Introduction

This course defines the scope of nursing responsibilities in the correctional setting during an emergency. Emergencies in the penitentiary setting frequently stem from four main categories: medical, disturbance, fire, and miscellaneous. As with any emergency in a setting that houses many people, multiple individuals (including inmates and staff) may be involved, and the events may be singular or acute.

There are many roles that nurses must perform in the correctional setting, but the response to emergencies could be seen as the most challenging. In an emergency, correctional nurses respond to a situation that requires immediate assistance. In the correctional setting, equipment, medications, and supplies are limited and kept away from the incarcerated population, often behind locked areas. Nurses are responsible for the upkeep and maintenance of equipment and supplies. They must ensure equipment is functional and supplies are sufficiently stocked for varied emergency types. Equipment and supplies must be easily accessible and quickly brought to the area where the emergency is occurring. The nurse is not typically the first person to arrive at the scene of an emergency, and the knowledge and expertise of the correctional staff in responding to emergencies may be limited.

This is significantly different than a nurse’s role within the hospital setting.

Within the traditional healthcare facility setting, when a nurse enters a patient’s room and finds them unresponsive, they call for help. When the code is called, a team of experts arrives on the scene immediately to assist the nurse in caring for the patient. This isn’t the case in the correctional setting.

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Strategic Plans & Emergency Preparedness

Each correctional facility is responsible for knowing and following federal, state, and local guidelines. As such, depending on the type of correctional center, variations in laws, regulations, and guidance are recognized and must be clearly defined within facility policy.

To mitigate risk, improve outcomes, and ensure employees and prisoners remain safe during emergencies, there must be thorough preparation, defining the resources needed, and assessing gaps in knowledge, staffing, equipment, and supplies. Administration and leadership must know the laws surrounding the requirements for accreditation to meet national standards (1). The American Correctional Association advocates and publishes standards for meeting operational benchmarks across the United States. This national guidance addresses the programs and services required to effectively manage the administrative and fiscal policies and procedures, and the development of staff training, environmental/building care and maintenance, dietary/food preparation requirements, and staff/behavioral rules, expectations, and policies. There are different aspects to being prepared (2):

• Planning
• Communication
• Training and Practice
• Equipment

These are important regarding emergency response in correctional nursing (2). The most common scenarios correctional nurses may encounter are man-down and mass disaster (2). Both of these will be discussed later in further detail.

Planning

The most updated strategic plan should be available in electronic and hardcopy print form for reference to respond to real and potential threats and emergencies.

The health aspects of the emergency response plan must be tailored to the specific type of medical emergency. This may include an individual event, such as a code blue, that requires patient-centered care while ensuring the safety of the staff and inmates. Mass health concerns, such as a pandemic or infectious disease spread within a facility, a riot or disaster resulting in multiple casualties and injuries, require a broad approach (1). The plan must accommodate the stress placed on staff resources and provide a triage focus to ensure that care is provided to those most in need of emergent and urgent care.

Triage categorizes and manages injured persons through a numerical system to prioritize care. The stages are usually classified as primary, secondary, and tertiary. During primary triage, the first responder assesses the injured, provides emergent life-saving measures, and arranges for the wounded to receive higher care. Secondary triage occurs when transport is delayed or resources are lacking. The assessment occurs when the injured patient can be transported and seen by emergency personnel at the nearest healthcare facility. Tertiary triage is the intervention based on the healthcare provider’s assessment, and the patient is admitted to specialty care (2, 3).

The primary triage that will typically occur within the correctional setting is a quick assessment of the patient to determine the emergent event, provide immediate care based on life-threatening systems, and arrange for expedited transport to an appropriate medical care facility. Algorithms are available that provide criteria to assess and mark patients with a color-coded identifier. These assist emergency medical teams in quickly identifying individuals who require immediate attention (3).

Mass disaster drills must be conducted annually to prepare for such events. Man-down drills focus on an individual’s singular event and should be completed quarterly. This could be any medical emergency, but typically involves cardiac or pulmonary arrest.

Having an emergency response plan is crucial to good patient outcomes. Emergency planning should be a multidisciplinary team effort based on agreed-upon and tailored policies and procedures. This should consider the staffing matrix, prisoner population, and facility layout. These principles are a critical component of the overall emergency preparedness process. Understanding the threats and providing appropriate resources is also vital. If you do not know your facility’s emergency response plan, contact a supervisor or someone who can provide information (2, 3).

