Design, Planning and Management of the Hospital Custody Unit at Hospital Universitario Fundación Alcorcón

Design, Planning and Management of the Hospital Custody Unit at Hospital Universitario Fundación Alcorcón

C de la Fuente-Martín, B de la Fuente-Martín, E Grifol-Clar

Hospital Universitario Fundación Alcorcón



Objective: The design and management of a Hospital Custody Unit at Hospital Universitario Fundación Alcorcón, to focus the aim of this study on specialized medical care for extra-penitentiary patients who have suffered from a disease. We are building a new space to facilitate their daily lives at hospital and we want to offer a double function to the patients that consists of a custody space and a health rehabilitation space.

Material and methods: We carried out a scientific literature search on the international and national databases, about Hospital Custody Units or Restricted Access Units. The language of the reviews that we checked was English and Spanish.

Results: We wrote the Action Guide of the Hospital Custody Unit for the design, planning and management of the Hospital Custody Unit at Hospital Universitario Fundación Alcorcón. (We included complementary bibliographic material and the Quick Guide in the Unit).

Discussion: The Hospital Custody Unit will be compatible with medical activity, occupational safety and the custody of patients that are in prison. We thus require consensus with police departments about custody protocols along with assistance from the clinicians’ teams at penitentiary centers and referral hospitals. Furthermore, it is important to step up special care for mental health and to promote telemedicine and new technologies to streamline medical care along with coordination with healthcare professionals.

Keywords: prisons; prisoners; custodial care; hospitalization; organization and administration; health law; nursing; health services.



1.1. Historical basis

In Spain, the current prison healthcare scenario differs greatly from that of past decades. Several factors such as the significant increase of the imprisoned population, substantial variations in its composition (greater presence of female, foreign and elderly inmates), as well as the emergence of new communicable diseases: AIDS, HIV and thus, the resurgence of conditions which had been long gone such as tuberculosis brought to light that prison healthcare was unable to meet inmates’ new needs and ensure efficiently their right to life, health and integrity. Therefore, the initial comprehensive model for the delivery of healthcare to inmates envisaged by Ley Orgánica General Penitenciaria y del Reglamento in 19811 is abandoned and a new mixed model is established: healthcare is directly provided by the Corrections Department, with its own means, or when not available, by external agreed entities and specialized care will be delivered by the National Health System2,3.

Moreover, the Secretary General executes cooperation agreements regarding hospital and specialized care in several autonomous communities.

The idea to create specific hospitals is therefore abandoned and public hospitals are expected to set up specialized spaces for the hospitalization and outpatient care of inmates owing to security reasons (articles 207 and 208 of Reglamento Penitenciario)4-6. These spaces are also known as Hospital Custody Units (HCU) or Restricted-Access units (RAU).

In 2013 in our country, forty-three HCU were operational. Currently in Madrid there are two hospitals which count upon HCU: Hospital Universitario 12 de Octubre and Hospital General Universitario Gregorio Marañón.

With the creation and implementation of a HCU in Hospital Universitario Fundación Alcorcón (HUFA), the rights of inmates as healthcare users and their access to healthcare resources are granted along with the quality of prison healthcare and equal access to care7.

Furthermore, to this purpose, the HCU is provided with the necessary human, material and financial resources. Appropriate relations are therefore established between individuals, institutions, the media and the procedures used for healthcare organization to improve planning and coordination.

Moreover, the achievement of both HUFA and HCU objectives and values is enhanced and the latter takes active part in incorporating the hospital’s quality plan.

The result of this paper is highly relevant for professionals in general and more specifically for both extra and intra-penitentiary healthcare professionals since it provides a practical and descriptive approach of the design, planning and organization of a HCU and therefore provides information to the scientific community for studying, sharing, teaching and discussing in terms of extra-penitentiary healthcare. The knowledge on the changes that the discipline has undergone, has allowed positioning this paper’s subject of study and purpose.

We aim to raise awareness among healthcare professionals on the advisability of HCU in enhancing equal and safe healthcare for patients under custody. It also enables continuous specialized and nursing care within the circuit of care between primary care and hospitals in the extra-penitentiary scope.

We expect that readers will integrate the knowledge acquired by means of this paper, in order to improve the quality of their professional activities.

Last, we would like to say that the development of this Project provides, from a narrative point of view, joint reflection by means of the touch with reality and sharing knowledge and experiences between those involved, who have observed the pros and cons of nursing practice in its many aspects (provision of healthcare, teaching, organization and management roles) for its continuing improvement.



General Objective:

— To plan and organize a HCU in HUFA to provide extra-penitentiary specialized and hospital care.

Specific objectives:

— To identify the main variables affecting its creation and functioning.

— To describe basic structural and service-related features

— To determine the type of activities and procedures.

— To describe the intervention of different parties involved in the planning and organization process.

— To provide appropriate material, human and financial resources

— To establish appropriate relations between professionals, material resources and the procedures used in healthcare organization for their coordination.

— To assess the development after one year.

— To manage quality systems.



