Healthy Skin Volume 10 Issue 1 by Medline Industries

VOLUME 10, ISSUE 1

Improving Quality of Care Based on CMS Guidelines

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HEALTHY SKIN

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Volume 10, Issue 1

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Collaboration 2012

You, our readers, are on the front lines of everything that happens in the healthcare industry – and we want to hear from you! Have you ever wished you could write an article that would be published in a large-circulation magazine? Now’s your chance. Healthy Skin is looking for writers and contributors. Whether you’d like to try your hand at writing or offer suggestions for future articles, we want to hear what you have to say! You never know – the next time you open an issue of Healthy Skin, it might be to read your own article!

Content Key We’ve coded the articles and information in this magazine to indicate which national quality initiatives they pertain to. Throughout the publication, when you see these icons you’ll know immediately that the subject matter on that page relates to one or more of the following national initiatives: • QIO – Utilization and Quality Control Peer Review Organization • Advancing Excellence in America’s Nursing Homes

We’ve tried to include content that clarifies the initiatives or gives you ideas and tools for implementing their recommendations. For a summary of each of the above initiatives, see Pages 6 and 7.

JOIN THE TEAM!

Healthy Skin

When it comes to hot topics in long-term care, you’re the experts! Date:

a. Document attempted alternatives and outcomes. b. Document rationale for use. *Identify reasons for selecting device. Base use on risks/benefits for resident. c. Document how you manage causes of falling, problematic behavior, or another condition for which a device is used OR explain why causes could not or should not be managed. d. Use device correctly: Apply it correctly, release it at right time, provide for exercise. Consider risk factors and how to minimize. e. Identify goal for device use, including least restrictive and reduction (i.e., correction of underlying causes). *Be specific! e.g. “Seat belt for positioning” is inadequate. Include cause of positioning problem.

STEP 6: care Plan - Treatment and Management

falling, problematic behavior, or other problem for using a device. b. Did practitioner help identify specific medical symptoms to use restraint? c. If the resident was not evaluated for the medical symptom(s) prior to using restraint, document why. d. For any device that is a restraint, obtain practitioner’s order. Orders must reflect presence of medical symptom; however, the order alone is not sufficient to warrant use. *If Resident/Family/Responsible party requests device and if not required to treat a medical symptom, the facility must evaluate reason for request and impact on resident. Facility may not use if violates the regulation based on legal surrogate / representative’s request /approval.

STEP 5: Diagnosis and identify cause a. Identify likely causes (medication side effects or environmental factors) of

MO-09-02-REST March 2009 This material was prepared by Primaris, the Medicare Quality Improvement Organization for Missouri, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services, and adapted from LHCR. The contents presented do not necessarily reflect CMS policy.

Page 4 of 4

Resident Name/Room Number:

a. Monitor impact of device on resident and problems or risks for which it was used. b. Monitor for complications related to device and stop or adjust use. c. Explain why continued use was needed despite complications. d. Maintain ongoing monitoring for safety hazard, stop use immediately and reassess if hazard detected. e. Periodically (at least quarterly) reassess the resident for continued need for device and document in care plan.

STEP 7: Monitoring

a. Document a detailed history of the symptom for using a device. CMS states that “falls do NOT constitute self-injurious behavior or a medical symptom that warrants the use of a restraint.” (S&CLetter-07-22: Restraint Clarification, June 2007) b. I.D triggers for restraint use from MDS. c. Notify practitioner about symptoms requiring device. d. I.D if problem is chronic/irreversible or acute /reversible. e. Attempt alternatives to manage the problem. Communicate risk/benefits to resident and family. f. Document ability to purposefully remove device and perform activity of choosing.

STEP 4: Assessment and Problem Recognition

Now that you’ve determined whether the device is a restraint, enabler and/or safety hazard, proceed to STEP 4 of the planning process. The use of any device requires a care plan. The following information should be included in the resident’s individual care plan.

Device care Planning Process

Device Decision Guide Forms & Tools

Improving Quality of Care Based on CMS Guidelines 95

Healthy Skin Improving Quality of Care Based on CMS Guidelines

Editor Sue MacInnes, RD Clinical Editor Margaret Falconio-West, BSN, RN, APN/CNS, CWOCN, DAPWCA Senior Writer Carla Esser Lake Creative Director Michael A. Gotti

Survey Readiness

24 Pressure Ulcer Rates: Prevalence and Incidence 36 Butterflies in the Nursing Home 42 Embracing Change: Promoting a Continence Management Program in Your Facility

Page 36

Prevention

48 Challenges of Preventing Moisture Associated Skin Damage in the Intensive Care Units Using No Sting Spray Skin Protectant 62 Automated Hand Hygiene Compliance Monitoring Systems

Clinical Team Dionie Bibat, BSN, RN, WOCN

Special Features

Clay Collins, BSN, RN, CWOCN, CFCN, CWS, DAPWCA

Lorri Downs, BSN, RN, MS, CIC Joyce Norman, BSN, RN, CWOCN, DAPWCA Kim Kehoe, BSN, RN, CWOCN, DAPWCA Elizabeth O’Connell-Gifford, BSN, MBA, RN, CWOCN, DAPWCA Jackie Todd, RN, CWCN, DAPWCA

9 Maintaining Quality Care During Challenging Times

14 2012 Prevention Above All Discoveries Grant Program

Page 42

15 2011 Prevention Above All Discoveries Grant Recipients 17 Identification of Staff RN’s Ability to Assess Community-Acquired Pressure Ulcers Among Ethnically Diverse Patients 27 Pressure Ulcer Prevalence Day 32 Impact of Pressure Ulcers Across Care Settings 51 The Bathing of Older Adults with Dementia 72 New QA System Improves Resident Quality Care; Builds Staff Morale