Communication 

Many levels of communication need to occur for an emergency to be managed well. The first call for medical attention needs to be easily heard by the medical team. There are many ways this occurs, depending on your facility. Some nurses carry mobile communication devices, which allow them to listen to a call coming through. Others rely on what can only be described as “word of mouth”. For example, security may hear it over the radio and tell the nurses secondhand. Some may telephone the medical center, which then tells the relevant staff member to respond to the patient safety concern (2).

This initial call for help from security can be the difference between life and death. Timely emergency responses will buy time for a critically ill patient.

Communication between nursing staff and security must also be planned and efficient during an emergency. As the medical team, security often waits for our decision or information to be relayed to them, looking for guidance on what will occur next. If you assess that it is obvious the patient needs an ambulance, do not assume that the officer sees this too. Clearly state to the security staff that this is the case. You must close the communication loop between all members involved in the correctional setting team. You must not assume that everyone has a medical background (2).

Let’s think about the emergency response plan again:

If the plan is for the correctional staff to communicate with the charge RN about the patient’s status, then there is a clear path for the information to be relayed. If there is no plan for what happens, time can be wasted until “someone says something.”

Communication between the nursing team is also crucial for the best outcome.

Proper planning can answer most of these questions, but sometimes, a situation arises that requires flexibility and adaptability. For example, what if a nurse freezes because they realize the patient is a family friend and is suddenly unable to manage the airway? Nurses in these situations must work as a team and use effective communication throughout the emergency to competently and efficiently manage the patient’s care.

Training and Practice

All new and current employees must understand the stringent expectations set forth by these accrediting bodies and follow policy and law to ensure these are met. Managers, supervisors, and administration are all responsible for ensuring that staff are educated and can speak to the safeguards. A plan to ensure understanding and consistency of staff awareness must be available, with individual staff competencies verified and documented (1).

The nurse’s role in an emergency in the correctional setting is similar to that of an emergency medical technician (EMT) or paramedic. If you are lucky enough to have a paramedic working in your facility, it is a good idea to set up practice scenarios with them and learn some of their skills. While nursing and EMTs share similar skill sets, EMTs’ focus is on rapid assessment, prevention of further injury, and transport to a higher level of care if needed. This process is not necessarily how nurses are trained or think (2).

Practicing basic skills like those above will improve your abilities and efficiency for real-life situations. Staff should familiarize themselves with safety and emergency equipment. For example, staff may practice proper mobilization and turning techniques for a patient who may have a spinal injury. The cervical collar (C-collar) can be applied to another staff member acting as the patient. Simulation training may be utilized to develop clinical nursing skills, such as using a prosthetic venipuncture training tool to allow staff to practice inserting an intravenous (IV) line. Staff managers should organize mock codes and other emergency simulations to enhance training and learning opportunities.

Equipment

In a correctional setting, equipment is not always in plentiful supply. The situations that nurses face can be so varied that stocking equipment and supplies for various emergencies would be expensive and inefficient. As a result, the equipment does tend to be limited. However, if you know that your facility has an issue with overdoses, then having multiple doses of Narcan on hand would be a priority. If your facility has a problem with physical altercations, then wound supplies must be kept reasonably.

A specific emergency bag or cart is the best option, no matter the size of your facility. This bag should be checked every shift to ensure it is sealed and complete. If oxygen is available, it is also advisable to check the oxygen cylinder to ensure that there is an adequate amount in the tank and that it is functional. There is nothing worse than arriving at an emergency situation that requires a piece of equipment, and it is not there or it is not working!

If there is concern that there is insufficient medical equipment, emergency response supplies, and medications, the nurse should look to accreditation bodies and national guidance for suggested par levels based on population size. The facility’s administration leadership is responsible for ensuring that emergency medical equipment and supplies are always available and replenished as needed. At minimum, this equipment includes an automatic external defibrillator (AED) (1).

Prison and Jail Populations

Prisons are generally under federal and state management, and inmates have sentences of more than one year. Jails are under local governance, with interim sentences and inmates detained for less than one year. In this setting, inmates are awaiting trial or violating parole terms requiring revocation of the parole, reincarceration, and possible retrial (4, 5).

