Wound Management Challenges in Prison Populations

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By Cheryl Carver, LPN, WCC, CWCA, DAPWCA, FACCWS

I am into my 20th year working as a wound care specialist. I must admit, I never thought much about wound management in the prison population until my son's wound care experiences during his incarcerations. I am quite transparent with this blog, and after you finish reading it, I hope you will have a different perspective on wound care in prison populations. I want to point out that this was my son's experience, which he encouraged me to share to help others. This blog is my view and does not define correctional nurses or wound care management in all prisons. I have the utmost respect for correctional nurses because I know that I could not do it. Through my son's experience, I identified various gaps in education and factors affecting quality of wound care that led to my interest in researching this area of wound care.

Wounds Common in Prison Populations

Wound care management, whether acute or chronic, can be a challenge for both providers and clinicians. However, wound care inside "the walls" adds a unique twist to the complexity. Wound types generally include arterial, venous, pressure, and diabetic neuropathic wounds, subdermal infections, stab wounds, lacerations, and abscesses. It has been reported that chronic health conditions in this population include arthritis, hypertension, asthma, heart disease, cancer, paralysis, stroke, diabetes, kidney disease, liver disease, hepatitis, sexually transmitted diseases, tuberculosis, and human immunodeficiency virus (HIV) infection.


Substance Abuse and Wound Care: Implications for Wound and Skin ManagementSubstance Abuse and Wound Care: Implications for Wound and Skin Management

Recent data report that lower limb ulcerations and self-harming wounds are more prevalent in the prison population than in the general community. Illicit drugs are used inside prisons every day. Inmates "on the needle" are at the highest risk for abscessed infections and complications. Prison physicians and nurses are constantly challenged with trying to mesh and balance clinical skills, mental health, and security. Federal prisons have five levels of security, while state prisons have only three; this determines the approach to health care needs.

My son has had several gang-related assaults, which left him with traumatic wounds to his head and chest region (laceration, stab wounds, third-degree burns). Naturally, as his mom and being a wound nurse, I was always concerned about the high risk of infection. The prison environment is already known as being much like a Petri dish.

He shared that on more than one occasion his wounds were not cleansed, and dressings were not changed, later leading to infection, and he was on intravenous and oral antibiotic therapy. My son's treatment was the same for all the wound types mentioned throughout the healing trajectory. Physician orders were as follows: silver sulfadiazine 1%, gauze, and tape. Frequency of change: twice daily. He was allowed Ibuprofen 600 mg every six to eight hours for severe pain. His chest wounds healed in six weeks. Wound healing times could have been faster if there had been practical knowledge of basic wound care and access to a wound care specialist via video telehealth.

Educational Needs

My son shared with me several times that he told the nurses changing his dressing that his mom was a wound nurse. These nurses shared they did not know wound care and stated they wanted to learn more. My son thanked the nurses for being kind and treating him like a human being. I instantly thought of the barriers involving nurse versus inmate and inmate versus nurse. I also felt disheartened that there was an educational need not being met.

Both correctional nurses and inmates struggle with the balance of compassion and trust with care. However, there are situations where an inmate may be non-compliant, self-harming, and/or violent. Communication between the correctional nurse and inmate is essential in continuity of care and planning when possible. Guidelines should be followed in the penitentiary environment to help providers and nurses to optimize treatment outcomes and support wound care.

Promoting Telemedicine in Correctional Facilities

I told my son on many calls that I wished I could see how his wound was doing. He came up with the idea to use the JPay kiosk (platform to communicate with family) to send me photos of his wound progress. We both knew there was a chance the images would be deleted but took the opportunity. I instructed him to attach a message each time referring to me as a wound specialist, etc. I received the photos.

The use of telemedicine technologies is currently on the rise because of the current COVID-19 pandemic. Telemedicine technology platforms are already being used in some prisons to help bolster education and optimize preventative care, wound care, and healing outcomes. Telemedicine has other advantages, including reduced emergency department visits and hospitalizations and lower costs for transporting inmates to and from specialized care appointments, while improving employee safety.

