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California Correctional Health Care Services 2011.

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Presentation on theme: "California Correctional Health Care Services 2011."— Presentation transcript:

1 California Correctional Health Care Services 2011

2 Alan Frueh MD Bonnie Gieschen MD Linda Maclachlan Pharm.D Jane Robinson RN Rebecca Yager RD John Zweifler MD Douglas Peterson MD

3 Distinguish between the handling of an individual hunger strike and a mass hunger strike. Describe the pathophysiology, stages, and risks of starvation. Stratify the risk of refeeding and prescribe an appropriate refeeding diet.

4 CCHCS Policy Highlights How it usually works Challenges of a Mass Hunger Strike What we knew and expected-July 2011 HS 1-July 1-July 21, 2011 Lessons learned Mass Hunger Strike Policy HS 2 September 26-October 14, 2011 Starvation and Refeeding Syndrome Stages of Hunger and Starvation Refeeding Risk Stratification Clinical Guidance



7 Front loaded with work Intense utilization of resources before most P/I experience adverse effects Inefficient, but manageable for sporadic strikers who are more likely to: Have mental health issues Have individual goals or grievances Respond to early and intense interventions by healthcare and custody.


9 Existing policy poorly adapted to a mass hunger strike which is l ikely to: Have large numbers of participants Be politically motivated Less likely participant has mental health condition contributing to strike Be organized/pre-planned (food storage) Be pre-announced

10 Strike rumors circulated in June 2011 CDCR Intelligence expected: strike participants at Pelican Bay State Prison Unknown numbers at CSP Corcoran

11 CCHCS medical leadership recognized the limitations of existing policy and the difficulties it created: How to do RN face-face assessments within 2 days How to do full RN daily assessments thereafter How to determine which participants are high risk How to have PCP evaluation within 72 hrs and order labs How to have Mental Health see every participant How to keep track of this many participants

12 Initial plans Follow policy whenever possible Fallback to declaring Emergency and following Emergency Incident Command System if needed

13 First day 6553 participants 16 sites Maximum 9,079 participants Challenge was much greater than anticipated


15 Due to large numbers of refusals staff was generally able to follow policy in spite of the large number of strike participants Of the 9079 participants only 143 were deemed Persistent Hunger Strikers defined as: Actively striking > 2 weeks and Had a beginning wt and > one wt recorded during strike Only 8 participants had weight loss > 15 lbs

16 Weight Lost7/20/2011 > 20 lbs lost lbs lost lbs lost lbs lost101 > 0 lbs gained6 Grand Total143 Note >7700 participants never had a weight done (refused) Custody did not clear or restrict canteen during HS 1

17 Primary Diagnosis Muscle weakness (generalized) 3 Dehydration 2 Abdominal pain, unspecified site 2 Other disorder metabolism 1 Other disorder eating 1 37 admissions out of 9079 participants 1/3 of these appeared related to lack of intake Most were Persistent Hunger Strikers Except for one patient inmate at PBSP, there was no evidence of refeeding problems at 3 wks.

18 Routine labs are not supported by available data: Especially electrolytes in the first 3 wks Glucose (mild hypoglycemia) can be done by FS UA (does not change management) Labs may remain normal until refeeding begins

19 Existing Policy not appropriate for a mass event Need a policy covering a large scale strike Identify, evaluate and follow high risk participants (underlying illness, meds, underweight etc.) Institution/provider high risk patient lists Clinically Complex Registry. UHR Mental Health Tracking System for MH patients. Clinical assessments safely delayed until participant has lost 5% body weight (except for high risk persons)

20 Baseline/periodic weights useful if can be obtained: Participants status –risk of adverse events Predicting risk of refeeding (Daily weights are not necessary) The large majority of participants refused weights AND evaluations. Close clinical observation needed for the participants who refuse weight and exam

21 Routine, early AD/POLST completion not useful Time consuming Many participants refused Those who completed chose full resuscitation and Rx Appropriate for participants who have lost significant weight and are at higher risk. Participants need education on responsibility to notify staff of need for health care Participants need education on risks of starvation and refeeding. Patient education hand-outs Documentation of informed consent/effective communication once weight loss documented.