Currently, close to two million individuals are housed within the United States’ jails and state and federal prisons (1). Over 60% are diagnosed with mental health disorders and/or substance abuse or addiction to drugs and/or alcohol. Often, these two health issues are co-dependent. Of all incarcerated patients, 40% are diagnosed with at least one chronic medical condition (6).

About 64% of patients incarcerated in jails have mental health disorders, and 65% qualify as having substance abuse or addiction to drugs and/or alcohol. It is also widely reported that substance/alcohol abuse is interlinked with mental health issues (6).

Approximately 40% of all incarcerated patients have a chronic medical condition. The prevalence inside facilities is higher in specific disease groups than in the general U.S. population. The most common chronic conditions among prison and jail settings include hypertension, cancer, asthma, stroke, and mental health disorders (7).

What health conditions are more prevalent based on the population and demographics within your community?

Types of Emergencies and Recognition

Due to the broad range of demographics, individual health conditions, and inherent acute and chronic maladies afflicting the prison and jail populations, emergency responding staff must be educated and familiar with the potential for common emergencies that can occur in the correctional setting. These include (3, 4):

• Riot
• Mental Health Crisis
• Suicide
• Overdose
• Stabbing
• Infectious Disease
• Code Blue – cardiac or pulmonary arrest

Two main categories of emergencies can occur in the correctional setting:

• Man down

This is an emergency in which only one person requires medical attention. It can be anyone in the facility—a member of staff, a volunteer, or a patient. This is the most common emergency that nursing staff will be called to.

• Mass Disasters

This is where more than one person requires attention. These require a triage system where the medical team should be organized to identify who needs priority attention. There are many examples of triage systems that can be adapted to the correctional setting, and there has yet to be an identified “best” one. The most common triage method used is the traffic light system. This occurs when a patient is given a colored tag after a primary assessment. The tags are:

• Red – immediate (care required)
• Yellow – delayed
• Green – walking wounded
• Black – deceased

If you are a team of three nurses attending a riot that has now been contained, you may be faced with 10-12 injured patients. A primary assessment will allow you to quickly tag each patient so that you can concentrate on the most immediate care needs and call for a higher level of care for the correct number (2).

Emergency drills are key components in determining the effectiveness of the emergency response plan. They should be simulated for a man-down situation and, separately, for a mass disaster.

For best practice, a man-down drill should be practiced once a year on every shift where medical staff are assigned in correctional facilities (1).

A debrief (a period of time immediately after the incident) is designed to record actions, including staff response time, communication processes, roles undertaken by staff members, and overall outcome. Although the debrief can identify inappropriate actions by staff members, the whole concept is for everyone involved to learn from the drill. Bear in mind that it is a drill designed to practice skills that correctional nurses do not use often. 

Responding to Emergencies

Staff members who work with inmates are trained to recognize verbal and behavioral cues that indicate potential medical emergencies and how to respond appropriately. The plan includes on-hire initial training and annual refreshers with competency-based verification of skills. This training is overseen by a medical director or appointed authority over health-related matters in conjunction with the facility administration. The training is provided to correctional and healthcare personnel with a goal of responding to any health-related emergency within four minutes (1).

Healthcare and non-healthcare staff must be adept at responding to any and all of the following (4):

• Recognition of the signs and symptoms, with appropriate action to respond to a real or potential emergent occurrence
• Procedure for initiating emergency response
• Basic first aid
• Basic lifesaving interventions
• Cardiopulmonary resuscitation (CPR) certification and use of an AED
• Processes to gain additional assistance
• Interfacility transfer protocols
• Early recognition of signs and symptoms of mental health crises, disruptive behavior, and drug or alcohol intoxication or withdrawal
• Suicide precautions and interventions

Sick call requests are the process by which inmates request healthcare services. A healthcare worker triages these requests and responds promptly, depending on the priority given to the health concern. An inmate’s emergent sick call request must be responded to within 24 hours. Urgent sick calls must be seen within 72 hours, while routine is within seven days (1).

