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Spring 2009 | Volume 23 | Issue 2


TThe magazine of the National Commission on Correctional Health Care

Nursing Practice
The Time Is Right!
Holistic Health Care Offers
Promise of Positive Outcomes
DOC-University Pharmacy Project
National Conference Preview

National Commission on Correctional Health Care

1145 W. Diversey Parkway, Chicago, IL 60614

National Conference
on Correctional
Health Care

Full page Ad

October 1721, 2009 Orlando

Presented by


8 x 10 1/2
Page 2

Just as architecture holds the power

to reshape the horizon, knowledge holds the
power to transform health care. The National Conference gives you
the blueprintss to understand, develop and imp
plement cost-effective, evidence-b
systems of care. Packed with lectures, panels, workshops, posters, exhibits and networking, th
his meeting will give you the knowledge and skills to reshape not only your institutions
health services, but also the well-b
being of your patients and the community at large.

For more information,

email info@ncchc.org, call 773-880-1460 or visit www.ncchc.org.

Spring 2009 | Volume 23 | Issue 2

CorrectCare is published quarterly by the National Commission on Correctional Health Care, a not-for-prot organization
whose mission is to improve the quality of health care in our nations jails, prisons and juvenile connement facilities.
NCCHC is supported by the leading national organizations representing the elds of health, law and corrections.




CDC Issues H1N1 Influenza

Guidelines for Corrections


National Conference Preview

Legal Affairs: Beware of the
Specialists Recommendations


News Watch
Clinical News Brief: Earlier ART
Yields Better Outcomes


Journal Preview: Brief

Negotiation Interviewing Lowers
HIV Risk, Increases Testing

Holistic Care Offers Promise of

Positive Health Outcomes


Spotlight on the Standards:

Medication Services

DOC-University Rx Project
Yields Big Savingsand
Awardin Rhode Island


Juvenile Voice: Nutritional Issues


Evidence-Based Nursing
Practice: The Time Is Right!



Force Feeding for Hunger Strikes


Joseph 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, CCHP
National Medical Association
Patricia Blair, JD
American Bar Association
Kleanthe Caruso, MSN, CCHP
American Nurses Association
Robert Cohen, MD
American Public Health Association
Eileen Couture, DO, CCHP
American College of Emergency Physicians
Charles A. Fasano
John Howard Association
Kevin Fiscella, MD
American Society of Addiction Medicine
Robert J. Gogats, MA
National Association of County & City Health Ofcials
Robert L. Hilton, RPh, CCHP
American Pharmacists Association
Renee Kanan, MD
American College of Physicians
JoRene Kerns, BSN, CCHP
American Correctional Health Services Association
Douglas A. Mack, MD, CCHP
American Association of Public Health Physicians
Nicholas S. Makrides, DMD
American Dental Association
Edwin I. Megargee, PhD, CCHP
International Association for Correctional and Forensic Psychology
Charles A. Meyer, Jr., MD, CCHP-A
American Academy of Psychiatry & the Law
Eugene A. Migliaccio, DrPH
American College of Healthcare Executives
Ronald C. Moomaw, DO
American College of Neuropsychiatrists
Peter C. Ober, PA-C, CCHP
American Academy of Physician Assistants
Peter E. Perroncello, MS, CCHP
American Jail Association
George J. Pramstaller, DO, CCHP
American Osteopathic Association
Patricia N. Reams, MD, CCHP
American Academy of Pediatrics
Judith Robbins, LCSW, CCHP-A
National Association of Social Workers
Sheriff B.J. Roberts
National Sheriffs Association
David W. Roush, PhD
National Juvenile Detention Association
Jayne Russell, MEd, CCHP-A
Academy of Correctional Health Professionals
Ronald M. Shansky, MD
Society of Correctional Physicians
Alvin J. Thompson, MD
American Medical Association
Ana Viamonte Ros, MD
Association of State and Territorial Health Ofcials
Barbara A. Wakeen, RD, CCHP
American Dietetic Association
Henry C. Weinstein, MD
American Psychiatric Association
Ronald Wiborg, MBA
National Association of Counties
Representative Appointment Pending
National District Attorneys Association

Field Notes
Classified Ads and Ad Index
Standards Q&A

Copyright 2009 National Commission on Correctional Health Care. Statements of

fact and opinion are the responsibility of the authors alone and do not necessarily
reect 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 space
allows. Articles without designated authorship may be reprinted in whole or in
part provided attribution is given to NCCHC.
Send correspondence to editor Jaime Shimkus
NCCHC, 1145 W. Diversey Pkwy, Chicago, IL 60614
Phone: 773-880-1460; Fax: 773-880-2424
E-mail: editor@ncchc.org; Web: www.ncchc.org

Survey Findings Will Help to Bridge
Gaps in Pandemic Flu Assistance
As always, NCCHC is at the forefront in helping correctional 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 great
importance is collaboration with county and state health
departments, which should have the resources to help correctional facilities before and during such an event.
As part of a nationwide effort to improve those relationships, NCCHC recently conducted a survey in cooperation
with the National Association of County and City Health
Officials and the Association of State and Territorial Health
Officials (both are NCCHC supporting organizations). We
sent an e-mail survey to the health administrators of all
NCCHC-accredited facilities asking about health department help in preparing for and responding to a possible
H1N1 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 Education

Even in these dicey economic times, savvy correctional
health professionalsand the administrators who approve
their budgetsknow a good deal when they see one.
Thats why they came out in droves to the Updates in
Correctional Health Care conference in April. It didnt hurt
that the meeting was held in fabulous Las Vegas! But the
real reason for the strong attendance, which was on par
with the previous year, was because of its intentional focus
on presentations designed to help you meet the fiscal and
human resources challenges of these times. With 55 sessions on a broad range of topics and plenty of quality time
for networking, this meeting was a sure bet!

of events
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.

The National Commission on Correctional Health Care

has no membership or dues. NCCHC does not require
any affiliation to be considered for accreditation, certification 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 accept
gifts or consulting fees from those we accredit or certify. NCCHC is impartial, unbiased and expert. And
dedicated only to recognizing and fostering improvements to the field of correctional health care.

Facilities Look to NCCHC for Help

When things go awry, correctional facilitieseven those
that are not accreditedturn to NCCHC for assistance. For
example, in Wisconsin, two deaths at a county jail prompted the sheriff to bring in NCCHC for an independent
consultation. Our report detailed 27 recommendations for
improvement and the jail staff is now busy with implementation, starting with the big issues, such as increasing physician hours and improving communication between the
county and the contract management firm that provides
health 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 strong
sense of pride and accomplishment in become accredited. In Virginia, the Albemarle-Charlottesville Regional Jail
recently received initial accreditation. Although the jails
health 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.

NCCHC Supports Global Principles for Socially Responsible

Associations & Nonprofits
NCCHC has always been committed to operating in a socially responsible manner.
Now, weve made that commitment in writing. NCCHC is proud to be a signatory 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 corporate citizenship among members of the association community. They are based
on universally accepted principles established by the United Nations Global
Compact. The Global Principles also help create a network of associations, nonprofits, 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/

Spring 2009 CorrectCare


CDC Issues H1N1 Influenza Guidance for

Corrections and Detention Facilities

uidance for correctional facilities on novel influenza

A virus (H1N1, initially known as swine flu) was
issued May 24 by the Centers for Disease Control
and Prevention. The recommendations aim to ensure continuation of essential public health services and protection
of the health and safety of inmates, staff and visitors. The
document is labeled interim to highlight the fact that
recommendations may need to be revised as more information becomes available.
Corrections-specific guidance was deemed necessary
because of the special risks and considerations that
these institutions pose. For instance, options for isolation
or removal of ill inmates are limited. Also, it is essential to
maintain 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 and
isolation of identified cases. A summary of key points that
pertain to corrections follows. A number of recommendations refer to other CDC guidance documents, all of which
are posted at the CDCs 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 the
illness 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 7
days or until 24 hours after symptoms resolve, whichever is
If ILI is present, cancel internal group gatherings and
stagger group meals and other activities to provide more
personal space between individuals. Consider temporarily
suspending 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 display symptoms of ILI. (See the CDCs interim guidance on
identifying 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 infection control for the care of patients with confirmed or suspected 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 separate

guidance 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 cell
mates of sick inmates for 48 hours for observation.
Provide care of inmates with ILI, including scheduled
temperature checks and access to increased fluids, and antiviral 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 facility and restrict inmates from leaving or transferring between
facilities during the 7 days after onset of symptoms or until
24 hours after symptoms resolve, whichever is longer, unless
necessary for medical care, infection control or lack of isolation 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 members movement to different parts of the facility. (See Using
Antiviral Medications to Control Influenza Outbreaks in
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 setting. Persons who handle laundry should avoid hugging it
before washing it, and should wash their hands with soap
and water or alcohol-based hand sanitizer immediately after
handling it.
Assess and treat as appropriate soon-to-be released
inmates with ILI or other flu symptoms and make direct
linkages 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 complications from infection with H1N1 virus. These include the
groups typically at high risk for seasonal flu complications,
such as the elderly, pregnant women, patients with chronic
medical conditions and those who are immunocompromised. (See guidance specific to these populations.)

To nd the latest CDC

for corrections, visit

Click on Guidance,
then scroll down to
Clinician Guidance for
Specic Audiences.

Other Recommendations
Recommendations on general preventive measures and
workforce protection are generic in that they would apply
to any health care setting, discussing topics such as hygiene
practices and vaccinations.
Finally, .non-English speaking inmates should be given
educational materials and information that they can understand. If possible, provide a translator when evaluating and
treating persons with symptoms. The CDC H1N1 Web site
offers materials in Spanish and other languages.


Spring 2009 CorrectCare

17% of New Jail Inmates Have Serious Mental Illness
A study of more than 20,000 people entering jail found
that nearly 17% of have serious mental illness, says a recent
report from the Council of State Governments and Policy
Research Associates. Serious mental illness was found
among 31% of women and 14.5% of males, a particularly troubling finding given the growth in the female jail
population and the lack of research on the reasons for this
overrepresentation. Overall, these estimates are three to six
times higher than in the general population, and indicate
that as many as 2 million bookings of people with serious
mental illnesses may occur each year. The study is the most

Tel: 267/927-5000
Fax: 267/927-5007

accurate accounting on the subject in more than 20 years.

Source: http://consensusproject.org/updates/features/
PBS Highlights Woes of Releasees With Mental Illness
In 2005, the PBS series Frontline aired The New Asylums,
a riveting documentary on mental illness in Ohios prisons
(and winner of NCCHCs 2005 Award of Excellence in
Communication). In a follow-up, the same two filmmakers
have produced The Released, which examines what happens to the seriously mentally ill when they leave prison
and why their recidivism rates are so high. According to
program information, more than 350,000 prisoners with
mental illnesses will be released to the community this year.
Typically, they are given a bus ticket, $75 and two weeks
worth of medication. Within 18 months, nearly two-thirds
are rearrested. The program, which aired April 28, may be
viewed online, along with supplemental material such as
story updates, a profile of a successful model for residential
treatment in the community and a discussion board with
dozens of thoughtful comments.
Learn more: www.pbs.org/wgbh/pages/frontline/released
Hepatitis A, B Rates Down Sharply; Hep C Plateaus
Recommendations for childhood vaccination against HAV
and HBV appear to have dramatically reduced infections,
with rates in 2007 the lowest ever recorded, according to
a report from the CDCs National Center for HIV/AIDS,
Viral Hepatitis, STD, and TB Prevention. Acute hepatitis A
incidence declined 92% from 1995 to 2007, from 12.0 to 1.0
case per 100,000 population. Acute hepatitis B incidence
declined 82% from 1990 to 2007, from 8.5 cases 1.5 cases
per 100,000 population. Declines occurred in all age groups
but were greatest among children younger than 15. Higher
rates 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 possibly
because of changes in IDU behavior and practices. Since
2003, however, rates have plateaued. In 2007, as in previous
years, 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 programs and increased vaccination of adults with risk factors will eventually eliminate domestic HBV transmission.
Further prevention of HBV and HCV relies on identifying
and preventing transmission in hospital and other health
care settings. HCV prevention also relies on identifying and
counseling uninfected persons at risk about ways to protect
themselves. Public health management of persons with
chronic HBV or HCV infection will help prevent transmission to susceptible persons, and their medical management
will reduce secondary effects of chronic liver disease.
Source: MMWR Surveillance Summaries, May 22;

Spring 2009 CorrectCare


Meeting Challenges
Colorado-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
efciency, 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

We Deliver:

Innovative cost containment services

Provider network development

Claims processing

Care management and coordination

Prior authorization and

utilization management

Pharmacy management, including

formulary development

Reporting and analysis

Quality improvement

Delivering Quality Outcomes

Discover 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.