Wound Care Advisory Board

83 Congratulations, Lexington Medical Center: First Place Winner Pink

Christine Baker, MSN, RN, CWOCN, APN

Glove Dance Competition

Page 51

Katherine A. Beam, DNP, RN, ACNS-BC Patricia Rae Brooks, MSN, RN, ANP, CWOCN

Regular Features

Amparo Cano, MSN, CWON

Jill Cox, PhD, RN, APN-C, CWOCN

68 Hotline Hot Topic: Addressing Resistance to New Types of Wound

Sue Creehan, RN, CWOCN Donna Crossland, MSN, RN, CWOCN Barbara Delmore, PHD, RN, CWCN, AAPWCA Karen Keaney Gluckman, MSN, FNP-BC, APN, CWOCN Anita Prinz, RN, MSN, CWOCN, CFNC, COS-C Mary Ransbury, RN, BSN, PHN, CWON Denise Robinson, MPH, RN, CHWOCN Diane Whitworth, RN, CWOCN

6 Two Important Quality Initiatives for Improving Quality of Care

Dressings for Skin Tears Caring for Yourself

76 Fear: How to Kill It Dead!

Page 62

86 Healthy Eating: Roasted Winter Vegetables Forms & Tools

89 Cover Your Cough 90 Supporting Your Employees’ Physical Activity Goals 91 Safe Disposal of Needles and Other Sharps 92 Device Decision Guide Page 76

About Medline Medline, headquartered in Mundelein, IL, manufactures and distributes more than 100,000 products to hospitals, extended care facilities, surgery centers, home care dealers and agencies and other markets. Medline has more than 800 dedicated sales representatives nationwide to support its broad product line and cost management services. ©2012 Medline Industries, Inc. Healthy Skin is published by Medline Industries, Inc. One Medline Place, Mundelein, IL 60060. 1-800-MEDLINE.

Improving Quality of Care Based on CMS Guidelines 3

Healthy Skin Letter from the Editor

t’s 2012 and things are changing rapidly in health care. No longer can different care settings maintain their own personal individuality. It’s time for all of us to push for collaboration, teamwork and communication to include all providers of care…the hospital, the skilled nursing facility, the homecare setting and the physician’s office. Basically anywhere the patient goes for health care needs to be a part of a cooperative system operating with one voice… guiding the patient between settings, communicating necessary data, following up amongst each other as professionals and sharing our successes so that everyone benefits. The “patient” has always been the focus. However, today, the patient is an even more integral part of the culture of health care than ever before. Why? Because our potential patients have higher expectations, their families have higher expectations and each of them wants to participate in both decision making and the care they will receive. The “patient experience” has taken on new meaning. It is no longer about “satisfaction.” A satisfied patient feels that his or her care is average. Average does not make patients raving fans of your institutions. Today consumers want an “experience” that is memorable, an experience they would like to share with a friend. Good is no longer good enough. And it’s no wonder, because we, as consumers, are paying a lot for health care and expect to get what we are paying for. We do not expect to pay a lot to be the unfortunate recipient of medical errors, infections or complications. So as we move closer to a healthcare model where we all must work together, it’s time we started learning about each other. This edition has a lot of information and insight on just one leg of the healthcare continuum: skilled nursing care. Skilled nursing care is an important part of the continuum of care. If you work in an acute care setting, you need to understand your partners outside of the hospital. Skilled nursing care today includes patient-centered care, participation of families and resi-

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dents and choices involving dignity and an environment you would want for your own mother or father. Hopefully this edition of Healthy Skin will begin to bridge the gap between all of us as we focus on some of the key issues in long-term care, i.e. bathing with dignity, the long term care survey process, the changing culture and importance of establishing a robust continence care program. These are but a few of the topics discussed in this edition. It is an exciting time, a time to learn and share with each other. If you work in the acute care setting, use this opportunity to see how you can reach out to your longterm care and home care affiliates. If you are a long-term care or home care professional, begin with creating relationships in the hospital setting. You can only learn from each other. And, those educational experiences will begin to bridge the gap, ultimately building a transparent process regardless of who is providing the health care. Thanks for listening, and I welcome your comments.

Sue MacInnes, RD Editor

895 facilities have joined the program. Are you one of them? Get results with

Medline’s Pressure Ulcer Prevention Program • Average reduction in facility-acquired pressure ulcers: 67.8% • Average annual savings: $153,000

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VIEW A PRESSURE ULCER PREVENTION PROGRAM SUCCESS STORY

Two Important National Initiatives for Improving Quality of Care Achieving better outcomes starts with an understanding of current quality of care initiatives. Here’s what you need to know about national projects and policies that are driving changes in nursing home and home health care.

QIO Utilization and Quality Control Peer Review Organization 10th Round Statement of Work

Origin:

The QIO Statement of Work is based upon Part B of the Title XI of the Social Security Act. The Medicare-funded “10th Scope of Work” plan became effective August 1, 2011 and will remain in effect through July 31, 2014.

Purpose:

To carry out statutorily mandated review activities, such as: • Reviewing the quality of care provided to beneficiaries; • Reviewing beneficiary appeals of certain provider notices; • Reviewing potential anti-dumping cases; and • Implementing quality improvement activities as a result of case review activities.

Of note: QIOs are required to help Medicare promote Four Aims: 1. Beneficiary and family-centered care 2. Improve individual patient care - Reduce healthcare-associated infections - Reduce healthcare-acquired conditions by 40% in nursing homes - Reduce adverse drug events and medication harm 3. Integrate care for populations and communities - Improve quality of care for Medicare patients through a comprehensive community effort designed to reduce readmissions following hospitalization by 20% over three years 4. Improve health for populations and communities - The QIO shall improve participation in the Physician Quality Reporting System (PQRS) and improve the use of EHR for care management Under the direction of the Centers for Medicare and Medicaid Services (CMS), the QIO Program consists of a national network of 53 QIOs located in each of the 50 U.S. states, the District of Columbia, Puerto Rico and the Virgin Islands.

