2009 23 2 CrrectCare - National Commission on Correctional ... · PDF fileFull page Ad 8” x 10 1/2” Page 2 National Conference on Correctional Health Care October 17–21, 2009•

rrectCare™CC 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 17–21, 2009 • Orlando

Presented by

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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

Care™CorrectCare™ is published quarterly by the National Commission on Correctional Health Care, a not-for-profi t organization whose mission is to improve the quality of health care in our nation’s jails, prisons and juvenile confi nement facilities.

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

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

American Academy of Child & Adolescent Psychiatry

Nina Dozoretz, RHIA, CCHP (Chair-Elect)American Health Information Management Association

Robert E. Morris, MD, CCHP (Immediate Past Chair)Society for Adolescent Medicine

Thomas J. Fagan, PhD (Secretary)American Psychological Association

Nancy 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 Offi cials

Robert L. Hilton, RPh, CCHPAmerican Pharmacists Association

Renee Kanan, MDAmerican College of Physicians

JoRene Kerns, BSN, CCHPAmerican Correctional Health Services Association

Douglas A. Mack, MD, CCHPAmerican Association of Public Health Physicians

Nicholas 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 Association

Patricia 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 Offi 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

refl 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 Specialist’s 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 Savings—and Award—in 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 professionals—and the administrators who approvetheir budgets—know a good deal when they see one. That’s why they came out in droves to the Updates inCorrectional Health Care conference in April. It didn’t 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 facilities—even those that are not accredited—turn 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 jail’shealth 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, we’ve 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 CDC’s 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 CDC’s 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 fi nd the latest CDC

recommendations

for corrections, visit

www.cdc.gov/h1n1flu.fl

Click on Guidance,

then scroll down to

Clinician Guidance for

Specifi 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 Ohio’s prisons (and winner of NCCHC’s 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 CDC’s 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.

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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 efficiency, 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 wommenen’s’s 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 17-21Disney’s 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-ment—packed d wiwithth lece tutututures,,s ppaannelle s, workshops, posters, exhibits and networking—you will gain the knnowowleedgdggee anandd skillllss toot reshape not only your institution’s 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

• L LLeaearnrn hhoww ootht erer o organizizatattioioionns have immimmplp emenennteted sus cceessffulul p rorogrramams fof r imimprp oving g ththe efeffif ciencyy o of f clclinical p pprooocececc sss es

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

• UU U UUpddpdpp ate anand d refrreesh your skikilllls s whwhile e eae rnrninng coontntininuiingg e ducatit on crediit

• Netwoworkkrk wwwititth h cocococ lllll eagues, frfromom t topop d dececisision mamakers to inn-tthehe-trenches s ststs afaff,ff, tototo lll llleeeaeae rnrnn howow ttthhheh y y arare e hahandndlilingng tt he p proroobllems s ththat you face evevevveree y dayy

• EExpxpplololoorerere prprobblelemm-solvinng prroodo ucuctsts a annd services in the exhibiit t haallll

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. Herere’e 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 Death

•Manan 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, children’s 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 generally

“not 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 prisoner’s requested course of treatment.

Furthermore, because the practice of medicine remains an art, judges recognize that “[T]here is not one ‘proper’way 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-ist’s assistance. The correctional physician is unable to treatthe inmate’s 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 specialist’s 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 specialist’s 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 inmate’s 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 physician’s refusal to follow the special-ist’s 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-ist’s 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 Specialist’s Recommendations

continued on page 8


may still defer to the correctional physician’s 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 physician’s decision to provide an inmate with some,but not all, of the specialist-recommended medications.The physician’s 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 physician’s decision to forgo a specialist’s 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 specialist’s recommendations even though appro-priate alternatives are available. To help reduce any potentialexposure, a correctional physician opting not to implement a specialist’s 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 board’s 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 INTERACTIONS

Efavirenz: 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 Interaction

Antiretroviral 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 <60 kg. Coadministration of ATRIPLA and didanosineshould be undertaken with caution and patients receiving this combination should be monitored closelyfor didanosine-associated adverse reactions. For additional information, please consult the Videx/Videx EC(didanosine) prescribing information.

Other Agents: Anticoagulant — Warfarin:↑or↓warfarin concentration. Plasma concentrations and effectspotentially increased or decreased by efavirenz.Anticonvulsants — Carbamazepine:↓carbamazepine concentration,↓efavirenz concentration. There areinsufficient data to make a dose recommendation for ATRIPLA. Alternative anticonvulsant treatment should be used.Phenytoin, Phenobarbital:↓anticonvulsant concentration,↓efavirenz concentration. Potential for reduction inanticonvulsant and/or efavirenz plasma levels; periodic monitoring of anticonvulsant plasma levels should beconducted.Antidepressant — Sertraline:↓sertraline concentration. Increases in sertraline dose should be guided by clinicalresponse.Antifungals — Itraconazole:↓itraconazole and hydroxy-itraconazole concentration. Since no dose recommendationfor itraconazole can be made, alternative antifungal treatment should be considered. Ketoconazole:↓ketoconazoleconcentration. Drug interaction studies with ATRIPLA and ketoconazole have not been conducted. Efavirenz has thepotential to decrease plasma concentrations of ketoconazole.Anti-infective — Clarithromycin:↓clarithromycin concentration,↑14-OH metabolite concentration. Clinicalsignificance unknown. In uninfected volunteers, 46% developed rash while receiving efavirenz and clarithromycin.No dose adjustment of ATRIPLA is recommended when given with clarithromycin. Alternatives to clarithromycin, suchas azithromycin, should be considered. Other macrolide antibiotics, such as erythromycin, have not been studied incombination with ATRIPLA.Antimycobacterials — Rifabutin:↓rifabutin concentration. Increase daily dose of rifabutin by 50%. Considerdoubling the rifabutin dose in regimens where rifabutin is given 2 or 3 times a week. Rifampin:↓efavirenzconcentration. Clinical significance of reduced efavirenz concentration is unknown. Dosing recommendations forconcomitant use of ATRIPLA and rifampin have not been established. Calcium channel blockers — Diltiazem: ↓diltiazem, desacetyl diltiazem, and N-monodesmethyl diltiazemconcentrations. Diltiazem dose adjustments should be guided by clinical response (refer to the completeprescribing information for diltiazem). No dose adjustment of ATRIPLA is necessary when administered withdiltiazem. Others (eg, felodipine, nicardipine, nifedipine, verapamil): ll ↓calcium channel blocker. No data areavailable on the potential interactions of efavirenz with other calcium channel blockers that are substrates of theCYP3A4 enzyme. The potential exists for reduction in plasma concentrations of the calcium channel blocker. Doseadjustments should be guided by clinical response (refer to the complete prescribing information for the calciumchannel blocker).HMG-CoA reductase inhibitors — Atorvastatin:↓atorvastatin concentration, Pravastatin:↓pravastatinconcentration, Simvastatin:↓simvastatin concentration. Plasma concentrations of atorvastatin, pravastatin, andsimvastatin decreased with efavirenz. Consult the complete prescribing information for the HMG-CoA reductaseinhibitor for guidance on individualizing the dose.Narcotic analgesic — Methadone:↓methadone concentration. Coadministration of efavirenz in HIV-1 infectedindividuals with a history of injection drug use resulted in decreased plasma levels of methadone and signs of opiatewithdrawal. Methadone dose was increased by a mean of 22% to alleviate withdrawal symptoms. Patients should bemonitored for signs of withdrawal and their methadone dose increased as required to alleviate withdrawalsymptoms.Oral contraceptive — Ethinyl estradiol:↑ethinyl estradiol concentration. Clinical significance unknown. Because thepotential interaction of efavirenz with oral contraceptives has not been fully characterized, a reliable method of barriercontraception should be used in addition to oral contraceptives.*Please see Full Prescribing Information (Table 4) for additional information; this list is not all inclusive.

USE IN SPECIFIC POPULATIONS

Pregnancy: Pregnancy Category D [see Warnings and Precautions]ssNursing Mothers: The Centers for Disease Control and Prevention recommend that HIV-1-infected mothersnot breast-feed their infants to avoid risking postnatal transmission of HIV-1. Studies in rats havedemonstrated that both efavirenz and tenofovir are secreted in milk. It is not known whether efavirenz,emtricitabine, or tenofovir is excreted in human milk. Because of both the potential for HIV-1 transmission and thepotential for serious adverse reactions in nursing infants, mothers should be instructed not to breast-feed if theyare receiving ATRIPLA (efavirenz 600 mg/emtricitabine 200 mg/tenofovir disoproxil fumarate 300 mg).

