California Correctional Health Care Services
Alan Frueh MD
Bonnie Gieschen MD
Linda Maclachlan Pharm.D
Jane Robinson RN
Rebecca Yager RD
John Zweifler MD
Douglas Peterson MD
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.
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
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.
Existing policy poorly adapted to a mass hunger strike
which is likely 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
Strike rumors circulated in June 2011
CDCR Intelligence expected:
◦ 1000+ strike participants at Pelican Bay State Prison
◦ Unknown numbers at CSP Corcoran
CCHCS medical leadership recognized the
limitations of existing policy and the difficulties it
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
Initial plans
◦ Follow policy whenever possible
◦ Fallback to declaring Emergency and following
Emergency Incident Command System if
◦ First day 6553 participants
◦ 16 sites
◦ Maximum 9,079 participants
◦ Challenge was much greater than anticipated
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
Only 8 participants had weight loss > 15 lbs
Weight Lost
> 20 lbs lost
19.9-15 lbs lost
14.9-10 lbs lost
9.9-0 lbs lost
> 0 lbs gained
Grand Total
Note >7700 participants never had a weight done (refused)
Custody did not clear or restrict canteen during HS 1
 37 admissions out of 9079 participants
 1/3 of these appeared related to lack of intake
Most were “Persistent Hunger Strikers”
Primary Diagnosis
Muscle weakness (generalized)
Abdominal pain, unspecified site
Other disorder metabolism
Other disorder eating
Except for one patient inmate at PBSP, there
was no evidence of refeeding problems at 3 wks.
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
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.
◦ Mental Health Tracking System for MH patients.
Clinical assessments safely delayed until
participant has lost 5% body weight (except for high
risk persons)
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
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
◦ Patient education hand-outs
◦ Documentation of informed consent/effective communication
once weight loss documented.
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
Literature based clinical guidance useful for staff
◦ Role of vitamins/mineral supplements
◦ Assessment of risk/management of refeeding
 Share with ED doc’s 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
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
High numbers but:
◦ Resources focused more appropriately
◦ Improved organization and communication
◦ Less staff and leadership stress and fatigue
Weight loss: HS 1 vs HS 2
0-9.9 lbs
10-14.9 lbs 15-19.9 lbs
> 20 lbs
HS 1 10
HS 2 417
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
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…
1-3 days
4-7 days
8-14 days
Use up
Muscle protein
 metabolized
to glucose
Risk of
begins Day 10
Depletion of K+
Phos, Mg++
15-18 d
35-42 d
> 42 days
•sensation of
“oculo-motor “
Loss of > 30% body
wt life-threatening
•trouble swallowing
•extreme vertigo
• increased
• trouble
• somnolent state
• incoherent
• arrhythmias
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
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
Wide spectrum of biochemical abnormalities
and clinical consequences
Hypophosphatemia is the adopted surrogate
marker but not pathognomonic.
When a malnourished
person begins to eat:
Glucose enters blood
Insulin follows
Glucose takes K+, P,
Mg++ into the cells
Increased 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.
Clinical Manifestations:
◦ 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.
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
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
Negligible risk:
Fasting < 7-9 days, with BMI>18.5 kg/m2
Modest risk:
Any one of the following criteria:
High risk: (either)
a BMI > 16 but <18.5 kg/m2 or
loss of >10% body weight (but < 15%)
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)
Extreme risk:
a BMI <18.5 kg/m2
weight loss >10%
H/O ETOH, co-morbid/meds
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
Level of Risk
Management of Patient
Negligible risk:
Fasting < 7-9 days, with BMI>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
 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
 Daily multi-vitamin and trace element supplement.
Level of Risk
Management of Patient
High risk:
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
 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 (LFT’s 2x/wk)
Daily multi-vitamin and trace element supplement.
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
Level of Risk
Management 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
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 can’t 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 (LFT’s 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
Once po well established begin daily MVI & trace element
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For copies of Policy, Clinical Guidance and Decision Support

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