Shared learning database

Royal Free Hospital
Published date:
July 2012

An intiative to improve the identification and management of TB patients in an inner city prison

Guidance the shared learning relates to:
Does the example relate to a general implementation of all NICE guidance?
Does the example relate to a specific implementation of a specific piece of NICE guidance?


Aims and objectives

Aim - To improve the identification and management of TB patients in an inner city prison.

Imprisonment is an opportunity to provide healthcare to individuals that find it difficult to access healthcare in the community. Prisoners can be some of the most marginalised people in society. My unique role as a nurse specialist was to improve the management of the high levels of TB in London prisons in particular HMP Pentonville and raise awareness of TB in the prison setting. Based at Pentonville I provided on site management of TB cases and TB screening of prisoners. An important part of my role was to liaise with the local community TB team who are responsible for the patient's treatment whilst in prison and teams responsible for care post release from prison.

I worked very closely with the Find and Treat service. Find and Treat are a London based multidisciplinary service that supports the detection, diagnosis and management of TB in hard-to-reach-groups across the capital.

Prison is a challenging environment where security comes first. This means working closely with security as well as prison healthcare to plan and implement initiatives and changes. Working as part of the healthcare team as well as the local TB service is important to ensure a coordinated approach. It is important to ensure systems are in place in the prison to facilitate effective TB management and to maximise screening for TB.

My objectives were to:
- improve management of the prisoners with suspected or confirmed TB (Recs 8, 9, 10, 12, 13)
- improve management of TB screening for prisoners (Recs 8,9, 10, 12, 13)
- raise the profile of TB and TB awareness in the prison (Recs 5 and 6)

Related NICE Recommendations:
- Recommendation 5 - Raising and sustaining awareness of TB among health professionals and those working with hard-to-reach groups
- Recommendation 6 - Raising and sustaining awareness of TB among hard-to-reach groups
- Recommendation 8 - Identifying and managing active TB in prisons or immigration removal centres: organisational factors
- Recommendation 9 - Identifying active TB in prisons or immigration removal centres
- Recommendation 10 - Managing active TB in prisons or immigration removal centres
- Recommendation 12 - Identifying and managing latent TB: substance misusers and prison populations
- Recommendation 13 - Contact tracing
- Expert testimony 10 - managing a tuberculosis service in prison

Reasons for implementing your project

Providing healthcare within the prison setting is not without its challenges. Security is the first priority for a prison and prisons have a highly mobile population with prisoners going to and from court and being transferred between prisons. Pentonville has a population of over 1200 and this may mean up to a 100 prisoners or more going to and from court or other prisons on a daily basis. Remand prisoners may be released from court unexpectedly. Managing the link between prison and the community and ensuring continuity of care can be very challenging, for example prisoners who are homeless or who have no right to public funds may be released directly back onto the street. Discharge planning is essential; this means close liaison with the local TB service and may also involve the local authority, health authority and the voluntary sector.

All prisons should screen new prisoners for TB on arrival, where possible this includes an X-ray for TB. An initial screen takes place on the first night in custody to ensure that important or urgent medical, psychological and social issues are addressed and that the prisoner is safe for their first night in custody. This initial screening is followed by a more comprehensive healthcare assessment the next day. Five London prisons and three prisons outside London have digital X-ray machines. All new prisoners and prisoners transferred in from another prison should have a chest x-ray to screen for TB, although this initiative is yet to start.

I managed on average 18 cases of TB a year. Keeping track of prisoners is essential. Previous to my post some prisoners on TB treatment were released without the local TB service being informed and became lost to follow up straight away; also prisoners were being transferred to other prisons without proper planning or liaison with local TB services. Being on site meant I was able to monitor prisoner's movements very closely to ensure continuity of care and manage discharges, this is particularly important when a prisoner is released directly from court or released from the prison at very short notice. Prisoners on TB treatment or being screened for TB should be on 'medical hold'. Medical hold means the prisoner should return to the prison after court appearances rather than being sent to another prison and also any transfers to another prison can be done in a managed way.

How did you implement the project

The prison had a protocol for TB management which I reviewed and updated in collaboration with prison health and the local TB service.

