Managing COVID symptoms (including at the end of life) in a prison setting

Hanham Secure Health (HSH) works in partnership with Avon & Wiltshire Mental Health Partnership NHS Trust (AWP) to deliver a holistic healthcare service to offenders within the five prison establishments in Bristol, South Gloucestershire and Wiltshire. This service is commissioned by NHS England Health and Justice, in partnership with the Ministry of Justice and Her Majesty’s Prison and Probation Service. HSH delivers the physical healthcare aspect of this service, using a primary care model.

The aim of this work was to ensure rapid and effective triaging of COVID-19 positive patients residing in the secure prison estate, to support appropriate stratification to implement effective management plans. The work would also enable and support patients in receiving COVID-19 care and treatment - including end of life (Eol) care - within the prison establishment in the event of local hospitals reaching capacity and becoming overwhelmed. In turn, this would ensure that care within the prison estate during the COVID-19 pandemic could be dignified, responsive, safe and effective.

Key objectives:

• To adopt a Single Treatment Escalation Plan (STEP) across five local prison healthcare services
• To rapidly train, enable and empower healthcare staff in recognising/identifying the deterioration of patients with COVID-19 and rapidly providing the skills and competencies requiring to manage symptoms and support end of life care
• To implement and keep up-to-date guidance for COVID-19 palliative care prescribing-
• To ensure the availability and safe management of medication to treat symptoms at end of life in each of the five prisons
• To develop and deliver an ’End of Life Care’ training package to healthcare staff, in conjunction with the local hospice, applying guidance to practice in a prison environment
• To create an easy-read and accessible resource pack for healthcare staff working in the prison estate that incorporates guidance and information for managing and treating COVID-19, and for end-of-life prescribing associated with COVID-19.

Health inequalities within the prisoner population are significant; although the health and social care needs of older prisoners are not all the same. It is broadly recognised that many prisoners have the biological characteristics of those who are ten years older than their years; they may have chronic health and mental health disorders as well as disabilities which, in the community, would be typical among those who are significantly older (PHE, 2017). This puts them at greater risk of severe illness resulting from COVID-19.

With end-of-life care not routinely provided in prisons and recognition that most prisons lack the facilities to support dignified end of life care, the prison authorities and NHSE must often consider other options. Whilst one of our prisons does have a small palliative care unit, equipped to manage up to two patients at a time, this facility is only available by arrangement and requires support from the local district nursing team for symptom management, as well as a local hospital for expert advice and support.

When COVID-19 first hit in March 2020, there was widespread concern that a national outbreak could cause acute hospitals to become overwhelmed. Within prisons, there was further concern over the capacity to facilitate large sections of the prison population to be cared for within hospitals. It was essential to consider how care and management of people with acute needs could be managed within the prison, including end of life care. Providing this degree of care and support in a prison required a considerable amount of thought and planning. Initial challenges included gaps in clinical knowledge, lack of 24-hour healthcare service in 3 of the 5 prisons, equipment availability, safety, security and a restrictive prison regime.

It was recognised that this predicted change in care delivery would create substantial challenges for the prison healthcare team; therefore, key priorities were identified to address this:

• Triage
• Staff training
• Emotional support of staff
• Environmental, security and prison regime
• Clear escalation pathways

These needed to be addressed quickly, supportively and in conjunction with other stakeholders; HMPPS, NHSE, AWP, hospices, and Public Health England.

There was a system-wide approach to develop a STEP. This meant that we could dovetail our work within the prison to this and ensure that we were working to the same care escalation plan as our other healthcare colleagues. Therefore, if we did need to triage and manage people’s care in this way, our secondary care and paramedic colleagues would understand the decision making and assessment frameworks our team used.

We recognised a coordinated approach to the potential change in care delivery was needed and that provision of support/knowledge to prison teams was essential to enable resilience and confident management of EoL symptoms in the unconventional prison setting. We felt these could best be addressed by working with the hospice to deliver an online training package, inclusive of clear guidance on triage, treatment and escalation pathways.

We worked quickly and collaboratively to foster strong links with the hospice and on a training package that would support the team to understand key elements of triaging a person acutely unwell with COVID-19 and supporting decision making regarding local management and/or referral to secondary care.