Dressings and Supplies

Prisons and jails already had limited access to supplies before COVID-19. Infection control supplies, wound care dressings, syringes, hand washing areas, and isolation rooms are few and far between, for two reasons—the current pandemic and the high incidence of theft. Conventional dressings include oil emulsions, non-adherents, gauzes, alginates or hydrofibers, abdominal pads, tape, and elastic wraps, as well as negative pressure wound therapy, if appropriate and approved on an individualized basis.

Goal Planning in Education

It is essential to provide ongoing education to correctional providers and nurses to optimize prevention and management. Implementing clear clinical guidelines is most effective for consistent quality of care across the health care continuum. Nurses need guidance on basic wound care and documentation to establish the most effective treatment plans and goals for wound healing. Practical knowledge about performing wound assessments, documenting, identifying wound types, pinpointing mechanisms of injury, and implementing timely necessary interventions is vital to ensure the best wound healing outcomes for prisoners.

Strategies in Supporting Wound Care Management

The following strategies can be used to encourage better wound care management within correctional facilities:

  • Ongoing staff education on basic wound care prevention and management will help bolster the quality of care.
  • A basic wound assessment approach using the wound color method for tissue types (pink, red, yellow, black) will simplify care planning goals.
  • Implement a wound care algorithm that includes topical agents and dressing options. Include the wound color method for dressing selection to support moist wound healing practices.
  • Nutritional screening should be part of the clinical pathway to wound healing.
  • Educate nursing staff on medical devices, offloading devices, support surfaces, and wheelchair cushions, etc.

Conclusion

Many persons believe prisoners do not deserve high-quality health care. Health care professionals working in correctional facilities are confronted with many more challenges inside "the walls" than you can imagine. However, there are legal, ethical, social, and public health reasons to validate that prisoners receive good health care services.

Resources

Boulton A, Vileikyte L, Ragnarson-Tennvall G, Appelquist J. The burden of diabetic foot disease. Lancet. 2005;366(9498):1719-1724.

Cook L, Jordon K. Leg ulceration in drug users: development of a multidisciplinary care pathway. Wounds UK. 2010;6(4):74-82.

Federal Bureau of Prisons. Prevention and management of acute and chronic wounds clinical practice guidelines. March 2014. https://www.bop.gov/resources/pdfs/wounds.pdf. Accessed May 19, 2020.

Hammett TM, Harmon MP, Rhodes W. The burden of infectious disease among inmates of and releases from US correctional facilities, 1997. Am J Public Health. 2002;92:1789-1794.

Health Protection Agency (HAP), Health Protection Scotland, National Public Health Service for Wales, CDSC Northern Ireland. Shooting Up: Infections Among Injecting Drug Users in the United Kingdom 2008. HPA, London, United Kingdom: HPA; 2009.

Pedagogy Education. Correctional Healthcare Campus. https://www.pedagogyeducation.com/Correctional-Healthcare-Campus/Home.aspx. Accessed May 18, 2020.

Wilper AP, Woolhandler S, Boyd JW, et al. The health and health care of US prisoners: results of a nationwide survey. Am J Public Health. 2009;99(4):666‐672. doi:10.2105/AJPH.2008.144279

About the Author
Cheryl Carver's experience includes over a decade of hospital wound care and hyperbaric medicine. She currently works as a Clinical Specialist for a leading independent provider of wound care solutions for long term care facilities in the United States, American Medical Technologies a d/b/a of Gordian Medical, Inc. Carver is not only known for her knowledge and expertise, but for enjoying her vocation as much as anyone possibly could. Her strong passion is driven from a life long list of personal experiences as a caregiver. Her mother passed away in in her arms at the young age of 47, due to complications from diabetes, amputation, and pressure ulcers. She now has dedicated her professional career to wound care education in hopes to bolster quality of care and strengthen pressure ulcer prevention. She has received many high reviews from her fellow physician and nurse students from across the country, including but not limited to: plastic surgeons, cardio-thoracic surgeons, general surgeons with wound care experience. Ms. Carver single-handedly developed a comprehensive educational training manual for onboarding physicians and is the star of disease specific educational video sessions accessible to employee providers and colleagues.

The views and opinions expressed in this blog are solely those of the author, and do not represent the views of WoundSource, Kestrel Health Information, Inc., its affiliates, or subsidiary companies.

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