CorrectCare

Sick Call Out of Control? This Jail Nurse Tamed the Beast

By Margo Dowdy, RN, C

When our regular sick-call nurse quit, I thought I’d have to fight hordes of senior RNs clamoring to take on her position. Boy, was I wrong.

Cumberland County Jail in Portland, ME, has a population in the vicinity of 500 inmates on nine pods (two smaller and seven larger ones). Triaging out on the pods and utilizing nursing protocols appeared to me to be the epitome of interesting work. I really wanted to go out among the jail population, work with the inmates’ myriad medical, dental and psychiatric problems—and fix these problems wherever I could.

When the dust settled and I had finally experienced the sick-call regimen, however, I found that I had leapt blindly into the chasm of frenzied overwork—alone. I discovered why nobody wanted this job. Our sick-call procedures were very disorganized and time-consuming, and everything conspired to make the job more difficult.

The sick-call slips were available to inmates 24/7. This system allowed them enough time to think of trivial complaints. (For example, I had to address issues such as, “I’m allergic to hot dogs and beans.” When I asked the inmate which doctor had diagnosed this allergy, he just chuckled.) Inmates wrote their medical requests on the slips and placed them in boxes that were emptied nightly on all nine pods.

In the morning, I had to wade through hundreds of slips, many of which described multiple problems (“my foot hurts, I have heartburn, I have athlete’s foot and I have to see the psychiatrist”). Triaging the requests in the medical department took hours. By the time I actually got to the pods, I found that I was able to take care of only 15 to 20 medical requests, and that was on a good day.

Naturally grievances ran rampant. In the inmates’ minds, their medical issues were being ignored since it was impossible to process all of their requests in a timely manner.

No one was happy—not the inmates, not me, not the medical administrators. Our director of nursing and our health services administrator decided that enough was enough: We had to fix this.

Seeking a Solution
Thus, our three-member committee for quality improvement was formed, made up of veteran nursing staff members who were familiar with the situation and motivated to improve it. The committee was charged with assessing the problem and suggesting solutions, and was given time and resources during work hours to do so.

Our first task—identifying the problem—was simple. The present system placed too many demands on one person to be handled in a timely fashion. The first few times I did sick call, because of the sheer volume of daily requests and the sheer impossibility of getting to them all, I found myself triaging requests from weeks ago. The committee counted the slips coming into the sick-call boxes, and they averaged around 118 per 24 hours—all to be addressed by one nurse.

We had to find a way to change a system that could not work, and we did. We created a pilot program that we called “open sick call.” Using this model, I would go to a pod with the sick-call slips and call out, “Open sick call! Fill out slips, stand in line and come on in when the other guy comes out!” Then I’d set up shop in the triage room and cringe.

In the first few months it was a feeding frenzy. Following this procedure, I could get through only a few pods in a day while promising the other pods I’d get to them in the next week or so. The next day, I’d do open sick call in the next pods.

But by going through the pods in order, I soon found that I could complete all nine in about a week and a half. I now could take care of around 56 problems per day instead of the usual 15 or 20.

This had a snowball effect: Because sick call was being done more quickly, the inmates’ medical problems were not compounded and so they had fewer sick-call needs. After a little while, I could get the entire jail done in a week. Medical needs were being met almost immediately, so there was no backlog.

The pilot program worked so well that it quickly became official procedure. With this system, the sick-call nurse was capable of triaging and addressing inmates’ medical problems on all nine pods twice a week.

Fine-tuning the Process
However, even that did not meet the NCCHC standards, which state that all sick-call issues must be addressed within 24 hours on weekdays and 72 hours on weekends (J-E-07).

What a daunting task. Time to tweak the process. When we did, we found that we actually could meet the standards.

We simply divided the work. The regular sick-call nurse continued to handle the seven large pods, while the intake nurse took over the task in the two small pods, where there are usually only a few issues to address. With this system, sick call for the jail initially took two days. Very soon, however, we were doing on-site sick call for the entire jail on a daily basis five days a week.

Still not quite good enough. To meet the standards, now we also do sick call on weekends and holidays, even though technically no sick-call nurse is on duty those days and it’s handled by the intake nurse.

Our new sick-call procedure works this way. Monday through Friday, the sick-call nurses go to the classroom in each pod throughout the day, announce sick call and leave the slips on tables in the middle of the pod.

The inmates line up for the slips and fill them out on the spot. They then come in to see the nurse, one at a time, first come, first served. The nurse reads the slip and listens to the inmate describe the problem or problems. This is necessary because not all inmates can write adequate descriptions. If an inmate cannot read or write, I fill out their slip for them. I happen to speak Spanish, so I can help Spanish-speaking inmates describe their problem. (I should stress that communication skills are important to this whole procedure.)

So first I read and listen. Second, I assess the inmates while they read the pertinent information about their specific problem from the nursing protocol book. If they cannot do this, I read it to them, or translate for Spanish-speaking inmates.

Assessment and Triage
The nursing assessment usually takes about five minutes, depending on the problem. Most problems can be dealt with by normal nursing protocols. If it’s a common cold, for example, I give the inmate the normal cold pack.

If the problem is something that the nursing protocol does not address (for example, someone with hepatitis C complaining of liver pain), the inmate is put on a “provider’s list” to see the facility’s physician or physician’s assistant.

If it’s a psychiatric problem, I take the sick-call slip afterward and drop it in the psych box for triage by our mental health staff. Of course, if the inmate’s need is urgent, then the mental health staff is summoned immediately.

Dental issues are assessed via on-site sick call and addressed appropriately. For example, indications of an abscess would be placed on the medical provider’s list to be seen immediately to determine the need for antibiotics. If the need isn’t urgent, the inmate is placed on the dentist’s list and is given appropriate pain meds as per nursing protocols.

As a rule, the aim is to keep inmates off the provider’s list, thereby reserving that list for the more serious problems. By going through this process regularly, inmates become better acquainted with the entire sick-call process and learn to handle it more efficiently. This, too, lowers the number of visits and time per visit.

On weekends and holidays the procedure differs somewhat. As there is no sick-call nurse on schedule, the intake nurse goes to all nine pods and hands out sick-call slips to all who request them. We plead for mercy, though, asking the inmates to save trivial complaints for later.

The slips are taken back to medical and triaged there. Urgent issues are addressed immediately, while routine requests (“Can I have another mattress?”) will be addressed on Monday if it’s a weekend, or the next day if it’s a holiday.

As always, walk-ins are welcome 24/7. And our corrections officers are most diligent and will call the medical department whenever an inmate requests medical services. Thus, all of the inmates’ medical issues are addressed, whether by on-site sick call or by triage, seven days a week.

Now, rather than being overwhelmed with requests, I find that sick call is sometimes greeted by silent indifference. I go to the pods, throw sick-call slips on the table and yell. “Open sick call! Anything new since...umm...yesterday? Please?” They mostly tell me to go away.

— About the author:  Margo Dowdy, RN, C, is employed by Correctional Medical Services and works at the Cumberland County Jail in Portland, ME.

[This article first appeared in the Fall 2005 issue of CorrectCare.]