Advancing Excellence in America’s Nursing Homes

Origin: Purpose: Goal:

A coalition-based campaign initiated on September 26, 2006 to improve quality of life for nursing home residents and staff. A coalition consisting of the Centers for Medicare & Medicaid Services (CMS), organizations representing providers, consumers and government that developed a grassroots campaign to build on and complement the work of existing quality initiatives including Nursing Home Quality Initiative (NHQI), Quality First and the culture change movement. To ensure that continuous quality improvement is comprehensive, sustainable and consumer-focused, the coalition has adopted goals that seek to improve clinical care, incorporate nursing home resident and family satisfaction surveys into continuing quality improvements and increase staff retention to allow for better, more consistent care for nursing home residents.

Participating providers will commit to focusing on at least three of the eight measurable goals, including at least one clinical goal and one operational process goal. Current participants may choose to continue with the same goals, add additional goals or change goals for the next two-year campaign.

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10th Statement of Work (SOW) Three Key HHS Activities Shape the 10th Statement of Work: • National Quality Strategy • Partnership for Patients • HHS Action Plan to Prevent Healthcare-Associated Infections

Partnership for Patients Two Goals: 1. Keep patients from getting injured or sicker. By the end of 2013, preventable hospital-acquired conditions would decrease by 40% compared to 2010. 2. Help patients heal without complication. By the end of 2013, preventable complications during a transition from one care setting to another would be decreased so that all hospital readmissions would be reduced by 20% compared to 2010.

National Quality Strategy Three Broad Aims: 1. Better health care 2. Better health for people and communities 3. Lower costs through improvement

HHS Action Plan to Prevent Healthcare-Associated Infections Two Tiers: 1. Focus on six high-priority HAI-related areas within the acute care hospital setting: • Surgical site infections • Central line-associated bloodstream infections • Ventilator-associated pneumonia • Catheter-associated urinary tract infections • Clostridium difficile • Methicillin-resistant Staphylococcus aureus (MRSA)

Six Priorities: 1. Making care safer 2. Promoting effective coordination of care 3. Assuring care is person- and family-centered 4. Promoting the best possible prevention and treatment of the leading causes of mortality, starting with cardiovascular disease 5. Helping communities support better health 6. Making care more affordable for individuals, families, employers and governments by reducing costs of care through continual improvement

2. Expand efforts outside of the acute care setting into outpatient facilities, including strategies to reduce HAIs in ambulatory surgical centers and end-stage renal disease facilities, as well as a strategy to increase influenza vaccination coverage among healthcare personnel

Advancing Excellence Phase 2 Goals Goal 1 – Staff Turnover: Nursing homes will take steps to minimize staff turnover in order to maintain a stable workforce to care for residents.

Goal 5B: Short Stay (shorter than 90 days) People who come from a hospital to a nursing home for a short stay will receive appropriate care to prevent and minimize episodes of moderate or severe pain.

Goal 2 – Consistent Assignment: Being regularly cared for by the same caregiver is essential to quality of care and quality of life. To maximize quality, as well as resident and staff relationships, the majority of Nursing Homes will employ “consistent assignment” of CNAs.

Goal 6 – Advance Care Planning: Following admission and prior to completing or updating the plan of care, all NH residents will have the opportunity to discuss their goals for care including their preferences for advance care planning with an appropriate member of the healthcare team. Those preferences should be recorded in their medical record and used in the development of their plan of care.

Goal 3 – Restraints: Nursing home residents are independent to the best of their ability and rarely experience daily physical restraints. Goal 4 – Pressure Ulcers: Nursing home residents receive appropriate care to prevent and appropriately treat pressure ulcers when they develop. Goal 5 – Pain: Nursing home residents will receive appropriate care to prevent and minimize episodes of moderate or severe pain. Objectives for long stay and short stay are slightly different. Goal 5A: Long Stay (longer than 90 days) nursing home residents will receive appropriate care to prevent and minimize episodes of moderate or severe pain.

Goal 7 – Resident/Family Satisfaction: Almost all Nursing Homes will assess resident and family experience of care and incorporate this information into their quality improvement activities. Goal 8 – Staff Satisfaction: Almost all nursing homes will assess staff satisfaction with their work environment at least annually and upon separation and incorporate this information into their quality improvement activities. Participating nursing homes: 7,894 Percentage of participating nursing homes:* 50.4% Participating consumers: 3,138 *Based on the latest available count of Medicare/Medicaid nursing homes

Visit this Web site to view progress by state! www.nhqualitycampaign.org/star_index.aspx?controls=states_map

Improving Quality of Care Based on CMS Guidelines 7

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Special Feature

Maintaining Quality Care During Challenging Times Reducing costs while simultaneously improving care delivery is perhaps the central challenge for healthcare leaders today. American Health Care Association (AHCA) ABM Committee President and AHCA board member Shawn Scott, who works with the long-term care sector in his position with Medline, recently had the opportunity to speak with AHCA President and CEO Mark Parkinson, and AHCA Quality Officer David Gifford. You will find they share the same desire for collaboration across the continuum of care as leaders in other healthcare fields, such as acute care and home care.

“

In a time when there are budget cuts and budgets are tight, it’s really tempting to pull back on quality initiatives and quality measures, but we really need to do just the opposite. We have to continue to put quality at the forefront of everything we do because if we don’t, we’re not going to do well. If we do, the profession will thrive for a long time.” Mark Parkinson, AHCA president and CEO, 45th Governor of the State of Kansas

Shawn Scott: We’ve all heard about the Super Committee and how Congress couldn’t agree on a plan to reduce the deficit. We know that sequestration triggered an automatic 2% cut to Medicare providers. What can you tell us about how AHCA views these cuts and their impact on the longterm and post-acute care sector? Mark Parkinson: The LTC sector has taken a significant number of cuts. They started out with the automatic cuts we received with the passage of the Affordable Care Act. Every year we now take a productivity adjustment that lowers our rates a little over 1%. Those were followed by cutbacks in states to Medicaid programs. Over 30 states have either frozen or reduced Medicaid rates. Most recently, Congress has put another 2% cut on us with sequestration.