Call toll-free 1.866.932.7185

or visit us on the web at www.CHPnow.com
1515 Arapahoe Street

Suite 300, Tower 1

Denver, Colorado 80202

1.866.932.7185 phone


National Conference on
Correctional Health Care

Register by August 28 for significant

early-bird savings! And see the Preliminary
Program for other money-saving tips.

Building Health Care Systems That Work

October 17-21

Tod y, cos
fecctivve, evidenc
nccee ba
b sed systems are the building blocks for transformation
of correct
ionaal he
th car
are. The
h N
Naational Conference gives you the blueprints to unders annd,
d develop, im
pleementt an
d im
mprove such systems. In this high-intensity environmentpacked
d wi
th lec
e tu
tures,s, paneells, workshops, posters, exhibits and networkingyou
will gain the knnow
owleedgge an
d skillls ttoo reshape not only your institutions health services,
but also the well-be
ingg off yyoour p
t ents and the community at large.
For even greater benefitt, attend
d tth
he preconference seminars to reinforce the foundations of yourr kn
o ledge. The confeere
nce proper begins Sunday evening with the Exhibit
Hall Openiingg R
e tion, wheere collllea
e mingle and take a first look at the wealth of
u ts and
d services on disspl

Disneys Coronado Springs Resort

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, childrens pool, full-service restaurant, food court, health club, laundry facilities, business center and game room.
Also enjoy complimentary transportation to Walt Disney World sites.



rn how
w oth
t er oorganiz
ionns have im
p emen
ted su
s cceessfful pro
ams fo
f r
g th
the ef
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clinical prooce
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budget cut
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whilee ea
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Expploore prprobblelemm-solvinng prroducuctsts aannd services in the exhibiit haall

mmerse your
elf in 3 days of programming and over 1000
ducationall sessioons
ns, each designed to provide cur
n in
tion on subjectss imp
o tant to our field. Her
e s a saam
plil ng

cover the late
test too
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nd tec
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serrvices del
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more costt-effective


ing qualityy off ccar
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nciaal mana
mentt and
n workforce
Identify major h
e lth
h care, reese
a ch
h aand policcy is
e faccin
ing in
individuals, includi
ng inffec
ectiouus dise
s asses
es, ment
tal illn
lllness, su
n e ab
a use
and special needs (e.g.,., w
ens iss
u s, juuvenilee healt
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Demonstrate increased
d un
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Describe legal, ethical and
d ad
ve iiss
ssues and de
d ve
lop solu
luttions for
the correctional setting

i g Nursingg Sk
Skills Through Competencyy Deve
Beyonond Diagnossis: The Soul of the Psychopathh
Chestst Pain: Getetinng to the Heart of the Matteteer
Efffecctitivev Corrrectioons Crisis Intervention Training
Esssentials of Corrrectional Juvenile Health Care
Excited Deliriuum and Sudden In-Custody Death
Manangementt of Hypertension and Diabetees
Mananagaing thee DiD ffficult Patient
MRSAA: The Supererbbug of Corrections
Pandeemimc Preppararedednness Plans
Seizuureres:s: EEffffecectitivveve Treatment and Cost Mananagementnt
e It Right:
Reduce Your Lawsuit Ris
isk by IImp
m ro
r vinng
ur Documentation

Up to 322 hours of CE credit may be earned
d in
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Social Worker



Special interest discussion groups

Opening ceremony and keynote
Exhibit hall networking breaks
NCCHC bookstore

Speaker Q&A sessions

Educational poster display
Exhibit hall raffles
Orlando attractions

V si
sitt th
thee Naati
t onnal
a Conference Web site for detailed information
on,, inncl
ng registration fees and policies, a schedule of
i ns
ns,, th
thee Preliminary Program and online registration. Or
call us to req
u st Preliminary Program by mail.



Spring 2009 CorrectCare


Beware of the Specialists Recommendations
by Robert P. Vogt, JD, CCHP

s a rule of thumb, courts prefer to leave the practice 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 the
propriety of a particular course of medical treatment for
a given prisoner-patient. Medical
professionals are not required to provide proper medical treatment to
prisoners, but rather they must provide medical treatment that reflects
professional judgment, practice or
standards. The treatment decisions of
medical professionals are given deference by the courts unless no minimally competent professional would
have so responded under those circumstances.
The cases also hold that the
Constitution is not a medical code mandating that specific
medical treatment must be provided to an inmate. Inmates
do not have a constitutional right to demand a particular
type 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 prisoners 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 Specialist

While these principles are fairly well-established, the law
becomes murky when a specialist comes into the mix. In
the eyes of the judiciary, a specialist often stands on a different footing and the willingness of the courts to defer to the
correctional physician is much less.
It is important to note that, presumably, a correctional
physician sends an inmate to see a specialist because the
correctional physician recognizes the need for the specialists assistance. The correctional physician is unable to treat
the inmates particular problem and reaches out for help
from a professional whom the correctional physician recognizes as having expertise in that area. If the specialist examines 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 can
refuse to implement the recommendations of the specialist to whom the correctional physician turned for help in
the first place. The judges look for evidence that a physician may have deliberately ignored the express orders of a
specialist for reasons unrelated to the medical needs of the
In such a circumstance,
the courts generally do
not decide that the correctional physician was
deliberately indifferent in
choosing not to follow
the specialists advice.
Instead, the courts simply
determine that there is
enough of a question that
the issue should be left
for a jury to resolve. As
described by one court, An inference of deliberate indifference mayy arise when prison officials refuse to follow an
outside specialists orders or recommendations.
The case of Gil v. Reed
d is perhaps the leading decision in
this area. In Gill, the inmate suffered from a rectal prolapse
and was referred by the prison physician to a surgeon specialist. Surgery was performed and the inmates surgeon
specialist specifically instructed the prison medical staff not
to provide certain pain relievers because of their constipating effect. Nonetheless, on three occasions after receiving
these instructions, the prison physician ordered the inmate
to be given the very medication that the specialist had
warned against. This was done even though nonconstipating alternative pain relievers were available.
Under these circumstances, the Gill court could not make
sense of the prison physicians refusal to follow the specialists instruction and ruled that a jury should decide if the
prison physician acted with deliberate indifference.

Conscious Decision or Blanket Denial?

In addressing inmate claims that a correctional physician
was deliberately indifferent by refusing to follow a specialists recommendations, the courts try to assess whether
the refusal reflected a conscious decision to try a different
course of medical treatment or a simple blanket denial. The
former 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 treatment
based on the prevailing standards in the field, the courts

continued on page 8


Spring 2009 CorrectCare

Earlier ART Yields Better Outcomes

HIV-infected adults in a resource-limited setting are more
likely to survive if they start antiretroviral therapy before
their immune systems are severely compromised, according
to a randomized clinical trial in Haiti. In an interim review,
an independent data and safety monitoring board found
overwhelming statistically significant evidence that starting ART at CD4+ T cell counts between 200 and 350 cells/
mm3 improves survival compared with deferring treatment 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 boards 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 adults

with early HIV disease and CD4+ T cell counts from 200 to
350 cells/mm3. Half of the participants began ART within
two weeks of enrollment; for the others treatment began
when their counts dropped below 200 cells/mm3 or they
were diagnosed with AIDS. This deferred treatment is the
standard of care in Haiti and in keeping with World Health
Organization guidelines. The first-line treatment regimen
consisted 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 treatment group (23 vs. 6, respectively). Also, participants who
began the study without TB infection were twice as likely to
develop TB in the standard of care group (36) compared to
the early treatment group (18).
The investigators say this finding may change the standard of care in dozens of countries where ART is initiated
only 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 study
finding also underscores the importance of identifying HIV
infections earlier and starting ART earlier.
Source: NIH News; www.nih.gov/news/health/jun2009/

(continued from page 7)


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may still defer to the correctional physicians judgment. As

one court explained, What we have here is not deliberate indifference to a serious medical need, but a deliberate
decision by a doctor to treat a medical need in a particular
In one case, for example, the court sustained a correctional physicians decision to provide an inmate with some,
but not all, of the specialist-recommended medications.
The physicians decision was based on his belief that some
of the recommended medications were duplicative of
others. Similarly, in another case, the court upheld a correctional physicians decision to forgo a specialists recommendation to obtain an MRI. Here, the physician relied on his
own multiple clinical examinations of the inmate, and the
findings of an x-ray, as guiding his course of treatment.
Electing to forgo the recommendations of a specialist
presents liability risks and should be done only after careful
consideration. Inmates often feel that they are legally entitled to a specialists recommendations even though appropriate alternatives are available. To help reduce any potential
exposure, a correctional physician opting not to implement
a specialists recommendation should document the basis
for his medical judgment and outline the alternative course
of 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 professionals and institutions in Illinois, Indiana and Wisconsin.
Contact him at bvogt@wlv-online.com.

Spring 2009 CorrectCare


Efavirenz: Efavirenz has been shown in vivo to induce CYP3A. Other compounds that are substrates of CYP3A may
have decreased plasma concentrations when coadministered with efavirenz. In vitro studies have demonstrated
that 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 plasma
concentrations of the coadministered drug. Therefore, appropriate dose adjustments may be necessary for these
drugs. Drugs that induce CYP3A activity (eg, phenobarbital, rifampin, rifabutin) would be expected to increase the
clearance 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) with
drugs that reduce renal function or compete for active tubular secretion may increase serum concentrations of
emtricitabine, 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 this
combination should be monitored closely for didanosine-associated adverse reactions. Didanosine should be
discontinued in patients who develop didanosine-associated adverse reactions. Suppression of CD4+ cell counts
has been observed in patients receiving tenofovir DF with didanosine 400 mg daily. Atazanavir and
lopinavir/ritonavir have been shown to increase tenofovir concentrations. ATRIPLA should be discontinued in
patients who develop tenofovir-associated adverse reactions. Coadministration of atazanavir with ATRIPLA is not
recommended. There are insufficient data to support dosing recommendations for atazanavir, with or without
ritonavir in combination with ATRIPLA.
Efavirenz, Emtricitabine and Tenofovir DF: Other important drug interaction information for ATRIPLA is
summarized below. The drug interactions described are based on studies conducted with efavirenz, emtricitabine
or tenofovir DF as individual agents or are potential drug interactions; no drug interaction studies have been
conducted 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 Be
Recommended Based on Drug Interaction Studies or Predicted Interaction
Antiretroviral agents: Protease Inhibitors Atazanavirr: atazanavir concentration, tenofovir concentration.
Coadministration of atazanavir with ATRIPLA is not recommended. Coadministration of atazanavir with either
efavirenz or tenofovir DF decreases plasma concentrations of atazanavir. The combined effect of efavirenz plus
tenofovir DF on atazanavir plasma concentrations is not known. Also, atazanavir has been shown to increase
tenofovir concentrations. There are insufficient data to support dosing recommendations for atazanavir or
atazanavir/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 been
established. Fosamprenavir/ritonavir: An additional 100 mg/day (300 mg total) of ritonavir is recommended when
ATRIPLA is administered with fosamprenavir/ritonavir once daily. No change in the ritonavir dose is required when
ATRIPLA is administered with fosamprenavir plus ritonavir twice daily. Indinavir:indinavir concentration. The optimal
dose of indinavir, when given in combination with efavirenz, is not known. Increasing the indinavir dose to 1000 mg
every 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 to
600/150 mg (3 tablets) twice daily may be considered when used in combination with efavirenz in treatmentexperienced patients where decreased susceptibility to lopinavir is clinically suspected (by treatment history or
laboratory evidence). Patients should be monitored for tenofovir-associated adverse reactions. ATRIPLA
should be discontinued in patients who develop tenofovir-associated adverse reactions. Ritonavir:ritonavir
concentration,efavirenz concentration. When ritonavir 500 mg every 12 hours was coadministered with efavirenz
600 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 is
recommended when ATRIPLA is used in combination with ritonavir. Saquinavir:saquinavir concentration. Should not
be used as sole protease inhibitor in combination with ATRIPLA.
NRTI Didanosine:didanosine concentration. Higher didanosine concentrations could potentiate didanosineassociated adverse reactions, including pancreatitis, and neuropathy. In adults weighing >60 kg, the didanosine
dose should be reduced to 250 mg if coadministered with ATRIPLA. Data are not available to recommend a
dose adjustment of didanosine for patients weighing <60 kg. Coadministration of ATRIPLA and didanosine
should be undertaken with caution and patients receiving this combination should be monitored closely
for didanosine-associated adverse reactions. For additional information, please consult the Videx/Videx EC
(didanosine) prescribing information.
Other Agents: Anticoagulant Warfarin:orwarfarin concentration. Plasma concentrations and effects
potentially increased or decreased by efavirenz.
Anticonvulsants Carbamazepine: carbamazepine concentration,efavirenz concentration. There are
insufficient data to make a dose recommendation for ATRIPLA. Alternative anticonvulsant treatment should be used.
Phenytoin, Phenobarbital:anticonvulsant concentration,efavirenz concentration. Potential for reduction in
anticonvulsant and/or efavirenz plasma levels; periodic monitoring of anticonvulsant plasma levels should be
Antidepressant Sertraline:sertraline concentration. Increases in sertraline dose should be guided by clinical
Antifungals Itraconazole:itraconazole and hydroxy-itraconazole concentration. Since no dose recommendation
for itraconazole can be made, alternative antifungal treatment should be considered. Ketoconazole:ketoconazole
concentration. Drug interaction studies with ATRIPLA and ketoconazole have not been conducted. Efavirenz has the
potential to decrease plasma concentrations of ketoconazole.
Anti-infective Clarithromycin:clarithromycin concentration,14-OH metabolite concentration. Clinical
significance 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, such
as azithromycin, should be considered. Other macrolide antibiotics, such as erythromycin, have not been studied in
combination with ATRIPLA.
Antimycobacterials Rifabutin:rifabutin concentration. Increase daily dose of rifabutin by 50%. Consider
doubling the rifabutin dose in regimens where rifabutin is given 2 or 3 times a week. Rifampin:efavirenz
concentration. Clinical significance of reduced efavirenz concentration is unknown. Dosing recommendations for
concomitant use of ATRIPLA and rifampin have not been established.
Calcium channel blockers Diltiazem: diltiazem, desacetyl diltiazem, and N-monodesmethyl diltiazem
concentrations. Diltiazem dose adjustments should be guided by clinical response (refer to the complete
prescribing information for diltiazem). No dose adjustment of ATRIPLA is necessary when administered with
diltiazem. Others (eg, felodipine, nicardipine, nifedipine, verapamill ): calcium channel blocker. No data are
available on the potential interactions of efavirenz with other calcium channel blockers that are substrates of the
CYP3A4 enzyme. The potential exists for reduction in plasma concentrations of the calcium channel blocker. Dose
adjustments should be guided by clinical response (refer to the complete prescribing information for the calcium
channel blocker).
HMG-CoA reductase inhibitors Atorvastatin: atorvastatin concentration, Pravastatin: pravastatin
concentration, Simvastatin:simvastatin concentration. Plasma concentrations of atorvastatin, pravastatin, and
simvastatin decreased with efavirenz. Consult the complete prescribing information for the HMG-CoA reductase
inhibitor for guidance on individualizing the dose.
Narcotic analgesic Methadone:methadone concentration. Coadministration of efavirenz in HIV-1 infected
individuals with a history of injection drug use resulted in decreased plasma levels of methadone and signs of opiate
withdrawal. Methadone dose was increased by a mean of 22% to alleviate withdrawal symptoms. Patients should be
monitored for signs of withdrawal and their methadone dose increased as required to alleviate withdrawal
Oral contraceptive Ethinyl estradiol:ethinyl estradiol concentration. Clinical significance unknown. Because the
potential interaction of efavirenz with oral contraceptives has not been fully characterized, a reliable method of barrier
contraception should be used in addition to oral contraceptives.
*Please see Full Prescribing Information (Table 4) for additional information; this list is not all inclusive.


