Border detention facilities that house immigrants have been in the news recently because of their policy of not providing influenza vaccinations to their detainees, sparking high-profile protests. Why would an immigration detention facility, tasked among other things with providing comprehensive medical care to its detainees, refuse to provide them with flu vaccines?
To answer this question, it might be instructive to ask how influenza vaccinations are handled at other prisons and jails in the U.S. It depends on what type of facility you are in and how long you will be there. All prison systems I know of offer influenza vaccinations to their inmates. On the other hand, most jails (short-term detention facilities) do not have a routine flu vaccination program, though there are exceptions.
Vaccinations in Prisons
Inmates are sentenced to prison for a minimum of one year and usually longer. As a result, prison populations are stable. Almost all of the inmates in a particular prison now will still be there next year. Also, prisons are tasked with providing comprehensive medical care to their inmates. This includes influenza vaccinations, but also other recommended vaccinations and boosters. Of course, just like in the community at large, not all inmates want to be vaccinated. The percentage of prison inmates who get vaccinated depends on how vigorously the prison pushes the program.
If a prison advertises the availability of the flu vaccine and actively encourages its inmates to be vaccinated, the acceptance rate can be greater than 50% (compared to about 33% of adults in the community who get vaccinated). Most prisons have a “big push” campaign to encourage flu vaccines once a year in the fall. However, if a prison does not advertise the availability of the flu vaccine, the percentage of inmates vaccinated can be very low. It makes economic sense for prisons to actively encourage their inmates to be vaccinated. Every dollar spent on influenza vaccinations will save more than a dollar down the road trying to deal with influenza outbreaks.
Vaccinations in Jail
Influenza programs in jails are
different for several reasons. The first issue is that the inmate population in
a jail is not stable. The average length of stay in the average jail in the
U.S. is around 2-3 weeks and many are released within days. If a jail offers
influenza vaccinations in October, most of the inmates vaccinated will be gone
by November. The jail will now be filled with new, unvaccinated inmates. If you
vaccinate the November inmates, most (again) will be gone by December. So, to
be effective, influenza programs in a jail must last the length of the
influenza season — making jail influenza programs more difficult and expensive
to administer than a prison program.
As an example, remember that one
must order influenza vaccines well in advance. In order to have influenza
vaccines ready in the fall, a prison or a jail has to order them at least six
months earlier. A prison will know how many influenza doses it will need based
on its population and previous acceptance rate. But how many doses will a jail
need with inmates coming and going over the course of an entire flu season?
That can be hard to get right in a jail! It is expensive and maddening to order
too many vaccines only to throw the unused doses away at the end of the flu season.
Also, jails vary greatly by size and
sophistication of the medical services they provide. There are many small jails
in the U.S. (think 10 beds) where no medical personnel ever come to the jail
for routine medical care. If their inmates need medical attention, the deputies
have to load them into a van and take them to a clinic or ER in the community.
Such a jail is unlikely to offer influenza vaccinations to their inmates. On
the other hand, bigger jails (say, more than 1,000 beds) with a full-time medical
staff may indeed have an influenza vaccination program.
“Kicking the Can Down the Road”
The most successful jail influenza
programs that I have seen are done in cooperation with the local health
department. The health department is tasked with providing vaccinations to the
community at large, which includes jail inmates. When asked, health departments
often will come to the local jail once a month to provide influenza
vaccinations to any inmate who requests one. (This is also a good way to
provide screening for sexually transmitted diseases in asymptomatic inmates.)
Even small jails can approach their local health department about providing
immunizations to inmates, though few do.
Customs and Border Patrol reportedly
defended its policy of not providing influenza vaccinations during border detention
by saying that immigrants are only there for a few days and are expected to get
the flu vaccine later, when they are moved to a long-term facility. Where I
grew up, this was called “kicking the can down the road.” To my mind,
deferring vaccinations until later makes little medical or financial sense.
Since none of these detainees is going to be released, and since you are going
to vaccinate them later anyway (as reported), why not do it as part of their
initial medical screening?
Jeffrey E. Keller, MD, FACEP, is a
board-certified emergency physician with 25 years of experience before moving
full time into his “true calling” of correctional medicine. He now
works exclusively in jails and prisons, and blogs about correctional medicine
This post was originally published in MedPage Today.
Patients recovering from opioid
addiction are seen at the local emergency department every day, according to
Martha Roberts, a critical care Nurse Practitioner (NP) and Georgetown University School of Nursing & Health Studies
alumna. Roberts works in Berkshire’s emergency department, which sees 50,000
patients per year — more than a third of the county’s population.