SS: How do you think facility members will be affected by these cuts? MP: Each of the cuts has hurt, and when you add them up, they are an enormous problem. Collectively, these cuts have put the sector on the brink. Facilities that take care of the poorest members of the greatest generation, and therefore rely on Medicaid, are at risk of losing money. The combination of the cuts that we have already taken is taking its toll, and we’re at a point where we just can’t take any more cuts. So that’s been our clear message here on Capitol Hill, and it will continue to be our message.

Improving Quality of Care Based on CMS Guidelines 9

“

The combination of the cuts that we have already taken is taking its toll, and we’re at a point where we just can’t take any more cuts.”

SS: Knowing that skilled nursing facilities will still be held to high quality standards by CMS despite the reimbursement cuts, what can AHCA’s membership do to continue to meet these standards? MP: First, I am very proud that our members have been committed to making sure not to cut frontline nursing staff. They have gone out of their way to do everything they can to reduce the impact of the cuts on our residents. Instead, they’ve had to get creative and reduce costs in other areas, but they’re at a point where there just aren’t any more areas to cut. Over 50% of costs are in labor. If there are additional cuts, the consequence will be layoffs. ur members are implementing technologies into their O operations. The overall economy has seen a tremendous increase in productivity as we’ve integrated more technological advances into everyday business operations. Healthcare has been slow to do that. But our members are realizing that they need to speed that process along. So, you see more of them implementing electronic medical records (EMRs) and other systems to reduce costs and improve efficiencies. SS: What suggestions would you give to companies such as Medline on how they might help skilled nursing facilities with today’s challenges? MP: Our vendors have been very supportive of our membership during this difficult time, and we greatly appreciate the support. I tell our vendors that our members need products that both reduce our costs and improve quality.

A good example is a product Medline’s very involved with – abaqis. A lot of nursing homes have had a really difficult time transitioning to the QIS survey. They’ve had to spend an inordinate amount of time adjusting to the survey, reacting to bad surveys, and in some cases, even having to pay civil monetary fines because of bad surveys. The abaqis product has come in and helped people understand how to get through the survey process in a more seamless way, reducing deficiencies and increasing their overall operational ability. I think that’s one reason why the abaqis product has done so well. dditional helpful products are those that allow nurses to walk A around the floors and instantly pull up records and record exactly what’s happening with the residents. This is another way efficiencies have increased. SS: This is the time of year when people are making New Year’s resolutions. What would you say are AHCA’s resolutions for 2012? MP: Our resolution must be to continue our quality efforts. It is essential that we continue our quality improvement because it’s the right thing to do. It’s the reason most of our members got into this profession in the first place. It’s also critical because as payment models change, if we don’t continue along this quality journey, the nursing home sector is going to get left out. In a time when there are budget cuts and budgets are tight, it’s really tempting to pull back on quality initiatives and quality measures, but we really need to do just the opposite. We have to continue to put quality at the forefront of everything we do because if we don’t, we’re not going to do well. If we do, the profession will thrive for a long time. Continued on page 12

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“

The skilled nursing facility of the future will be much more integrated into the healthcare delivery system with better relationships with the hospitals, emergency departments, physicians and home health agencies” David R. Gifford, AHCA Senior VP of Quality and Regulatory Affairs, former Director, Rhode Island Department of Health

Shawn Scott: The Affordable Care Act requires all skilled nursing facilities to develop Quality Assurance and Performance Improvement (QAPI) programs. Can you explain what skilled nursing facilities need to do to develop these programs? David Gifford: CMS is still working on the requirements for these programs, but basically the objective is to move toward a proactive improvement approach. Rather than waiting until something bad happens, facilities need to devise strategies in advance. The programs should focus on more proactive improvements that allow staff to be more engaged in the process. SS: We understand that you are an expert in the field of quality, and you have been tasked by AHCA to develop new programs to help association members provide highquality, person-centered care. Can you tell us a little about AHCA’s quality objectives for 2012? DG: I am very excited to be a part of AHCA. In the past the industry has approached quality improvement using a “disease of the month approach.” But we have found that there’s no spillover effect to other areas with that approach. It’s also difficult to sustain gains. Now, we are focusing on four broad areas of quality improvement for 2012: preventing re-hospitalization, increasing staff stability, improving customer satisfaction and better management and prevention of behavior problems among individuals with dementia. e see these four strategies fitting together, and I think they all W complement each other. We are very excited that we will see changes not only in these specific areas but positive changes across the board.

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SS: How does rehospitalization affect skilled nursing facilities and why should they be concerned about this issue? DG: A lot of individuals come back from the hospital in worse condition than when they left the skilled nursing facility. They often return with pressure ulcers, HAIs, or are generally more debilitated. Sending an individual to the hospital is not always in their best interest. Actually, some data suggest that pneumonia (a leading cause for hospitalization) can be managed with the same outcomes by keeping the individual in the nursing facility rather than sending them to the hospital. Also, rehospitalization is a marker that people are declining and nearing the end of life. We need to have a better dialogue about end-of-life decisions regarding these individuals. Lastly, it’s really costly to have someone go back to the hospital, and hospitalizations in general are the major driver of healthcare costs in this country. The high costs of hospital care are making all of healthcare unsustainable. When we know you can manage someone just as effectively and it saves money, it’s a win-win situation and so that’s one of the reasons we think it’s very important. And if hospitalizations are not lowered, Medicare and payers are starting to cut payments until we do a better job. SS: What are your thoughts on staffing stability and why is this issue so important in the skilled nursing and postacute care sector? DG: In fact, data suggest that in skilled nursing facilities staff retention is more highly associated with better quality measures than nurse-patient ratios. Data is also pretty strong that stable, consistent staffing helps prevent a lot of different problems across a whole array of diseases and conditions. Low turnover makes it easier to sustain programs. And when staff