Pregnancy: Pregnancy Category D [see Warnings and Precautionss]
Nursing Mothers: The Centers for Disease Control and Prevention recommend that HIV-1-infected mothers
not breast-feed their infants to avoid risking postnatal transmission of HIV-1. Studies in rats have
demonstrated 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 the
potential for serious adverse reactions in nursing infants, mothers should be instructed not to breast-feed if they
are 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-dose
combination tablet containing a component, tenofovir DF, for which safety and efficacy have not been established
in this age group.
Geriatric Use: Clinical studies of efavirenz, emtricitabine, or tenofovir DF did not include sufficient numbers of
subjects aged 65 and over to determine whether they respond differently from younger subjects. In general, dose
selection 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 hepatic
impairment. Because of the extensive cytochrome P450-mediated metabolism of efavirenz and limited clinical
experience in patients with hepatic impairment, caution should be exercised in administering ATRIPLA to these
patients [see Warnings and Precautionss].
Renal Impairment: Because ATRIPLA is a fixed-dose combination, it should not be prescribed for patients requiring
dosage adjustment such as those with moderate or severe renal impairment (creatinine clearance <50 mL/min)
[see Warnings and Precautionss].
If overdose occurs, the patient should be monitored for evidence of toxicity, including monitoring of vital signs and
observation of the patients 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 remove
both 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 system
symptoms. One patient experienced involuntary muscle contractions.
Emtricitabine - Limited clinical experience is available at doses higher than the therapeutic dose. In one study single
doses 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 starting
within 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 is
available. In one study, 600 mg tenofovir DF was administered to 8 patients orally for 28 days, and no severe
adverse 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 a
single 300 mg dose of tenofovir DF, a 4-hour hemodialysis session removed approximately 10% of the dose.
See FDA-Approved Patient Labeling (17.12) in Full Prescribing Information
Drug Interactions: A statement to patients and healthcare providers is included on the products 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 any
other prescription, nonprescription medication, or herbal products, particularly St. Johns wort.
Information for Patients: Patients should be advised that: ATRIPLA is not a cure for HIV-1 infection and patients
may continue to experience illnesses associated with HIV-1 infection, including opportunistic infections; they should
remain under the care of a physician when using ATRIPLA; the use of ATRIPLA 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
ATRIPLA are unknown; redistribution or accumulation of body fat may occur in patients receiving antiretroviral
therapy and that the cause and long-term health effects of these conditions are not known; ATRIPLA should not be
coadministered 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 or
pronounced hepatotoxicity [see Warnings and Precautionss].
they may be tested for hepatitis B virus (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
EMTRIVA or VIREAD, which are the components of ATRIPLA.
renal impairment, including cases of acute renal failure and Fanconi syndrome, has been reported. ATRIPLA
should be avoided with concurrent or recent use of a nephrotoxic agent [see Warnings and Precautionss].
decreases in BMD have been observed with the use of tenofovir DF; BMD monitoring may be performed in
patients who have a history of pathologic bone fracture or at risk for osteopenia [see Warnings and Precautionss].
take ATRIPLA orally on an empty stomach and that it is important to take ATRIPLA on a regular dosing schedule
to avoid missing doses.
Nervous System Symptoms: Patients should be informed that central nervous system symptoms (NSS) are commonly
reported during the first weeks of therapy with efavirenz. Dosing at bedtime may improve the tolerability of these
symptoms, which are likely to improve with continued therapy. Patients should be alerted to the potential for additive
effects when ATRIPLA is used concomitantly with alcohol or psychoactive drugs. Patients should be instructed that if
they experience NSS they should avoid potentially hazardous tasks such as driving or operating machinery [see
Warnings and Precautions and Dosage and Administration (2) in Full Prescribing Information].
Psychiatric Symptoms: Patients should be informed that serious psychiatric symptoms have been reported in
patients receiving efavirenz. If they experience severe psychiatric adverse experiences they should seek immediate
medical evaluation. Patients should be advised to inform their physician of any history of mental illness or substance
abuse [see Warnings and Precautionss].
Rash: Patients should be informed that a common side effect is rash. Rashes usually go away without any change
in treatment. However, since rash may be serious, patients should be advised to contact their physician promptly if
rash occurs.
Reproductive Risk Potential: Women receiving ATRIPLA should be instructed to avoid pregnancy [see Warnings
and Precautionss]. A reliable form of barrier contraception should always be used in combination with other methods
of contraception, including oral or other hormonal contraception. Because of the long half-life of efavirenz, use of
adequate contraceptive measures for 12 weeks after discontinuation of ATRIPLA is recommended. Women should
be advised to notify their physician if they become pregnant or plan to become pregnant while taking ATRIPLA. If
this 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 of
Bristol-Myers Squibb Company. Pravachol is a registered trademark of ER Squibb & Sons, LLC. Other brands listed are the
trademarks of their respective owners.
2008 Bristol-Myers Squibb & Gilead Sciences, LLC.
Based on: 21-937-GS-005



September 2008

Nursing Practice
The Time Is Right!

by Lorry Schoenly, PhD, RN, CCHP

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.

udging from the response to a recent NCCHC conference session, interest is growing for application of
evidence-based nursing practice (EBNP) in correctional
health care. Speaker Susan Laffan, RN, CCHP-A, considers
this 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 consultant
based in Toms River, NJ. Our, clinical practice should rest
on solid research evidence where possible.
In fact, the origins of the modern nursing profession
in the 1800s with Florence Nightingale included seeds of
EBNP. In her 1861 landmark book, Notes on Nursingg, she
states, The most important practical lesson that can be
given to nurses is to teach them what to observehow to
observewhat symptoms indicate improvementwhich
are of nonewhich are the evidence of neglectand what
kind of neglect.

that most relied on nursing school, workplace sources,

physicians and intuition. Although enthusiastic about using
research evidence as a basis for practice, nurses can be
bewildered by how to do so.
EBNP brings many potential advantages, including more
effective practice, greater confidence in decision-making
and better patient outcomes. Sara Jo Brown, PhD, RN,
author of Evidence-Based Nursing: The Research-Practice
Connectionn, a nursing textbook, sees a bright future for
nursing practice built on a strong foundation of credible
Nursing is science and artsort of like yin and yang
that are complementary opposites within a greater whole,
Brown says. Many nurses have strong nursing art knowledge and skills but have not incorporated the use of science
into their practice. Effective practice needs both. The correctional nursing specialty can undoubtedly help inmates
achieve better health outcomes by turning more often to
research evidence as a basis for practice.

What Is EBNP?

Key Steps to EBNP

Evidence-based nursing practice involves the use of the

most credible and up-to-date research to guide patient
care. This way of practicing 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. A 1992 survey of staff nurses regarding
the sources of knowledge used to guide practice revealed

Practicing nurses need not conduct an actual research

study to determine effective interventions. Fortunately,
that is neither desirable nor advocated by EBNP specialists.
Instead, EBNP focuses on using the wide array of published
research to determine application to practice. Here are the
key steps to the practice of evidence-based nursing.

Spring 2009 CorrectCare


Web Site



National Guideline Clearinghouse


A resource from the Agency for Healthcare Research and Quality,

U.S. Department of Health and Human Services

Cochrane Collaboration


Produces systematic reviews of health care interventions

Joanna Briggs Institute


Research review database on nursing and other health care topics

Registered Nurses Association of



RNAO Nursing Best Practice Guidelines on a variety of topics

Source: Evidence-Based Nursing: The Research-Practice Connection

n, S. J. Brown, 2009

Identify a specific patient problem or situation that is in

need 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 relevance 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
Evaluate the outcome of the decision

Locating and Assessing Evidence

The isolated nature of correctional nursing practice once
made it difficult to find clinical research. Without easy
access to a medical library or hospital resources, correctional nurses could be frustrated in attempts to locate
answers 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 barriers
to acquiring information. Now there are many Internet sites
dedicated to serving as health care data repositories, with
some specific to nursing.
Thus, the Internet is a great first stop on the road to
implementing EBNP. The table above lists some of the most
fruitful sites. Of course, traditional sources such as university
and medical libraries are also helpful, if available.
The fastest road to EBNP is locating evidence-based clinical guidelines already developed by a reliable entity. In this
case, there is no need to go back to the original studiesit
has already been done for you. The next most helpful is a
published systematic research review. Here, the author has
studied the array of research in a particular area and synthesized 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 understanding of research principles to determine if the findings
are applicable in your setting.
Many organizations that produce evidence-based guidelines rate the strength of the evidence in support of each
of the recommendations that make up the guideline. The
table at right is an abbreviated version of one of these rating
systems. The strongest evidence classification for a recommendation is 1A and the weakest is 4.