24 Institutions need to stock up on supplies and equipment : Scales (mark them, digital if possible), BP cuffs Oral and intravenous rehydration supplies MVI, thiamine (oral and IV or IM) Pre-printed documentation templates.

25 Literature based clinical guidance useful for staff Role of vitamins/mineral supplements Assessment of risk/management of refeeding Share with ED docs if participant transferred out Communication and tracking issues: Daily manual tracking + large # of participants = errors Participants start and stop eating Recognize data limitations due to refusals and initial collection and recording errors do not allow firm conclusions


27 Custody had different approach: Treated HS 2 as a disturbance Separated HS leaders from rest of population Removed food and canteen items from identified participants cells Disallowed canteen privileges (except for hygiene items) for participants Coordinated tracking with medical via SharePoint site.

28 High numbers but: Resources focused more appropriately Improved organization and communication Less staff and leadership stress and fatigue


30 Weight loss: HS 1 vs HS lbs lbs lbs> 20 lbs HS HS

31 Larger numbers of weights recorded probably due to: Greater number of inmates consenting to being weighed Improved tracking on the SharePoint Increased weight loss could be due to: More weights taken Participants did not have access to stored food this time No deaths or serious morbidity occurred

32 Continue to improve shared tracking Removal/restriction of canteen helpful Dis-incentive to participants More certain of actual intake, clinically more predicable Mass HS Policy needs improvement How best to monitor large #s of participants Time vs Weight vs Both? Regular direct observation of refusers? How best to manage starvation- when start vitamins? How best to address refeeding Determine risk and control initial intake Institution and HQ meeting to revise… stay tuned …



35 1-3 days Use up glycogen 8-14 days Risk of refeeding syndrome begins Day days Muscle protein metabolized to glucose Depletion of K + Phos, Mg ++

36 15-18 d ataxia difficulty standing bradycardia orthostasis mental sluggishness sensation of cold weakness > 42 days Loss of > 30% body wt life-threatening increased confusion trouble concentrating somnolent state incoherent arrhythmias d oculo-motor nystagmus diplopia trouble swallowing extreme vertigo vomiting converging strabismus

37 Initiate applicable CCHCS Hunger Strike Policy Baseline weight (same scale/digital if possible) Identify high risk participants Refer as appropriate to Mental Health Review medication lists Stop nonessential mediations Stop antacids (interfere with phosphate absorption) Stop diuretics if possible Offer educational information Document refusals

38 Offer patients: Thiamine 100 mg po daily B complex 1 po daily Multi-vitamin (e.g. Tab-a-vite) one po daily Encourage 1.5L or more /day fluid intake Watch more closely if refusing fluids If clinically significant dehydration offer: Oral rehydration Pedialyte- (IV only if refuses) Symptomatic hypoglycemia treat as clinically indicated: Food, LNS, Glucose gel, D50 IV Fall precautions Before voluntary refeeding assess risk

39 Definition: Wide spectrum of biochemical abnormalities and clinical consequences Hypophosphatemia is the adopted surrogate marker but not pathognomonic.

40 40 How to recognize and respond to refeeding syndrome: Yantis, Mary Ann; Velander, Robyn Nursing2011 Critical Care. 4(3):14-20, May Glucose takes K+, P, Mg++ into the cells Increased demand for thiamine (cofactor cellular enzymatic reactions) Insulin follows When a malnourished person begins to eat: Glucose enters blood

41 Clinical Manifestations: Symptoms : Unpredictable Deterioration can be rapid May occur late. Variable Mild derangements may have no symptoms. Spectrum: N/V, lethargy respiratory insufficiency, cardiac failure, hypotension, arrhythmias, delirium, coma death.

