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Correctional nurses have limited access to hands-on experience with medical emergencies. Therefore, they must rely on the knowledge and skills they have and adapt them to the correctional setting. This course will discuss how correctional nurses can use the resources they have to provide the best possible care for their patients in an emergency. It will also review the types of emergencies they may encounter and the correctional nurse’s role in managing the emergency. 

Introduction 

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

There are many roles in the correctional setting that nurses must perform, but the response to emergencies could be seen as the most challenging. In an emergency, correctional nurses are responding 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 to 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, accordance, 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 preparation that is thorough, defines the resources needed, and assesses gaps in knowledge, staffing, equipment and supplies. Administration and leadership are required to be knowledgeable of 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, as well as 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  

All of these are important when it comes to emergency response in the correctional nursing setting (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 event resulting in multiple casualties and injuries, require a broad approach (1). The plan must accommodate for 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 is the process of categorizing and managing injured persons through a numerological system with a goal 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 transport of the injured to a higher level of care. Secondary triage occurs when transport is delayed or there is a lack of resources. The assessment then occurs when the injured patient is able to be transported and seen by emergency personnel at the nearest healthcare facility. Tertiary triage is the intervention decided based upon the assessment of the healthcare provider, and the patient is admitted to specialty care (2, 3).  

The triage that will typically occur within the correctional setting is primary. It 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 that require immediate attention (3). 

To be prepared for such events, mass disaster drills must be conducted at least annually. Man-down drills focus on a singular event of an individual 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 that is based on agreed-upon and tailored policies and procedures. This should consider 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 critical. If you do not know of your facility’s emergency response plan, contact a supervisor or someone who can provide you with information (2, 3).  

Communication 

There are many levels of communication that 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 hear 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 second hand, and some telephone the medical center who 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. 

During an emergency, communication between nursing staff and security also needs to be planned and efficient. 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. It is very important that you close the loop of communication 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 the status of the patient, then there is a clear path for the information to be relayed. If there is no plan for what happens, then time can be wasted until “someone says something.”  

Communication between the nursing team is also an important aspect for the best outcome.  

Most of these questions can be answered by proper planning, but sometimes a situation can arise where we have to be flexible and adaptable. 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 nature of the 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 role of the nurse in an emergency in the correctional setting is very 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 the skills that they have. 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, such as these above, will improve your abilities and efficiency for real-life situations. It is advisable for staff to 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 correctional setting, equipment is not always in plentiful supply. The situations that nurses are faced with can be so varied that stocking equipment and supplies for all the various possible emergency possibilities 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 would need to be kept to a good level. 

Having 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 it is functional. There is nothing worse than arriving to 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 and 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 available at all times 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 that are more than one year. Jails are under local governing with interim sentences and inmates detained for less than one year. In this setting, inmates are awaiting trial or are in violation of parole terms requiring revocation of the parole, reincarceration, and possible retrial (4, 5).  

Currently, there are close to two million individuals harbored within the United States’ jails and state and federal prisons (1). Over 60% are diagnosed with having 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. For specific disease groups, the prevalence inside facilities is higher than 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 when an emergency where only one person requires medical attention. These emergencies can be anyone in the facility – whether 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 is complete. 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 patients who have injuries. A primary assessment is going to give you the ability 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 right number (2). 

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

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

A debrief (period of time immediately after the incident) is designed to record actions, including response time by staff, communication processes, roles undertaking 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, it is a drill and 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 upon-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 in a timely manner depending on the type of priority given to the health concern. Any emergent sick call request from an inmate must be responded to within 24 hours. Urgent sick calls must be seen within 72 hours, while routine is within seven days (1). 

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

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 that occur. This will be dependent on the age of the prison population and demographics that contribute to occurrence of acute and chronic health conditions. Overall, almost half of injuries that occur within correctional facilities are due to violence or self-injurious behavior (4). Regardless of the type of emergency, once it is identified the first step to providing care is the assessment. 

Primary Assessment 

With any emergency response, medical personnel must begin the care of their patient with a primary assessment. Assessments that involve inmates must take into account the additional need for 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 remains safe. When there is concern of violence, the inmate must be made secure prior to attempting an assessment. In the correctional facility, safety is paramount. 

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

A primary assessment starts with “Scene Set-up” (1) – when you access the area of the emergency, your primary assessment starts 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 at the time the emergency took place. Clearly communicate any identified concerns or dangers that you are aware of 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 there is no compromise of the following: Airway, Breathing, Circulation, Disability (including the level of consciousness) (3). 

The goal of the primary assessment is to identify and begin treatment of any 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 full head-to-toe assessment of the patient. When additional staff is 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 always very important 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 full examination may be done in a more private area, such as at 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 to the emergency room in shackles and remain in shackles throughout the course of their stay. Some surgery residents have even reported caring for patients who are shackled to the bed while intubated and sedated. There are some policies 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 use of physical restraints in pregnancy, except when considered 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 who are employed in correctional settings are not always trained or experienced in these skills, so it is important that nurses 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 has the knowledge and sufficient number of competencies to respond effectively and safely to emergency situations. 

The facility in which you work must conduct man down and mass disaster drills on a regular basis to help with the development of these skills. Debriefing after simulation training and actual emergency responses will enable responding staff to review what their actions were and allow them to learn from the experience. This will promote teamwork and ultimately lead to the best delivery of patient care within the correctional setting. 

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