Pediatric Use: ATRIPLA is not recommended for patients less than 18 years of age because it is a fixed-dosecombination tablet containing a component, tenofovir DF, for which safety and efficacy have not been establishedin this age group.Geriatric Use: Clinical studies of efavirenz, emtricitabine, or tenofovir DF did not include sufficient numbers ofsubjects aged 65 and over to determine whether they respond differently from younger subjects. In general, doseselection for the elderly patients should be cautious, keeping in mind the greater frequency of decreased hepatic,renal, or cardiac function, and of concomitant disease or other drug therapy.Hepatic Impairment: The pharmacokinetics of efavirenz have not been adequately studied in patients with hepaticimpairment. Because of the extensive cytochrome P450-mediated metabolism of efavirenz and limited clinicalexperience in patients with hepatic impairment, caution should be exercised in administering ATRIPLA to thesepatients [see Warnings and Precautions].sRenal Impairment: Because ATRIPLA is a fixed-dose combination, it should not be prescribed for patients requiringdosage adjustment such as those with moderate or severe renal impairment (creatinine clearance <50 mL/min)[see Warnings and Precautions].sOVERDOSAGE

If overdose occurs, the patient should be monitored for evidence of toxicity, including monitoring of vital signs andobservation of the patient’s clinical status; standard supportive treatment should then be applied as necessary.Administration of activated charcoal may be used to aid removal of unabsorbed efavirenz. Hemodialysis can removeboth emtricitabine and tenofovir DF, but is unlikely to significantly remove efavirenz from the blood.Efavirenz - Some patients accidentally taking 600 mg twice daily have reported increased nervous systemsymptoms. One patient experienced involuntary muscle contractions.Emtricitabine - Limited clinical experience is available at doses higher than the therapeutic dose. In one study singledoses of emtricitabine 1200 mg were administered to 11 patients. No severe adverse reactions were reported.Hemodialysis treatment removes approximately 30% of the emtricitabine dose over a 3-hour dialysis period startingwithin 1.5 hours of emtricitabine dosing (blood flow rate of 400 mL/min and a dialysate flow rate of 600 mL/min).It is not known whether emtricitabine can be removed by peritoneal dialysis.Tenofovir DF - Limited clinical experience at doses higher than the therapeutic dose of tenofovir DF 300 mg isavailable. In one study, 600 mg tenofovir DF was administered to 8 patients orally for 28 days, and no severeadverse reactions were reported. The effects of higher doses are not known.Tenofovir is efficiently removed by hemodialysis with an extraction coefficient of approximately 54%. Following asingle 300 mg dose of tenofovir DF, a 4-hour hemodialysis session removed approximately 10% of the dose.PATIENT COUNSELING INFORMATION

See FDA-Approved Patient Labeling (17.12) in Full Prescribing InformationDrug Interactions: A statement to patients and healthcare providers is included on the product’s bottle labels:ALERT: Find out about medicines that should NOT be taken with ATRIPLA.

ATRIPLA may interact with some drugs; therefore, patients should be advised to report to their doctor the use of anyother prescription, nonprescription medication, or herbal products, particularly St. John’s wort.Information for Patients: Patients should be advised that: ATRIPLA is not a cure for HIV-1 infection and patientsmay continue to experience illnesses associated with HIV-1 infection, including opportunistic infections; they shouldremain under the care of a physician when using ATRIPLA; the use of ATRIPLA has not been shown to reduce therisk of transmission of HIV-1 to others through sexual contact or blood contamination; the long-term effects ofATRIPLA are unknown; redistribution or accumulation of body fat may occur in patients receiving antiretroviraltherapy and that the cause and long-term health effects of these conditions are not known; ATRIPLA should not becoadministered with SUSTIVA, EMTRIVA, VIREAD, or TRUVADA, or drugs containing lamivudine, including Combivir,Epivir, Epivir-HBV, Epzicom, or Trizivir.Patients should also be advised that: • lactic acidosis and severe hepatomegaly with steatosis, including fatal cases, have been reported. Treatment with

ATRIPLA will be suspended in any patients who develop clinical symptoms suggestive of lactic acidosis orpronounced hepatotoxicity [see Warnings and Precautions].s

• they may be tested for hepatitis B virus (HBV) before initiating antiretroviral therapy. Severe acute exacerbationsof hepatitis B have been reported in patients who are coinfected with HBV and HIV-1 and have discontinuedEMTRIVA or VIREAD, which are the components of ATRIPLA.

• renal impairment, including cases of acute renal failure and Fanconi syndrome, has been reported. ATRIPLAshould be avoided with concurrent or recent use of a nephrotoxic agent [see Warnings and Precautions].s

• decreases in BMD have been observed with the use of tenofovir DF; BMD monitoring may be performed inpatients who have a history of pathologic bone fracture or at risk for osteopenia [see Warnings and Precautions]. ss

• take ATRIPLA orally on an empty stomach and that it is important to take ATRIPLA on a regular dosing scheduleto avoid missing doses.

Nervous System Symptoms: Patients should be informed that central nervous system symptoms (NSS) are commonlyreported during the first weeks of therapy with efavirenz. Dosing at bedtime may improve the tolerability of thesesymptoms, which are likely to improve with continued therapy. Patients should be alerted to the potential for additiveeffects when ATRIPLA is used concomitantly with alcohol or psychoactive drugs. Patients should be instructed that ifthey experience NSS they should avoid potentially hazardous tasks such as driving or operating machinery [seeWarnings and Precautions and Dosage and Administration (2) in Full Prescribing Information].Psychiatric Symptoms: Patients should be informed that serious psychiatric symptoms have been reported inpatients receiving efavirenz. If they experience severe psychiatric adverse experiences they should seek immediatemedical evaluation. Patients should be advised to inform their physician of any history of mental illness or substanceabuse [see Warnings and Precautions].sRash: Patients should be informed that a common side effect is rash. Rashes usually go away without any changein treatment. However, since rash may be serious, patients should be advised to contact their physician promptly ifrash occurs.Reproductive Risk Potential: Women receiving ATRIPLA should be instructed to avoid pregnancy [see Warningsand Precautions]. A reliable form of barrier contraception should always be used in combination with other methodssof contraception, including oral or other hormonal contraception. Because of the long half-life of efavirenz, use ofadequate contraceptive measures for 12 weeks after discontinuation of ATRIPLA is recommended. Women shouldbe advised to notify their physician if they become pregnant or plan to become pregnant while taking ATRIPLA. Ifthis drug is used during the first trimester of pregnancy, or if the patient becomes pregnant while taking this drug,she should be apprised of the potential harm to the fetus.

Bristol-Myers Squibb & Gilead Sciences, LLC. Foster City, CA 94404

ATRIPLA is a trademark of Bristol-Myers Squibb & Gilead Sciences, LLC. EMTRIVA, TRUVADA, and VIREAD are trademarks of Gilead Sciences, Inc.SUSTIVA is a registered trademark of Bristol-Myers Squibb Pharma Company. REYATAZ and VIDEX are registered trademarks ofBristol-Myers Squibb Company. Pravachol is a registered trademark of ER Squibb & Sons, LLC. Other brands listed are thetrademarks of their respective owners.© 2008 Bristol-Myers Squibb & Gilead Sciences, LLC. Based on: 21-937-GS-005

ST0062 SF-B0001A-10-08 697US08PBS00202 September 2008


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 correctional

health 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 observe—how toobserve—what symptoms indicate improvement—which are of none—which are the evidence of neglect—and 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 art—sort 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 studies—ithas 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 aren’t 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!

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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 Mölnlycke Health Care, Biogel®, Hibiclens® and BARRIER® names and logos are registered globally to one or more of the Mölnlycke Health Care Group of Companies. Distributed by Mölnlycke Health Care US, LLC, Norcross, Georgia 30092.©2009 Mölnlycke 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.

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skin and continues to kill germs for up to 6 hours after use2.

To learn how to prevent MRSA, call 1.800.843.8497 or go to www.hibigeebies.com/prison


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 patient’s 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 we’ve 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 Project’s 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 RhodeIsland’s 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, RIDOC’s 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 system’s 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 URI’s 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 Pharmacy’s 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. RIDOC’s daily popula-

tion averages 3,800 inmates and annual admissions are 18,000 per year. Based on pharmaceutical trend data, thesystem’s 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 consult“whenever we have a question about ordering medica-

DOC-University Rx Project Yields Big Savings—and Award—in 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 hisdepartment’s relationship with the state Board of Pharmacy by helping the board understand the complexities of cor-rectional pharmacy care. “It’s not a nursing home; it’s not a hospital; it’s not an ambulatory care center. It’s 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. That’s 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, RIDOC’s associate director of health care services.