An EoL care group was formed, comprising stakeholders from all sites, to collaboratively identify what needed to be done, understand the timeframes within which a uniform approach to the challenge was needed and deliver a consistent message to our very anxious team. We used internal project management to track tasks and ensure timescales were met.

Guidelines for management/treatment being clear, applicable and accessible to all were a priority. Advice was sought nationally, system wide and locally, to write a series of research-based documents informed by NG163 that were applicable and specific to prisons.

Appropriate just-in-case medication for the prisons was agreed and mapped against possible COVID-19 symptoms. Consideration was needed as to how symptom control would be managed without syringe drivers (due to shortage/not being readily available) and to how we might need to manage a patient’s deterioration if they had a history of substance misuse. Advice/support from the hospice was identified as a priority and reference to their 24hr support line was made.

Emotional/resilience support for staff was identified as a priority that would be needed for the duration of this difficult and unprecedented time. We operate under a primary care model; therefore, delivering EoL care is not within our usual skill set. EoL care within the prison estate is not planned for or delivered comparably to services within hospital/hospice settings. We therefore had to work with the local hospice's education team to be able to talk about holistic care and environmental comforts within the prison setting. We worked hard to ensure teams feel supported, providing/signposting to relevant wellbeing resources, having regular team debriefs, 1:1s and a counselling service.

The project was successful. The collaborative working with all stakeholders meant everyone understood and was committed to the aims. The support and expertise of the hospice was invaluable to support and educate the team. All registered clinicians participated in the training programme which was delivered in a train-the-trainer model, with team leaders and clinical nurse managers plus other nominated individuals attending the initial training. This was delivered by telephone conference call by the Head of Nursing and a trainer from the hospice. Feedback from the staff was that they felt more confident and able to see how they might be able to deliver EoL care in a prison environment. They had support and an escalation point should they need to speak to someone.

There was a system-wide approach to develop a STEP. This meant that we could dovetail our work within the prison to this and ensure that we were working to the same care escalation plan as our other healthcare colleagues. Therefore, if we did need to triage and manage people’s care in this way, our secondary care and paramedic colleagues would understand the decision making and assessment frameworks our team used.

Our collaborative EoL care group was able to distil the guidance and also identify areas which need to be addressed in order to be able to deliver EoL care in the prison and a time line to support delivery. Examples include identifying cells which were bigger and could hold equipment, ordering required consumables, ensuring the pharmacy had adequate stocks of appropriate medications for treatment of COVID-19 and for the symptoms of EoL and liaising with the prison to explain the requirements in order to deliver EoL care.

To date, (February 2021)  we have not needed to apply this project to practice, as the hospitals have not become over-full and we have managed to control the spread of the virus in the prison. The relationship with the hospice has developed further and they now support us to manage the symptoms of long COVID-19 and we are now looking at how we can facilitate prisoners attending support/education as to manage the symptoms of breathlessness.

Our COVID-19 documents have been shared nationally in the RCGP Secure Environments Group and are available on our local intranet site for staff to review. 

This project ran in a very short timeframe at the start of the pandemic, to prepare teams for a potential significant change in care. Microsoft (MS) Teams had not been introduced to the service and the telephone conference line in place was very rudimentary. Historically, the prison authorities have had very strict rules and policies around the use of digital technologies within the estate, for security reasons, which has held prison healthcare services back from advancing in these areas. A change in mindset was needed and, as a result of the pandemic, has very much taken effect.

We have now learnt a lot about MS Teams, how to use it to facilitate  online training and collaborating when working on documents especially when it is mandated that face-to-face meetings and cross site meetings cannot occur. There remains a challenge in that video cameras are not routinely used in the prison for security reasons, headsets are not provided to all staff, meaning at present the work-around for this is both logging in via the computer to see any documents but dialling in to speak.

Collaboration and joint working with all stakeholders have improved as we have worked together to manage the virus within the secure estate as well as opened up other ways of working such as remote secondary care consultations.

Uploading documents on relevant electronic platforms can facilitate exchange and information with teams who are working in a similar setting across the country for them to put into practice.

The key learning was that we needed to support our staff emotionally through this phase of learning and change in working. Resilience within the team needed to be supported due to: anxieties caused by the pandemic; recognition of physical ill health and; isolation requirements of the virus. By distilling information and delivering it in easy-to-follow documents, and having training to reference, the team felt better supported and had the knowledge to apply to practice, if required.