Where to Start
Brown suggests starting with clinical issues that arent currently 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 identified
through the continuous quality improvement program. A
quality deficit generates an opportunity to pursue better
patient outcomes. The standard of care, the nursing interventions, should be based on available research.
EBN Example: Pressure Ulcer Prevention
Pressure ulcer prevention is an example of a thorny correctional nursing issue that could be improved by adopting
evidence-based interventions. The first step is to identify
the populations that are developing pressure ulcers in your
setting. Then, search the literature for research evidence
relevant to your population. Look first for evidence-based
clinical practice guidelines produced by respected organi-

continued on page 12

Agency for Healthcare Research and

Quality (AHRQ) Levels of Evidence
Type of Evidence


Meta-analysis of multiple well-designed controlled studies


Well-designed randomized controlled trials

Well-designed nonrandomized controlled trials

(quasi-experimental studies)

Observational studies with controls

Retrospective studies
Interrupted time studies
Case-control studies
Cohort studies with controls

Observational studies without controls

Cohort studies without controls
Case series


Spring 2009 CorrectCare

Evidence-Based Nursingg (continued from page 11)

Pressure Ulcer Search Results

National Guideline Clearinghouse
Current 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 Collaboration
Research reviews on ...
Surface support for pressure ulcer prevention
Repositioning for pressure ulcer prevention
Wound cleansing for pressure ulcers
Much more

Joanna Briggs Institute

Best practice guidelines in PDF format:
Pressure Ulcers: Prevention of Pressure Related Damage
Pressure Ulcers: Management of Pressure Related Tissue

Registered Nurses Association of Ontario

RNAO Best Practice Guideline:
Risk Assessment and Prevention of Pressure Ulcers


zations. If you cannot find one, then look for a systematic

research review about the issue. Carefully consider all of the
keywords that might lead to information about pressure
ulcer prevention and management. Search words could
include wound care, pressure ulcer, decubiti and wound
healing. The box at left outlines search findings from the
Web 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 encourages
staff 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 evidence
available from research taking place in the nursing community. The time is right to enhance the quality of care for our
inmate-patients through EBNP.

Lorry Schoenly, PhD, RN, CCHP, is a clinical education manager with Correctional Medical Services and is based in
Pennsylvania. Contact her at lschoenly@cmsstl.com. She also
hosts an Internet site dedicated to increasing awareness of
correctional nursing practice: www.correctionalnurse.net.
Follow her on Twitter: lorryschoenly.

You have OPTIONS!

Correctional Medical Services (CMS), is the nation's largest
private provider of contract healthcare services to correctional
facilities. As a Professional Healthcare provider, You have options,
We have opportunities!
We are currently seeking Physicians to fill the following positions:

Medical Directors, Staff Physicians,

Psychiatrists and Dentists
in Delaware, Arkansas, Maine, Missouri,
Indiana, Maryland and New Mexico.
For more information please contact:
Dee Thandi, Physician Recruiter
Phone: 800-893-2118 Fax: 866-303-2728
Email: dthandi@cmsstl.com EOE/AAP/DTR

Different and Making a Difference

Spring 2009 CorrectCare


Guard against M R SA .
In prison, the last thing
you need is a break out.
Keep costly MRSA and staph infections at bay
with Hibiclens antiseptic skin cleanser

Clean-up with the benets:

antimicrobial activity
by contact with organic
matter like blood4
antiseptic washes5

It can cost a correctional facility tens of thousands of dollars

to treat and manage a single case of MRSA infection2. Your
best defense is to prevent cross-contamination. At a cost of just pennies per use,
Hibiclens kills MRSA1 and other staph infections (in vitro). Infections can spread
and wreak havoc in a facility. Hibiclens, as part of a daily hand washing routine,
can reduce the risk of cross contamination. Hibiclens also combats C-DIFF3,
another usual suspect in prison infections. Hibiclens bonds instantly to the
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

Tests 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 Mlnlycke Health Care,
Biogel, Hibiclens and BARRIER names and logos are registered globally to one or more of the Mlnlycke Health Care Group of Companies. Distributed by Mlnlycke Health Care US, LLC, Norcross, Georgia 30092.
2009 Mlnlycke Health Care AB. All rights reserved. 1.800.843.8497 www.hibigeebies.com

Holistic Care Offers Promise of

Positive Health Outcomes
by Heidi Bale, RN, CCHP, and Jane Grametbaur, RN, CCHP-A

n a society brought up with scientific medicine, holistic

medicine is generally perceived as all smoke and mirrors.
Although some types of holistic medicine, like acupuncture, have become more mainstream recently, many medical professionals regard holistic treatment as ineffective or
downright 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 as
effective today are the opium poppy, from which we derive
morphine, and foxglove, which the ancient herbalist prescribed for cardiac problems and from which digitalis was
later extracted.
As the only known antidote to poisoning caused by the
death cap mushroom, which kills by destroying the liver, the
herb milk thistle has great potential for use in treating liver
damage caused by cirrhosis and hepatitis. European doctors
frequently use milk thistle to treat patients with liver disease
and numerous studies have shown it is effective. A number
of other herbs and over-the-counter vitamins, such as those
containing omega-3 fatty acids, may be of use in treating
other 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. We
know this form of energy healing as acupuncture. Some
Chinese patients have major surgery with nothing but acupuncture 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 their
daily activities become calmer and have better control
in stressful situations. With time, practitioners can lower
blood pressure and heart rate, diminishing the need for
Several traditional Native American practices also may
be useful as an adjunct with current medical treatment for
cardiovascular disease. In addition, Native American community leaders have used medicine men and women and
ancient traditions to treat drug addiction and alcoholism in
at-risk youth. Some traditions and ceremonies, such as the
sweat lodge ceremony, have shown promise in treatment of
PTSD and drug and alcohol addiction.

Well-Suited to Corrections
Correctional medicine traditionally has focused on the conservative 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 for

use in correctional populations.
Inmates suffer from varying degrees of anxiety due to
the circumstances of their incarceration and to the stress of
living in a correctional setting. Communal housing, disruption 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 the
individual as a whole, encompassing care for not only the
physical symptoms of illness but also the mental and spiritual symptoms. Meditation, relaxation techniques, Reiki, tai
chi, guided imagery and gardening are methods most commonly used in corrections today.

A Sampling of Programs
In 2003 and 2004, the San Diego County Sheriffs
Department instituted a program for psychiatric patients
incarcerated in its facilities. The goals included identifying
mental health inmates who did not require care by a psychiatrist, treating this population using holistic methods,
reducing the number of patients who required treatment
with mental health medications, increasing the efficacy of
time spent with patients by psychiatrists and decreasing
wait 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 special
training. The patients also received handouts on improving
sleep and reducing stress.
As reported in the July 2006 issue of the Journal of
Correctional Health Care, a study to assess program outcomes found that approximately half of the inmates initially
seen needed no further follow up after holistic treatment.
A small group did require follow-up visits but were managed without medication. Approximately 30% of the group
required 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 efficient use of time by the psychiatrists allowed more time for
the evaluation and care of acutely ill mental health patients.
A number of studies have examined the use of meditation in prisons and jails. One of the most recent was completed by a group from Old Dominion University in Virginia
and published in the January 2009 issue of the Journal of
Correctional Health Caree. The researchers hypothesized that
the use of meditation by inmate populations would be a
cost-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 structured meditation program would decrease medical symptoms, emotions and behaviors in a female population.

Spring 2009 CorrectCare


The study group received training in meditation practices

We added the Wii program to our mental health group
by trained facilitators. Emphasis was placed on enhancing
sessions in an effort to engage more of our seriously meninner calm and learning to live in the moment, as well as
tally ill patients, says health services administrator Kathy
discussion with other study group members and facilitaWild, RN, MPA, CCHP. We looked at the recent increase in
tors. Results showed that inmates who participated in
the use of this equipment for nursing home residents and
meditation had fewer sleep problems, fewer problems with
were impressed with the results. We do this group several
angry outbursts, and
times a week and include the mental health
reduced feelings of
clinicians and our nurses during the sessions.
stress and anxiety.
This engages the patient with the staff. We are
In San Francisco,
very impressed with the results weve seen so far.
the city and county
Inmates who rarely come out of their cells look
jails implemented a
forward to using the system and often are seen
meditation program
laughing and talking with staff during the course
through the San
of the group.
Francisco Zen Center
Significant Benefits
for a number of years.
This class lasted about
Whether it is through yoga, guided imagery (a
90 minutes, incorpoform of guided meditation), tai chi, gardening or
Tony and Willie center themselves at Insight Prison
rating tai chi and yoga Projects Integrative Health Yoga and Meditation
other means, the reduction of stress and anxiety
exercises to quiet the class. (photo courtesy of IPP/James Fox)
is proven to reduce pain, improve sleep quality,
mind and body. This
calm emotions and produce a sense of wellprogram was directed at women who were incarcerated for being. This, in turn, decreases the need for expensive medialcohol and drug crimes.
cations and
At the Hampshire County House of Correction in
reduces behavioral outbursts
Massachusetts, inmates have been trained to practice Reiki
on each other. Reiki is a Japanese technique for relaxation
and assaults
in which practitioners use their hands in positions over the
on staff. Given
patients body to sense energy centers, or chi. With intuthe escalating
ition and training, the practitioners unblock trapped energy,
costs of health
thereby releasing stress, easing withdrawal symptoms and
care and the
smoothing out emotions. Students are taught to practice
difficulties in
recruiting staff,
Reiki on themselves before mastering higher levels and
tending to other inmates.
the potential
In 2006, San Quentin State Prison in California estabbenefits of
lished a gardening program for inmates through the Insight
holistic care are
Prison Project, a not-for-profit organization that aims to
provide unique rehabilitation programs for the prison.
With a little
Participants were taught to cultivate plants and gardens
on the grounds of the prison. As they learned to nurture
and innovaflowers and vegetables, these men also learned to nurture
tion, staff can
positive responses to negative emotions and interactions.
blend holistic
This program sought to plant responsibility, teamwork and
care with
appreciation through mindful gardening. Prison officials
hope to expand this program, which now operates indemedical treatAn inmate at the San Bernardino County jail
pendently as the Insight Garden Project.
engages with a Wii program. (photo courtesy ment. The end
Insight Prison Project also offers a mindful meditation
result will benof SBSD/Kathy Wild)
program. Increasingly popular in recent years, mindful
efit both the
meditation requires no special skills or training and instead
patient and the health care system by decreasing exacerbations of chronic illness, teaching patients new methods of
simply focuses on being in the present and allowing the
practitioner to let various thoughts surface while meditatcoping with pain and anxiety, and providing patients with
ing. This form of meditation honors all belief systems and
self-care practices that will last a lifetime.
backgrounds and can be performed anywhere.
As more correctional facilities see the benefit of using
Heidi Bale, RN, CCHP, is health services coordinator for the
holistic treatment as an adjunct to scientific practices, we can Washington State Department of Corrections, Raymond,
expect to see more innovative and creative solutions to med- WA. Jane Grametbaur, RN, CCHP-A, is the principal of
ical and psychiatric issues. For instance, the San Bernardino
Grametbaur & Associates Legal Nurse Consultants, Riverside,
County, CA, jail recently purchased a Wii play station by
CA. To contact the authors about this article, send an e-mail
Nintendo for use in treatment of mental health patients.
to jgrametbaurRN@aol.com.