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A World of Opportunities


by Marc F. Stern, MD, MPH

Whether you think it’s a step forward or back-ward, the Supreme Court of Washington Staterecently issued a ruling in a case that adds some

clarity 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 declareWDOC’s 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 McNabb’s 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 inmate’s right to marry, the U.S. Supreme Court found that the state’s interest outweighs the inmate’s interestwhen the state has a legitimate penologic interest to deny the inmate’s right. So, for example, if the state felt that the inmate’s hunger strike might spread to other inmates,impairing the state’s 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 WDOC’sforce-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 patient’s 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 WDOC’s 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), rWDOC’s 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

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in correctional facilities1

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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

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■ 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)30–49 mL/min: 1 tablet every 48 hours. CrCl <30 mL/min or hemodialysis: do not use TRUVADA

■ No dose adjustment is necessary for patients with mild renal impairment (CrCl 50–80 mL/min)

Warnings and precautions■ New onset or worsening renal impairment

■ Emtricitabine and tenofovir are principally eliminated by the kidney. Renal impairment can include acute renal failure and Fanconi syndrome

■ Assess CrCl before initiating treatment with TRUVADA. Routinely monitor CrCl and serum phosphorus in patients at risk

■ Dosing interval adjustment of TRUVADA and close monitoring of renalfunction are recommended in all patients with CrCl 30–49 mL/min.No safety or efficacy data are available in patients with renalimpairment who received TRUVADA using these dosing guidelines, sothe potential benefit of TRUVADA therapy should be assessed against the potential risk of renal toxicity

■ Avoid administering TRUVADA with concurrent or recent use ofnephrotoxic drugs

■ Decreases in bone mineral density (BMD): consider monitoring BMD in patients with a history of pathologic fracture or who are at risk for osteopenia

■ Redistribution/accumulation of body fat: observed in patients receiving antiretroviral therapy

■ Immune reconstitution syndrome: may necessitate further evaluation and treatment

■ Triple nucleoside-only regimens: early virologic failure has been reported in HIV-infected patients. Monitor carefully and consider treatment modification

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emergent (Grade 2–4, occurring in ≥5% of patients) adverse reactionsoccurring in Study 934 through 144 weeks include diarrhea, nausea, fatigue, sinusitis, upper respiratory tract infections, nasopharyngitis, headache, dizziness, depression, insomnia, abnormal dreams, and rash

■ The following postapproval adverse reactions may occur as a consequenceof proximal renal tubulopathy: rhabdomyolysis, osteomalacia, hypokalemia, muscular weakness, myopathy, hypophosphatemia

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Drug interactions■ Didanosine (ddI): tenofovir disoproxil fumarate increases ddI concentrations.

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■ Lopinavir/ritonavir: coadministration increases tenofovir concentrations. Monitor for evidence of tenofovir -associated adverse reactions

* Combivir® (zidovudine/lamivudine), Epivir® or Epivir HBV® (lamivudine), Epzicom® (abacavirsulfate/lamivudine), or Trizivir® (abacavir sulfate/lamivudine/zidovudine).

References: 1. Derived from patient chart audit, Synovate Healthcare Data, US HIV Monitor. 2008, Q3.rr2. TRUVADA®AA (emtricitabine/tenofovir disoproxil fumarate) Prescribing Information. Gilead Sciences, Inc. November 2008. 3. Panel on Antiretroviral Guidelines for Adults and Adolescents. Guidelines for the use ofantiretroviral agents in HIV-1- infected adults and adolescents. Department of Health and Human Services. November 3, 2008; 1-139. Available at: http://www.aidsinfo.nih.gov/ContentFiles/AdultandAdolescentGL.pdf. Accessed February 3, 2009. 4. Johnson M, Grinsztejn B, Rodriguez C, et al. 96-week comparison of once-daily atazanavir/ritonavir and twice-daily lopinavir/ritonavir in patients with multiple virologic failures. AIDS.SS2006;20:711-718. 5. Riddler SA, Haubrich R, DiRienzo AG, et al, for the AIDS Clinical Trials Group Study A5142 Team. Class-sparing regimens for initial treatment of HIV-1 infection. N Engl J Med.dd2008;358:2095-2106. 6. Molina J-M, Podsadecki TJ, Johnson MA, et al. A lopinavir/ritonavir-based once-daily regimen results in better compliance and is non-inferior to a twice-daily regimen through 96 weeks. AIDS Res Hum Retroviruses. 2007;23:1505-1514. ss 7. Young B, Smith K, Patel P, et al. Characterization of virologicfailure over 96 weeks by drug resistance and antiviral response in ART naïve patients receiving abacavir/lamivudine (ABC/3TC) or tenofovir/emtricitabine (TDF/FTC) each with lopinavir/ritonavir QD in the HEATstudy. Presented at: 48th Annual Interscience Conference on Antimicrobial Agents and Chemotherapy (ICAAC)and the Infectious Diseases Society of America (IDSA) 46th Annual Meeting; October 25-28, 2008; Washington, DC. 8. Mills A, Nelson M, Jayaweera D, et al. ARTEMIS: efficacy and safety of darunavir/ritonavir (DRV/r)800/100 mg once-daily vs lopinavir/ritonavir (LPV/r) in treatment-naïve, HIV-1-infected patients at 96 wks. Abstract presented at: 48th Annual Interscience Conference on Antimicrobial Agents and Chemotherapy (ICAAC®). October 25-28, 2008; Washington, DC. 9. Molina J, Andrade-Villanueva J, Echevarria J, et al. CASTLE: atazanavir-ritonavir vs lopinavir-ritonavir in antiretroviral-naïve HIV-1 infected patients: 96 week efficacy & safety. Abstract presented at: 48th Annual Interscience Conference on Antimicrobial Agents and Chemotherapy(ICAAC®). October 25-28, 2008; Washington, DC.

Please see brief summary of full Prescribing Information on following page, including boxed WARNING information about lactic acidosis, severe hepatomegaly with steatosis, and exacerbations of hepatitis B upon discontinuation of therapy.

©2009 Gilead Sciences, Inc. All rights reserved. QD1065 04/09

The following is a brief summary for TRUVADA®AA (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 30–49VVmL/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 50–80 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 HBV shouldbe closely monitored with both clinical and laboratory follow up for at least severalmonths after stopping treatment with TRUVADA. If appropriate, initiation of anti-Hepatitis B therapy may be warranted.New Onset or Worsening Renal Impairment: Emtricitabine and tenofovir areprincipally eliminated by the kidney. Renal impairment, including cases of acute renalfailure and Fanconi syndrome (renal tubular injury with severe hypophosphatemia), hasbeen reported with the use of VIREAD [See Adverse Reactions].]]It is recommended that creatinine clearance be calculated in all patients prior toinitiating therapy and as clinically appropriate during therapy with TRUVADA. Routinemonitoring of calculated creatinine clearance and serum phosphorus should beperformed in patients at risk for renal impairment.Dosing interval adjustment of TRUVADA and close monitoring of renal function arerecommended in all patients with creatinine clearance 30–49 mL/min [See Dosage and[[Administration]. No safety or efficacy data are available in patients with renal impairment]]who received TRUVADA using these dosing guidelines, so the potential benefit of TRUVADAtherapy should be assessed against the potential risk of renal toxicity. TRUVADA should not beadministered to patients with creatinine clearance <30 mL/min or patients requiring hemodialysis.TRUVADA should be avoided with concurrent or recent use of a nephrotoxic agent.Coadministration with Other Products: TRUVADA should not be coadministeredwith ATRIPLA, EMTRIVA, or VIREAD. Due to similarities between emtricitabine andlamivudine, TRUVADA should not be coadministered with other drugs containing lamivudine,including Combivir® (lamivudine/zidovudine), Epivir®rr or Epivir-HBV®VV (lamivudine), Epzicom®

(abacavir sulfate/lamivudine), or Trizivir® (abacavir sulfate/lamivudine/zidovudine).TRUVADA should not be administered with HEPSERA® (adefovir dipivoxil).Decreases in Bone Mineral Density: Bone mineral density (BMD) monitoringshould be considered for HIV-1 infected patients who have a history of pathologic bonefracture or are at risk for osteopenia. Although the effect of supplementation with calciumand vitamin D was not studied, such supplementation may be beneficial for all patients. Ifbone abnormalities are suspected then appropriate consultation should be obtained.Tenofovir Disoproxil Fumarate: In a 144-week study of treatment naïve patients,decreases in BMD were seen at the lumbar spine and hip in both arms of the study. At Week 144,there was a significantly greater mean percentage decrease from baseline in BMD at thelumbar spine in patients receiving VIREAD + lamivudine (3TC) + efavirenz (EFV) compared with

Creatinine Clearance (mL/min)*≥50 30–49 <30 (Including Patients

Requiring Hemodialysis)

RecommendedDosing Interval

Every24 hours

Every48 hours

TRUVADA shouldnot be administered.

WARNINGS: LACTIC ACIDOSIS, SEVERE HEPATOMEGALY WITHSTEATOSIS and POST TREATMENT ACUTE EXACERBATION OFHEPATITIS B.Lactic acidosis and severe hepatomegaly with steatosis, includingfatal cases, have been reported with the use of nucleoside analogs,including VIREAD, a component of TRUVADA, in combination withother antiretrovirals [See Warnings and Precautions].TRUVADA is not approved for the treatment of chronic hepatitis B virus(HBV) infection and the safety and efficacy of TRUVADA have not beenVVestablished in patients coinfected with HBV and HIV-1. Severe acuteexacerbations 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 andlaboratory follow-up for at least several months in patients who arecoinfected with HIV-1 and HBV and discontinue TRUVADA. Ifappropriate, initiation of anti-hepatitis B therapy may be warranted[See Warnings and Precautions].]]

