Commentary: Providing Infection and Skin Care Education in Prisons
Marie Brown-Etris, RN, CWON, CCHP
In response to the article on inmate care in a Brazilian prison, Wound Management & Prevention requested the perspective of Marie Brown-Etris, RN, CWON, CCHP, a certified correctional health care provider for the Philadelphia (Pennsylvania) prison system. The author extends sincere appreciation to Elizabeth Dolan-Bird, MHA, BSHA, RN, CCHP, Regional Health Educator; and Sharon Bunting-Talarowski, BSN, RN, CCHP, Regional Infection Control Coordinator, for providing information for this commentary.
Infection control and education are taken seriously in jails and prisons, where hundreds to thousands of people can live in one very large building in close proximity and share community showers. In the Philadelphia Prison System, the Regional Infection Control Coordinator and Regional Health Educator oversee infection control and education for approximately 5000 inmates at any given time, as well as the 240 nurses plus other professional health care providers, administrative staff, ancillary health care staff, and hundreds of correctional officers. Their responsibilities include dealing with communicable diseases, vaccinations, and interfacing with city representatives and the city health department. Our facility not only provides these services, but it is also accredited by the National Commission on Correctional Health Care (NCCHC) for Health Services in Jails.
Because educating inmates was the focus of the article on the Brazilian prison population, I will focus my commentary on how education, both for staff and inmates, is handled where I work.
Educating Staff and Inmates
There is a contractual and collaborative relationship between the City of Philadelphia and Corizon Health, the company providing the health care services. Correctional officers (COs) are city employees, and health care providers are employees or contractors to Corizon.
COs. The COs are our first responders. If an inmate experiences bleeding from a cut incurred while working in the kitchen or from an altercation, these officers have been trained extensively on response, both from a security and health care perspective. This includes initial first aid, personal protective equipment, blood spill containment, blood-borne pathogens, and making the decision to alert the medical response team or bring the injured inmate to the medical area. All COs are CPR-certified and are mandated to attend annual training that includes education regarding various issues such as disease processes, initial response for seizures and chest pain, and infectious diseases such as human immunodeficiency virus (HIV), shingles, flu, colds, and hepatitis. Hepatitis A is a concern due to a recent outbreak in Philadelphia. Our Infection Control Coordinator is currently overseeing vaccination of COs, health care providers, and high-risk inmates. COs also are mandated to attend a biannual NCCHC Officer Training (ie, health-related training in order to promote recognition of serious medical health problems requiring immediate care). This includes topics such as blood-borne pathogen exposure, handwashing techniques, and understanding the Health Insurance Portability and Accountability Act.
COs also are required to attend an annual 3-hour training class given by our Regional Health Educator on various skin issues and interventions, including abscess, rashes, scabies and lice, and handwashing technique. This training utilizes a variety of instructional tools, including handouts, manuals, and visual projections. The educator also oversees the “monthly roll call,” a 3-minute session that provides a DVD on such topics as hepatitis and blood-borne pathogens that all COs must attend.
Nursing staff. Health care personnel of all levels are provided a variety of learning opportunities. I give a vivid PowerPoint presentation on wound interventions and healing to our nursing and medical staff. In addition, Corizon Philadelphia Region presents an annual Nursing Competency Skills Fair, which is mandatory for all 240 nurses. Every nurse must attend one session, each designed to be interactive, educational, and fun. Each station focuses on a different skill set, including trauma, respiratory, and cardiac concerns, to name a few. For example, a variety of dressings or interventions will be displayed at the wound care station, and the nurses will play a match game to connect the intervention to the appropriate wound. The nurses are required to complete competency sheets for each station.
Inmates. When an individual is arrested and incarcerated, the intake process includes testing for tuberculosis, HIV, and sexually transmitted diseases (STDs). If any of these are identified, protocols for intervention will be followed by various medical personal. The intake process also includes nurse identification and treatment of various types of wounds (eg, abscesses and boils). Intravenous (IV) drug abuse has increased the development of abscesses in the community; we are noting these on intake.
Our Infection Control Coordinator maintains skin/soft tissue surveillance spreadsheets to track prevalence, incidence, and other pertinent medical information. Newly incarcerated individuals are quarantined for a period of time and then released into the prison population when cleared or appropriate. Our Infection Control Coordinator has developed educational fact sheets pertaining to Staphylococcus infections and methicillin-resistant S aureus (MRSA) for distribution to inmates. These sheets include information regarding what is MRSA, do’s and don’ts of MRSA, how to help prevent becoming infected with MRSA, and who to notify if you should develop a rash, fever, or chills. The Infection Control Coordinator also has developed a video that is shown inhouse on a closed circuit loop in which she discusses such things as Staph infections, why it is important to take antibiotics as prescribed when ordered, and proper handwashing techniques. Personal hygiene signs are displayed in housing areas with instruction on how to avoid an infection (eg, do not share personal items such as deodorant, razors, or tooth brushes).
Educational posters on such topics as smoking cessation and proper handwashing technique are displayed throughout our housing and medical areas; patient literature on such topics as HIV and STD prevention and treatment also are available.