Spring 2009 CorrectCare

DOC-University Rx Project Yields Big

Savingsand Awardin Rhode Island

whole picture: our formulary, who was on what meds and

aving an estimated $12 million over the course of a
seven-year program is sweet enough. It was the cherry why, cost analysis and cost-saving measures, plus reporting
on top when the Pharmacy Benefit Management
on all of this, Marocco explains.
Again they turned to outside expertise. After a competiInstitute honored the collaboration that produced those
savings with its 2009 Rx Benefit Award, which recognizes
tive bidding process, the agency awarded URIs College of
innovation in pharmacy management.
Pharmacy a three-year, $454,000 contract in 2002 to manThe initiative is a joint effort between the Rhode Island
age its pharmacy program using pharmacy benefit manageDepartment of Corrections and the University of Rhode
ment strategies. The new approach was a success, and the
Islands College of Pharmacy.
two organizations are
In its award announcement,
now in the midst of a
PBMI said the two entities are
four-year, $682,000 conpioneering a new higher educatract.
tion/state agency management
Today, pharmacy
model. This is the first time the
services are managed
institute has honored a collabojointly by the College of
ration involving a university or
Pharmacys Healthcare
college and a state agency.
Utilization Management
Since its inception in 2002,
Center and RIDOC
the collaborative management
medical staff. The colmodel has enabled RIDOC to
lege provides an on-site
reduce medication waste by
pharmacy manager and
extensive data analysis,
nearly 75% and to hold the
trend line on expenditures
reporting, clinical supdespite significant drug cost
port and management
Displaying the 2009 Rx Benefit Award are Matt Coty, URI pharmacy resources. Pharmacy stuinflation and increases in the
student, and Rita Marcoux, URI assistant professor of pharmacy
inmate population.
dents assist with much
research. Also present (L-R): student Brian Touhey; Michael Poshkus,
Our 2009 award recipients
of the data analysis.
RIDOC medical director; E. Paul Larrat, associate dean, URI College
have differentiated themselves
Prescription fulfillment
of Pharmacy; Joseph Marocco, RIDOC associate director of health
care services; and Larry Myerson, the URI on-site pharmacy manfrom industry norms with
is done via contract with
ager. (photo credit: URI/Michael Salerno)
creative new approaches, said
CPS (Contract Pharmacy
Dana Felthouse, president of
Services Inc.) using an
PBMI, which helps health care benefit executives work
electronic pharmacy order system.
with pharmacy benefit managers and other pharmacy
The results speak for themselves. RIDOCs daily populaprofessionals to design prescription drug benefit programs.
tion averages 3,800 inmates and annual admissions are
Another hallmark of the winners is a passion for collabora18,000 per year. Based on pharmaceutical trend data, the
systems medication costs had been projected to be $13.7
tion among stakeholders. The solutions are programs that
million from 2003 through 2006, but its actual costs were
demonstrate success in improving pharmaceutical health
care, as well as curbing costs.
$8.8 million. Total overall savings have climbed to $12
million as the program has matured, according to E. Paul
Then and Now
Larrat, associate dean of the College of Pharmacy and
The situation was not so rosy 10 years ago, when the
HUMC codirector, along with Rita Marcoux, an assistant
Department of Corrections operated an on-site pharmacy
professor of pharmacy research.
staffed with state employees, says Joseph Marocco, MPA,
This is an impressive feat given the growth in inmate
CCHP, RIDOCs associate director of health care services. It
numbers, the changing demographics and health problems
among the patient population, and rising drug prices, says
was difficult to recruit and retain staff for several reasons,
including a national shortage of pharmacists and correcMarocco.
tional salaries that did not match those in the community.
Rx for Quality
To try to keep up with the growing demands of a growing
inmate population, contract pharmacists were often used,
RIDOC relies on the college pharmacy experts and students
at a hefty cost.
for medication quality review, says medical director Michael
To remedy those problems, in 2000 RIDOC decided to
Poshkus, MD, CCHP. This includes help with quality assuroutsource pharmacy services. Although that was a definite
ance programs and review of medication use as well as any
improvement, the prison systems health administrators
medication errors that may occur.
wanted to get a better handle on overall pharmacy manPoshkus appreciates having pharmacy experts to consult
agement. We wanted to make sure we were looking at the whenever we have a question about ordering medica-

Spring 2009 CorrectCare


tions and what would be the most cost-effective means

to provide pharmaceuticals to our patient population. He
also values the work of the students. Their projects involve
reviewing our utilization of different drugs and helping us
come up with protocols that allow us to better utilize medications for our populations.
Marocco adds that the program has improved his
departments relationship with the state Board of Pharmacy
by helping the board understand the complexities of correctional pharmacy care. Its not a nursing home; its not a
hospital; its not an ambulatory care center. Its a little bit of
Larrat says it is unusual to apply pharmacy benefit management 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. Thats helped with access to information and our ability to educate the staff about pharmaceutical care, which
hopefully filters down to better care and treatment of the

Fostering Future Pharmacists

Both Poshkus and Marocco praise the work of the URI
pharmacy students and are pleased that the prison setting
can serve as a teaching facility for them. Indeed, Marcoux
says PBMI was very excited that we are taking this opportunity to introduce students to a part of pharmacy that
often, students are not aware of. They are gaining experience that prepares them for jobs that many organizations in
the 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 prescription
trends. I reviewed utilization of emergency prescriptions to
see where we can maximize the effectiveness of the ordering system, says Matt Coty, who graduated in May after
completing his six-year doctor of pharmacy degree He says
the program is important because everybody deserves
appropriate medications, and they should be treated just as
any other individual would be treated.
Brian Touhey, who also graduated in May with a doctorate in pharmacy, says he would encourage other pharmacy
students to make this one of their rotations. Part of it was
being on campus analyzing the numbers and then coming
here to see it all come to fruition. This helped me not only
with my clinical judgment, but my personal judgment as
well.... You have to use your professional judgment, your
clinical judgment, put everything else aside and do your
best 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, RIDOCs
associate director of health care services.

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Spring 2009 CorrectCare

Force Feeding for Hunger Strikes

by Marc F. Stern, MD, MPH

hether you think its a step forward or backward, the Supreme Court of Washington State
recently issued a ruling in a case that adds some
clarity to how correctional health care physicians should
deal with hunger strikers. The events in the case, McNabb
v. Department of Correctionss (2005) took place in 2004; the
court heard the case in 2005 and handed down its ruling in
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 and
had 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 WDOC
claiming WDOC had violated his right to refuse treatment
under his right to privacy. He asked the court to declare
WDOCs force-feeding policy unconstitutional.
The court concluded that WDOC was correct in force
feeding 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 McNabbs right to refuse
artificial means of nutrition and hydration against
the existence of five compelling state interests:
(1) the maintenance of security and orderly
administration 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 component
tests are not new. Indeed, the first test is also known as
the Turner Rule. In Turner v. Safleyy (1987), a case regarding
an inmates right to marry, the U.S. Supreme Court found
that the states interest outweighs the inmates interest
when the state has a legitimate penologic interest to deny
the inmates right. So, for example, if the state felt that
the inmates hunger strike might spread to other inmates,
impairing the states 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. In
fact, 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 tests
were borrowed from another Washington State case
(Welfare of Colyerr, 1983).

applicable to this situation and was properly executed by

WDOC. Thus the policy itself has now been subject to judicial review and has survived. This may provide some guidance to other jurisdictions.
As of this writing, the 2007 policy in effect is essentially
the 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 the
patient 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 trying to determine whether or not the patients 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 WDOCs policy
on involuntary medication administration for severe mental disease (which was upheld by the Supreme Court in
the well-known case Washington DOC v. Harperr, 1990),
WDOCs forced feeding policy does not include a due process component. The current court did not take issue with
this. They noted and were satisfied that medical staff issued
a written determination.

Unsettled Question
Whether increased authority on the part of correctional
systems to force feed inmates is a good thing is not a
settled question. That, certainly, is an ethical question for
each of us to ponder. However, from a legal standpoint, at
least, not all courts have agreed with the Washington State
Supreme Court that prison walls separate citizens from
their constitutional rights. At least three state courts have
reached an opposite conclusion (California Supreme Court:
Thor v. Superior Courtt, 1993; Georgia Supreme Court: Zane
v. Prevattee, 1982; Florida appeals court: Singletary v. Costelloo,
1996; all cited in AELE Monthly Law Journall, Jail & Prisoner
Law Section, December 2007).
Finally, the reader should carefully note that all the cases
discussed 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 should
not, 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 consultant. At the time this article was written, he was the assistant secretary for health services at the Washington State
Department of Corrections. To contact him, send an e-mail
to mfstern@u.washington.edu.

WDOC Policy Passes Muster

In its decision, the court referred frequently to WDOCs
force-feeding policy, including the fact that the policy was

Spring 2009 CorrectCare


TRUVADA is a once a day backbone for combination therapy in adults with HIV-1

at HIV confidently
with TRUVADA in
corrrectional facilities

Demonnstrated efficacy and tolerability profile

through 3 years in Study 9342

TRUVADA is the only DHHS-preferred dual NRTI3

TRUVADA or its compo

onents have been chosen
in long-term clinical tria
als with leading PIs1,4-9


NRTI backbone



Depend on TRUVADA to
be your partner with PIs

emtricitabine tenofovir disoproxil fumarate

Safety information: drug interactions have been observed between tenofovir DF annd atazanavir or lopinavir/ritonavir. Atazanavir 300 mg should be boosted with ritonavir
100 mg and taken with food when administered with TRUVADA. Atazanavir without ritonavvir should not be coadministered with TRUVADA. Patients on atazannavir or lopinavir/ritonavir
plus TRUVADA should be monitored for tenofovir-associated adverse reactions. TRUVADA shhould be discontinued in patients who develop tenofovir-associateed adverse reactions.2
Indications and usage2
TRUVADA, a combination of EMTRIVA (emtricitabine) and VIREAD
(tenofovir disoproxil fumarate), is indicated in combination with other
antiretroviral agents (such as non-nucleoside reverse transcriptase inhibitors
or protease inhibitors) for the treatment of HIV-1 infection in adults. The
following 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
Lactic acidosis and severe hepatomegaly with steatosis, including fatal cases,
have been reported with the use of nucleoside analogs, including VIREAD, a
component 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 been
established in patients coinfected with HBV and HIV-1. Severe acute
exacerbations of hepatitis B have been reported in patients who are
coinfected with HBV and HIV-1 and have discontinued TRUVADA. Hepatic
function should be monitored closely with both clinical and laboratory
follow-up for at least several months in patients who are coinfected with
HIV-1 and HBV and discontinue TRUVADA. If appropriate, initiation of
anti-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 or
without food
Dose recommended in renal impairment: creatinine clearance (CrCl)
3049 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 5080 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 renal
function are recommended in all patients with CrCl 3049 mL/min.
No safety or efficacy data are available in patients with renal
impairment who received TRUVADA using these dosing guidelines, so
the potential benefit of TRUVADA therapy should be assessed against
the potential risk of renal toxicity
Avoid administering TRUVADA with concurrent or recent use of
nephrotoxic 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
Adverse reactions
The most common (incidence 10%, any severity) and/or treatmentemergent (Grade 24, occurring in 5% of patients) adverse reactions
occurring 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 consequence
of proximal renal tubulopathy: rhabdomyolysis, osteomalacia, hypokalemia,
muscular weakness, myopathy, hypophosphatemia

Other adverse reactions that occurred in at least 5% of patients receiving

EMTRIVA or VIREAD with other antiretroviral agents in clinical trials include
anxiety, arthralgia, increased cough, dyspepsia, fever, myalgia, pain,
abdominal pain, back pain, paresthesia, peripheral neuropathy (including
peripheral neuritis and neuropathy), pneumonia, and rhinitis

Drug interactions
Didanosine (ddI): tenofovir disoproxil fumarate increases ddI concentrations.
Consider dose reductions or discontinuations of ddI if warranted
Atazanavir (ATV): coadministration decreases ATV concentrations and
increases tenofovir concentrations. Use ATV with TRUVADA only with
ritonavir; monitor for evidence of tenofovir-associated adverse reactions
Lopinavir/ritonavir: coadministration increases tenofovir concentrations.
Monitor for evidence of tenofovir-associated adverse reactions
*Combivir (zidovudine/lamivudine), Epivir or Epivir HBV (lamivudine), Epzicom (abacavir
sulfate/lamivudine), or Trizivir (abacavir sulfate/lamivudine/zidovudine).
References: 1. Derived from patient chart audit, Synovate Healthcare Data, US HIV Monitor.r 2008, Q3.
2. TRUVADAA (emtricitabine/tenofovir disoproxil fumarate) Prescribing Information. Gilead Sciences, Inc.
November 2008. 3. Panel on Antiretroviral Guidelines for Adults and Adolescents. Guidelines for the use of
antiretroviral 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.
2006;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.
2008;358:2095-2106. 6. Molina J-M, Podsadecki TJ, Johnson MA, et al. A lopinavir/ritonavir-based oncedaily regimen results in better compliance and is non-inferior to a twice-daily regimen through 96 weeks. AIDS
Res Hum Retroviruses.s 2007;23:1505-1514. 7. Young B, Smith K, Patel P, et al. Characterization of virologic
failure over 96 weeks by drug resistance and antiviral response in ART nave patients receiving abacavir/
lamivudine (ABC/3TC) or tenofovir/emtricitabine (TDF/FTC) each with lopinavir/ritonavir QD in the HEAT
study. 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-nave, 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-nave 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.