“It’s challenging,” she
said. “It’s also an opportunity to help those patients in a way that may
improve their outcomes.”
Patients in addiction recovery aren’t
exempt from the need for pain relief in the case of acute injuries, surgical
operations, or chronic pain. Providers like Roberts are tasked with finding and
offering alternatives to opioids.
How can clinicians balance the
weight of ethical responsibility with a patient’s need for immediate relief?
Opioid Dependence and Addiction in the United States
Even if the patient is not
demonstrating symptoms of addiction, providers look for specific signs of
dependence, according to Dr. Jill Ogg-Gress, assistant
Family Nurse Practitioner (FNP) program director at Georgetown University.
“Opiate medications have side
effects of dependence,” said Ogg-Gress, who works as a board-certified
emergency NP in several Iowa and Nebraska emergency rooms. “If a provider
recognizes that a patient is experiencing dependence, or if a patient
demonstrates behaviors of dependence, it should be recommended to the patient
they should talk to their primary care provider or the prescriber of the
Signs of opioid dependence
Taking painkillers more frequently than prescribed
Taking higher doses than prescribed
Seeking a euphoric effect to counter physical pain
Experiencing excessive sleepiness or irritability
Taking these signs into account,
providers can evaluate patients’ needs on an individual level to assess the
magnitude of pain. If the patient is likely to develop a dependence, the
providers may need to help them find an alternative treatment plan that is
effective and sustainable.
Ruling out opioids altogether isn’t
a realistic approach, Roberts said.
“There are still some painful
injuries that will benefit from short-term opioid use,” she said.
Her key to implementing an effective
treatment plan is working with the patient to assess their needs and openness
to non-opioid pain medication.
Individuals recovering from drug
addiction might encounter injuries or surgical operations that require
management of immediate acute pain or chronic pain in the long term. Providers
can evaluate a patient’s needs when creating a treatment plan to manage that
Pharmacological alternatives to opioids
Analgesics: Some of the most common painkillers can be obtained over the counter in small doses or prescribed in high doses by a health care provider. Roberts and Ogg-Gress agreed that these are the most common alternatives to opioid prescriptions.
Gabapentinoids: This class
of drugs includes gabapentin and pregabalin and has been historically used for
seizure prevention. It is available by prescription to address pain but only in
circumstances set by the Food and Drug Administration. While these painkillers
can be an alternative to opioids, Roberts said they are not her intervention of
choice because studies show there are other, more
When medication isn’t appropriate or
preferable, many non-pharmacological options exist to relieve pain and
“There are a lot of other nonpharmacological therapies that are available, if people are willing to try it,” Ogg-Gress said. “Providers need to educate patients regarding these pain therapies instead of the common thought of, ‘Here, take a pill, swallow it, and you’ll feel better.'”
Roberts said providers can help
patients identify ways to care for themselves before writing a prescription for
opioids. She recommended a gradual approach to trying different types of
A Step-Wise Approach for Pain Management
Get to know the patient
Use analgesics to address pain
Use non-pharmacological treatments
as intervention for side effects
Encourage patient to stop smoking
and drinking alcohol
Eliminate foods that irritate the
stomach or digestive system
Reflect on previous steps: Did you
really exhaust everything?
Consider opioids as a last resort, and only enough to support immediate pain relief
Nurse Practitioners who work with a
multidisciplinary team are uniquely positioned to provide holistic care.
Clinicians serving communities with large addicted populations have to be
familiar with law enforcement, social work organizations and, in the case of
making a referral outside the clinic or emergency department, recovery programs
and child protective services.
Roberts also acknowledged that
providers working in communities fraught with addiction are at a high risk for
fatigue. “If you have three back pain patients in a row, you’re going to
be pretty burned out within two hours of working your shift, so you really,
truly have to look at each case individually,” she said.
Taking time to self-reflect on
personal motivations for treating patients can help remind providers of why
caring for others is important to them.
“It’s hard to walk in and do a
good job if you’re upset about the work you’re doing,” Roberts said.
“Make sure you can do this without letting your own bias get in the way.”
Please note that this article is for
informational purposes only. Individuals should consult their health care
professionals before following any of the information provided.
In early 2016, Mt. Sinai Hospital* approached the Visiting Nurse Service of New York (VNSNY) to propose that VNSNY offer home care services to post-operative transgender patients. This was the genesis of VNSNY’s Gender Affirmation Program (known as GAP), which to date has provided home care to over 400 transgender patients. *a strategic partner of VNSNY
DailyNurse recently interviewed Shannon Whittington, RN MSN PCC C-LGBT Health, the Clinical Director of GAP at VNSNY. We asked her about the nature of gender affirmation treatment, the home nursing care that VNSNY provides, and the outstanding LGBT-friendly services that VNSNY offers to patients across the Tri-State New York area.