Our computer system provides access to patient education materials that are specific to various disease processes. These publications can be printed and reviewed with the patient, who can keep them for future reference. I also utilize literature and educational materials from our industry manufacturers. I have educational booklets on venous ulcer disease and compression, diabetic foot ulcers and offloading, and pressure ulcers. I sit with my patients and educate them utilizing these booklets and then give them to the inmates to keep and read, just as I would outside of the prison. For ostomy patients, I educate just as I would out in the community utilizing educational booklets from ostomy manufacturers; these materials also are available to the nursing staff for distribution to patients. I also incorporate materials from the United Ostomy Association of America (eg, their Phoenix magazine) and the Philadelphia Ostomy Association’s newsletter, so inmates have a local resource when released from custody. If the possibility exists that they will be out of custody before I would next see them, I make sure to provide a list of the ostomy equipment they are using and a medical equipment company resource. All ostomy patients enjoy my instruction on the anatomy and physiology of the gastrointestinal tract utilizing the 5 foot poster of the GI system that hangs in my exam room.
Inmate workers. The Philadelphia Prison System includes workers in a multitude of areas including the kitchen, housekeeping, laundry, and our medical areas. These employees go through an educational process with involvement from our Infection Control Coordinator specific to their work area. Medical area workers are trained on how to handle red bags and medical waste for biohazard pick up, kitchen workers are educated on safe food preparation and handling practice, and laundry workers are instructed to add a specific amount of bleach to every laundry load to help kill bacteria. Instructional signs also hang by our washing machines.
Inmate buddy training program. This select program trains inmates how to buddy with others who may require physical assistance with such care areas as eating, transfer from bed to wheelchair or gerichair, or wheelchair transport to a clinic appointment in the medical area. This training is provided by both Corizon health care team members and members of the Philadelphia Department of Prisons. I have wound patients who are transported via wheelchair to my clinic by a buddy, who also helps transfer the inmate onto the exam table. Our Regional Health Educator provides classes for Infirmary workers covering topics such as caring for inmates with dementia, aspiration precautions, handling soiled linens, personal protection, safe transfers, and proper cleaning of the environment. These infirmary buddies are an extension of our medical team. My instructions to these men include the importance of and how to check for proper inflation of air mattresses and seat cushions, proper positioning and repositioning in a chair, the use of wedges and pillows for positioning, the importance of utilizing pillows for heel suspension, and how to properly apply heel protectors when transferring the patient back to bed. I also provide instruction on various wound types, wound healing, and dressings. I have encouraged a few of these men to explore opportunities in health care and related fields when released from custody. Inmate participation in the buddy program provides for reduced sentencing.
General wound care instructions and precautions.
Showering with dressings. I tell my patients MRSA grows on wet and dry surfaces and lives for about 30 days so that they take their wound care seriously. Although showers are cleaned regularly, many people from all walks of life are using them. I instruct my patients to take their showers with wound dressings in place, and/or cover them with a plastic bag if available; the nurse will change their dressing in the medical area at scheduled wound care times. If an inmate is unable to get out when wound care is “called,” (eg, because they are being housed in protective custody or punitive segregation (“the hole”), I add a transparent film dressing to protect the dressing from getting wet to allow them to shower when given the opportunity.
Self dressing change. Some inmates can competently perform their own dressing changes because they have had their diabetic foot ulcers or venous leg ulcers before incarceration and were changing their own dressings at home. Depending on the status of the wound and treatment ordered, an inmate may be provided products and do his own dressing change in his housing area. Once a wound is improving, I will cut pieces of hydrocolloid or foam dressing and tape, place them in a clear zip bag, and write the inmate’s name, prison photo number, and “KOP” (keep on person) on the bag. This identifies that the inmate is permitted to possess these supplies so they won’t be confiscated by the correctional officers as contraband. However, these supplies are subject to confiscation during a cell block shake down.
Supplies. Our facility has a formulary for our wound supplies that is established within Corizon Health corporate. Administrators of the individual housing areas and buildings place orders. In Philadelphia, we have a full range of wound dressings available to meet our patients’ needs; special nonformulary items can be obtained upon special request.
Understanding Our Roles
My job is to care for patients and collaborate closely with other health care providers so we can heal our patients’ wounds, prevent pressure ulcers from occurring, get patients ambulating, and see they are provided leg prothesis or diabetic shoes. I collaborate closely with our physical therapy (PT) team; I once requested that a man who was paraplegic secondary to a gun shot wound be referred to PT. He was wheelchair bound when initially incarcerated from the community; when I met him, he had a stage 4 pressure ulcer. Because of his category of spinal cord injury, our PT and PT aides were able to work with him and within about 6 weeks he came into my wound clinic using a walker.
Our nurse liaison monitors the status of our hospitalized patients. She travels to the various hospitals and acute rehab facilities in the city to ascertain patient status and speaks with discharge planners, nurses, physicians, and the patient. She reports their status back to our Regional Medical Director, our Infirmary Chief Medical Officer, and charge nurse so our Infirmary staff can plan for incoming patients’ needs, such as antibiotics for their peripherally inserted central catheter lines, dialysis, or physical therapy (all provided in-house), pressure redistribution support surfaces, and negative pressure wound therapy.
I commend the Brazilian corrections health care team for developing a skin care manual for incarcerated individuals in their country. I can envision its use expanding into other countries. Skin care may sound so simple, but in the correctional environment it can be a challenge.