The following is a brief summary for TRUVADA

A (emtricitabine/tenofovir
disoproxil fumarate [DF]) tablets. Before prescribing, see full Prescribing
Information, including boxed WARNINGS.
Lactic acidosis and severe hepatomegaly with steatosis, including
fatal cases, have been reported with the use of nucleoside analogs,
including VIREAD, a component of TRUVADA, in combination with
other 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 been
established in patients coinfected with HBV and HIV-1. Severe acute
exacerbations of hepatitis B have been reported in patients who are
coinfected with HBV and HIV-1 and have discontinued TRUVADA.
Hepatic function should be monitored closely with both clinical and
laboratory follow-up for at least several months in patients who are
coinfected with HIV-1 and HBV and discontinue TRUVADA. If
appropriate, initiation of anti-hepatitis B therapy may be warranted
[See Warnings and Precautions].
TRUVADA, a combination of EMTRIVA (emtricitabine) and VIREAD (tenofovir
disoproxil fumarate), is indicated in combination with other antiretroviral agents (such
as non-nucleoside reverse transcriptase inhibitors or protease inhibitors) for the treatment
of HIV-1 infection in adults.
The following 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 [See Warnings and Precautions].
In treatment experienced patients, the use of TRUVADA should be guided by laboratory
testing and treatment history.
The dose of TRUVADA is one tablet (containing 200 mg of emtricitabine and 300 mg of
tenofovir disoproxil fumarate) once daily taken orally with or without food.
Dose Adjustment for Renal Impairment: Significantly increased drug exposures
occurred when EMTRIVA or VIREAD were administered to patients with moderate to severe
renal impairment [See EMTRIVA or VIREAD Package Insert].] Therefore, the dosing interval
should be adjusted in patients with baseline creatinine clearance 3049
mL/min using the recommendations in Table 1. These dosing interval recommendations
are based on modeling of single-dose pharmacokinetic data in non-HIV-1 infected
subjects. The safety and effectiveness of these dosing interval adjustment
recommendations have not been clinically evaluated in patients with moderate renal
impairment, therefore, clinical response to treatment and renal function should be closely
monitored in these patients [See Warnings and Precautions].]
No dose adjustment is necessary for patients with mild renal impairment (creatinine
clearance 5080 mL/min). Routine monitoring of calculated creatinine clearance and serum
phosphorus should be performed in patients [See Warnings and Precautions].]
Table 1.
Dosage Adjustment for Patients with Altered Creatinine Clearance

Recommended Every
Dosing Interval 24 hours

Creatinine Clearance (mL/min)*

<30 (Including Patients
Requiring Hemodialysis)
48 hours

patients receiving stavudine + lamivudine + efavirenz. Changes in BMD at the hip were similar
between the two treatment groups. In both groups, the majority of the reduction in BMD
occurred in the first 2448 weeks of the study and this reduction was sustained through
144 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 the
VIREAD group and 6 patients in the comparator group. Tenofovir disoproxil fumarate was
associated with significant increases in biochemical markers of bone metabolism (serum bonespecific alkaline phosphatase, serum osteocalcin, serum C-telopeptide, and urinary N-telopeptide),
suggesting increased bone turnover. Serum parathyroid hormone levels and 1,25 Vitamin D
levels were also higher in patients receiving VIREAD. The effects of VIREAD-associated changes
in BMD and biochemical markers on long-term bone health and future fracture risk are
unknown. For additional information, please consult the VIREAD prescribing information.
Cases of osteomalacia (associated with proximal renal tubulopathy and which may contribute
to fractures) have been reported in association with the use of VIREAD[See
[ Adverse Reactions]].
Fat Redistribution: Redistribution/accumulation of body fat including central
obesity, dorsocervical fat enlargement (buffalo hump), peripheral wasting, facial
wasting, breast enlargement, and cushingoid appearance have been observed in
patients receiving antiretroviral therapy. The mechanism and long-term consequences
of these events are currently unknown. A causal relationship has not been established.
Immune Reconstitution Syndrome: Immune reconstitution syndrome has been
reported in patients treated with combination antiretroviral therapy, including TRUVADA.
During the initial phase of combination antiretroviral treatment, patients whose immune
system responds may develop an inflammatory response to indolent or residual
opportunistic infections [such as Mycobacterium avium infection, cytomegalovirus,
Pneumocystis jirovecii pneumonia (PCP), or tuberculosis], which may necessitate
further evaluation and treatment.
Early Virologic Failure: Clinical studies in HIV-infected patients have demonstrated that
certain regimens that only contain three nucleoside reverse transcriptase inhibitors (NRTI)
are generally less effective than triple drug regimens containing two NRTIs in combination
with either a non-nucleoside reverse transcriptase inhibitor or a HIV-1 protease inhibitor. In
particular, early virological failure and high rates of resistance substitutions have been
reported. Triple nucleoside regimens should therefore be used with caution. Patients on a
therapy utilizing a triple nucleoside-only regimen should be carefully monitored and
considered for treatment modification.
Adverse Reactions from Clinical Trials Experience: Because clinical trials are
conducted under widely varying conditions, adverse reaction rates observed in the clinical
trials of a drug cannot be directly compared to rates in the clinical trials of another
drug 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 disoproxil
fumarate, include diarrhea, nausea, fatigue, headache, dizziness, depression, insomnia,
abnormal dreams, and rash. See also full Prescribing Information for the frequency of
treatment-emergent adverse reactions (Grade 24) occurring in 5% of patients treated
with efavirenz, emtricitabine, and tenofovir disoproxil fumarate in this study.
Skin discoloration, manifested by hyperpigmentation on the palms and/or soles was
generally mild and asymptomatic. The mechanism and clinical significance are unknown.
Study 934 - Treatment Emergent Adverse Reactions: In Study 934, 511 antiretroviralnave patients received either VIREAD + EMTRIVA (emtricitabine) administered in
combination with efavirenz (N=257) or zidovudine/lamivudine administered in combination
with efavirenz (N=254). Adverse reactions observed in this study were generally consistent
with those seen in other studies in treatment-experienced or treatment-nave patients
receiving VIREAD and/or EMTRIVA, including diarrhea, nausea, vomiting, fatigue, sinusitis,
upper respiratory tract infections, nasopharyngitis, headache, dizziness, depression,
insomnia, and rash event.

TRUVADA should
not be administered.

Lactic Acidosis/Severe Hepatomegaly with Steatosis: Lactic acidosis and
severe hepatomegaly with steatosis, including fatal cases, have been reported with the use
of nucleoside analogs, including VIREAD, a component of TRUVADA, in combination with
other antiretrovirals. A majority of these cases have been in women. Obesity and prolonged
nucleoside exposure may be risk factors. Particular caution should be exercised when
administering 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. Treatment
with TRUVADA should be suspended in any patient who develops clinical or laboratory
findings suggestive of lactic acidosis or pronounced hepatotoxicity (which may include
hepatomegaly and steatosis even in the absence of marked transaminase elevations).
Patients Coinfected with HIV-1 and HBV: It is recommended that all patients with
HIV-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 and
efficacy 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 coinfected
with HBV and HIV-1 and have discontinued TRUVADA. In some patients infected with HBV
and treated with EMTRIVA, the exacerbations of Hepatitis B were associated with liver
decompensation and liver failure. Patients who are coinfected with HIV-1 and HBV should
be closely monitored with both clinical and laboratory follow up for at least several
months after stopping treatment with TRUVADA. If appropriate, initiation of antiHepatitis B therapy may be warranted.
New Onset or Worsening Renal Impairment: Emtricitabine and tenofovir are
principally eliminated by the kidney. Renal impairment, including cases of acute renal
failure and Fanconi syndrome (renal tubular injury with severe hypophosphatemia), has
been reported with the use of VIREAD [See Adverse Reactions].]
It is recommended that creatinine clearance be calculated in all patients prior to
initiating therapy and as clinically appropriate during therapy with TRUVADA. Routine
monitoring of calculated creatinine clearance and serum phosphorus should be
performed in patients at risk for renal impairment.
Dosing interval adjustment of TRUVADA and close monitoring of renal function are
recommended in all patients with creatinine clearance 3049 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 TRUVADA
therapy should be assessed against the potential risk of renal toxicity. TRUVADA should not be
administered 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 coadministered
with ATRIPLA, EMTRIVA, or VIREAD. Due to similarities between emtricitabine and
lamivudine, TRUVADA should not be coadministered with other drugs containing lamivudine,
including Combivir (lamivudine/zidovudine), Epivirr or Epivir-HBVV (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) monitoring
should be considered for HIV-1 infected patients who have a history of pathologic bone
fracture or are at risk for osteopenia. Although the effect of supplementation with calcium
and vitamin D was not studied, such supplementation may be beneficial for all patients. If
bone abnormalities are suspected then appropriate consultation should be obtained.
Tenofovir Disoproxil Fumarate: In a 144-week study of treatment nave 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 the
lumbar spine in patients receiving VIREAD + lamivudine (3TC) + efavirenz (EFV) compared with

emtricitabine tenofovir disoproxil fumarate

Laboratory Abnormalities: Laboratory abnormalities observed in this study were generally

consistent with those seen in other studies of VIREAD and/or EMTRIVA.
Postmarketing Experience: The following adverse reactions have been identified
during postapproval use of VIREAD: allergic reaction, lactic acidosis, hypokalemia,
hypophosphatemia, dyspnea, pancreatitis, increased amylase, abdominal pain, hepatic
steatosis, hepatitis, increased liver enzymes (most commonly increased AST, ALT, Gamma GT),
rash, rhabdomyolysis, osteomalacia (manifested as bone pain and which may contribute to
fractures), muscular weakness, myopathy, acute renal failure, renal failure, acute tubular
necrosis, Fanconi syndrome, proximal renal tubulopathy, interstitial nephritis (including
acute cases), nephrogenic diabetes insipidus, renal insufficiency, increased creatinine,
proteinuria, polyuria, asthenia. No additional adverse reactions have been identified during
postapproval use of EMTRIVA. Because postmarketing reactions are reported voluntarily
from a population of uncertain size, it is not always possible to reliably estimate their frequency
or establish a causal relationship to drug exposure.
The following adverse reactions, listed above, may occur as a consequence of proximal
renal tubulopathy: rhabdomyolysis, osteomalacia, hypokalemia, muscular weakness,
myopathy, hypophosphatemia.
No drug interaction studies have been conducted using TRUVADA tablets. Drug interaction
studies have been conducted with emtricitabine and tenofovir disoproxil fumarate, the
components of TRUVADA. This section describes clinically relevant drug interactions
observed with emtricitabine and tenofovir disoproxil fumarate.
Didanosine: Coadministration of TRUVADA and didanosine should be
undertaken with caution and patients receiving this combination should
be monitored closely for didanosine-associated adverse reactions.
Didanosine should be discontinued in patients who develop didanosineassociated adverse reactions. When tenofovir disoproxil fumarate was
administered with didanosine the Cmax and AUC of didanosine administered as either the
buffered or enteric-coated formulation increased significantly. The mechanism of this
interaction is unknown. Higher didanosine concentrations could potentiate didanosineassociated adverse reactions, including pancreatitis, and neuropathy. Suppression of CD4+ cell
counts has been observed in patients receiving tenofovir DF with didanosine 400 mg daily. In
adults weighing >60 kg, the didanosine dose should be reduced to 250 mg when it is
coadministered with TRUVADA. Data are not available to recommend a dose adjustment of
didanosine for patients weighing <60 kg. When coadministered, TRUVADA and Videxx 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 be
under fasted conditions.
Atazanavir: Atazanavir has been shown to increase tenofovir concentrations. The mechanism
of this interaction is unknown. Patients receiving atazanavir and TRUVADA should
be monitored for TRUVADA-associated adverse reactions. TRUVADA should
be discontinued in patients who develop TRUVADA-associated adverse
reactions. Tenofovir decreases the AUC and Cmin of atazanavir. When coadministered with
TRUVADA, 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 tenofovir
concentrations. The mechanism of this interaction is unknown. Patients receiving
lopinavir/ritonavir and TRUVADA should be monitored for TRUVADA-associated
adverse reactions. TRUVADA should be discontinued in patients who develop
TRUVADA-associated adverse reactions.