It is very important to know if a prisoner is on remand, sentenced, have court or release dates. In my experience most prisoners knew their court dates. Release dates and court dates are important for planning care and ensuring continuity of care. Having access to NOMIS (the prison database) was very helpful as the database records all prisoner movements. I was able to access information on the database about movement between prisons as well as within the prison. I needed special permission to obtain this level of access; particularly helpful when trying to trace contacts of TB cases.

For patients transferring to other prisons, I transferred responsibility for the patient's care to the local TB service and to the receiving prison having first checked that the prison could provide Directly Observed Therapy (DOT). Part of the transfer plan should ensure that the receiving prison has a stock of the necessary TB medication and can care for the patient. Pentonville stock the common TB drugs, but smaller prison pharmacies have to order in medication. Once the transfer was arranged the prisoner was taken off medical hold. I would check that the transfer prison was expecting the patient and on prison transfer day, I checked that the patient was transferred and had arrived. This level of supervision is necessary as medical hold is not fail proof, there were occasions when a prisoner on TB treatment was suddenly transferred despite being on medical hold.

I ensured that questions about TB were included as part of the health screen when a prisoner arrives in the prison. This is now part of the electronic healthcare recording system (System1 in Pentonville). If there were any concerns on arrival then the prisoner was assessed by the doctor and if necessary isolated, a chest x-ray ordered and three sputum samples for AFB obtained, blood tests were also ordered.

Prison health must contact the local TB clinic for information if a prisoner arrives already on TB treatment. It is very important to obtain information on treatment regimens and adherence to treatment and for advice on the patient's management in order to ensure continuity of care and the safe and correct management of patients. Non English speaking people require interpreters which is expensive but necessary to obtain information.

Key findings

My role was monitored by offender health; we met regularly to discuss progress. It was not formally evaluated but it was my experience that the role of the TB nurse does not need to be an onsite role. In reach from the local TB service is sufficient. Detection and management of TB must be embedded in every day prison healthcare practice. The local TB service found my role useful since I formed a link between them and the prison. Being based in the prison as a nurse specialist was isolating. In reach from the local service is a better model.

Increased screening for TB raised the numbers of TB cases. Developing good relationships with the local TB service and the prison staff helped improve management of screening. For newly diagnosed pulmonary TB cases prison health, the local TB service and the Health Protection Unit should convene a meeting to discuss management and contact tracing. For patients being released continuity of care was planned in close liaison with the local TB service, this usually meant the prisoner going to the clinic the next day to continue with DOT.

Multi drug resistant TB required specialist care and isolation in a hospital negative pressure room which is sealed. The accompanying officers would sit outside the room having had a risk assessment for security purposes carried out by the prison security team. I delivered this role using paper records. The introduction of electronic records with alerts and instructions was very successful, for example using medical hold. The offender management unit and prison nurses noticed alerts and informed me if people were moving; this was very helpful. It is very important that local TB teams in reach into the prisons in their patch. Prisons are part of their community. Developing good links with the prison and obtaining security clearance will facilitate in reach.

Key learning points

The key points were:
- Raising awareness of TB in the prison.
- Developing good relationships with prison staff.
- Have a protocol for the management of TB in place that everyone is aware of and familiar with.
- Always have a care plan and importantly a discharge plan in place.
- Discharge planning can be challenging and time consuming but having the correct alerts and a plan that the patient is aware of will aide care and treatment.
- Good communication between the local TB services and prison healthcare is vital.
- Regular contact between local TB teams and prison healthcare will maintain good relationships.
- Keep track of patients effectively.
- Make sure transfers between prisons are managed closely.
- Review prison medication records regularly to ensure compliance.

Local TB nurses should visit the prison and review patients on treatment regularly. Prison nurses are good at providing DOT. Provide regular training sessions for staff even when case numbers are low. The prison healthcare admin staff are office based, you can access them easily, they know who is on duty, how to contact staff and can organise passes.

Local TB nurses should get security clearance, have a prison pass/prison ID card and be able to access keys so that visiting the prison is an easy and straight forward process.

Contact details

Susan Yates
TB Nurse
Royal Free Hospital

Is the example industry-sponsored in any way?