42 Clinical Evaluation: Screening exam, review medications Risk assessment based on: BMI, wt loss, length of fasting What if no baseline weight? ECG (if irregular pulse, abnormal HR, K + or Phos) If cardiac abnormalities-monitoring recommended

43 Clinical Evaluation: (cont) Labs: Baseline Phos +, Mg + +, Ca + +, K +, Na +, urea, Cr before refeeding During refeeding monitor electrolytes daily (as indicated based upon refeeding risk assessment) Life-threatening changes usually seen in the first 3 days Watch fluid intake/output and weight If gain > ½ lb per day or 3.3 lbs/wk likely fluid retention


45 Negligible risk : Fasting 18.5 kg/m2 Modest risk:Any one of the following criteria: a BMI > 16 but <18.5 kg/m2 or loss of >10% body weight (but < 15%) High risk: (either)Major risk factors (any one of the following) a BMI <16 kg/m2 weight loss >15% Low K+, Mg++,Phos Lesser risk factors: (two or more of the following) a BMI <18.5 kg/m2 weight loss >10% H/O ETOH, co-morbid/meds Extreme risk:More than one of the following: BMI <16 kg/m2 weight loss >15% Low K+, Mg++, Phos No food > 21 days H/O ETOH, co-morbid/meds ChemoRx, other significant comorbidity


47 Level of RiskManagement of Patient Negligible risk: Fasting 18.5 kg/m2 Eat and drink freely and no monitoring is necessary. Watch hydration if have not been taking fluids Modest risk: BMI > 16 but <18.5 kg/m2 or loss of >10% body weight (but < 15%) Strongly consider giving thiamine 100 mg prior to refeeding Add to D5NS or given IM. <20 kcals/kg/day for the first 2 days CDCR Heart Healthy Diet tray (Provides 2750 kcal) ½ of each meal tray the first 2 days Fluid limited to around 30ml/kg/day (Example 170 lb man= 2310 ml/day) Blood tests above before refeeding starts Repeated at approximately 24 and 48 hours of refeeding Daily multi-vitamin and trace element supplement.


49 Level of RiskManagement of Patient High risk: Major risk factors : (any one of the following) a BMI <16 kg/m2 weight loss >15% Low K+, Mg++,Phos Lesser risk factors: (two or more of the following) a BMI <18.5 kg/m2 weight loss >10% H/O ETOH, co-morbid/meds Refeeding in clinical setting with careful observation ( In most cases community hospital) Monitor closely-transfer to higher level of care if: K+ <3.0 mmol/l Mg++ <0.5 mmol/l Phos <0.5 mmol/l Strongly consider Phos, K+, Mg++ even if baseline ok Strongly consider thiamine 100 mg prior to refeeding. Intake 10 kcal/kg/day for the first 24 hours, taking either: CDCR Heart Healthy or Carnation Instant Breakfast Lactose Free Increase by 5-10 kcal/kg/day. Fluid < 30ml/kg/day. (zero fluid balance x 1 wk) Blood test daily x 1 week (LFTs 2x/wk) Daily multi-vitamin and trace element supplement.

50 Level of RiskManagement of Patient Extreme risk: More than one of the following: BMI <16 kg/m2 weight loss >15% Low K +, Mg ++, Phos No food > 21 days H/O ETOH, co-morbid/meds ChemoRx, other significant comorbidity Admit to hospital Restore volume, fluid balance and electrolytes. IV Thiamine Supplementation of K+, Phos, Mg++ 5 kcal/kg/day for Day 1 NG continuous or intermittent LNS if cant eat Carnation Instant Breakfast Lactose or If pt can eat CDCR Heart Healthy diet Monitoring of the ECG for at least the first 48 hours Blood test daily x 1 week (LFTs 2x/wk) Normal labs- can have TOTAL body depletion low Even if high or renal failure may need supplements If low need to give supplements WITH low levels of feeding Once po well established begin daily MVI & trace element


52 For copies of Policy, Clinical Guidance and Decision Support

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