Drugs Affecting Renal Function: Because emtricitabine and tenofovir are primarily
excreted by the kidneys, coadministration of TRUVADA (emtricitabine/tenofovir disoproxil
fumarate) with drugs that are eliminated by active tubular secretion may increase
concentrations of emtricitabine, tenofovir, and/or the coadministered drug. Some examples
include, but are not limited to acyclovir, adefovir dipivoxil, cidofovir, ganciclovir, valacyclovir,
and valganciclovir. Drugs that decrease renal function may increase concentrations of
emtricitabine and/or tenofovir.
Pregnancy Category B: Emtricitabine: The incidence of fetal variations and
malformations was not increased in embryofetal toxicity studies performed with
emtricitabine in mice at exposures (AUC) approximately 60-fold higher and in rabbits at
approximately 120-fold higher than human exposures at the recommended daily dose.
Tenofovir Disoproxil Fumarate: Reproduction studies have been performed in rats and
rabbits at doses up to 14 and 19 times the human dose based on body surface area comparisons and
revealed 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 animal
reproduction studies are not always predictive of human response, TRUVADA should be used
during pregnancy only if clearly needed.
Antiretroviral Pregnancy Registry: To monitor fetal outcomes of pregnant women
exposed 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 Prevention
recommend that HIV-1-infected mothers not breast-feed their infants to
avoid risking postnatal transmission of HIV-1. Studies in rats have demonstrated
that tenofovir is secreted in milk. It is not known whether tenofovir is excreted in human
milk. It is not known whether emtricitabine is excreted in human milk. Because of both the
potential for HIV-1 transmission and the potential for serious adverse reactions in nursing
infants, mothers should be instructed not to breast-feed if they are
receiving TRUVADA.
Pediatric Use: TRUVADA is not recommended for patients less than 18 years of age
because it is a fixed-dose combination tablet containing a component, VIREAD (tenofovir
disoproxil fumarate), for which safety and efficacy have not been established in this age group.
Geriatric Use: Clinical studies of EMTRIVA (emtricitabine) or VIREAD did not
include sufficient numbers of subjects aged 65 and over to determine whether they
respond differently from younger subjects. In general, dose selection 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.
Patients with Impaired Renal Function: It is recommended that the dosing
interval for TRUVADA be modified in patients with creatinine clearance 3049 mL/min.
TRUVADA should not be used in patients with creatinine clearance <30 mL/min and in
patients with end-stage renal disease requiring dialysis [See Dosage and Administration].]
Carcinogenesis, Mutagenesis, Impairment of Fertility
Emtricitabine: In long-term oral carcinogenicity studies of emtricitabine, no drug-related
increases in tumor incidence were found in mice at doses up to 750 mg/kg/day (26 times the
human systemic exposure at the therapeutic dose of 200 mg/day) or in rats at doses up to 600
mg/kg/day (31 times the human systemic exposure at the therapeutic dose).
Emtricitabine was not genotoxic in the reverse mutation bacterial test (Ames test), mouse
lymphoma or mouse micronucleus assays.
Emtricitabine did not affect fertility in male rats at approximately 140-fold or in
male and female mice at approximately 60-fold higher exposures (AUC) than in humans
given the recommended 200 mg daily dose. Fertility was normal in the offspring of mice
exposed daily from before birth (in utero) through sexual maturity at daily exposures
(AUC) of approximately 60-fold higher than human exposures at the recommended
200 mg daily dose.
Tenofovir Disoproxil Fumarate: Long-term oral carcinogenicity studies of tenofovir
disoproxil fumarate in mice and rats were carried out at exposures up to approximately 16
times (mice) and 5 times (rats) those observed in humans at the therapeutic dose for HIV-1
infection. At the high dose in female mice, liver adenomas were increased at exposures 16
times that in humans. In rats, the study was negative for carcinogenic findings at exposures up
to 5 times that observed in humans at the therapeutic dose.
Tenofovir disoproxil fumarate was mutagenic in the in vitro mouse lymphoma assay and
negative in an in vitro bacterial mutagenicity test (Ames test). In an in vivo mouse micronucleus
assay, tenofovir disoproxil fumarate was negative when administered to male mice.
There were no effects on fertility, mating performance or early embryonic development when
tenofovir disoproxil fumarate was administered to male rats at a dose equivalent to 10 times
the human dose based on body surface area comparisons for 28 days prior to mating and to
female rats for 15 days prior to mating through day seven of gestation. There was, however, an
alteration of the estrous cycle in female rats.
Patients 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. Patients
should 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 develop
clinical symptoms suggestive of lactic acidosis or pronounced hepatotoxicity (including
nausea, vomiting, unusual or unexpected stomach discomfort, and weakness) [See
Warnings 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 with
concurrent or recent use of a nephrotoxic agent [See Warnings and Precautions].] Dosing
interval of TRUVADA may need adjustment in patients with renal impairment [See
Dosage 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), Epivir
or Epivir-HBV (lamivudine), Epzicom (abacavir sulfate/lamivudine), or Trizivir (abacavir
sulfate/lamivudine/zidovudine) [See Warnings and Precautions].]
TRUVADA should not be administered with HEPSERA (adefovir dipivoxil) [See
Warnings and Precautions].
Decreases in bone mineral density have been observed with the use of VIREAD. Bone
monitoring should be considered in patients who have a history of pathologic bone
fracture or at risk for osteopenia [See Warnings and Precautions].]
*Calculated using ideal (lean) body weight.
Gilead Sciences, Inc. Foster City, CA 94404 November 2008

TRUVADA, EMTRIVA, HEPSERA, and VIREAD are trademarks of Gilead

Sciences, Inc. ATRIPLA is a trademark of Bristol-Myers Squibb & Gilead
Sciences, LLC. All other trademarks referenced herein are the property of
their respective owners.
2008 Gilead Sciences, Inc. All rights reserved. 11/08

Study: Brief Negotiation Interviewing

Lowers HIV Risk, Increases Testing
Researchers and public health practitioners recognize that
incarceration provides a great opportunity to intervene
with populations at high-risk for HIV and AIDS largely
because of their drug-use behavior. However, at any given
time, twice as many offenders are under community supervision 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, Sonia
Alemagno, PhD, and colleagues sought to develop and test
an intervention that addresses reduction of HIV risk and
encourages 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 motivational
interviewing. With evidence of positive outcomes mounting in the literature, this approach allows intervention staff
to help clients express concerns about their health and selfexamine motivation for change. A newer, related model,
brief negotiation interviewing, is being applied to hectic
settings such as emergency rooms and courts. According
to the authors, BNI is a computerized, self-directed intervention that combines a short structured interview with a
brief 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 participants recruited from a probation department and two
substance abuse treatment agencies in Cleveland, OH. The
study examined whether BNI could decrease HIV risks and
increase testing for HIV in this population. A trained interviewer conducted individual, face-to-face interviews in a
private setting at baseline and two months later. The interview questions focused on drug-use and sexual behaviors
associated with HIV risk.
After the first interview, the 104 control group members
received the Treatment Alternatives to Street Crime (TASC)
intervention: written educational materials on HIV, STDs,
TB and hepatitis, plus a list of community providers who
conduct testing and counseling. They also were given a bus
pass and reminded of the follow-up interview.
The 108 experimental group members were invited to
engage 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 sexual
risk, and focused on good things and not so good things
about these behaviors. Personal-risk feedback was provided
with objectivity, emphasizing personal choice and responsibility for change. Finally, participants were given a personal
prevention 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 experimental
group and 75% in the control group were located and interviewed.
Results indicate that, overall, both programs produced
positive results as indicated by the improvement in risky
sexual behavior and attitudes toward behavior change.
However, those who received the BNI component demonstrated increased AIDS awareness, had a significantly higher
rate 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 TobaccoFree Correctional Facility Thomas Lincoln, MD, Robert
W. Tuthill, PhD, Cheryl A. Roberts, MPA, Sofia Kennedy,
MPH, Theodore M. Hammett, PhD, Elizabeth LangmoreAvila, MA, DTR, and Thomas J. Conklin, MD
Alcohol, Marijuana, and Perceptions of Influence on
Social and Sexual Behavior Among African American
Adolescent 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,
NCCHC Position Statement: Prevention of Juvenile
Suicide in Correctional Settings
Each issue of JCHC
C also has a self-study exam by which
physicians, nurses, psychologists and CCHPs may earn
continuing education credit.
Members of the Academy of Correctional Health
Professionals receive JCHC
C (hard copy and online) as a
benefit of membership. To learn how to obtain JCHC
contact Sage Publications: 800-818-7243, ext. 7100;
order@sagepub.com; http://jchc.sagepub.com.


Spring 2009 CorrectCare

on the standards
by Jennifer E. Kistler, MPH

D-02 Medication
Medication services are
clinically appropriate
and provided in a timely, safe, and sufficient
2008 Standards for
Health Services for jails
and prisons

n the 2008 Standards for Health Servicess, the standard

on Medication Services (D-02) contains a new compliance indicator: Inmates entering the facility on prescription medication continue to receive the medication in a
timely fashion as prescribed, or acceptable alternate medications are provided as clinically indicated.
Newly admitted inmates who report taking medications currently or who bring medications with them are
to continue their medication unless there is a clinical reason to alter or discontinue the medication. Note that the
E-02 Receiving Screening standard states in Compliance
Indicator 9 that prescribed medications are reviewed
and appropriately maintained according to the medication schedule the inmate was following before admission.
Protocols should be in place so that the drugs are administered in a timely fashion as dictated by clinical need. Clinical
need 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 receive
necessary drugs. Perhaps the physician or on-call physician
is contacted by health staff for a verbal order once they



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have verified the medication through the community prescribing clinician or pharmacy. Another option is authorizing nurses to give medications based on the community
clinicians valid order until the facility physician is able to see
the inmate. Some facilities do allow the use of medication
that is brought in if it is contained in the original pharmacy
packaging, labeled as required and staff have verified the
order with the community prescriber or pharmacist.
A physician, dentist or other legally authorized individual
may determine that a prescribed treatment is no longer
clinically indicated or that there is an alternative to a medication that the patient was taking before incarceration. It is
good practice to explain to patients the clinical justification
behind discontinuing or prescribing alternate medication
so that they understand that health care decisions are
made based on their health needs and not for any punitive

Importance of Continuity
Continuity of care is an important concept in this standard
as it intends to help prevent adverse patient outcomes. For
instance, it may not be possible to maintain a therapeutic
dose of medication unless medications are taken as prescribed. Inordinate delays in receiving clinically indicated
prescription medication may result in significant morbidity or mortality. Adverse patient outcomes can also occur
when there are frequent changes in medication orders,
medication histories are not reviewed by the clinician or
treating clinicians are unaware of each others prescribing
We all understand the importance of patients continuing
to take medication as prescribed for health conditions such
as high blood pressure or diabetes. There are also many
other prescription medications that could have adverse
health consequences if abruptly discontinued or not taken
in a timely manner; steroids, antidepressants, antibiotics,
and others require strict regimens in order to remain effective or prevent side effects. The facility provider will evaluate the medical necessity of prescriptions for newly admitted inmates to ensure that there is continuity of care and
that health needs are met.
Medication services should, of course, be clinically
appropriate and provided in a timely, safe and sufficient
manner commensurate with current community practice.
Therefore, the responsible physician should establish the
policies regarding all prescription medications administered
or delivered in the facility.

Jennifer E. Kistler, MPH, is NCCHCs director of accreditation. To contact her, e-mail jenniferkistler@ncchc.org, 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.

Spring 2009 CorrectCare



n this column, Judith Robbins, LCSW, JD, CCHP-A, talks

with nutrition consultant Barbara Wakeen, MA, RD,
CCHP, about nutritional issues specific to juvenile detention populations.
JR: What are the special dietary needs of adolescents and
how can corrections facilities meet these needs?
BW: Adolescents require more calories, calcium, phosphorus 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 Ive learned from
other corrections dietitians, most juveniles are receiving
more 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 Breakfast
Program. These programs require certain food groups and
quantities to be offered, along with some nutrient restrictions such as types and amounts of fats. Participants are also
entitled to purchase commodity food items, which can help
food budgets. Whether or not facilities participate, I have
found 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 to
some 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 can
address 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 exercise 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 all
juveniles, not just those at risk. This is somewhat akin to
NCCHC standards in their proactive stance for health during and after incarceration. Information on the wellness
policy requirements can be found at www.fns.usda.gov/TN/
JR: Registered dietitians are in short supply in many juvenile systems. When an RD is not on staff, how can professionals collaborate to improve dietary choices for kids?
BW: RDs write and approve menus based on state regu-

lations, accreditation standards, facility policy and other

guidelines (e.g., the USDA Child Nutrition Program) with
which the facilities must comply. However, unless we are
there to monitor, we cannot guarantee the outcomes.
Start by reviewing the various requirements noted
above. Look at what is offered in commissaries and vending machines, if these are available to the juveniles. Look
at 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 can
validate the need for a visit or consult from the RD to assist
in 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 healthy
diets while managing tightening budgets?
BW: Although its not always popular with the kids, strive
to 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 with
very 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 do
not honor personal food preferences in terms of likes and
dislikes. I am in agreement with this. That said, standard
menu planning usually does factor in preferences according
to population demographics. Some accreditation standards
require food preference surveys. Facilities use this information 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 be
less popular but are nutrient dense. This approach results in
healthy 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 NCCHCs juvenile health committee. She is the author
of Nutrition and Foodservice Management in Correctional
Facilities. Reach her at bwakeen@neo.rr.com.
Judith Robbins, LCSW, JD, CCHP-A, represents the National
Association of Social Workers on the board and chairs the
juvenile health committee. She directs the Juvenile Detention
Mental Health Program of Yale Behavioral Health, Department 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
editor@ncchc.org or CorrectCare, c/o NCCHC, 1145 W.
Diversey Pkwy, Chicago, IL 60614.