get to know residents and families, they are much more likely to notice problems early and get them treated before they lead to hospitalization or behavior problems. Also, it’s very costly to hire new staff in recruiting time, training, and overtime or outsourcing to cover empty positions. SS: How is quality going to be measured through customer satisfaction? DG: The only way to measure customer satisfaction is to ask the customer how satisfied they are. The two most important questions are: 1. How satisfied are you with the care you are receiving overall? 2. Would you recommend this facility to someone else? Those are the two most critical questions in pretty much every satisfaction survey instrument I’ve seen. SS: Why is it so important to manage behavior issues in individuals with dementia? DG: A big component is that behavior issues often lead to prescribing a lot of different medications, which have adverse effects on individuals. Maintaining consistent staffing and understanding individuals and their preferences for waking, sleeping, and dining all really help prevent individuals with dementia from developing chronic behavior problems that are harmful to staff and other residents. Managing the behaviors in this way also helps prevent over-prescribing of medications.

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SS: Everyone is very excited to have you on board with AHCA leading the drive for quality. What do you envision a skilled nursing facility of the future will look like? DG: I’m really excited to be a part of AHCA. They have a long history of being committed to quality. Joining their team and being able to deal with the issues facing our members and nursing facilities as a whole – it’s just an exciting time. The skilled nursing facility of the future will be much more integrated into the healthcare delivery system with better relationships with hospitals, emergency departments, physicians and home health agencies, and will be providing a much wider range of services. Right now, nursing facilities mainly provide either skilled care after being hospitalized or long-term care for individuals who can’t go home. In the future, I believe they will be utilizing adult day care activities and visiting therapy services. I see a redesign that is less institutional and much more homelike, where the staff and residents are working more closely together on making sure that each resident can access the activities they want in terms of dressing, bathing, dining, waking and sleeping. The general perception of years past of nursing home residents just playing bingo and doing arts and crafts has already changed, but I really expect them to change even more in the near future. 

2012 Prevention Above All Discoveries Grant Program Supporting the adoption of solutions and interventions into everyday practice

In today’s healthcare environment, healthcare-acquired conditions, once considered a “side effect,” are no longer accepted. The government does not accept them, patients are not accepting them and the facilities themselves continually look for ways to build better systems to improve the quality of care. Knowing that clinicians in the field have some of the best ideas for improving care, Medline launched the Prevention Above All Discoveries Grant Program in 2008 as a way to help stimulate the gathering of solid evidence that supports the adoption of solutions into clinical practice. Through this innovative program, Medline has awarded more than $1.1 million in funding to front-line healthcare workers researching evidence-based solutions and interventions for the very conditions that CMS has declared as preventable. Medline is accepting letters of intent from May 1 through June 30, 2012 for the 2012 Prevention Above All Discoveries Grant program and intends to award up to $1 million in grants for research on innovative ideas and evidence-based practices that will improve patient safety and quality of care. Healthcare providers interested in submitting letters of intent can apply for one of two funding categories: Pilot Grants of up to $25,000 for projects that can be completed within six months; or Empirical Study Grants of up to $100,000 for projects completed within 12 months. How to apply for a grant More information about the grant program, as well as a sample letter of intent, can be found at www.medline.com/ prevention-above-all/grants.asp. To submit a grant letter of intent, contact Toni Marchinski, grant coordinator, at grantprogram@medline.com or call 866-941-1998.

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“Historically, these research projects are great ideas that could significantly help in the fight against some of the toughest hospital-acquired conditions,” said Andrew Kramer, MD, Head of the Department of Medicine’s Health Care Policy and Research Division at the University of Colorado and Grant Review Committee Chair. “What’s unique about this funding is that it is all going to providers who are on the front lines of health care. The feedback this group gives us is critical to advancing healthcare technology.”

2011 Prevention Above All Discoveries Grant Recipients Title:

CAUTI Prevention Program

Institution:

Piedmont Healthcare Philanthropy, North Carolina

Principal Investigator:

Monica Tennant & Dee Tucker

Title:

Incidence of Falls Among Oncology Patients Who Are Cared for by Family Caregivers within Their Home.

Institution:

Siteman Cancer Center at Barnes Jewish Hospital, Missouri

Principal Investigator:

Patricia Potter, RN, PhD, FAAN; Marilee Kuhrik RN, PhD; Nancy Kuhrik RN, PhD, Sarah Olsen RN, BSN.

Title:

Quick Room Turnaround Time (QRTAT) Ultraviolet Light Disinfection for Decreasing HAI

Institution:

Ohio State University Hospital, Ohio

Principal Investigator:

Christina Liscynesky, MD & Julie E. Mangino, MD

Title:

Warfarin Safety Pilot Program

Institution:

Foundation for Quality Care, New York

Principal Investigator:

Nancy Merlino Leveille, RN, MS & Darren M. Triller, Pharm.D.