What is gender affirmation surgery (GAS)?
A surgical procedure that creates or removes body
parts that align with the patients’ gender expression. E.g. vaginoplasty,
phalloplasty, metoidioplasty, facial feminization, breast
Is this the same thing as “sex-change surgery?”
SW: It is the same thing but we don’t use the terms “sex-change
Gender Affirmation or Gender Confirming surgeries are the correct terms now. Understanding that this is a linguistically fluid language, words and meanings are always changing and we need to be mindful of correct terminology.
What are the components of the VNSNY Gender Affirmation Program?
The program emphasizes home care following surgery from other providers. I train clinicians (nurses, social workers, physical
therapists, home health aides, speech and occupational therapists) in cultural
sensitivity as it particularly relates to transgender patients. The training is extensive and they are also
educated in how to teach the patients to care for their new or altered body
parts (i.e. penis, vagina, breast, face)
DN: How did you come to specialize in the treatment of Gender Affirmation surgery patients?
SW: Fortunately, I was chosen for this project by my
manager. I had no idea what I was saying
yes to but this has literally changed the trajectory of my career path. I discovered a passion that I did not know I
What sorts of clinical training do nurses in the program need to take care of
GAS post-surgery patients?
They need to know what to assess for and what is
normal and what is not. They learn about
vaginal dilation because the patients who undergo vaginoplasty must do this on
a regular basis. Patients come home with VACs, JP drains, foleys and supra
pubic catheters. Although the nurses are already familiar with these devices,
they need to teach the patients how to manage them. The clinicians are also
trained in social determinants of health for this cohort.
DN: What sorts of cultural issues do nurses need to learn about before tending to a GAS patient?
SW: We really need to understand that these patients, like all
of our patients, are patients first who happen to be transgender. We must
respect their chosen names, their pronouns and their gender expression. We
focus on getting them better and integrated back into society. It’s a beautiful
thing to witness and an honor to be associated in such a transitional journey.
DN: How does the Gender Affirmation Program reflect the larger VNSNY commitment to LGBT patients?
It reflects our commitment to this population on an
agency wide basis. What is great is that
we are now getting non-operative transgender patients who are seeking home care
services for reasons other than gender affirming surgeries. They feel safe here and seek care outside of
gender affirming surgeries.
We are initiating various ways to continue to be inclusive along
the binary spectrum by hiring gender non-confirming and non-binary individuals.
These individuals have a lot to offer and need to be the best expressions of
themselves in their work environment just like the heteronormative society we
all live in.
And can you tell us something about the SAGE training in your organization?
All divisions of the Visiting Nurse Service of New York have been awarded Platinum
certification (the highest level possible) from SAGE, the world’s largest and oldest organization dedicated to
improving the lives of LGBT older people.
than 80 percent or more of VNSNY’s clinical and other staff have received SAGE Care LGBT cultural competency
training, further establishing VNSNY as a
preferred health care provider for New York City’s LGBT residents.
SAGE training is designed to increase awareness among VNSNY clinical and
administrative staff of cultural issues and sensitivities around sexual
orientation and gender identification, so as to ensure a welcoming and
respectful health care environment for all individuals within the LGBTQ
Among other things, the training stresses the importance of approaching each patient in a non-judgmental fashion and never making assumptions about anyone’s sexual orientation or family structure. We want every patient to feel they can be totally open about who they are with every member of our GAP team who walks through their door.
Coming in March 2020!
Annals of LGBTQ Public and Population Health
The mission of Annals of LGBTQ Public and Population Health is to bring together state-of-the-art cross-disciplinary scholarship which seeks to enhance the health and well-being of sexual and gender minority (SGM) individuals at the population level with an eye to the intersectional identities that SGM people possess.
We are interested in papers that advance education, policies, laws, and approaches to enhance SGM care and SGM health.
Helping patients to navigate what comes after a difficult diagnosis is a necessary part of our profession. In my many years working with patients facing progressive diseases, like chronic obstructive pulmonary disease (COPD), I have found that they often have questions, namely:
do I do now?