Once the primary research question was posed, initial contact with concerned institutions was sought: HCUs in Madrid: Hospital Universitario 12 de Octubre and Hospital General Universitario Gregorio Marañón and Hospital Universitario Lucus Augusti in Lugo (Galicia). Furthermore, representatives from the Library of the Directorate General of Penal Institutions were contacted as well as those from the Library of Law of the Illustrious Bar Association of Madrid (ICAM in Spanish)8.

Exhaustive literature search in bibliographic databases such as PubMed-Medline, IME, Dialnet, Cuiden and MEDES were conducted on planning of Hospital Custody Units, under the following search strategy: hospitalization unit AND prisoners.

We first observed from the data obtained that the issue has been thoroughly assessed from the intrapenitentiary point of view whereas results regarding extra-penitentiary healthcare are scarce and/or of little relevance.

The issue is widely covered under 1996 Reglamento Penitenciario (Prison Regulations), title IX and other references are also found in the corresponding healthcare regulations, both nationally and internationally3,5,7,9-11. The major role of professional and specialized journals is highlighted, such as that of the Revista Española de Sanidad Penitenciaria RESP (Spanish Journal of Prison Health), several usefullinks from official institutions and other entities, as well as professional associations or unions, with comments, considerations, and publications based on the provision of healthcare and its specific features in both the intra and extra-penitentiary areas.

Zulaika13 shows the initial problem that País Vasco (the Basque Country) had to face with the new penitentiary care model and input for the continuous improvement of these units.

There are internal protocols on HCUs (Hospital Universitario Gregorio Marañón, Hospital Universitario Lucus Augusti in Lugo, Complejo Asistencial (Health Complex) in Palencia, etc.) which show some contribution to the study of extra-penitentiary healthcare partly focused on everyday contexts. However, the result of this paper is the creation and organization of a HCU regarding all its stages of development (see Table 1).

All of it highlights the need for more research, reports, studies, conferences or technical meetings on the influence and impact of these extra-penitentiary care units in hospitals, professionals, users, society and the development of healthcare quality as a whole.

It is necessary to approach this issue from a more updated and contextualized point of view, both technically and practically: by ensuring evolutionary longitudinal cross sectional and transcultural studies, with a series of specific methods and research designs, adapted to the nature of their study object and to their degree of development to move forward in the administration, management, functioning and assessment of these units.


The target population of this HCU is that deprived of liberty— those individuals under detention and/or hosted in the Penitentiaries of Aranjuez and Navalcarnero, both located in the Autonomous Community of Madrid— requiring specialized and hospital care.

In February 2014 there were 66706 people imprisoned in Spain. Moreover we should also consider those under alternative sentences13, which makes Spain the fourth European country with a higher imprisoned population14.

The vast majority were between 41 and 60 years old (33.5% of the population). 7.6% were female inmates. In fact, the imprisoned population of the Penitentiary of Madrid IV-Navalcarnero consisted of 1119 men and that of Madrid VI-Aranjuez consisted of 57 women and 1311 men15.



The HCU is a hospital unit for the admittance of inmates derived from prisons under police custody, with any type of medical or surgical conditions, whose care cannot be provided in the infirmary of the prison itself or by means of outpatient care. Furthermore, it is intended to ensure the active safety of the rest of admitted patients, users in general and healthcare professionals16-19.

Currently, HCUs are architectonically designed with perimeter security to ensure the creation of spaces that facilitate everyday activities in hospital and meet the double need of providing a space of custody and a space to promote the rehabilitation of health.

In HUFA, the HCU is located on the second floor of the Hospitalization Unit which depends of Control 1 (HC2-C1) within the Medical Hospitalization Unit (MHU). The HCU is separated from the MHU by a two door interlock system under custody of the National Police throughout the year. It is a protected unit whose access is restricted and whose equipment and surveillance protocols have been approved by the Directorate General of Penal Institutions.

The Unit has five double-bed rooms, one of which has been fully adapted for disabled patients and a maximum security single-bed room for those requiring isolation. It also has an electronically centralized police control area and a visiting room.

The Unit counts upon modern security systems such as several close-circuit television networks, armored doors and security barrier doors, anti-vandal materials, bars on windows, alarm sensors, etc. which allow the control of both inmates and visits therefore ensuring maximum security and independence from the rest of the hospital, as to avoid attempts to escape and avoid that patients under custody can access any material to attack healthcare providers or police officers, and to avoid self-injury18.

The Unit also counts upon healthcare resources and protocols, administrative procedures and clinical control systems for the provision of healthcare to inmates (see Table 1).

The HCU is made up of a multi-disciplinary team which is also included in the MHU (HC2C1). For its appropriate functioning it is essential that all the hospital’s personnel be involved.

The main roles of those working within the HCU are the same as those developing their activities in hospitalization units. They only assume the responsibility entailed by the provision of healthcare yet with the particularity that patients admitted to this Unit are deprived of liberty and have been convicted, due to which they need the surveillance and custody of the judiciary and law enforcement bodies, who assume this competence5,19.