Title:

Sensor Technology for Tracking and Displaying Bed Elevation Data for Mechanically Ventilated Patients

Institution:

University of Iowa Hospital, Iowa

Principal Investigator:

Alberto Maria Segre, Philip Polgreen, Geb Thomas, Ted Herman

Title:

Testing Patient Education Handbooks

Institution:

Good Samaritan Hospital, Pennsylvania

Principal Investigator:

Patricia Donley, RN, MSN, Stephanie Andreozzi, Doctorate in Physical Therapy

Title:

Using GRASP as Home Treatment for Upper Extremity (UE) Paresis Post-Stroke

Institution:

Abbotsford Regional Hospital, Canada

Principal Investigator:

May Chan, B.OT, Janice Eng, Ph.D. PT, OT, Shu-Hyun Jang, M.Sc.OT A Standardized Process of Preoperative Body Cleansing with Comfort Bath速 Cleansing Washcloths

Title:

Compared to Sage速 2% Chlorhexidine Gluconate (CHG) Cloths to Reduce Prosthetic Joint Infections at Cambridge Hospital

Institution:

Cambridge Health Alliance, Harvard Medical Center, Massachusetts

Principal Investigator:

Lou Ann Bruno-Murtha, DO, Virginia Caples, RN, CIC and Diane Lancaster, RN, PhD

Title:

Falls Risk Assessment Study

Institution:

Provena St. Joseph Medical Center, Illinois

Principal Investigator:

Jackie Medland RN, PhD

Title:

The Effectiveness of Team Training on Fall Reduction

Institution:

Wellstar Health System, Georgia

Principal Investigator:

Bethany Robertson, LeeAnna Spiva & Marcia Delk, MD

Improving Quality of Care Based on CMS Guidelines 15

OPTILOCK™

Super Absorbent Wound Dressing

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Special Feature

CE ARTICLE

Identification of Staff RNâ&#x20AC;&#x2122;s Ability to Assess Community-Acquired Pressure Ulcers Among Ethnically Diverse Patients: Hispanics and African Americans Utilizing Simulation Katherine Ricossa, MS, RN Principal Investigator, Director of Education Kaiser Permanente - San Jose, California Email: Kathy.Ricossa@kp.org

Research Study Funded by Medline Industries, Inc. Prevention Above All Discoveries Grant

Abstract: 1. Purpose, aims, hypotheses or research questions Are RNs able to identify community-acquired pressure ulcers among ethnically diverse patient populations: Hispanics and African-Americans utilizing simulation? 2. Background and significance Regulatory agencies such as the Department of Health and Human Services are required to be notified when a patient exhibits a Stage III pressure ulcer. If a nurse does not identify a community-acquired pressure ulcer upon admission, then it will be considered a hospital-acquired pressure ulcer, and the hospital will have to manage and treat this pressure ulcer as if it occurred in the hospital. It is in the best interest of hospitals to train RN staff to completely assess skin integrity to prevent a community-acquired pressure ulcer from turning into a hospital-acquired pressure ulcer for the health of the patient and subsequently reduce financial cost burden to the hospital. There are few research studies on ethnically diverse patients with pressure ulcers. Upon reviewing the few articles that focus on pressure ulcers and ethnically diverse patients, most of those articles focus on prevention by using the Braden Scale as a risk indicator. There are no articles that discuss actual identification or lack of pressure ulcer detection on ethnically diverse patient populations. 3. Methods (design, sample characteristics, measures or instruments, procedures for data collection and data analysis) Prior to implementing the study, a pilot group tested the methods which were used, and changes were made accordingly. A randomized, controlled, crossover trial was conducted with a convenience sample of 72 staff RNs from Patient Care Services (Maternal Child, Med /Surg, Telemetry, Stepdown, ICU and ED). Admission assessments were performed on simulated patients with dark pigmented skin and bony prominences while examining under medical assistive devices. Study subjects were randomly assigned to either the control or

Improving Quality of Care Based on CMS Guidelines 17

CE ARTICLE

Identification of Staff RNâ&#x20AC;&#x2122;s Ability to Assess Community-Acquired Pressure Ulcers Among Ethnically Diverse Patients: Hispanics and African Americans Utilizing Simulation

Abstract (continued): intervention group. The morning group was given two scenarios in which the RN was to perform an initial admission assessment without prompts to focus on skin assessment utilizing Hispanic and African-American mannequins as a baseline. Each mannequin, Hispanic and African-American, demonstrated the same pressure ulcer location, number and level of breakdown. After the first scenario was completed, targeted skin integrity education was presented, including deconditioning and assessing two Caucasian simulated models: pelvis and foot with pressure ulcers. Group 2 Post Intervention Group identified the number of pressure ulcers on a Caucasian simulation buttock and foot prior to participating in the two scenarios described above. 4. Data findings, results and conclusions There were no differences between Hispanic and African-American assessments of pressure ulcers. A slight improvement was noted between the morning session and the afternoon session. The skin integrity education supported the RNsâ&#x20AC;&#x2122; ability to conduct a more thorough assessment of pressure ulcers during the afternoon session. 5. Implications for practice and further study This small study demonstrated further research is needed into additional education in assessing ethnically diverse patients and in-hospital devices that can contribute to pressure ulcers. The post test should have been conducted within four to six weeks post intervention to determine a difference between the baseline and post test. Skin beneath devices must be assessed with education and training provided initially upon hire and annually there after. Homogenous populations may need additional training on ethnic skin. 6. Acknowledgement Thank you to Medline Industries, Inc. for funding this research study.

18 Healthy Skin

Kaiser Permanente Educational Services Left to right: Farouze Fahieh, Karla Manfut, Rosa Moreno, Kathy Ricossa, Linda Clar, Jean Hively, Bic Diep, Carol Bautista (Not pictured: Elizabeth Scruth, Gail DePinna)