That’s where we, as
nurses and other health care providers, can offer answers. COPD is not
currently curable; however, there is still hope for these patients. Lifestyle
changes and medical advancements make it possible for patients to improve their
ability to breathe and overall quality of life. The objective of treatment is
to slow the progression of the disease and assist with managing its symptoms. As
patients with COPD come to terms with their disease, here’s what I would
recommend to guide them through the next steps of their journey, from diagnosis
With Them to Create a Plan
After giving a
diagnosis of COPD, educating patients on the disease and working with them on a
personalized plan to start addressing their symptoms is an important first
step. In fact, there are many lifestyle changes that patients can make every
day to not only accommodate their new medical needs but also to help improve
lung function. Committing to a diet of anti-inflammatory foods — like fatty
fish or dark leafy greens — participating in regular low-impact physical
activities and other techniques can help to reduce inflammation in the lungs
that can exacerbate symptoms.
Them Take the Steps to Quit Smoking
Smoking can cause
significant damage in the lungs which only increases over time. One of the best
things that patients can do if they’ve been diagnosed with chronic lung disease
is to quit smoking if they currently smoke. It’s important to arm them with information
and tools they need to successfully do so — whether it’s helping them to
identify smoking triggers, create an exercise and diet regimen or connect to
support groups or other resources. For example, at Lung Health Institute, we
offer our patients access to programs like American Lung Association’s Freedom
From Smoking® Plus, a flexible online smoking
cessation program that can be completed in six weeks.
Have an Honest
Conversation About What Treatment Is Right for Them
patient is different, and treatments will vary for each patient with COPD — depending
on the severity of the disease and other factors, including age, fitness level or
medical history. That’s why it’s critical to create an environment where patients
are comfortable being completely honest about how they’re feeling both
physically and mentally. That will ensure that we can provide them with the
best course of action when it comes to their treatment.
Melissa Rubio, Ph.D., APRN, is a nurse practitioner and principal investigator for research at the Lung Health Institute, based at its Dallas clinic. Rubio also currently serves as a visiting professor at DeVry University’s Chamberlain College of Nursing in Downers Grove, Illinois. Prior to joining Lung Health Institute, Rubio worked at Pleasant Ridge Internal Medicine in Arlington, Texas, as a family nurse practitioner. Rubio holds a doctorate in philosophy from the University of Wisconsin-Milwaukee College of Nursing. She also earned a bachelor’s degree in nursing from the same school. She is a board-certified family nurse practitioner and a certified principal investigator. Rubio is also a member of the North Texas Nurse Practitioners and the Southern Nursing Research Society.
It was no great leap for Austin Regional Clinic to embrace the
concept of population health, an approach that aims to improve the health of groups
of people, particularly those with more medically complex conditions. Our
medical group was founded on those principles back in 1980, when no one ever
heard of the term. Over time, we became very good at population health and now we
are often asked to present our “best practices.”
What’s the secret to
our success? The
long answer often includes a description of our IT investments. No doubt the
advent of electronic medical records has made us better — instead of reacting
to illness, we are beginning to use the data to predict illness, allowing us to
shift resources to the sickest patients.
But it is the human
element — the way each provider engages with the patient — that takes us from
simply identifying the high-risk to making a difference in their lives. The
technique we’ve honed is motivational interviewing.
Listen Versus Fix
The “front line” of
our population health program is our nurse navigation team. Ten years ago, it
consisted of four trained nurse navigators who primarily guided our Medical
Home patients — individuals living with chronic conditions who rely on frequent
care from various specialists. Today, this team has grown to 25 and now
includes in-hospital nurse navigation as well as a Home Health Navigator.
While the roles within
our team have expanded, our approach to patient interaction has not. Instead of
telling our patients, we ask questions. We hire listeners, not fixers.
To a psychologist, motivational interviewing is a fundamental technique. It is less well known in most doctor and nurse cultures. Providers are taught to fix. Yet, we’ve found, that without first understanding the patients’ goals and then uncovering the obstacles that stand in the way of their goals, our sickest patients don’t feel compelled to change.
How does it work? Instead of telling
patients to change, we guide them to express their own commitment out loud,
which has been shown to improve patients’ ability to actually make a change.
‘Fishing with My
When I asked one of my
patients with a chronic breathing disorder about his goal, he replied, “I’d
like to be able to fish with my grandson.” Later, at his appointment and
others, I asked questions about what might be getting in the way of his goal.
“I can’t breathe outside” or “I can’t leave the house without my breathing
device.” We discussed the obstacles and set forth reasonable small goals to
progress him forward. Each time he achieved a goal, he was motivated to set another.