patients receiving stavudine + lamivudine + efavirenz. Changes in BMD at the hip were similarbetween the two treatment groups. In both groups, the majority of the reduction in BMDoccurred in the first 24–48 weeks of the study and this reduction was sustained through144 weeks. Twenty-eight percent of VIREAD (tenofovir disoproxil fumarate)-treated patients vs.21% of the comparator patients lost at least 5% of BMD at the spine or 7% of BMD at the hip.Clinically relevant fractures (excluding fingers and toes) were reported in 4 patients in theVIREAD group and 6 patients in the comparator group. Tenofovir disoproxil fumarate wasassociated with significant increases in biochemical markers of bone metabolism (serum bone-specific alkaline phosphatase, serum osteocalcin, serum C-telopeptide, and urinary N-telopeptide),suggesting increased bone turnover. Serum parathyroid hormone levels and 1,25 Vitamin Dlevels were also higher in patients receiving VIREAD. The effects of VIREAD-associated changesin BMD and biochemical markers on long-term bone health and future fracture risk areunknown. For additional information, please consult the VIREAD prescribing information.Cases of osteomalacia (associated with proximal renal tubulopathy and which may contributeto fractures) have been reported in association with the use of VIREAD [See Adverse Reactions][[ .]]Fat Redistribution: Redistribution/accumulation of body fat including centralobesity, dorsocervical fat enlargement (buffalo hump), peripheral wasting, facialwasting, breast enlargement, and “cushingoid appearance” have been observed inpatients receiving antiretroviral therapy. The mechanism and long-term consequencesof these events are currently unknown. A causal relationship has not been established.Immune Reconstitution Syndrome: Immune reconstitution syndrome has beenreported in patients treated with combination antiretroviral therapy, including TRUVADA.During the initial phase of combination antiretroviral treatment, patients whose immunesystem responds may develop an inflammatory response to indolent or residualopportunistic infections [such as Mycobacterium avium infection, cytomegalovirus,Pneumocystis jirovecii pneumonia (PCP), or tuberculosis], which may necessitatefurther evaluation and treatment.Early Virologic Failure: Clinical studies in HIV-infected patients have demonstrated thatcertain regimens that only contain three nucleoside reverse transcriptase inhibitors (NRTI)are generally less effective than triple drug regimens containing two NRTIs in combinationwith either a non-nucleoside reverse transcriptase inhibitor or a HIV-1 protease inhibitor. Inparticular, early virological failure and high rates of resistance substitutions have beenreported. Triple nucleoside regimens should therefore be used with caution. Patients on atherapy utilizing a triple nucleoside-only regimen should be carefully monitored andconsidered for treatment modification.ADVERSE REACTIONSAdverse Reactions from Clinical Trials Experience: Because clinical trials areconducted under widely varying conditions, adverse reaction rates observed in the clinicaltrials of a drug cannot be directly compared to rates in the clinical trials of anotherdrug and may not reflect the rates observed in practice.The most common adverse reactions (incidence≥10%, any severity) occurring in Study 934,an active-controlled clinical study of efavirenz, emtricitabine, and tenofovir disoproxilfumarate, include diarrhea, nausea, fatigue, headache, dizziness, depression, insomnia,abnormal dreams, and rash. See also full Prescribing Information for the frequency oftreatment-emergent adverse reactions (Grade 2–4) occurring in ≥5% of patients treatedwith efavirenz, emtricitabine, and tenofovir disoproxil fumarate in this study.Skin discoloration, manifested by hyperpigmentation on the palms and/or soles wasgenerally mild and asymptomatic. The mechanism and clinical significance are unknown.Study 934 - Treatment Emergent Adverse Reactions: In Study 934, 511 antiretroviral-naïve patients received either VIREAD + EMTRIVA (emtricitabine) administered incombination with efavirenz (N=257) or zidovudine/lamivudine administered in combinationwith efavirenz (N=254). Adverse reactions observed in this study were generally consistentwith those seen in other studies in treatment-experienced or treatment-naïve patientsreceiving VIREAD and/or EMTRIVA, including diarrhea, nausea, vomiting, fatigue, sinusitis,upper respiratory tract infections, nasopharyngitis, headache, dizziness, depression,insomnia, and rash event.

Laboratory Abnormalities: Laboratory abnormalities observed in this study were generallyconsistent with those seen in other studies of VIREAD and/or EMTRIVA.Postmarketing Experience: The following adverse reactions have been identifiedduring postapproval use of VIREAD: allergic reaction, lactic acidosis, hypokalemia,hypophosphatemia, dyspnea, pancreatitis, increased amylase, abdominal pain, hepaticsteatosis, hepatitis, increased liver enzymes (most commonly increased AST, ALT, Gamma GT),rash, rhabdomyolysis, osteomalacia (manifested as bone pain and which may contribute tofractures), muscular weakness, myopathy, acute renal failure, renal failure, acute tubularnecrosis, Fanconi syndrome, proximal renal tubulopathy, interstitial nephritis (includingacute cases), nephrogenic diabetes insipidus, renal insufficiency, increased creatinine,proteinuria, polyuria, asthenia. No additional adverse reactions have been identified duringpostapproval use of EMTRIVA. Because postmarketing reactions are reported voluntarilyfrom a population of uncertain size, it is not always possible to reliably estimate their frequencyor establish a causal relationship to drug exposure.The following adverse reactions, listed above, may occur as a consequence of proximalrenal tubulopathy: rhabdomyolysis, osteomalacia, hypokalemia, muscular weakness,myopathy, hypophosphatemia.DRUG INTERACTIONSNo drug interaction studies have been conducted using TRUVADA tablets. Drug interactionstudies have been conducted with emtricitabine and tenofovir disoproxil fumarate, thecomponents of TRUVADA. This section describes clinically relevant drug interactionsobserved with emtricitabine and tenofovir disoproxil fumarate.Didanosine: Coadministration of TRUVADA and didanosine should beundertaken with caution and patients receiving this combination shouldbe monitored closely for didanosine-associated adverse reactions.Didanosine should be discontinued in patients who develop didanosine-associated adverse reactions. When tenofovir disoproxil fumarate wasadministered with didanosine the Cmax and AUC of didanosine administered as either thebuffered or enteric-coated formulation increased significantly. The mechanism of thisinteraction is unknown. Higher didanosine concentrations could potentiate didanosine-associated adverse reactions, including pancreatitis, and neuropathy. Suppression of CD4+ cellcounts has been observed in patients receiving tenofovir DF with didanosine 400 mg daily. Inadults weighing >60 kg, the didanosine dose should be reduced to 250 mg when it iscoadministered with TRUVADA. Data are not available to recommend a dose adjustment ofdidanosine for patients weighing <60 kg. When coadministered, TRUVADA and Videx®xx EC(didanosine) may be taken under fasted conditions or with a light meal (<400 kcal, 20% fat).Coadministration of didanosine buffered tablet formulation with TRUVADA should beunder fasted conditions.Atazanavir: Atazanavir has been shown to increase tenofovir concentrations. The mechanismof this interaction is unknown. Patients receiving atazanavir and TRUVADA shouldbe monitored for TRUVADA-associated adverse reactions. TRUVADA shouldbe discontinued in patients who develop TRUVADA-associated adversereactions. Tenofovir decreases the AUC and Cmin of atazanavir. When coadministered withTRUVADA, it is recommended that atazanavir 300 mg is given with ritonavir 100 mg.Atazanavir without ritonavir should not be coadministered with TRUVADA.Lopinavir/Ritonavir: Lopinavir/ritonavir has been shown to increase tenofovirconcentrations. The mechanism of this interaction is unknown. Patients receivinglopinavir/ritonavir and TRUVADA should be monitored for TRUVADA-associatedadverse reactions. TRUVADA should be discontinued in patients who developTRUVADA-associated adverse reactions.

