Infirmary-Level Care

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Prior to publication of the 2018 Standards for Health Services for jails and prisons, an infirmary was defined as a place within a facility where patients in need of a higher level of care were housed. However, the physical location was often used to house other inmates whose health or custody needs required a more protective environment than that in general housing (e.g., juveniles, administrative or protective custody inmates, patients with medical equipment).

Thinking of an infirmary as a location caused two issues. The first arose when health staff applied the former G-03 Infirmary Care compliance indicators to inmates in the “infirmary” who did not need of that level of care. This wasted valuable staff time and resources. The second arose when there was a belief that the facility did not have an infirmary even when that level of care was being provided. The standard’s requirements were not followed, although some patients truly needed more frequent monitoring and skilled nursing intervention. The 2018 Standards focus on the level of care provided, not a designated area.

Definition and Policy Development
Infirmary-level care is defined as care provided to patients with an illness or diagnosis that requires daily monitoring, medication and/or therapy or assistance with activities of daily living at a level needing skilled nursing intervention. Typically, this includes patients who require more intensive care than can be provided in the general population and for a period of 24 hours or more. Patients who need skilled nursing care but do not need hospitalization or placement in a licensed nursing facility and whose care cannot be managed safely in an outpatient setting would qualify for infirmary-level care.

Administrators need to determine if patients who fall into this category will be housed in the facility. This frequently depends on the available resources and skill level of the health staff. If the facility does not have the appropriate resources for these types of patients, policies should be developed that outline how patients who need this level of care will receive it (e.g., transfer to local hospital, transfer to another facility). However, if resources allow infirmary-level care on-site, then policies should define the scope of medical, psychiatric and nursing care available to these patients.

Logistical Considerations
Once the scope of on-site care is determined, logistics need to be considered. Infirmary-level patients may be housed in a single designated area or in locations throughout the facility, as long as all requirements of the standard can be met. For example, patients in need of infirmary-level care must always be within sight or hearing of a staff member, which could be a custody or health staff employee. This is a change from the 2014 standards, where only a qualified health care professional could be the person within sight or hearing at all times.

A qualified health care professional must also be able to respond in a timely manner. Administrators should consider the response times of qualified health care professionals when determining housing locations for infirmary-level patients. The more security barriers between the response personnel and the patient (e.g., multiple locked doors or sliders, housing on a complex far removed from health staff), the less likely it is that a qualified health care professional can respond in a timely manner.

Staffing
Health care staffing should be based on the number of patients who need infirmary-level care, the severity of their illnesses and the level of care required for each. It is recommended that patients who need psychiatric infirmary-level care be supervised by mental health clinicians. A supervising RN should ensure that care is being provided as ordered on a daily basis.

The frequency of nursing and provider rounds should be based on clinical acuity and categories of care provided. Many systems choose to adopt several level of care (e.g., level 1-4, color-coded levels), defining the types of patients in each category and determining the frequency of rounds for each. This type of system may help keep health staff consistent with following treatment plans.

Documentation
Patients should be enrolled in infirmary-level care by provider order. Health records should contain the following:
• Documented reason for infirmary-level care
• Treatment plan
• Monitoring plan
• Complete documentation of care and treatment provided

When a patient no longer requires infirmary-level care, the discontinuation should also be by provider order.

More Flexibility for Clinicians
As facilities transition to the 2018 standards, it is important to remember the shift in focus of this standard: It is not a physical location that defines infirmary-level care, but the scope of care provided. Whether or not there is a designated “infirmary” area, clinicians now have more flexibility to develop treatment plans for on-site care when, in their clinical judgement, resources are available to provide the ordered care. The changes also removed many specific documentation requirements, again giving the clinicians flexibility when documenting the treatment plan.

[This article first appeared in the Winter 2019 issue of CorrectCare.]

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