Nurses and Chronic Care Clinics. What Do You Think?

TaserCamIn my last post, I discussed the differences between how nurses are used in Acute Care Clinics in the community versus how they are used in corrections.  Today, I would like to discuss the differences between the community and corrections on how nurses are used in Chronic Care Clinics.

Again, these remarks are based on a talk that Dr. Marc Stern gave at the Essentials of Correctional Medicine conference last year.  It was quite a thought-provoking talk.

First, let’s define the difference between an Acute Care Clinic and a Chronic Care Clinic.  An Acute Care Clinic is one where the patient has asked to be seen because of some problem or complaint.  Examples would be “I have a rash,”  “I have chest pain,” or “I am having a hard time breathing.”  The patient is asking for a diagnosis (“What is causing this?”) or for relief of symptoms (“I want pain medication for this headache!”) or both.  The key is that the clinical encounter is patient driven—the patient has asked to be seen—due to some acute symptom.

Visits to a Chronic Care Clinic, on the other hand, are scheduled by the medical provider to assess progress made in treating some chronic medical problem.  These are scheduled months in advance and occur even if the patient is doing well.  One example is a patient on blood pressure medications who is scheduled for a follow-up visit to see how the blood pressure is doing.  Another example is a patient with hypothyroidism who is scheduled for a thyroid panel blood test to see if she is on the correct levothyroxine dose.  Patients taking warfarin come to an anti-coagulation clinic to have their INRs checked.  Each chronic disease, from COPD to rheumatoid arthritis, has a different set of monitoring tasks which are routinely done in a Chronic Care Clinic.

The key difference here is that chronic care visits are scheduled by the clinic, not the patient, and are expected to occur even if the patient is feeling well and has no complaints. Also, what will occur at the clinic visit is known beforehand.  Usually, there is a checklist of tasks that are scheduled to be done each visit.

However, nurses once again tend to be used differently in Correctional Chronic Care Clinics than they are in the Community.  But interestingly, the situation is exactly reversed from the Acute Care Clinic situation!

Community Chronic Care Clinics

In the Community, Chronic Care Clinics are most commonly run by nurses.  The patient may not see a practitioner every time.  Take the case of a Type 2 diabetic in the community.  Three or four times a year, this patient is scheduled to come to the diabetes clinic for a Chronic Care visit.  At that time, routine blood work (a Hemoglobin A1C, for example) is drawn, the patient is screened for diabetic complications (a foot exam, say, and blood pressure) and the patient receives counseling and teaching (for example, about the importance of the diabetic diet).  All of these tasks are typically done by a community nurse.  The patient may not see the doctor unless the nurse identifies a problem or unless the Chronic Care protocol specifies a practitioner visit.  Otherwise, if the patient is doing well, the practitioner may only see them once a year.  This is the community standard.

Correctional Chronic Care Clinics

However, as pointed out by Dr. Stern in his lecture, this is not how Chronic Care Clinics are typically done in corrections.  In jails and prisons, Chronic Care Clinics tend to be run exclusively by practitioners. And using practitioners to do work done by nurses in the community tends to be inefficient for a couple of reasons (these are my opinions, not necessarily Dr. Stern’s).

  1. Practitioners tend not to do as good of a job with Chronic Care Clinic tasks as nurses do.  Chronic Care, properly done, is a time intensive process that includes meticulously going through a checklist, answering questions and teaching.  Practitioners (and I am including myself here) tend to go too fast.  Nurses do a better job.
  2. Every minute a physician spends doing Chronic Care Clinic tasks typically done in the community by a nurse is a minute she cannot spend doing acute care evaluations and diagnostics she is better trained to do.  This is a time management issue.  The nurses will let the practitioner know if they find something during the chronic care visit that needs acute attention.

The practitioner, of course, should review the work done by the nurse in the Chronic Care clinic.  The easiest way to do this is to use a Chronic Care Flow Sheet filled out by the nurses at the chronic care visit and signed off by the practitioner at review.  And the practitioner should still be scheduled to see each chronic care patient periodically, say once a year.  But other than that, the system will run more efficiently if nurses run chronic care clinics as is done in the community.

Interesting Article of the Week

Right in line with the theme of who should run Chronic Care Clinics is this interesting article:

Delegating responsibility from clinicians to nonprofessional personnel: the example of hypertension control.  Margolius, et. al. J Am Board Fam Med. 2012 Mar-Apr;25(2):209-15. doi: 10.3122/jabfm.2012.02.100279.

In this study, the researchers delegated responsibility for Chronic Hypertension Follow-up to non-medically trained “Health Coaches.” These lay Health Coaches spoke to patients in the study frequently and counseled them on hypertension control and answered questions.  These untrained Health Coaches were even authorized to titrate patient blood pressure medications according to a written protocol!  Whoa! This was a “Mikey-Likes-It” type of study–after 6 months, the clinicians involved were asked how they liked the program–and most did, though some disagreed with the medication titration aspect.