Drugs Affecting Renal Function: Because emtricitabine and tenofovir are primarilyexcreted by the kidneys, coadministration of TRUVADA (emtricitabine/tenofovir disoproxilfumarate) with drugs that are eliminated by active tubular secretion may increaseconcentrations of emtricitabine, tenofovir, and/or the coadministered drug. Some examplesinclude, but are not limited to acyclovir, adefovir dipivoxil, cidofovir, ganciclovir, valacyclovir,and valganciclovir. Drugs that decrease renal function may increase concentrations ofemtricitabine and/or tenofovir.USE IN SPECIFIC POPULATIONSPregnancy Category B: Emtricitabine: The incidence of fetal variations andmalformations was not increased in embryofetal toxicity studies performed withemtricitabine in mice at exposures (AUC) approximately 60-fold higher and in rabbits atapproximately 120-fold higher than human exposures at the recommended daily dose.Tenofovir Disoproxil Fumarate: Reproduction studies have been performed in rats andrabbits at doses up to 14 and 19 times the human dose based on body surface area comparisons andrevealed no evidence of impaired fertility or harm to the fetus due to tenofovir.There are, however, no adequate and well-controlled studies in pregnant women. Because animalreproduction studies are not always predictive of human response, TRUVADA should be usedduring pregnancy only if clearly needed.Antiretroviral Pregnancy Registry: To monitor fetal outcomes of pregnant womenexposed to TRUVADA, an Antiretroviral Pregnancy Registry has been established.Healthcare providers are encouraged to register patients by calling 1-800-258-4263.Nursing Mothers: The Centers for Disease Control and Preventionrecommend that HIV-1-infected mothers not breast-feed their infants toavoid risking postnatal transmission of HIV-1. Studies in rats have demonstratedthat tenofovir is secreted in milk. It is not known whether tenofovir is excreted in humanmilk. It is not known whether emtricitabine is excreted in human milk. Because of both thepotential for HIV-1 transmission and the potential for serious adverse reactions in nursinginfants, mothers should be instructed not to breast-feed if they arereceiving TRUVADA.Pediatric Use: TRUVADA is not recommended for patients less than 18 years of agebecause it is a fixed-dose combination tablet containing a component, VIREAD (tenofovirdisoproxil fumarate), for which safety and efficacy have not been established in this age group.Geriatric Use: Clinical studies of EMTRIVA (emtricitabine) or VIREAD did notinclude sufficient numbers of subjects aged 65 and over to determine whether theyrespond differently from younger subjects. In general, dose selection for the elderlypatients should be cautious, keeping in mind the greater frequency of decreasedhepatic, renal, or cardiac function, and of concomitant disease or other drug therapy.Patients with Impaired Renal Function: It is recommended that the dosinginterval for TRUVADA be modified in patients with creatinine clearance 30–49 mL/min.TRUVADA should not be used in patients with creatinine clearance <30 mL/min and inpatients with end-stage renal disease requiring dialysis [See Dosage and Administration].]]NONCLINICAL TOXICOLOGYCarcinogenesis, Mutagenesis, Impairment of FertilityEmtricitabine: In long-term oral carcinogenicity studies of emtricitabine, no drug-relatedincreases in tumor incidence were found in mice at doses up to 750 mg/kg/day (26 times thehuman systemic exposure at the therapeutic dose of 200 mg/day) or in rats at doses up to 600mg/kg/day (31 times the human systemic exposure at the therapeutic dose).Emtricitabine was not genotoxic in the reverse mutation bacterial test (Ames test), mouselymphoma or mouse micronucleus assays.Emtricitabine did not affect fertility in male rats at approximately 140-fold or inmale and female mice at approximately 60-fold higher exposures (AUC) than in humansgiven the recommended 200 mg daily dose. Fertility was normal in the offspring of miceexposed daily from before birth (in utero) through sexual maturity at daily exposures(AUC) of approximately 60-fold higher than human exposures at the recommended200 mg daily dose.Tenofovir Disoproxil Fumarate: Long-term oral carcinogenicity studies of tenofovirdisoproxil fumarate in mice and rats were carried out at exposures up to approximately 16times (mice) and 5 times (rats) those observed in humans at the therapeutic dose for HIV-1infection. At the high dose in female mice, liver adenomas were increased at exposures 16times that in humans. In rats, the study was negative for carcinogenic findings at exposures upto 5 times that observed in humans at the therapeutic dose.Tenofovir disoproxil fumarate was mutagenic in the in vitro mouse lymphoma assay andnegative in an in vitro bacterial mutagenicity test (Ames test). In an in vivo mouse micronucleusassay, tenofovir disoproxil fumarate was negative when administered to male mice.There were no effects on fertility, mating performance or early embryonic development whentenofovir disoproxil fumarate was administered to male rats at a dose equivalent to 10 timesthe human dose based on body surface area comparisons for 28 days prior to mating and tofemale rats for 15 days prior to mating through day seven of gestation. There was, however, analteration of the estrous cycle in female rats.PATIENT COUNSELING INFORMATIONPatients should be advised that:• TRUVADA is not a cure for HIV-1 infection and patients may continue to experience

illnesses associated with HIV-1 infection, including opportunistic infections. Patientsshould remain under the care of a physician when using TRUVADA.

• The use of TRUVADA has not been shown to reduce the risk of transmission of HIV-1 to others through sexual contact or blood contamination.

•The long term effects of TRUVADA are unknown.• TRUVADA tablets are for oral ingestion only.• It is important to take TRUVADA with combination therapy on a regular dosing schedule to

avoid missing doses.• Lactic acidosis and severe hepatomegaly with steatosis, including fatal cases, have been

reported. Treatment with TRUVADA should be suspended in any patients who developclinical symptoms suggestive of lactic acidosis or pronounced hepatotoxicity (includingnausea, vomiting, unusual or unexpected stomach discomfort, and weakness) [SeeWarnings and Precautions].]]

• All patients with HIV-1 should be tested for HBV before initiating antiretroviral therapy.• Severe acute exacerbations of Hepatitis B have been reported in patients who are

coinfected with HBV and HIV-1 and have discontinued TRUVADA.• Renal impairment, including cases of acute renal failure and Fanconi syndrome, has been

reported in association with the use of VIREAD. TRUVADA should be avoided withconcurrent or recent use of a nephrotoxic agent [See Warnings and Precautions]. Dosing]]interval of TRUVADA may need adjustment in patients with renal impairment [SeeDosage and Administration].]]

• TRUVADA should not be coadministered with ATRIPLA, (efavirenz 600 mg/emtricitabine 200 mg/tenofovir disoproxil fumarate 300 mg) EMTRIVA, or VIREAD;or with drugs containing lamivudine, including Combivir (lamivudine/zidovudine), Epiviror Epivir-HBV (lamivudine), Epzicom (abacavir sulfate/lamivudine), or Trizivir (abacavirsulfate/lamivudine/zidovudine) [See Warnings and Precautions].]]

• TRUVADA should not be administered with HEPSERA (adefovir dipivoxil) [SeeWarnings and Precautions].WW

• Decreases in bone mineral density have been observed with the use of VIREAD. Bonemonitoring should be considered in patients who have a history of pathologic bonefracture or at risk for osteopenia [See Warnings and Precautions].]]

©2008 Gilead Sciences, Inc. All rights reserved. 11/08

TRUVADA, EMTRIVA, HEPSERA, and VIREAD are trademarks of GileadSciences, Inc. ATRIPLA is a trademark of Bristol-Myers Squibb & GileadSciences, LLC. All other trademarks referenced herein are the property oftheir respective owners.

*Calculated using ideal (lean) body weight.

Gilead Sciences, Inc. Foster City, CA 94404 November 2008

emtricitabine • tenofovir disoproxil fumarate

®


Study: Brief Negotiation Interviewing Lowers HIV Risk, Increases TestingResearchers and public health practitioners recognize that incarceration provides a great opportunity to intervenewith populations at high-risk for HIV and AIDS largely because of their drug-use behavior. However, at any giventime, “twice as many offenders are under community super-vision as are incarcerated, and the HIV prevention needs of probationers and parolees have been largely overlooked,”according to data cited in the latest issue of the Journal of Correctional Health Care.

Turning their attention to this “hidden population,” SoniaAlemagno, PhD, and colleagues sought to develop and testan intervention that addresses reduction of HIV risk andencourages HIV testing. But they wanted to go beyond the “education only” approaches, which often fail to change behavior, without going to the other extreme, “expensive and involved enhanced interventions.”

Instead, they explored a strategy known as motivationalinterviewing. With evidence of positive outcomes mount-ing in the literature, this approach “allows intervention staff to help clients express concerns about their health and self-examine motivation for change.” A newer, related model,brief negotiation interviewing, is being applied to “hectic settings” such as emergency rooms and courts. Accordingto the authors, BNI is a computerized, self-directed inter-vention that combines a short structured interview with abrief counseling session. It is “not seen as actual treatment, but rather as a step in the process of connecting with the treatment system” and is meant to encourage testing and counseling and to promote specific behavioral changes.

A randomized clinical trial was conducted among par-ticipants recruited from a probation department and twosubstance abuse treatment agencies in Cleveland, OH. The study examined whether BNI could decrease HIV risks andincrease testing for HIV in this population. A trained inter-viewer conducted individual, face-to-face interviews in aprivate setting at baseline and two months later. The inter-view questions focused on drug-use and sexual behaviorsassociated with HIV risk.

After the first interview, the 104 control group membersreceived the Treatment Alternatives to Street Crime (TASC) intervention: written educational materials on HIV, STDs,TB and hepatitis, plus a list of community providers whoconduct testing and counseling. They also were given a buspass and reminded of the follow-up interview.

The 108 experimental group members were invited toengage in a single 20-minute BNI session using a “talking”computer. Specific topics varied depending on whether the participant was an injection drug user or was at sexualrisk, and focused on “good things” and “not so good things”about these behaviors. Personal-risk feedback was providedwith objectivity, emphasizing personal choice and responsi-bility for change. Finally, participants were given a personalprevention checklist based on individual responses, along with a voucher for free HIV and STD testing and a bus pass.They were given additional information on HIV and were

encouraged to discuss the intervention with their case manager, who could assist further with referrals.

At follow-up, 95% of participants in the experimentalgroup and 75% in the control group were located and inter-viewed.

Results indicate that, overall, both programs producedpositive results as indicated by the improvement in risky sexual behavior and attitudes toward behavior change.However, those who received the BNI component demon-strated increased AIDS awareness, had a significantly higherrate of HIV testing and were more likely to say that they wanted to make some changes to reduce their AIDS risk.