Spring 2009 CorrectCare


Step Up! Seeking Candidates for Board

Serving on the Certified Correctional Health Professional
board of trustees is a great way to give back to this important program and the thousands of people who participate
in it. But the benefits go both ways: It is also a wonderful
opportunity for leaders in this field to continue their professional growth and build their network of like-minded
If that piques your interest, step up! CCHPs in good

The National Commission on Correctional Health Care and

the Certified Correctional Health Professionals Board of
Trustees are pleased to announce


NEW for 2009!


Specialty certification for nurses

working in the correctional setting

Recognizing the work you do and the

difference you make

Exclusively for nurses already CCHP certified

From the most widely-accepted correctional

health care certification program

Certification in correctional nursing makes a differenceto 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
caatio when itt bec
mes av
e, co
ontactt uus
at cchp@ncchc.org or 773-880-1460.
0. Also look
ok for updates
ates and
announcements on our Webb site
sitte at www.ncchc.org/cchp.

standing are encouraged to seek nomination, or to

nominate a fellow CCHP, to serve on the board of trustees. Elections are held every year to fill a three-year term.
Comprised of 10 correctional health professionals, the
board is charged with guiding the CCHP program and
improving it as necessary to make it more responsive to the
needs of the correctional health care community. Trustees
are also responsible for developing, scoring and evaluating
the various certification exams.
Upon acceptance of nomination, candidates will be
asked 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 will
begin their term immediately after the annual board meeting 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 February
and 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 the
complex and ever-changing field of correctional health care.
If you do not yet participate in the program but would like
to know more, please visit the Web to read about the benefits of certification as well as the application and examination process, and to obtain an application. Or contact us at
cchp@ncchc.org or 773-880-1460. We also present informational 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 the
CCHP coordinator at 773-880-1460 or cchp@ncchc.org.

Spring 2009 CorrectCare

NursingAd CC HalfIsland.ind1 1

12/4/08 5:12:29 PM


This department features news and information from
NCCHCs supporting organizations and other partners that
share our goal of promoting quality health care in correctional institutions. If your organization has news to share,
please contact editor@ncchc.org, 773-880-1460.

American Correctional
Health Services

in America. Laws and legal services play a pivotal role in

stemming the spread of HIV by reducing stigma and discrimination linked to the virus, according to the committee.
This, in turn, encouraging greater HIV testing, which is critical 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 Physicians

The ACP is offering its members free copies

Jacqueline Moore, PhD, RN,
of a patient education guidebook on how
CCHP-A, was honored with
to manage high blood pressure. Released in
ACHSAs 2009 Distinguished
April, the guide is accompanied by a DVD
Service Award. Presented during
that features sportscaster James Brown. Both
the associations annual meeting
are designed to help patients learn about high
in March, the award is given to
blood pressure, what steps to take to control
individuals who have attained
it and how to lower the risk of heart and
significant achievement or con- Jacqueline Moore, PhD, RN, CCHP-A,
tribution to correctional health receives the award plaque from (L) ACHSAs blood vessel problems. Almost everyone with
outgoing president, Royanne Schissel, RN,
hypertension can bring their numbers down
service and/or ACHSA.
CCHP, and (R) the 2008 award winner,
with lifestyle changes, medicines or both,
Now an independent consul- Kathryn Wild, RN, MPA, CCHP.
said ACPs director of education. Know Your
tant based in Colorado, Moore
Numbers: A Guide to Managing High Blood
has had a long and illustrious career in the correctional
Pressure is sponsored by Daiichi Sankyo, Inc. ACP members
health field. There are five criteria by which nominees are
can order the materials by calling ACP at 800-523-1546, ext.
evaluated; many recipients excel in two or three, it was
2600, or online at www.acponline.org.
noted. Moore, however, was praised for displaying excellence in all five criteria. Among the specific achievements
cited are the following:
1. Development of a model program: launching a new concept of comprehensive contract health services in a jail
2. Research: conducting doctoral research on factors related
to the shortage of nurses working in corrections
3. Publications: writing and editing copious published works
4. Training and education: developing surveyor training
when she was NCCHCs accreditation director
5. Public relations and management: overall leadership and
Developed by leaders in the field, these
management expertise
benchmark standards will help you:


American Medical Association

At its annual meeting in June, the AMA adopted a public
health policy concerning the use of tasers by law enforcement agencies. According to a brief issued by the association, an AMA report finds that tasers, when used appropriately, 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 be
ensured through specific guidelines, rigorous training and
an accountability system, said AMA board member Joseph
Annis, MD. There should also be a standardized approach
to the medical evaluation of subjects exposed to tasers.

American Bar Association

The ABAs AIDS Coordinating Committee has issued A
National 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

Standards CC Ad qrtr pgNEW.indd 1


 improve health services delivery

 increase organizational effectiveness
 enhance overall health care for inmates

1145 W. Diversey Parkway, Chicago, IL 60614

phone: (773)880-1460 fax: (773)880-2424
email: info@ncchc.org

To order or to see a list of all publications

available, visit our Web site at



6/10/08 7:56:04 AM

Spring 2009 CorrectCare

Exhibitor Opportunity

National Conference on Correctional Health Care

Orlando, Florida October 17-21, 2009
NCCHCs 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 convene
in Orlando for education, networking and career development. They are the leadersand emerging leaderswho make
and influence purchase decisions, and they will be looking for information about products and services that can help them
deliver quality care. The NCCHC exhibit hall is a hot spot for you to define your role in this specialty field. When you connect 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 nations jails, prisons and juvenile facilities. At the state level, correctional
health care costs have been growing by 10% annually. Dont miss this chance to develop valuable prospects and reconnect
with customers during three days of exhibit hall activities.

Did You Know?

77% of last years 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


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

Contact INFOCUS Today!


Kerry Tranfa
800.708.LIST (5478), ext 3247


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 NCCHCs online Buyers Guide
Lead retrieval technology available for rental on site
Opportunity to participate in raffle drawings
Discounted advertising in the conference programs and
Priority booth selection for the 2010 Updates conference

Sponsorship Opportunities
Enhance your presence and maximize marketing dollars
through these outstanding opportunities.
Premier programming: Sponsorship of educational sessions on hot topics demonstrates support of the correctional field and gives your company high-profile exposure.
Final proceedings: The CD-ROM provides a lasting record
of concurrent sessions, with abstracts, handouts and
PowerPoints. The sponsor is acknowledged on the cover.
Internet Cafe: Enjoy a high-tech presence by sponsoring
the exhibit hall computer stations, where attendees gather
to 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 visibility. Have an idea we havent mentioned? Let us know!

Registration Information
The meeting site is Disneys Coronado Springs Resort in
Orlando, FL. Standard booth sizes are 10' x 10'; double-size
and premium spaces are available. For details or to reserve
your space, please see the Exhibitor Prospectus, available at
www.ncchc.org, or contact us at info@ncchc.org or

Spring 2009 CorrectCare


Come Join Our Winning Correctional
Health Team, CFG Health Systems
CFG Health Systems, LLC (sister corp.
of Center for Family Guidance, PC) is a
physician-owned and operated behavioral healthcare organization providing a
full range of mental health services. We
offer many diverse career opportunities
with excellent benefits and are currently
looking to place professionals within several correctional facilities in New Jersey or
Physicians (Psychiatry, General Medicine)
Dentists (General Dentistry)
Nurse Practitioners
Interested candidates please contact:
Physician/Dentists: Frank Zura, Coordinator,
Phone: 856-797-4760, fzura@cfgpc.com
Nurses: Nancy DeLapo, Director, Phone
856-797-4761, ndelapo@cfgpc.com

10% discounts are offered for Academy members (single copies) and for bulk purchases of a
single title. To order, or for an NCCHC catalog,
visit www.ncchc.org or call 773-880-1460.

NCCHC Standards for Mental Health

Services in Correctional Facilities. These
standards support an accreditation program
for mental health services that operate under
an authority different from health services.
They parallel the standards for health services in format and substance, but make more
explicit what is required for adequate delivery of mental health services. General areas
covered include patient care and treatment,
clinical records, administration, personnel and
legal issues. These standards can help facilities
determine proper levels of care, organize systems more effectively and efficiently, and demonstrate that constitutional requirements are
being met. Glossary + index. Softcover, $69.95
Corrections Nursing: Scope and Standards
of Practice. Corrections RNs must practice
in work settings and environments for which
health care is not a primary mission, delivering adequate and humane care in an unbiased
manner. They must be qualified to address an
enormous range of patient needs. They must
understand and apply the concepts of primary
care services, employing skill sets of ambulatory care, community health, emergency,
occupational health, public health and school
nursing. This book articulates the essentials of
this specialty, its activities and accountabilities.
American Nurses Association (2007). Softcover,
95 pages, $18.95


If you source or purchase products for your department, you have
a powerful tool at your fingertips. The NCCHC Buyers Guide search
engine continually indexes the Web sites of all companies represented in
the directory. You can easily locate products and services unique to this
field 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.

About CorrectCare
CorrectCaree is the quarterly magazine of the
National Commission on Correctional Health Care.
Its mission is to publish news, articles and commentary of relevance to professionals in the field of
correctional health care.
Subscriptions: CorrectCaree is mailed free of
charge to members of the Academy of Correctional Health Professionals, key personnel at
accredited facilities and other recipients at our
discretion. To see if you qualify for a subscription,
submit a request online at www.ncchc.org or by
e-mail to info@ncchc.org. The magazine is also
posted at www.ncchc.org.
Change of Address: Send notification four weeks
in advance, including both old and new addresses
and, if possible, the mailing label from the most
recent issue. See page 1 for contact information.
Editorial Submissions: Submitted articles may be
published at our discretion. Manuscripts must be
original and unpublished elsewhere. For guidelines,
contact Jaime Shimkus at editor@ncchc.org or
773-880-1460. We also invite letters or correction
of facts, which will be printed as space allows.

Bristol-Myers Squibb / Gilead Atripla ..................Insert, 9
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

A downloadable application enables you to search from a small window

on your desktop, making the process even more convenient and timeefficient. Using the Request for Proposal (RFP) tool, you can contact a
group of suppliers with one click of a button.

National Conference on Correctional Health Care ..IFC


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

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

Prison Health Services (PHS)...........................................................22
Wexford Health Sources ........................................................................8


Spring 2009 CorrectCare

Expert Advice on NCCHC Standards
by Jennifer E. Kistler, MPH, and
R. Scott Chavez, PhD, MPA, CCHP-A

Suicide Prevention Checks


We perform 15-minute checks on our potentially suicidal inmates. Is this practice in compliance with the
G-05 Suicide Prevention Program standard?

Potentially 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 irregular
intervals, with no more than 15 minutes in between each
check (see Compliance Indicator 1d). Lastly, if the potentially suicidal inmate is placed in isolation, then constant
observation is required.

Emergency Response Critiques

Recently, we had a fire in our facility and had to

implement our emergency response plan and evacuate 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?

Yes. Actual emergencies, whether or not injuries

were involved, can certainly be critiqued and shared
with staff to meet the intent of this standard. (See
the Discussion section in the standard.)

Clinical Mortality Review

Typically, we wait for the results of the autopsy in

order to complete a clinical mortality review. This
often takes 60 days or more. Is it acceptable to wait
for the autopsy results before completing the clinical mortality review?

Death reviews should be completed in a timely

manner 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 be
reviewed within 30 days (see Compliance Indicators).
Reviews consist of an administrative review, a clinical
mortality review and, if the death is by suicide, a psychological 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


I 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.

No, the E-02 Receiving Screening standard for jails

does not require inmates to receive a tuberculosis
test at the time of the receiving screening. Mainly
this is because detainees often do not remain in the facility 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 control 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 Screening
standard (Compliance Indicator 10).

Health Assessments for Infirmary Orders


I was wondering if a history and physical is required

as part of the infirmary admitting order, under the
G-03 Infirmary Care standard?

No. A patient may have just had a health assessment prior to being placed in the infirmary, so
an additional history and physical would not be
required. An infirmary order should include the admitting diagnosis, medication, diet, activity restrictions,
diagnostic testing required, frequency of vital sign monitoring 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 and
scope of practice).

Jennifer E. Kistler, MPH, is NCCHCs director of accreditation. R. Scott Chavez, PhD, MPA, CCHP-A, is NCCHCs vice
president and liaison to the policy and standards committee.
If you have a question about the NCCHC standards, please
write to info@ncchc.org 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 intended outcomes, compliance concerns and the impact on the
accreditation process.

Spring 2009 CorrectCare


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