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Spotlight on the Standards
The
Most Important Standard: Receiving Screening
For the
correctional facility concerned about effective health services
management, essential standard Receiving Screening (E-02) might
well be the most important of all standards in the NCCHC
manuals. From the first jail
version in 1977...
“Receiving
screening is performed on all inmates upon admission to the
facility before being placed in the general population or
housing area, with the findings recorded on a printed screening
form approved by the responsible physician”
to
the current version common to jails, prisons and juvenile
facilities...
“Receiving
screening is performed on all inmates immediately upon arrival
at the intake facility”
this
standard is meant to protect the individuals being admitted,
address liability for the facility and safeguard the general
health environment for staff, other inmates and visitors.
The
standard’s threefold intent is outlined in the Discussion
section: “(1) to identify and meet any urgent health needs of
those admitted; (2) to identify and meet any known or easily
identifiable health needs that require medical intervention
before the health assessment; and (3) to identify and isolate
inmates who appear potentially contagious.”
Quick,
Effective Screening
Receiving screening can
be accomplished quickly and effectively as soon as an inmate
enters the facility. For NCCHC’s purposes, screening is a
brief but comprehensive process that for the trained screener
normally will take about 10 minutes or less.
Depending on
the number of inmates entering and the support available to
screening personnel, the intent of “immediate” can be met
with appropriate modifications. For example, when 20 individuals
come in at one time, a two-tiered process may be useful. A
trained officer checks each entering inmate for need of
immediate medical attention and asks about any urgent health
needs. Those needing immediate attention undergo the full
screening process with health staff. All other newly received
inmates are watched in the intake area, where signs explain how
to access health services, until the health staff gets to each
in turn and completes the full screening.
If no health
staff are on site, an on-call professional can be telephoned for
guidance on steps to take to meet the inmate’s health needs,
including further evaluation in a community emergency room.
Meeting
Identified Needs
The purpose of
identification of health needs is to meet those needs as
dictated by the arriving inmate’s clinical condition. In fact,
this standard is not fully met until the needs are met. To put
it simply, appropriate clinical intervention must occur in a
timely fashion in keeping with community standards of care.
Ideally,
receiving screening is done by health staff, and the more
experienced the screener, the more effective the process.
However, the reality is that many correctional facilities,
especially medium to small jails and juvenile facilities, health
staff are not on site “24/7”. Even in facilities where a
nurse is present, it may not be possible for the nurse to do the
screening. NCCHC standards do allow for trained correctional
staff to do the receiving screening in facilities with an
average daily population of less than 500.
No matter who
does the screening, however, findings of immediate, urgent and
ongoing health needs must be followed up with further evaluation
and treatment by qualified health professionals. Even in
facilities where health staff are not on duty, protocols must be
in place to access qualified health providers who can either
respond personally or direct staff in taking needed action.
Facility staff
usually can recognize when an incoming inmate presents with
clear emergency needs requiring immediate intervention.
Virtually all facilities today respond immediately to bleeding
wounds or suicide threats. Such intervention does not always
occur, however, when the screening identifies other significant
health needs. Lack of appropriate training, poor procedures,
insufficient guidelines and miscommunication all contribute to
the possibility that needed services are inappropriately
delayed.
The
insulin-dependent inmate who states his need for a meal and ends
up in an acute low-blood-sugar reaction, the depressed inmate
who does not receive her antidepressant for a week after
admission and cuts herself, the hypertensive inmate who ends up
in the ER because his usual medication was not on the formulary,
the inmate in DTs because no watch was initiated when he arrived
in an inebriated state—all are the result of poor policies and
procedures or lack of follow-through.
Once problems
are identified, failure to intervene in a timely fashion can
have dire consequences. Consider, for example, the suffering of
an adolescent with impacted wisdom teeth who gets no pain
medication; staff exposure to contagious disease when the inmate
with active TB is admitted to general population; or the
significant legal action a facility may face when an inmate dies
because her brain-injury-related seizure was not identified.
Getting It
Right
To meet the intent of the
screening for those with identified health needs, facilities
must have clear policies and procedures developed by the
responsible physician, health authority and legal authority and
must ensure that they are followed. When health staff are not
available on site to assess the significance of the findings,
on-call procedures can dictate that the screening officer
contact a health professional by telephone as the next step.
Nurses who
provide screening or who are the health staff consulted by
screening personnel should understand when they need to contact
the midlevel practitioner or physician and not exceed their
scope of practice in determining dispositions. The same clinical
decision making that occurs in free world settings should be in
place in correctional settings. It is the nature and extent of
the medical or mental health condition that dictates the
response, not the legal status of the inmate.
The
understanding and positive working relationship between custody
and health staff concerning their roles when an inmate is
admitted are factors that affect timely, appropriate
interventions. Health staff need orientation that enables them
to appreciate security concerns, while custody staff require
training to understand that meeting the identified health needs
of inmates being admitted is as much a legal mandate for
correctional authorities as for health professionals.
One common
problem is the inmate admitted who is on medications and for
whom delay or change in medication may have significant negative
results. NCCHC does not dictate how this is to be done, but a
process must be exist to ensure that inmates continue medication
as medically necessary in a timely fashion. The responsible
physician may implement a policy that allows medications
accompanying the inmate to be administered until the physician
sees the inmate. This would require safeguards such as accepting
only medications in original pharmacy containers, individually
labeled, with a telephone check to the prescribing physician or
dispensing pharmacy.
Another option
is to disallow the use of medication not provided by the
facility, with arrangements to obtain any necessary medications
by at least verbal order of the facility physician. Protocol may
require that the physician alone may prescribe the medication,
but this means that the physician must be on site during
admission hours or come in after hours as needed.
Whether the
screening is done by health or trained correctional staff,
periodic reviews of outcomes and refresher training should be in
place. Review and debriefing with staff involved when a problem
develops should be routine. When something is missed and bad
outcomes happen, it is critical that the review process be one
not of fault finding, but rather of identifying where things
went wrong and what corrective action is needed. This is where
the link to an active continuous quality improvement program is
beneficial.
(This article first appeared in the
Summer 2004 issue of CorrectCare.)
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Do you have a question about the NCCHC standards for health services?
Contact us at:
Standards Q&A
National Commission on Correctional Health Care
1145 W. Diversey Pkwy.,
Chicago, IL 60614
Phone (773) 880-1460 • Fax (773) 880-2424
E-mail info@ncchc.org
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