JCHC Volume 15, Issue3

The Enduring Menace of MRSA: Incidence, Treatment, and Prevention in a County Jail — Grant E. Deger, MD, CCHP, and David W. Quick, DO, PhD

A Qualitative Exploration of HIV/AIDS Health Care Services in Indian Prisons — Sayantani Guin, MPhil, MA

Resumption of Smoking After Release From a Tobacco-Free Correctional Facility — Thomas Lincoln, MD, Robert W. Tuthill, PhD, Cheryl A. Roberts, MPA, Sofia Kennedy, MPH, Theodore M. Hammett, PhD, Elizabeth Langmore-Avila, MA, DTR, and Thomas J. Conklin, MD

Alcohol, Marijuana, and Perceptions of Influence on Social and Sexual Behavior Among African AmericanAdolescent Female Detainees — Lindsay Danielle du Plessis, MPH, Rhonda Conerly Holliday, PhD, Alyssa G. Robillard, PhD, and Ronald L. Braithwaite, PhD

Brief Motivational Intervention to Reduce HIV Risk and to Increase HIV Testing Among Offenders Under Community Supervision — Sonia A. Alemagno, PhD, Richard C. Stephens, PhD, Peggy Stephens, PhD, Peggy Shaffer-King, MA, and Patrick White, MA

Commentary: A Personal Retrospective: In the Eye of the Accreditation Storm (Part II) — Judith A. Stanley, MS, CCHP-A

NCCHC Position Statement: Prevention of Juvenile Suicide in Correctional Settings

Each issue of JCHC also has a self-study exam by whichCphysicians, nurses, psychologists and CCHPs may earncontinuing education credit.

Members of the Academy of Correctional HealthProfessionals receive JCHC (hard copy and online) as aCbenefit of membership. To learn how to obtain JCHC,Ccontact Sage Publications: 800-818-7243, ext. 7100;[email protected]; http://jchc.sagepub.com.


by Jennifer E. Kistler, MPH

In the 2008 Standards for Health Services, the standardson Medication Services (D-02) contains a new compli-ance indicator: Inmates entering the facility on prescrip-

tion medication continue to receive the medication in atimely fashion as prescribed, or acceptable alternate medi-cations are provided as clinically indicated.

Newly admitted inmates who report taking medica-tions currently or who bring medications with them areto continue their medication unless there is a clinical rea-son to alter or discontinue the medication. Note that the E-02 Receiving Screening standard states in ComplianceIndicator 9 that “prescribed medications are reviewed and appropriately maintained according to the medica-tion schedule the inmate was following before admission.” Protocols should be in place so that the drugs are adminis-tered in a timely fashion as dictated by clinical need. Clinicalneed is the key factor; therefore, medications should be prescribed only when they are clinically indicated.

There are different options to ensure that inmates who are admitted on prescribed medication continue to receivenecessary drugs. Perhaps the physician or on-call physicianis contacted by health staff for a verbal order once they

have verified the medication through the community pre-scribing clinician or pharmacy. Another option is authoriz-ing nurses to give medications based on the communityclinician’s valid order until the facility physician is able to seethe inmate. Some facilities do allow the use of medicationthat is brought in if it is contained in the original pharmacypackaging, labeled as required and staff have verified the order with the community prescriber or pharmacist.

A physician, dentist or other legally authorized individualmay determine that a prescribed treatment is no longerclinically indicated or that there is an alternative to a medi-cation that the patient was taking before incarceration. It is good practice to explain to patients the clinical justificationbehind discontinuing or prescribing alternate medicationso that they understand that health care decisions are made based on their health needs and not for any punitive reason.

Importance of ContinuityContinuity of care is an important concept in this standardas it intends to help prevent adverse patient outcomes. For instance, it may not be possible to maintain a therapeuticdose of medication unless medications are taken as pre-scribed. Inordinate delays in receiving clinically indicated prescription medication may result in significant morbid-ity or mortality. Adverse patient outcomes can also occur when there are frequent changes in medication orders, medication histories are not reviewed by the clinician ortreating clinicians are unaware of each other’s prescribingpractices.

We all understand the importance of patients continuingto take medication as prescribed for health conditions suchas high blood pressure or diabetes. There are also manyother prescription medications that could have adversehealth consequences if abruptly discontinued or not taken in a timely manner; steroids, antidepressants, antibiotics, and others require strict regimens in order to remain effec-tive or prevent side effects. The facility provider will evalu-ate the medical necessity of prescriptions for newly admit-ted inmates to ensure that there is continuity of care andthat health needs are met.

Medication services should, of course, be clinicallyappropriate and provided in a timely, safe and sufficientmanner commensurate with current community practice.Therefore, the responsible physician should establish thepolicies regarding all prescription medications administeredor delivered in the facility.

Jennifer E. Kistler, MPH, is NCCHC’s director of accredita-tion. To contact her, e-mail [email protected], call 773-880-1460 or write to NCCHC, 1145 W. Diversey Pkwy, Chicago, IL 60614. For an archive of Spotlight articles, visit the Resources section at www.ncchc.org.

e standardse standardson thon thon thon th

D-02 Medication Services(essential)

Medication services are clinically appropriate and provided in a time-ly, safe, and sufficient manner.—2008 Standards for Health Services for jails and prisons

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In this column, Judith Robbins, LCSW, JD, CCHP-A, talks with nutrition consultant Barbara Wakeen, MA, RD, CCHP, about nutritional issues specific to juvenile deten-

tion populations.

JR: What are the special dietary needs of adolescents and how can corrections facilities meet these needs?

BW: Adolescents require more calories, calcium, phos-phorus and iron than most adult age groups. The key is to provide a balanced diet of adequate nutrients and calories.

In my experience and based on what I’ve learned fromother corrections dietitians, most juveniles are receivingmore than 3,000 calories per day, including snacks. Some facilities offer double entrees at lunch and dinner meals.

Many juvenile facilities participate in the USDA Child Nutrition National School Lunch Program/School BreakfastProgram. These programs require certain food groups and quantities to be offered, along with some nutrient restric-tions such as types and amounts of fats. Participants are also entitled to purchase commodity food items, which can helpfood budgets. Whether or not facilities participate, I havefound that their meals are usually visually very balanced—that is, fruits and/or vegetables and milk at all meals.

Likewise, juveniles housed in adult facilities are usually recognized as having special nutritional needs and are served the adult menus augmented with milk, fruit and one or two snacks per day.

Unfortunately, even though nutritionally balanced meals are offered, adolescents often have not been exposed tosome of the food served or dislike it and choose not to eat it. Thus, it can be challenging to ensure adequate intakes.

JR: How can juvenile correctional facilities provide the most helpful guidance for kids with, or at risk of, obesity,diabetes and other conditions?

BW: Classes, handouts and one-on-one counseling are good ways to provide education. The subject matter canaddress nutrition basics, therapeutic diets, activity, etc. Ideally, a registered dietitian is available to offer education,but most often the medical department performs that task.

Incorporating daily physical activity and structured exer-cise can also yield positive results for some kids at risk.

Educational agencies (including correctional facilities) that participate in the Child Nutrition Program are required to establish a school wellness policy that applies to alljuveniles, not just those at risk. This is somewhat akin to NCCHC standards in their proactive stance for health dur-ing and after incarceration. Information on the wellness policy requirements can be found at www.fns.usda.gov/TN/Healthy/wellness_policyrequirements.html.

JR: Registered dietitians are in short supply in many juve-nile systems. When an RD is not on staff, how can profes-sionals collaborate to improve dietary choices for kids?

BW: RDs write and approve menus based on state regu-

lations, accreditation standards, facility policy and otherguidelines (e.g., the USDA Child Nutrition Program) withwhich the facilities must comply. However, unless we are there to monitor, we cannot guarantee the outcomes.

Start by reviewing the various requirements notedabove. Look at what is offered in commissaries and vend-ing machines, if these are available to the juveniles. Lookat trends in weight gain, food waste, health and behavioral issues. Meet with the food service director to address any problems you find. If there is cause for concern, this canvalidate the need for a visit or consult from the RD to assistin modifications for compliance or healthier menu options. Ultimately, the RD will have to approve any menu changes.

JR: Do you have any suggestions for maintaining healthydiets while managing tightening budgets?

BW: Although it’s not always popular with the kids, striveto omit or reduce “empty calories,” such as candy, cookies,cake, soda pop or other calorie-dense, low-nutrient foods.

JR: Most juvenile settings have a diverse population withvery different food preferences. Do you have any advice about whether these preferences should be reflected in the menus?

BW: Most correctional facilities in the United States donot honor personal food preferences in terms of likes anddislikes. I am in agreement with this. That said, standard menu planning usually does factor in preferences accordingto population demographics. Some accreditation standardsrequire food preference surveys. Facilities use this informa-tion to incorporate popular foods on cycle menus when possible or to omit unpopular foods. Meal participation and plate waste are also indicators of food popularity.

Foods usually popular with juveniles are incorporated into menus that offer a variety of other foods that may beless popular but are nutrient dense. This approach results inhealthy menus that introduce new foods into the diet.

Barbara Wakeen, MA, RD, CCHP, is the principle of Correctional Nutrition Consultants, Ltd., based in North Canton, OH. She represents the American Dietetic Association on the NCCHC board of directors and serves on NCCHC’s juvenile health committee. She is the author of Nutrition and Foodservice Management in Correctional Facilities. Reach her at [email protected].

Judith Robbins, LCSW, JD, CCHP-A, represents the NationalAssociation of Social Workers on the board and chairs the juvenile health committee. She directs the Juvenile Deten tion Mental Health Program of Yale Behavioral Health, Depart-ment of Psychiatry, Yale Medical School, New Haven, CT.

