Presentation on theme: "Surviving a Large Scale Organized Hunger Strike at your institution"— Presentation transcript:
1Surviving a Large Scale Organized Hunger Strike at your institution California Correctional Health Care Services2011
2Authors Have No Conflict of Interest Disclosures Alan Frueh MDBonnie Gieschen MDLinda Maclachlan Pharm.DJane Robinson RNRebecca Yager RDJohn Zweifler MDDouglas Peterson MD
3ObjectivesDistinguish 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.
4Outline CCHCS Policy Highlights Challenges of a Mass Hunger Strike How it usually worksChallenges of a Mass Hunger StrikeWhat we knew and expected-July 2011HS 1-July 1-July 21, 2011Lessons learnedMass Hunger Strike PolicyHS 2 September 26-October 14, 2011Starvation and Refeeding SyndromeStages of Hunger and StarvationRefeedingRisk StratificationClinical Guidance
6CCHCS Medical Services Program P & P: Hunger Strike Policy Chapter 22 (2006)
7CCHCS Medical Services Program P & P: Hunger Strike Policy Chapter 22 (2006) Front loaded with workIntense utilization of resources before most P/I experience adverse effectsInefficient, but manageable for sporadic strikers who are more likely to:Have mental health issuesHave individual goals or grievancesRespond to early and intense interventions by healthcare and custody.
9CCHCS Medical Services Program P & P: Hunger Strike Policy Chapter 22 (2006) Existing policy poorly adapted to a mass hunger strike which is likely to:Have large numbers of participantsBe politically motivatedLess likely participant has mental health condition contributing to strikeBe organized/pre-planned (food storage)Be pre-announced
10What we knew and expected July 2011 Strike rumors circulated in June 2011CDCR Intelligence expected:1000+ strike participants at Pelican Bay State PrisonUnknown numbers at CSP Corcoran
11Limitations with existing policy: CCHCS medical leadership recognized the limitations of existing policy and the difficulties it created:How to do RN face-face assessments within 2 daysHow to do full RN daily assessments thereafterHow to determine which participants are high riskHow to have PCP evaluation within 72 hrs and order labsHow to have Mental Health see every participantHow to keep track of this many participants
12Limitations with existing policy: Initial plansFollow policy whenever possibleFallback to declaring Emergency and following Emergency Incident Command System if needed
13HS 1: July 1-July 21, 2011 First day 6553 participants 16 sites Maximum 9,079 participantsChallenge was much greater than anticipated
14July 2011 Strike: Number of participants by Institution (Does not include Out of State)
15Experience July 1-July 21, 2011Due to large numbers of refusals staff was generally able to follow policy in spite of the large number of strike participantsOf the 9079 participants only 143 were deemed Persistent Hunger Strikers defined as:Actively striking > 2 weeks andHad a beginning wt and > one wt recorded during strikeOnly 8 participants had weight loss > 15 lbs
16July Strike: Outcome Weight Loss Weight Lost7/20/2011> 20 lbs lost4lbs lostlbs lost299.9-0 lbs lost101> 0 lbs gained6Grand Total143Note >7700 participants never had a weight done (refused)Custody did not clear or restrict canteen during HS 1
17July Strike: Outcome Admissions 37 admissions out of 9079 participants1/3 of these appeared related to lack of intakeMost were “Persistent Hunger Strikers”Primary DiagnosisMuscle weakness (generalized)3Dehydration2Abdominal pain, unspecified siteOther disorder metabolism1Other disorder eatingExcept for one patient inmate at PBSP, there was no evidence of refeeding problems at 3 wks.
18Lessons learned from HS 1 Routine labs are not supported by available data:Especially electrolytes in the first 3 wksGlucose (mild hypoglycemia) can be done by FSUA (does not change management)Labs may remain normal until refeeding begins
19Lessons learned from HS 1 Existing Policy not appropriate for a mass eventNeed a policy covering a large scale strikeIdentify, evaluate and follow high risk participants (underlying illness, meds, underweight etc.)Institution/provider high risk patient listsClinically Complex Registry.UHRMental Health Tracking System for MH patients.Clinical assessments safely delayed until participant has lost 5% body weight (except for high risk persons)
20Lessons learned from HS 1 Baseline/periodic weights useful if can be obtained:Participants status –risk of adverse eventsPredicting 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
21Lessons learned from HS 1 Routine, early AD/POLST completion not usefulTime consumingMany participants refusedThose who completed chose full resuscitation and RxAppropriate for participants who have lost significant weight and are at higher risk.Participants need education on responsibility to notify staff of need for health careParticipants need education on risks of starvation and refeeding.Patient education hand-outsDocumentation of informed consent/effective communication once weight loss documented.