Nursery Management creates the position of HCU nursing supervisor as a critical link between Management and the personnel in the Unit, to ensure the proper functioning of all human, material and technical resources to meet the health needs of inmates by ensuring quality nursing care through protocols and evidence-based procedures.

The budgetary provision for the creation of the HCU is established by the corresponding allocation of the General State Budget at the expense of the Penitentiary Administration of the Ministry of the Interior5,20.

This project is launched at the end of 2014, after the appropriate development stages and begins its activity in May 2016.



If the planning and organization of any hospitalization unit for its implementation and management is already a tough challenge, that of a HCU is even more due to the special features of both the service and patients themselves. Moreover it implies the coordination between different institutions, professionals from the penitentiary context, the police, healthcare providers, hospital staff and the interaction between different professional disciplines and technical, logistical, economical, job-related, judicial, ethical, moral, deontological, psychosocial and psychopathological factors.

Likewise, the search for information in this context and the study of a widely unknown scenario (and somewhat stigmatized), both regarding intra and extra-penitentiary healthcare allows for a different approach of this healthcare reality and thus of the provision of care, both from a professional and a personal point of view.

The UCH can be a most effective mechanism to increase the levels of coexistence, respect and harmony within the hospital organization, both for patients and healthcare providers and the society as a whole.

These units are considered supplementary to the rest of elements of the healthcare network of the Public Administration and a support element for Penal Institutions. They are included in a mixed model of comprehensive nature oriented towards the provision of healthcare, prevention, healing and rehabilitation. Their main objective should be envisaged as that of an instrument with the intention to rehabilitate both psychophysically and psychosocially inmates by taking into account themselves as individuals and their environment9.

In Spain, the right to health is a universal right which is never suspended and which cannot be limited nor restricted by imprisonment— whether under prevention detention or to serve a sentence. Therefore the health and welfare of inmates has always been an issue of special concern for the Penitentiary Administration2,19.

The Directorate General of Penal Institutions is in charge of ensuring the life, integrity and health of inmates according to Ley y Reglamento Penitenciarios (Prison Regulations and Law)10. Thus, the principles and criteria which allow to exercise the right to health are included in the corresponding General Health Law (Ley General de Sanidad)21 and related regulations.

When inmates need to be admitted to hospital, the Penitentiary Administration counts upon HCUs within public hospitals, which ensure appropriate care with full diagnostic and therapeutic resources for patients under custody.

The design and organization of HCUs has evolved throughout recent years due to improved concepts and the implementation of functionality principles which allows to adapt them to the objectives of specialized extra-penitentiary care of sick inmates and the custody of these patients, while ensuring the safety of providers and the rest of users22.

HCUs ensure the intimacy of patients under custody, the confidentiality of their healthcare procedure and the surveillance and custody needs by judicial and law enforcement bodies.

The need and relevance of the structure of these units with security measures is highlighted, yet a more vigilant attitude among healthcare professionals is observed, mainly due to the physical and functional features of these units.

The organization of the HCU has been envisaged from a modern model based on the responsible and effective design of clinical management, by adopting comprehensive management systems, as well as improved quality care and economical aspects. The need for effective teamwork and the development of professional and humanistic leadership which the role itself entails becomes more important in these units.

The HCU with the limitations derived from the regimen that regulates the situation of patients under custody and/or judicial sentences, takes part in the mission, vision and values of the organization that it belongs to. It has been essential to establish the healthcare, organizational and procedural regimen of the unit, with special emphasis on those relevant aspects for its operability and the development of quality technical-care activity.

Working in a HCU can entail several experiences. We must underline that the actions of healthcare providers must be holistic, from the establishment of a relationship with patients and the awareness on their specific profile to their clinical expertise and corresponding skillful execution by using different approaches to manage health and the use of evidence in everyday practice. We also need to highlight the need to reach agreement regarding protocols for continuing care between healthcare teams in prisons and those in the reference hospital, to enhance specialized care in mental health and telemedicine and new information technologies to streamline, facilitate and bring over healthcare to all users and effectively coordinate the work of professionals12.

Overall, it is the duty of healthcare providers to ensure swift efficient and satisfactory responses to the demands of patients by means of complementary and comprehensive systems which provide continuity to the provision of healthcare in prison, so that they are adapted to real needs without that meaning impaired guarantees and rights for patients under custody. This is how HCU, as productive units within hospitals, are responsible for the development of clinical management, meeting the health needs of a very specific population (patients under custody or imprisoned), with the corresponding human, physical, financial and technological means. These will be organized effectively and efficiently to ensure the best results regarding the provision of care to patients and to live up to the commitments agreed with the Hospital Management.



C. de la Fuente Martín
Hospital Universitario Fundación Alcorcón


To the Management of Hospital Universitario Fundación Alcorcón.

To the Nursing Management of Hospital Universitario Fundación Alcorcón.

To the Secretary General of Penal Institutions and the Penitentiary of Madrid IV-Navalcarnero.

To the Hospital Custody Units of Hospital Universitario 12 de Octubre in Madrid, Hospital Universitario Gregorio Marañón in Madrid and Hospital Lucus Augusti in Lugo.n




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