Introduction

The aim of this study is to determine whether registered nurses (RNs) are able to identify community -acquired pressure ulcers (CAPUs) on patients with dark pigmented skin on admission to the hospital. The research question asked: Are RNs able to identify community -acquired pressure ulcers among ethnically diverse patient populations: Hispanics and African-Americans utilizing simulation? Background and significance In the United States, regulatory agencies such as the Department of Health and Human Services are required to be notified when a patient exhibits a hospital-acquired pressure ulcer (HAPU) stage III or greater. If nurses do not identify a CAPU upon admission, then it will be considered a hospital-acquired pressure ulcer with the hospital being responsible to manage and treat this pressure ulcer without reimbursement. In addition, many health insurers and Medicare are no longer paying for hospital-acquired pressure ulcers. “The new rule will result in hospitals seeing substantial reductions in payment for the care of individual patients with preventable complications” (Rosenthal, 2007, 1573). It is estimated that 2.5 million patients are treated for pressure ulcers in an acute facility with an estimated cost of $11 billion per year (O’Neil, 2004). Regulatory agencies

such as the Department of Health and Human Services are required to be notified when a patient exhibits a hospitalacquired Stage III pressure ulcer or greater. It is in the best interest of hospitals to train RN staff to completely assess skin integrity upon admission to identify a CAPU from turning into a HAPU for the health of the patient and subsequently reduce financial cost burden to the hospital (Lapsley, 1996). It is critical to assess any patient carefully and examine skin for any breakdown and lesions at the front end. However, it is more important to critically assess ethnically diverse patients since the skin pigment is varied and may obscure the nurse’s initial assessment of skin breakdown. Additionally, pressure ulcers have been found beneath devices and nurses need to remove them and inspect those vulnerable areas. In the literature there are numerous articles on skin and pressure ulcers. However, there are few research studies on ethnically diverse patients with pressure ulcers. One study focused on the occurrence of pressure ulcers among Hispanics (Gerardo, 2009), while another study examined risk factors of pressure ulcers among African-Americans (Fogerty, 2009). However, most articles focus on prevention by using the Braden Scale as a risk indicator. There are no articles that discuss the actual assessment or identification of pressure ulcers on ethnically diverse patient populations.

Improving Quality of Care Based on CMS Guidelines 19

CE ARTICLE

Simulated wound on a mannequin with Hispanic skin tone.

Simulated pressure ulcer on a mannequin with AfricanAmerican skin tone.

This study will focus on targeted education by using medical simulation training. Medical simulation training is a leadingedge teaching methodology for adult learners to acquire and refresh their knowledge and skills through handson application in a “no harm” environment. This teaching methodology has been introduced to Kaiser Permanente San Jose staff nurses over the last two years to improve: (a) cognitive, (b) technical, and (c) behavioral skills at the bedside. High-fidelity human simulators are capable of mimicking real life patients.

diverse patients to determine whether or not there is a difference in nursing assessment of various skin tones. Utilizing simulation methodology, nurses will be facilitated and debriefed by nurse educators who have been trained as simulation experts. The training venue was the Center for Innovative Medical Simulation (CIMS), which is located on the campus of San Jose City College and operates as a high-fidelity community-based simulation center where ethnically diverse simulators are available to the community as a resource for training.

Scenarios will capture “real world” medical situations, thus creating “reality without risk” to actual patients. The human simulators serve as “patients” coming in from a skilled nursing facility with pneumonia or another complex condition with equipment, such as: (a) oxygen, (b) tracheostomies, (c) splints, (d) anti-embolic hose, and (e) eye glasses as distractors for skin assessment. Many bony prominences featured pressure ulcers, as well as under devices.

During this study, we examined the nurses’ ability to assess two patients head to toe focusing on actual pressure ulcers by using Kaiser Permanente’s downtime initial paper assessment documentation form to determine if there was a difference between the number of pressure ulcers identified by nurses between a Hispanic and an African-American patient. Nurses were not to stage the pressure ulcers, rather identify the number and location. Both simulated patients had the exact same number, location, and type of pressure ulcer for each session of training. After each scenario was completed, the team of participants reviewed their video for debriefing.

Method The targeted education component addresses assessments of two human simulators (one Hispanic, one AfricanAmerican) for an initial hospital assessment from a skilled nursing facility. Staff nurses will undergo two customized simulated scenarios to assess skin integrity of ethnically

20 Healthy Skin

Prior to conducting this study, approval from the Institutional Review Board was obtained. For recruitment, a flyer was

Comparison of Morning (AM) and Afternoon (PM) Sessions Using Frequency in Percentile and Numbers

distributed to invite subjects to participate and offered eight hours of continuing education. The method was a randomized, cross over trial. A convenience sample of 72 registered nurses participated in this study, each for eight hours, totaling 576 hours. Informed consent was obtained; the documents were coded to protect the identity of the participants. Before the study occurred, the nurses conducted a thorough inspection of the mannequins (pre-scenario, pre-application of pressure ulcers) to become familiarized. For the pretest, each nurse performed an admission assessment on one simulated patient with dark pigmented skin with pressure ulcers on bony prominences and devices. Following the first scenario, education consisted of: (a) identification of pressure ulcers through staging; (b) deconditioning; (c) examining of devices from head to toe; (d) inspection of pressure ulcer models (buttock and foot) and (e) a review of the SKIN bundle. The SKIN bundle is a special intervention based on focused assessment which is performed by all nurses at Kaiser Permanente Northern California. SKIN is an acronym meaning the following: S - surface; K - keep turning; I incontinence; and N - nutrition. The surface is observed and changes may be made based on patient needs. Keep

turning reminds the nurse to turn the patient at least every two hours. Incontinence is a prompt to toilet the patient. Nutrition is an alert for a dietary consult when appropriate. Immediately following the education, the post test was given wherein both mannequins had new pressure ulcers. Each subject assessed the opposite mannequin. For data collection purposes, the frequency of the pressure ulcers was identified from the admission assessment document and placed on a spreadsheet identifying the pre and post test scores on each mannequin. This quantitative data was maintained in a locked file cabinet in an aggregate form to protect the privacy of each participant. Results For this study, a total of 72 RNs participated. On the first day of the study, a pilot was done to determine the effectiveness of the education. Two hospital nurses participated: one from labor and delivery and the other from the intensive care unit. The pre test (baseline assessment) was done followed by the treatment, and then the post test. For this pilot, there was no improvement from the pre and post test. The education was retooled to include a head-to-toe assessment with devices which have been known to contribute in the development of pressure ulcers. After this education was conducted, an improvement in scores was noted.