My patient was aware
of his barriers. With motivational interviewing, he became empowered to learn
how to overcome them.
population health program is an investment in time and money, but the effort pays
off. As last year showed, Austin Regional Clinic’s success has the numbers
to back it up:
than $3 million in 2018 shared savings, bringing the total to almost $25
million in the past eight years
80% screening rate for depression and fall risk, up from 38% just two years
of diabetic patients moved to “good controlled” from “poor controlled”
of our Medicare population is up to date on their colorectal screenings, up
from 65% a few years before
Every year we set new
population health goals, raising the bar just a bit. Admittedly, improving
population health is a marathon, and we are only in the first leg of the race. Enhanced
predictive analysis using artificial intelligence and machine learning will guide
us to the patients for whom we can make the greatest impact on their health.
Our philosophy concerning our patients is unwavering — to not just consider each patient’s illness, but to see the person. To understand their values, their lives, and their support. To listen and to empower.
The most accurate
predictive analysis cannot compel a patient to change — a patient’s will
does that … and the dream to fish with a grandson.
In honor of “Nephrology Nurses Week,” September 8-14, 2019, Daily Nurse is highlighting two very special dialysis nurses.
At 25 years old, Jackson, KY resident Bridgette Chandler was living with her husband and raising two young children while enjoying a satisfying career as a nursing tech.
Bridgette’s life changed forever after she rushed to the emergency room with what she thought was a case of the flu. Instead of flu, doctors informed her, she was actually suffering from kidney failure. During the long wait for a transplant she underwent arduous four-hour dialysis treatments three times a week.
Despite finding that dialysis made her “a completely
different kind of tired that sleep doesn’t fix,” in her determination to remain
actively involved with her young family, Bridgette opted for at-home dialysis at
the Fresenius Kidney Care clinic in Kentucky. With her home treatments, Bridgette
managed to experience all of the special events that happen in a family, from
games and recitals to the hubbub of birthdays and holiday seasons. She remarks,
“For me, being able to take part in special moments with my family was most
important and that’s why I chose home therapy. It gave me the opportunity to
take back some of the control of my health.”
Five years later Bridgette found a donor and had her kidney transplant surgery. Even before the hospital had discharged her, she asked her doctor how long she had to wait before she could start school and become an RN. Now, Bridgette is working alongside her former nurses, treating home dialysis patients at the same clinic that treated her. “Because of my personal experience, my intention had always been to become a nephrology nurse” she says. “I stayed in touch with my nurses and doctors who made such a difference in my life. When a position became available in the clinic with those nurses and doctors, I jumped on it.”
Bridgette’s experience also creates a special bond with her
patients: “helping patients find ways to make dialysis work for them has
definitely been beneficial. I’ve had so many patients tell me they respected me
so much more because I understand what they are going through. Many of my patients
have even told me that I give them hope. That is just as important to me
as it is to them. That’s why I wanted to be a nurse.”
Anne Diroll was also destined to become a nephrology nurse.
A year after losing her father to a sudden heart attack, 15-year-old
Anne was hospitalized for a week after being struck by a car.
During her time in the hospital, unable to walk, and suffering from a “huge hematoma,” she had plenty of time to think and look around. She saw—and deeply admired—the nurses who cared for her, and was inspired by fellow patients stories, learning of “tragedies and hardships in others’ lives that I had never experienced or been aware of at a young age, and [I] thought ‘this is a part of life that needs healing.’”
Anne began her nursing studies almost as soon as she was
discharged from the hospital. Initially working as a pulmonary nurse, when she sought
a new job, she “didn’t know anything about kidneys, except that they made urine.
In my interview for a dialysis nurse position, my interviewer explained that the
reason dialysis nurses exist is because [failing] kidneys don’t make urine, so
I was able to understand that dialysis is to kidneys as ventilators are to
lungs. I got the job and have been a nephrology nurse ever since.”
Today Anne manages a Fresenius Kidney Care clinic in
California, overseeing the care of 50 patients.
The American Nephrology Nurses
Association (ANNA) launched Nephrology Nurses Week in 2005 to give employers,
patients and others the opportunity to thank nephrology nurses for their
life-saving work. In addition, ANNA seeks to interest other nurses in the career
opportunities available in nephrology.
About 30 million adults in the
United States suffer from chronic kidney disease. The nephrology nurses who
treat them make a positive difference in the lives of patients and their
families every day. Caring for kidney patients requires nurses to be highly
skilled, well educated, and motivated, and nephrology nurses cite the variety
and challenges of the specialty as fueling their ongoing passion.
For more information nephrology
nursing, the Nephrology Nurses Week celebration, and more, visit www.annanurse.org/