute exacerbations of hepatitis B have been reported in patients who arecoinfected with HBV and HIV-1 and have discontinued TRUVADA. Hepatic function should be monitored closely with both clinical and laboratoryfollow-up for at least several months in patients who are coinfected withHIV-1 and HBV and discontinue TRUVADA. If appropriate, initiation ofanti-hepatitis B therapy may be warranted.

Dosage and administration Recommended dose: one tablet (containing 200 mg of emtricitabine and

300 mg of tenofovir disoproxil fumarate) once daily taken orally with orwithout food

Dose recommended in renal impairment: creatinine clearance (CrCl)3049 mL/min: 1 tablet every 48 hours. CrCl

The following is a brief summary for TRUVADAAA (emtricitabine/tenofovirdisoproxil fumarate [DF]) tablets. Before prescribing, see full PrescribingInformation, including boxed WARNINGS.

INDICATIONS AND USAGETRUVADA, a combination of EMTRIVA (emtricitabine) and VIREAD (tenofovirdisoproxil fumarate), is indicated in combination with other antiretroviral agents (suchas non-nucleoside reverse transcriptase inhibitors or protease inhibitors) for the treatmentof HIV-1 infection in adults.The following points should be considered when initiating therapy with TRUVADA forthe treatment of HIV-1 infection: It is not recommended that TRUVADA be used as a component of a triple

nucleoside regimen. TRUVADA should not be coadministered with ATRIPLA (efavirenz 600 mg/

emtricitabine 200 mg/tenofovir disoproxil fumarate 300 mg), EMTRIVA, VIREAD, orlamivudine-containing products [See Warnings and Precautions].

In treatment experienced patients, the use of TRUVADA should be guided by laboratorytesting and treatment history.

DOSAGE AND ADMINISTRATIONThe dose of TRUVADA is one tablet (containing 200 mg of emtricitabine and 300 mg oftenofovir disoproxil fumarate) once daily taken orally with or without food.Dose Adjustment for Renal Impairment: Significantly increased drug exposuresoccurred when EMTRIVA or VIREAD were administered to patients with moderate to severerenal impairment [See EMTRIVA or VIREAD Package Insert]. Therefore, the dosing interval]]of TRUVADA should be adjusted in patients with baseline creatinine clearance 3049VVmL/min using the recommendations in Table 1. These dosing interval recommendationsare based on modeling of single-dose pharmacokinetic data in non-HIV-1 infectedsubjects. The safety and effectiveness of these dosing interval adjustmentrecommendations have not been clinically evaluated in patients with moderate renalimpairment, therefore, clinical response to treatment and renal function should be closelymonitored in these patients [See Warnings and Precautions].]]No dose adjustment is necessary for patients with mild renal impairment (creatinineclearance 5080 mL/min). Routine monitoring of calculated creatinine clearance and serumphosphorus should be performed in patients [See Warnings and Precautions].]]Table 1.Dosage Adjustment for Patients with Altered Creatinine Clearance

CONTRAINDICATIONSNone.WARNINGS AND PRECAUTIONSLactic Acidosis/Severe Hepatomegaly with Steatosis: Lactic acidosis andsevere hepatomegaly with steatosis, including fatal cases, have been reported with the useof nucleoside analogs, including VIREAD, a component of TRUVADA, in combination withother antiretrovirals. A majority of these cases have been in women. Obesity and prolongednucleoside exposure may be risk factors. Particular caution should be exercised whenadministering nucleoside analogs to any patient with known risk factors for liver disease;however, cases have also been reported in patients with no known risk factors. Treatmentwith TRUVADA should be suspended in any patient who develops clinical or laboratoryfindings suggestive of lactic acidosis or pronounced hepatotoxicity (which may includehepatomegaly and steatosis even in the absence of marked transaminase elevations).Patients Coinfected with HIV-1 and HBV: It is recommended that all patients withHIV-1 be tested for the presence of chronic HBV before initiating antiretroviral therapy.TRUVADA is not approved for the treatment of chronic HBV infection and the safety andefficacy of TRUVADA have not been established in patients coinfected with HBV and HIV-1.Severe acute exacerbations of Hepatitis B have been reported in patients who are coinfectedwith HBV and HIV-1 and have discontinued TRUVADA. In some patients infected with HBVand treated with EMTRIVA, the exacerbations of Hepatitis B were associated with liverdecompensation and liver failure. Patients who are coinfected with HIV-1 and H

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