We welcome your comments on this column or other juvenile correctional health topics. Please write to us at [email protected] or CorrectCare, c/o NCCHC, 1145 W. Diversey Pkwy, Chicago, IL 60614.

voice


Serving on the Certified Correctional Health Professionalboard of trustees is a great way to “give back” to this impor-tant program and the thousands of people who participate in it. But the benefits go both ways: It is also a wonderfulopportunity for leaders in this field to continue their pro-fessional growth and build their network of like-mindedcolleagues.

If that piques your interest, step up! CCHPs in good

standing are encouraged to seek nomination, or to nominate a fellow CCHP, to serve on the board of trust-ees. Elections are held every year to fill a three-year term. Comprised of 10 correctional health professionals, theboard is charged with guiding the CCHP program andimproving it as necessary to make it more responsive to theneeds of the correctional health care community. Trusteesare also responsible for developing, scoring and evaluatingthe various certification exams.

Upon acceptance of nomination, candidates will beasked to submit a short statement describing their ideas about the direction of the CCHP program. Elections will be conducted online later this summer. The new trustees willbegin their term immediately after the annual board meet-ing in October.

To make a nomination, complete the form online at www.ncchc.org/cchp by July 31, 2009.

Another Batch of CCHPs Makes Its Mark!The CCHP board of trustees and staff congratulate the 72 individuals who passed certification exams held in Februaryand March and officially became CCHP effective in April.For a complete list of their names, affiliations and locations,please visit the CCHP News page online.

Becoming a Certified Correctional Health Professional is an important step toward increased knowledge, greater professional recognition and identification as a leader in thecomplex and ever-changing field of correctional health care.If you do not yet participate in the program but would liketo know more, please visit the Web to read about the ben-efits of certification as well as the application and examina-tion process, and to obtain an application. Or contact us [email protected] or 773-880-1460. We also present informa-tional sessions at NCCHC conferences and seminars.

CCHP Exam Dates

July 12 Seattle, WA

August 1 Bastrip, TXs

August 22 Multiple regional sites

September 16 Sacramento, CA

September 19 & 20 Centennial, CO

October 18 Orlando, FL

For more information about the application process or the exams, please visit www.ncchc.org/cchp. Also, we are seeking additional sites for the August.and future exams, as well as CCHPs to proctor the exams. If you would like to participate, contact theCCHP coordinator at 773-880-1460 or [email protected].

page

Step Up! Seeking Candidates for Board

NEW for 2009!

l Specialty certification for nurses working in the correctional setting

l Recognizing the work you do and the difference you make

l Exclusively for nurses already CCHP certified

l From the most widely-accepted correctional health care certification program

The National Commission on Correctional Health Care and the Certified Correctional Health Professionals Board of Trustees are pleased to announce

CCHP CERTIFICATION FOR NURSES

Certification in correctional nursing makes a difference—to the patients whose care is provided by certified correctional nurses, to employers who must staff their facilities with skilled and experienced correctional nurses, and to the individual nurse who attains the CCHP-N© credential.

Certification Makes a Difference – Do You?

To receive an application when it becomes available, contact uscaatio itt bec mes av e, coonntactt uat [email protected] or 773-880-1460. Also look for updates and 773-88 0. Also ok for ates andannouncements on our Web site atb sitte www.ncchc.org/cchp.

CCHP NursingAd CC HalfIsland.ind1 1 12/4/08 5:12:29 PM


notesThis department features news and information from NCCHC’s supporting organizations and other partners that share our goal of promoting quality health care in correc-tional institutions. If your organization has news to share, please contact [email protected], 773-880-1460.

American Correctional Health Services AssociationJacqueline Moore, PhD, RN,CCHP-A, was honored with ACHSA’s 2009 DistinguishedService Award. Presented duringthe association’s annual meetingin March, the award is given toindividuals who have attainedsignificant achievement or con-tribution to correctional health service and/or ACHSA.

Now an independent consul-tant based in Colorado, Moore has had a long and illustrious career in the correctional health field. There are five criteria by which nominees areevaluated; many recipients excel in two or three, it wasnoted. Moore, however, was praised for “displaying excel-lence” in all five criteria. Among the specific achievements cited are the following:1. Development of a model program: launching “a new con-cept of comprehensive contract health services in a jail”2. Research: conducting doctoral research on factors relatedto the shortage of nurses working in corrections3. Publications: writing and editing copious published works4. Training and education: developing surveyor training when she was NCCHC’s accreditation director5. Public relations and management: overall leadership andmanagement expertise

American Medical AssociationAt its annual meeting in June, the AMA adopted a publichealth policy concerning the use of tasers by law enforce-ment agencies. According to a brief issued by the associa-tion, an AMA report finds that tasers, when used appropri-ately, can save lives during interventions that would have otherwise involved the use of deadly force. “While tasers can help law enforcement officers, proper use must beensured through specific guidelines, rigorous training andan accountability system,” said AMA board member JosephAnnis, MD. “There should also be a standardized approach to the medical evaluation of subjects exposed to tasers.”

American Bar AssociationThe ABA’s AIDS Coordinating Committee has issued “ANational AIDS Strategy: Legal Perspectives.” The purpose is to highlight some of the legal issues, and the laws to address them, that remain unsettled concerning HIV/AIDS

in America. Laws and legal services play a pivotal role in stemming the spread of HIV by reducing stigma and dis-crimination linked to the virus, according to the committee.This, in turn, encouraging greater HIV testing, which is criti-cal to prevention. A number of policy recommendations pertain to correctional settings and populations. The report

is posted at www.abanet.org/AIDS.

American College of PhysiciansThe ACP is offering its members free copiesof a patient education guidebook on how to manage high blood pressure. Released inApril, the guide is accompanied by a DVDthat features sportscaster James Brown. Bothare designed to help patients learn about high blood pressure, what steps to take to controlit and how to lower the risk of heart andblood vessel problems. “Almost everyone withhypertension can bring their numbers downwith lifestyle changes, medicines or both,” said ACP’s director of education. “Know Your Numbers: A Guide to Managing High Blood

Pressure” is sponsored by Daiichi Sankyo, Inc. ACP memberscan order the materials by calling ACP at 800-523-1546, ext.2600, or online at www.acponline.org.

1145 W. Diversey Parkway, Chicago, IL 60614phone: (773)880-1460 • fax: (773)880-2424

email: [email protected]

NCCHCStandards

Developed by leaders in the fi eld, these benchmark standards will help you:

� improve health services delivery

� increase organizational effectiveness

� enhance overall health care for inmates

To order or to see a list of all publicationsavailable, visit our Web site at

www.ncchc.org.

Standards CC Ad qrtr pgNEW.indd 1 6/10/08 7:56:04 AM

Jacqueline Moore, PhD, RN, CCHP-A, receives the award plaque from (L) ACHSA’s outgoing president, Royanne Schissel, RN, CCHP, and (R) the 2008 award winner, Kathryn Wild, RN, MPA, CCHP.


NCCHC’s National Conference is the must-attend event of the year for correctional health professionals, and now you can contribute to their experience. Nearly 2,000 high-level attendees from all sectors of this multidisciplinary field will convenein Orlando for education, networking and career development. They are the leaders—and emerging leaders—who make and influence purchase decisions, and they will be looking for information about products and services that can help themdeliver quality care. The NCCHC exhibit hall is a hot spot for you to define your role in this specialty field. When you con-nect with these influential professionals, you also reach the facilities, departments and staff they work with every day.

Correctional health care is a vast marketplace. Some $7 billion per year is spent to provide government-mandated health care to the 2.3 million individuals housed in the nation’s jails, prisons and juvenile facilities. At the state level, correctional health care costs have been growing by 10% annually. Don’t miss this chance to develop valuable prospects and reconnect with customers during three days of exhibit hall activities.

Did You Know?• 77% of last year’s attendees visited the exhibit hall at least

three times• 95% said they found the exhibit hall worthwhile• 78% said they visit to learn about products and services

Exhibitor Benefits• 2 full conference registration passes per 10’ x 10’ booth• Discounted registration for additional personnel (up to 5)• 75-word listing in the final program (deadline applies)• Electronic attendee lists for pre- and post-show marketing• Free listing in NCCHC’s online Buyers Guide• Lead retrieval technology available for rental on site• Opportunity to participate in raffle drawings• Discounted advertising in the conference programs and

CorrectCare• Priority booth selection for the 2010 Updates conference

Sponsorship OpportunitiesEnhance your presence and maximize marketing dollars through these outstanding opportunities.• Premier programming: Sponsorship of educational ses-

sions on hot topics demonstrates support of the correc-tional field and gives your company high-profile exposure.

• Final proceedings: The CD-ROM provides a lasting recordof concurrent sessions, with abstracts, handouts andPowerPoints. The sponsor is acknowledged on the cover.

• Internet Cafe: Enjoy a high-tech presence by sponsoring the exhibit hall computer stations, where attendees gatherto check e-mail and browse the Web.

• Exhibit Hall reception/luncheon/breaks: These events enable attendees to meet with exhibitors and network with colleagues while enjoying refreshments.

• Other opportunities: Conference bags, lanyards, water bottles, badges and banners are all good ways to boost vis-ibility. Have an idea we haven’t mentioned? Let us know!

Registration InformationThe meeting site is Disney’s Coronado Springs Resort inOrlando, FL. Standard booth sizes are 10' x 10'; double-sizeand premium spaces are available. For details or to reserveyour space, please see the Exhibitor Prospectus, available at www.ncchc.org, or contact us at [email protected] or773-880-1460.