I personally do not see those of us in corrections delegating responsibility for chronic care visits to a non-medically trained deputy.  However, if practitioners are running your facility’s Chronic Care Clinics exclusively, I agree with Dr. Stern that it is perfectly appropriate to delegate that responsibility to nurses, as is done in the community.

Who runs the Chronic Care Clinics at your facility?  Nurses, practitioners or a combination of the two? Please comment!

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Nursing Clinics and Scope of Practice. What Do You Think?

20130123-1At the last Essentials of Correctional Medicine conference, Dr. Marc Stern gave a thought-provoking lecture about the proper use of nurses in the correctional setting. I have to admit that his talk was a bit controversial; some of the nurses in attendance were uncomfortable and even a little offended.  But whether you like Dr. Stern’s talk or not, his thoughts deserve some consideration.

The main thrust of his talk was to compare how nurses are used outside of corrections—the community standard as it were–as opposed to how nurses are used inside jails and prisons.  There are quite a few differences.  Why is this so?  And if nurses are used inside of correctional facilities differently than the community standard, is this proper?

Dr. Stern brought up two distinct differences between how nurses are used in the community and how they tend to be used in corrections:  Acute Care and Chronic Care.  I am going to discuss the Acute Care issue today and the Chronic Care issue in my next post.

The Nursing Role in Acute Care Clinics–Community vs. Corrections

The single major difference between how nurses are used in the community and how they are used inside correctional facilities is this: in the community, nurses do not run acute care clinics–ever.  Nurses in the community do not diagnose or prescribe treatment.  It does not matter whether you go to your doctor’s office or a hospital emergency department or a “Doc-in-the-Box” urgent care clinic or even one of those mini-clinics you find in grocery stores nowadays.  In each case, you will be seen by a medical practitioner of some sort; whether a doctor, a physician assistant or a nurse practitioner.  Nurses will be there, but in the role of assisting the practitioner.  It just will not happen in the community that a patient will be seen only by a nurse—no practitioner in sight—who does an examination, makes a diagnosis like, “You have bronchitis,” and hands out a prescription.

On the other hand, acute “sick call” clinics in correctional facilities are commonly run only by nurses.  These nursing clinics tend to be of three main types:

  1.  Triage clinics.   In this type of clinic, a nurse sees every patient who puts in a medical request and schedules them to see a practitioner depending on the urgency of the complaint.  For example, a patient complaining of abdominal pain might be scheduled for the very next medical clinic whereas a patient complaining of dandruff might be scheduled a week out.  The Triage nurse could also have the on-call practitioner come in urgently to evaluate a patient with, say, chest pain or decide to send that patient to the ER.  However, in this model, nurses never diagnose or prescribe treatment.
  2. OTC clinics.  “OTC” stands for “Over-the-Counter” medications that do not require a doctor’s prescription.  In this type of nurse clinic, a nurse again sees every patient with a medical request and schedules medical clinic appointments, but also is authorized to dispense over-the-counter medications for common minor complaints.  For example, a patient with abdominal pain still would be scheduled in to medical clinic, but a patient with athlete’s foot might be given OTC clotrimazole cream by the nurse without the patient ever seeing a practitioner.  Some facilities have quite detailed protocols to guide nurses in this endeavor, but not all.
  3. Full Service Nurse Clinics.  In some correctional facilities, nurses take care of almost all sick call patients.  The nurse will still schedule complicated patients to see the practitioner, but will take care of other, simpler, problems even if these require a prescription medication.  If a nurse thinks that a patient needs a medication requiring a doctor’s prescription, he/she usually will call the on-call practitioner for authorization.  An example would be a female inmate thought to have a Urinary Tract Infection.  The nurse would call the practitioner for orders, say an antibiotic, and then administer it.    Sometimes, this patient will be seen by the practitioner in a subsequent clinic, but not always.

As Dr. Stern pointed out in his talk, it is clear that this system of using nurses in jails and prisons is very different from the “community standard.”  Dr. Stern also pointed out that in many correctional facilities, the nurse performing these tasks is not an RN, but an LPN or even a “Correctional Medical Technician” with even less formal medical training than an LPN.  The concern is that by running acute care clinics, which involves making diagnoses and prescribing treatment, nurses may be exceeding their scope of practice.

Why Are the Two Systems Different?

Personally, I can easily see how this system of nursing duties evolved within corrections.  Community urgent care clinics have a practitioner in attendance at all times.  These clinics are never staffed with nurses only.  But jails and prisons are not that way.  Consider very small jails, for example, where the doctor’s sick call clinic may only be held once a week.  Someone, then, has to evaluate inmate medical requests to decide if the inmate can safely wait until the next scheduled clinic, which may be days away.  You certainly don’t want the inmate with appendicitis to wait a week to see the doctor!  And the jail nurse is certainly a better choice to do this evaluation than a detention deputy!