24Lessons learned from HS 1 Institutions need to stock up on supplies and equipment :Scales (mark them, digital if possible), BP cuffsOral and intravenous rehydration suppliesMVI, thiamine (oral and IV or IM)Pre-printed documentation templates.
25Lessons learned from HS 1 Literature based clinical guidance useful for staffRole of vitamins/mineral supplementsAssessment of risk/management of refeedingShare with ED doc’s if participant transferred outCommunication and tracking issues:Daily manual tracking + large # of participants = errorsParticipants start and stop eatingRecognize data limitations due to refusals and initial collection and recording errors do not allow firm conclusions
27HS 2: Sept. 26-Oct. 17, 2011 Custody had different approach: Treated HS 2 as a “disturbance”Separated HS leaders from rest of populationRemoved food and canteen items from identified participants’ cellsDisallowed canteen privileges (except for hygiene items) for participantsCoordinated tracking with medical via SharePoint site.
28HS 2: Experience with new policy High numbers but:Resources focused more appropriatelyImproved organization and communicationLess staff and leadership stress and fatigue
30HS 2: Experience with new policy Weight loss: HS 1 vs HS 20-9.9 lbslbslbs> 20 lbsHS 110294HS 2417904018
31HS 2: Experience with new policy Larger numbers of weights recorded probably due to:Greater number of inmates consenting to being weighedImproved tracking on the SharePointIncreased weight loss could be due to:More weights takenParticipants did not have access to stored food this timeNo deaths or serious morbidity occurred
32Lessons learned-HS 2 Continue to improve shared tracking Removal/restriction of canteen helpfulDis-incentive to participantsMore certain of actual intake, clinically more predicableMass HS Policy needs improvementHow best to monitor large #’s of participantsTime vs Weight vs Both? Regular direct observation of refusers?How best to manage starvation- when start vitamins?How best to address refeedingDetermine risk and control initial intakeInstitution and HQ meeting to revise… stay tuned…
35Stages of Hunger Strike 4-7 daysMuscle protein metabolized to glucoseDepletion of K+ Phos, Mg++8-14 daysRisk of refeeding syndrome begins Day 101-3 daysUse up glycogen
36Stages of Hunger Strike 35-42 d“oculo-motor “nystagmusdiplopiatrouble swallowingextreme vertigovomitingconverging strabismus> 42 daysLoss of > 30% body wt life-threateningincreased confusiontrouble concentratingsomnolent stateincoherentarrhythmias15-18 dataxiadifficulty standingbradycardiaorthostasis“mental sluggishness”sensation of coldweakness
37Clinical Interventions- Early Initiate applicable CCHCS Hunger Strike PolicyBaseline weight (same scale/digital if possible)Identify high risk participantsRefer as appropriate to Mental HealthReview medication listsStop nonessential mediationsStop antacids (interfere with phosphate absorption)Stop diuretics if possibleOffer educational informationDocument refusals
38Clinical Interventions Offer patients:Thiamine 100 mg po dailyB complex 1 po dailyMulti-vitamin (e.g. Tab-a-vite) one po dailyEncourage 1.5L or more /day fluid intakeWatch more closely if refusing fluidsIf clinically significant dehydration offer:Oral rehydration Pedialyte- (IV only if refuses)Symptomatic hypoglycemia treat as clinically indicated:Food, LNS, Glucose gel, D50 IVFall precautionsBefore voluntary refeeding assess risk
39Refeeding Syndrome Definition: Wide spectrum of biochemical abnormalities and clinical consequencesHypophosphatemia is the adopted surrogate marker but not pathognomonic.
40Refeeding Syndrome Physiology When a malnourished person begins to eat:Glucose enters bloodInsulin followsGlucose takes K+, P, Mg++ into the cellsIncreased demand for thiamine (cofactor cellular enzymatic reactions)How to recognize and respond to refeeding syndrome: Yantis, Mary Ann; Velander, Robyn Nursing2011 Critical Care. 4(3):14-20, May 2009.