Exhibitor Opportunity

National Conference on Correctional Health CareOrlando, Florida • October 17-21, 2009

WHERE WILL YOU FIND YOUR NEXT GREAT HIRE?

Looking to recruit exceptional correctional health care professionals? Find your next leadwith the National Commission on Correctional Health Care mailing list, a proven tool to reachover 30,000 physicians, nurses, mental health care providers, medical directors, nurses and other alliedhealth professionals and administrators. What’s more, you can pinpoint only those most interestedin your offer with multiple selections, such as job title, work setting and demographics. No othermarketing channel allows you such a targeted marketing opportunity.

Contact INFOCUS Today!Kerry Tranfa [email protected] 800.708.LIST (5478), ext 3247

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MARKETPLACE10% discounts are offered for Academy mem-bers (single copies) and for bulk purchases of asingle title. To order, or for an NCCHC catalog, visit www.ncchc.org or call 773-880-1460.

NCCHC Standards for Mental HealthServices in Correctional Facilities. These standards support an accreditation program for mental health services that operate underan authority different from health services.They parallel the standards for health servic-es in format and substance, but make moreexplicit what is required for adequate deliv-ery of mental health services. General areascovered include patient care and treatment,clinical records, administration, personnel andlegal issues. These standards can help facilitiesdetermine proper levels of care, organize sys-tems more effectively and efficiently, and dem-onstrate that constitutional requirements arebeing met. Glossary + index. Softcover, $69.95

Corrections Nursing: Scope and Standardsof Practice. Corrections RNs must practicein work settings and environments for which health care is not a primary mission, deliver-ing adequate and humane care in an unbiasedmanner. They must be qualified to address anenormous range of patient needs. They must understand and apply the concepts of primarycare services, employing skill sets of ambu-latory care, community health, emergency,occupational health, public health and schoolnursing. This book articulates the essentials of this specialty, its activities and accountabilities.American Nurses Association (2007). Softcover, 95 pages, $18.95

ADVERTISER INDEXBristol-Myers Squibb / Gilead – Atripla ..................Insert, 9

CCHP-Nursing ..............................................................................................24

Correctional Health Partners (CHP) ...........................................5

Correctional Medical Services (CMS) ....................................12

Dentrust Dental .............................................................................................4

Geo Group ......................................................................................................17

Gilead Sciences – Truvada ........................................................19-20

Hibiclens ............................................................................................................13

InFocus Marketing ...................................................................................26

MHM Services ............................................................................................BC

National Conference on Correctional Health Care ..IFC

NCCHC Standards ...................................................................................25

Prison Health Services (PHS)...........................................................22

Spectra Diagnostics .............................................................................. IBC

Wexford Health Sources ........................................................................8

About CorrectCare™CorrectCare is the quarterly magazine of theeNational Commission on Correctional Health Care. Its mission is to publish news, articles and com-mentary of relevance to professionals in the field of correctional health care.

Subscriptions: CorrectCare is mailed free ofecharge to members of the Academy of Correc-tional Health Professionals, key personnel ataccredited facilities and other recipients at ourdiscretion. To see if you qualify for a subscription,submit a request online at www.ncchc.org or bye-mail to [email protected]. The magazine is also posted at www.ncchc.org.

Change of Address: Send notification four weeksin advance, including both old and new addresses and, if possible, the mailing label from the mostrecent issue. See page 1 for contact information.

Editorial Submissions: Submitted articles may bepublished at our discretion. Manuscripts must beoriginal and unpublished elsewhere. For guidelines, contact Jaime Shimkus at [email protected] or 773-880-1460. We also invite letters or correctionof facts, which will be printed as space allows.

Come Join Our Winning Correctional Health Team, CFG Health SystemsCFG Health Systems, LLC (sister corp. of Center for Family Guidance, PC) is aphysician-owned and operated behav-ioral healthcare organization providing afull range of mental health services. We offer many diverse career opportunities with excellent benefits and are currentlylooking to place professionals within sev-eral correctional facilities in New Jersey or Pennsylvania:• Physicians (Psychiatry, General Medicine)• Dentists (General Dentistry)• Nurse Practitioners• PhD/RN’s/LPN’sInterested candidates please contact:Physician/Dentists: Frank Zura, Coordinator,Phone: 856-797-4760, [email protected]: Nancy DeLapo, Director, Phone 856-797-4761, [email protected]

NCCHC BUYERS GUIDE FORCORRECTIONAL HEALTH CARE

If you source or purchase products for your department, you havea powerful tool at your fingertips. The NCCHC Buyers Guide search engine continually indexes the Web sites of all companies represented inthe directory. You can easily locate products and services unique to thisfield using these options:

• keyword-driven search (like a traditional search engine) • category-specific search

Both methods produce the most relevant results on the Web without the clutter of a general Internet search.

A downloadable application enables you to search from a small window on your desktop, making the process even more convenient and time-efficient. Using the Request for Proposal (RFP) tool, you can contact a group of suppliers with one click of a button.

www.ncchcbuyersguide.com


Q & A

by Jennifer E. Kistler, MPH, andR. Scott Chavez, PhD, MPA, CCHP-A

Suicide Prevention Checks

QWe perform 15-minute checks on our potentially sui-cidal inmates. Is this practice in compliance with theG-05 Suicide Prevention Program standard?

APotentially suicidal inmates are those who are not actively suicidal but express suicidal ideation and/or have a recent history of self-destructive behavior.

These inmates should be observed at staggered intervals not to exceed every 15 minutes (e.g., 5, 10, 7 minutes). It depends on what you mean by 15-minute checks: If the observation is occurring regularly every 15 minutes,this is not in compliance with the standard. The idea is to check on the potentially suicidal inmate at irregularintervals, with no more than 15 minutes in between each check (see Compliance Indicator 1d). Lastly, if the poten-tially suicidal inmate is placed in isolation, then constantobservation is required.

Emergency Response Critiques

QRecently, we had a fire in our facility and had to implement our emergency response plan and evacu-ate a housing unit. Can we use the critique of this

incident toward meeting the A-07 Emergency Response Plan standard, even though there were no casualties?

AYes. Actual emergencies, whether or not injurieswere involved, can certainly be critiqued and sharedwith staff to meet the intent of this standard. (See

the Discussion section in the standard.)

Clinical Mortality Review

QTypically, we wait for the results of the autopsy inorder to complete a clinical mortality review. Thisoften takes 60 days or more. Is it acceptable to wait

for the autopsy results before completing the clinical mor-tality review?

ADeath reviews should be completed in a timelymanner even if the autopsy results are not yet returned. According to standard A-10 Procedure

in the Event of an Inmate Death, all deaths should bereviewed within 30 days (see Compliance Indicators).Reviews consist of an administrative review, a clinicalmortality review and, if the death is by suicide, a psycho-logical autopsy. The intention of this standard is to avoid preventable deaths; therefore, any corrective actions identified through this process should be implemented and monitored sooner rather than later and treating staff should be informed of the administrative review and clin-

ical mortality review findings. Clinical mortality reviews can be appended with information from the medical autopsy report.

Tuberculosis Screening

QI work in a jail and would like to know if we are required to complete a screening test for tuberculosis as part of the receiving screening.

ANo, the E-02 Receiving Screening standard for jailsdoes not require inmates to receive a tuberculosistest at the time of the receiving screening. Mainly

this is because detainees often do not remain in the facil-ity long enough to have the tuberculin skin test read.However, TB testing is required under the E-04 Initial Health Assessment standard (see Compliance Indicators 2e and 5e). We also recommend that a tuberculosis con-trol plan be followed that is consistent with published guidelines from the Centers for Disease Control and Prevention. Please note that for prisons, a screening test for tuberculosis is required under the Receiving Screeningstandard (Compliance Indicator 10).

Health Assessments for Infirmary Orders

QI was wondering if a history and physical is required as part of the infirmary admitting order, under theG-03 Infirmary Care standard?

ANo. A patient may have just had a health assess-ment prior to being placed in the infirmary, so an additional history and physical would not be

required. An infirmary order should include the admit-ting diagnosis, medication, diet, activity restrictions,diagnostic testing required, frequency of vital sign moni-toring and other follow-up (Compliance Indicator 8a). Admission to and discharge from the infirmary should occur only on the order of a physician (or other clinician where permitted by virtue of his or her credentials andscope of practice).

Jennifer E. Kistler, MPH, is NCCHC’s director of accredita-tion. R. Scott Chavez, PhD, MPA, CCHP-A, is NCCHC’s vice president and liaison to the policy and standards committee. If you have a question about the NCCHC standards, please write to [email protected] or call 773-880-1460.

For an archive of past Standards Q&A questions, visit www.ncchc.org and go to the Resources section. There you will also find an archive of Spotlight on the Standards columns. These articles shed light on the nuances of various standards, explaining the rationale behind them, the intend-ed outcomes, compliance concerns and the impact on the accreditation process.

Expert Advice on NCCHC Standards

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Documents

2009 23 2 CrrectCare - National Commission on Correctional ... · PDF fileFull page Ad 8” x 10 1/2” Page 2 National Conference on Correctional Health Care October 17–21, 2009•