But what if the inmate complaint is so simple that it only requires an Over-the-Counter medication?  Say heartburn?  The inmate can certainly wait until clinic but why can’t the nurse just give out some OTC ranitidine?  Or foot fungus cream for athlete’s foot?  Is it even ethical to make the inmate suffer until clinic for such a simple problem?  On the outside, the inmate would not even have to go to medical.  They could just go to the store and buy ranitidine.  Can’t a nurse just give the patient some OTC ranitidine?

Other simple inmate complaints can be just as easily resolved with prescription medications.  Take the young healthy woman who has the classic symptoms of a urinary tract infection: dysuria, urgency and frequency.  Can’t we get the antibiotics started before the doctor’s clinic?  Do we make her wait?  And what about other, more serious, medical problems like alcohol withdrawal that absolutely should not wait until the next sick call.  Librium must be started now, whether there is a doctor on site or not.

But then, it is but a short, dangerous step to the next level:  By the time the doctor comes in for clinic, the woman with the UTI is cured!  The alcohol withdrawal patient is doing well!  The patient with heartburn has no complaint!  Isn’t it just a waste of the doctor’s valuable time to see these asymptomatic patients?

In the end, you have the scenario where a nurse has made a diagnosis and perhaps prescribed treatment without a practitioner ever having seen the patient and maybe even without ever having been contacted!  Somewhere along that continuum is a fine line that, when crossed, means that nurses are diagnosing and treating beyond their scope of practice.

In prisons, where a practitioner may be present in the facility every single day, it may be possible to run acute care clinics as they are done on the community.  However, it also may not be feasible.  Since I don’t practice in a prison setting, I will leave the discussion of the proper role of nursing clinics in prison to my prison based colleagues!  Please comment below!

However, in jails, it is simply not possible to run acute care clinics like the community standard.  No 50-bed jail can afford to have a doctor show up for clinic every day.  Even large jails don’t typically have practitioners on site every day.  There has to be some sort of partnership with nurses to triage medical requests and to take care of simple problems.  However, jails should take care not to cross the line where nurses exceed their scope of practice!

The following reflects my personal opinions on the subject:

  1. Nurses should have a protocol or guideline to follow when they evaluate simple complaints that can be treated with OTC medications.  Patients with complaints like “I have athlete’s foot and need cream for it” or “I have heartburn–can I have some Zantac?” do not necessarily need to be seen by a doctor since they do not need to see a doctor on the outside to obtain these items.  But even these simple complaints can be fraught with some danger—like when the guy with “heartburn” is really having a heart attack.  Nurses should have written guidelines that indicate when OTC remedies are appropriate and what “Red Flags” indicate a referral to clinic.  If nurses have such guidelines, they are not diagnosing and treating independently; they are instead assisting patient to obtain appropriate OTC medications.
  2. Why make inmates see a nurse to get OTC medications in the first place?  People outside of jail don’t have to go to a clinic to get Zantac or foot fungus cream or whatever.  They just go to the store and buy them!  So why do we make them do it in jails?  It is a waste of both the nurse’s time and the inmate’s time.  Put appropriate OTC medications on the commissary (see You Need a Medical Commissary in Your Facility! and Obstacles to a Medical Commissary Program.
  3. If a nurse thinks a patient needs an urgent prescription drug before the next medical clinic, the on-call practitioner must be called for an order! Nurses should not start prescription medications based on protocols alone.  That is not done in the community; it should not be done in correctional facilities.  For example, if a nurse sees a MRSA lesion and wants to start antibiotics before the next clinic, he must call for an order.  Does an alcoholic need to begin therapy for withdrawal tremors?  Call.  If these calls are not made, then the nurse has diagnosed and prescribed treatment independently, outside of the scope of practice.  The only exception to this rule is emergency treatment, like epinephrine for anaphylaxis.
  4. Every patient who receives a prescription medication should be seen by a practitioner!  I don’t mind authorizing antibiotics over the weekend for a woman with a UTI.  But I then am obligated to see her, however briefly, in my next medical clinic.  It doesn’t matter if she is better—that just means that the clinic visit will be brief.  But if I prescribed the medication, I need to document a history and an examination in her chart.  If I don’t, the nurse again diagnosed and prescribed beyond her scope of practice, albeit with my “rubber stamp.”  Interestingly, here in Idaho, the Board of Medicine recently condemned the practice of prescribing medication without examining the patient.  The Board was specifically addressing situations like when a family member or friend calls and says, “I have a sore throat.  Will you call something in?”  But the principle applies to this situation in corrections, as well.  If I prescribe something, I need to see the patient and document a history and physical.

As always, I have expressed my own opinion here.  Feel free to disagree.  I might be wrong!  But if you do disagree, please comment and explain why!

Next Post:  Chronic Care Clinics in Corrections vs. the Community!

In the Essentials of Correctional Medicine Conference, Dr. Stern’s lecture on nursing roles raised some eyebrows.  What is your opinion on nursing roles in corrections?