41Refeeding Syndrome Clinical Manifestations: Symptoms: Unpredictable Deterioration can be rapidMay occur late.VariableMild derangements may have no symptoms.Spectrum: N/V, lethargyrespiratory insufficiency, cardiac failure, hypotension, arrhythmias, delirium, coma death.
42Evaluation and Management Clinical Evaluation:Screening exam, review medicationsRisk assessment based on:BMI, wt loss , length of fastingWhat if no baseline weight?ECG (if irregular pulse, abnormal HR, ↓ K+ or Phos)If cardiac abnormalities-monitoring recommended
43Evaluation and Management Clinical Evaluation: (cont)Labs:Baseline Phos +, Mg + +, Ca + +, K +, Na +, urea, Crbefore refeedingDuring refeeding monitor electrolytes daily (as indicated based upon refeeding risk assessment)Life-threatening changes usually seen in the first 3 daysWatch fluid intake/output and weightIf gain > ½ lb per day or 3.3 lbs/wk likely fluid retention
45Risk Stratification Negligible risk: Fasting < 7-9 days, with BMI>18.5 kg/m2Modest risk:Any one of the following criteria:a BMI > 16 but <18.5 kg/m2 orloss of >10% body weight (but < 15%)High risk: (either)Major risk factors (any one of the following)a BMI <16 kg/m2weight loss >15%Low K+, Mg++,PhosLesser risk factors: (two or more of the following)a BMI <18.5 kg/m2weight loss >10%H/O ETOH, co-morbid/medsExtreme risk:More than one of the following:BMI <16 kg/m2Low K+, Mg++, PhosNo food > 21 daysChemoRx, other significant comorbidity
47Refeeding Risk- Modest Level of RiskManagement of PatientNegligible risk:Fasting < 7-9 days, with BMI>18.5 kg/m2Eat and drink freely and no monitoring is necessary.Watch hydration if have not been taking fluidsModest risk:BMI > 16 but <18.5 kg/m2 orloss of >10% body weight(but < 15%)Strongly consider giving thiamine 100 mg prior to refeedingAdd to D5NS or given IM.<20 kcals/kg/day for the first 2 daysCDCR Heart Healthy Diet tray (Provides 2750 kcal)½ of each meal tray the first 2 daysFluid limited to around 30ml/kg/day(Example 170 lb man= 2310 ml/day)Blood tests above before refeeding startsRepeated at approximately 24 and 48 hours of refeedingDaily multi-vitamin and trace element supplement.
49Refeeding Risk- High Level of Risk Management of Patient High risk: Major risk factors :(any one of the following)a BMI <16 kg/m2weight loss >15%Low K+, Mg++,PhosLesser risk factors:(two or more of the following)a BMI <18.5 kg/m2weight loss >10%H/O ETOH, co-morbid/medsRefeeding in clinical setting with careful observation ( In most cases community hospital)Monitor closely-transfer to higher level of care if:K+ <3.0 mmol/lMg++ <0.5 mmol/lPhos <0.5 mmol/lStrongly consider Phos, K+, Mg++ even if baseline okStrongly consider thiamine 100 mg prior to refeeding.Intake 10 kcal/kg/day for the first 24 hours, taking either:CDCR Heart Healthy orCarnation Instant Breakfast Lactose FreeIncrease by 5-10 kcal/kg/day.Fluid < 30ml/kg/day. (zero” fluid balance x 1 wk)Blood test daily x 1 week (LFT’s 2x/wk)Daily multi-vitamin and trace element supplement.
50Refeeding Risk- Extreme Level of RiskManagement of PatientExtreme risk:More than one of the following:BMI <16 kg/m2weight loss >15%Low K+, Mg++, PhosNo food > 21 daysH/O ETOH, co-morbid/medsChemoRx, other significant comorbidityAdmit to hospitalRestore volume, fluid balance and electrolytes.IV ThiamineSupplementation of K+, Phos, Mg++5 kcal/kg/day for Day 1NG continuous or intermittent LNS if can’t eatCarnation Instant Breakfast Lactose orIf pt can eat CDCR Heart Healthy dietMonitoring of the ECG for at least the first 48 hoursBlood test daily x 1 week (LFT’s 2x/wk)Normal labs- can have TOTAL body depletion lowEven if high or renal failure may need supplementsIf low need to give supplements WITH low levels of feedingOnce po well established begin daily MVI & trace element