A program must be set in place to address infectious disease control specifically. The contagious disease control program must involve recommendations from the local health department and the Centers for Disease Control and Prevention (CDC) to ensure an exposure control plan for inmates and staff. The plan must be developed and overseen by administration, with written policies and procedures in place that align with national guidance. Policies that cover standard isolation precautions are required, and audits must be completed to ensure staff and inmate compliance. Supplies, including isolation gowns, goggles, gloves, and masks, must be readily available.

Response Assessments in an Emergency

Emergency medical care, including first aid and basic life support, is provided by all health care professionals and health-trained correctional staff specifically designated by the facility administrator. Staff should be familiar with trends within their facility regarding the most common types of emergencies. This will depend on the prison population’s age and demographics, which contribute to the occurrence of acute and chronic health conditions. Overall, almost half of the injuries that occur within correctional facilities are due to violence or self-injurious behavior (4). Regardless of the type of emergency, the first step to providing care is the assessment once it is identified.

Primary Assessment 

With any emergency response, medical personnel must begin their patient’s care with a primary assessment. Assessments involving inmates must consider the additional need for the safety of the staff and the patient. Due to the nature of correctional settings, the nurse must be aware of their surroundings and ensure that the staff mix present is appropriate (3).

Basic Life Support (BLS) may teach nurses to look at the environment first, but if you have worked in a hospital or long-term care (LTC) facility, you already know your environment. In the correctional setting, the focus shifts from the primary assessment of the patient to the security of the environment and ensuring that all staff present remain safe. When there is a concern of violence, the inmate must be made secure before attempting an assessment. In the correctional facility, safety is paramount.

So, let’s use the EMT/paramedic book to respond to an emergency in the correctional setting.

A primary assessment starts with “Scene Set-up” (1) – when you access the emergency area, your primary assessment begins here.

• What is the noise level?
• Who and how many people are out and have access to you?
• How many security personnel are around?
• Are there any tools or external dangers?

Security personnel may not have done this, especially if they were on the scene when the emergency took place. Clearly communicate any identified concerns or dangers to security before attending to the patient.

Then, and only then, should nursing staff proceed with care. During an emergency, a focused assessment initially ensures that the following are not compromised: Airway, Breathing, Circulation, and Disability (including the level of consciousness) (3).

The primary assessment aims to identify and begin treatment of imminently life-threatening conditions and act to correct them. This does not involve vital signs. At this stage, you may be able to decide if the patient needs a higher level of care and if an ambulance is required (1). If the patient is in pulmonary or cardiac arrest, BLS should be initiated. Otherwise, the nurse may proceed with the secondary assessment (3).

Secondary Assessment 

This is a complete head-to-toe assessment of the patient. When additional staff are available for safety, it is appropriate for multiple nurses to coordinate care. While one nurse takes vital signs, another may focus on completing and documenting a comprehensive head-to-toe assessment. Throughout this period, it is crucial to talk with the patient (if conscious) and explain what you are doing and why. Doing so builds trust in the patient/nurse relationship and preserves the patient’s dignity (3).

Be aware that a complete examination may be done in a more private area, such as your medical area, if you have assessed that the patient can be moved safely.

Unique Needs of Incarcerated Patients

Despite the caution advised when using physical restraints, patients who are incarcerated often arrive at the emergency room in shackles and remain in shackles throughout their stay. Some surgery residents have even reported caring for patients who are shackled to the bed while intubated and sedated. Some policies are in place to limit the use of shackles in clinical settings. Recognizing the risks of physical restraints in pregnancy, many states have mandated against physical restraints for patients who are incarcerated in the perinatal period. Federal policies have also been enacted to restrict physical restraints in pregnancy, except when necessary for safety reasons (8).

Conclusion

Emergency response in the correctional setting is a skill that nurses need to learn and practice to ensure the patient has the best outcome. Nurses employed in correctional settings are not always trained or experienced in these skills, so nurses must understand their role and responsibility in an emergency. Administration must assess the skill level of staff and provide education and skill-building training to ensure that staff have the knowledge and sufficient number of competencies to respond effectively and safely to emergencies.

The facility where you work must regularly conduct man-down and mass disaster drills to help develop these skills. Debriefing after simulation training and actual emergency responses will enable responding staff to review their actions and learn from the experience. This will promote teamwork and ultimately lead to the best delivery of patient care within the correctional setting.