Improving Quality of Care Based on CMS Guidelines 21

CE ARTICLE

Paired T-Tests Comparison between Groups 1 and 2 AM and PM Assessments

0.6793

AM African American and PM Hispanic

0.7118

AM Hispanic and PM African American

0.8403

P < or = to 0.05 indicates statistical significance.

After the pilot, 70 hospital RNs participated in eight hours of simulation training in specialty areas from: (a) maternal child, (b) medical surgical, (c) telemetry, and (d) critical care units. The statistical method was paired t-tests. The paired t-test compared results from morning to afternoon and a comparison between Hispanic and African American mannequins. (See bar graph.) The number of pressure ulcers identified between the morning and afternoon sessions improved slightly, however, there were no differences between the Hispanic and African-American mannequins. (See table above.) A reason for not having any differences between the Hispanic and African-American mannequin is that Kaiser Permanente San Jose, California is rich in cultural diversity, and our nurse population mirrors our patient population. Additionally, the paired t-test indicated that these results were not statistically significant between comparisons. Implications There were several significant implications based on this study. It is important to provide education to all healthcare workers who provide patient care for examining diverse patient populations with medical devices. This education should be done initially as well as ongoing for all healthcare providers, such as: (a) respiratory therapists, (b) physical therapists, and (c) nursing assistants. Instead of conducting both the pre and post test together on the same day, a follow up study should be conducted between four and six weeks after the initial study. Results may show a difference by allowing the nurse time to assimilate the education with the post test. Within each specialty area, the sample size was small. Further research should be conducted in each

22 Healthy Skin

specialty focusing on the specific pressure ulcers that are unique to that area: (a) abdominal apron for laboring patients; (b) blanching in the coccyx area from immobility due to surgical procedures; and (c) nasal cannula use with neonates. Additional studies on the assessment of ethnic skin may need to be conducted in geographic areas with homogeneous patient populations focusing in on assessment of ethnic skin tones. Acknowledgements In appreciation to our funders, I would like to thank Medline Industries, Inc. for the opportunity to study communityacquired pressure ulcers at our local facility and their generous financial support. Also, in gratitude for Kaiser Permanente Nursing Research for financial support for participation at the University of California, San Francisco Research Days and purchase of the poster. Finally, thank you to the clinical education staff at Kaiser Permanente San Jose. Without their participation, this project would not have been realized. References Fogerty, M., Guy, J., Barbul, A., Nanney, L., & Abumrad, N.M. (2009). African Americana show increased risk for pressure ulcers: A retrospective analysis of acute care hospital in America. Wound Repair and Regeneration, 17, 678-684. Gerardo, M.P., Teno, J.M,. & More V. (2009). Not so black and white: Nursing home concentration of Hispanics associated with prevalence of pressure ulcers. Journal of American Medical Directors Association, 10:2, 127-32. Lapsley, H.M. & Vogels, R. (1996). Cost and prevention of pressure ulcers in an acute teaching hospital. International Journal of Quality Health Care, 8:1, 61-6. Oâ&#x20AC;&#x2122;Neil, C.K. (2004). Prevention and treatment of pressure ulcers. Journal of Pharmacy Practice, 1. Rosenthal, M.B. (2007). Nonpayment for performance? Medicareâ&#x20AC;&#x2122;s new reimbursement rule. The New England Journal of Medicine, 16:357, 1573-1575.

CE TEST

Identification of Staff RN’s Ability to Assess Community-Acquired Pressure Ulcers Among Ethnically Diverse Patients True/False

1. There are hundreds of research studies available on ethnically diverse patients with pressure ulcers. T F 2. The subjects of this study were actual hospital patients. T F 3. The research question asked if registered nurses (RNs) are able to identify community-acquired pressure ulcers among Hispanic and African-American patients. T F 4. The skin integrity education supported the RNs’ ability to conduct a more thorough assessment of pressure ulcers during the afternoon session. T F 5. Each RN received eight continuing education credit hours for completing this study. T F Multiple Choice

6. Regulatory agencies must be notified when a patient exhibits a hospital-acquired pressure ulcer that is a. Stage I or greater b. Stage II or greater c. Stage III or greater d. None of the above 7. Which of the following specialty units were represented by nurses who participated in this study? a. Telemetry b. Surgery c. Maternal/Child d. Both a and c

8. What is medical simulation training? a. A leading-edge teaching methodology for adult learners to acquire and refresh their knowledge and skills through hands-on application in a “no-harm” environment. b. A traditional training method from the 1970s that utilizes the simulation of medical practice at an actual healthcare facility.

c. Training that simulates emergency medical techniques used during military combat.

d. None of the above.

9. How many opportunities did the nurses have to assess the skin integrity of the simulated ethnically diverse patients? a. 1 b. 5 c. 3 d. 2 10. In the SKIN bundle acronym, what does the letter N stand for ? a. Nursing care b. Nutrition c. Necrosis d. New

Course is approved for continuing education by the Florida Board of Nursing and the California Board of Registered Nursing. Visit www.medlineuniversity.com and login or create an account. Choose your course to take the test and receive 1 FREE CE credit.

Improving Quality of Care Based on CMS Guidelines 23

Advancing

Pressure Ulcer Rates:

Prevalence and Incidence A basic principle of quality measurement is: If

you can’t measure it, you can’t improve it.

Therefore, pressure ulcer performance must be counted and tracked as one component of a quality improvement program. By tracking performance, you will know whether care is improving, staying the same, or getting worse in response to efforts to change practice.

Two types of measures can be monitored: prevalence and incidence rates. • Prevalence describes the number or percentage of people who have a pressure ulcer while at your facility, whether it was acquired before or after admission. Prevalence reflects the number of individuals with pressure ulcers at a certain point or period of time. • I ncidence describes the number or percentage of people who developed a new pressure ulcer while in your facility. In other words, incidence only counts pressure ulcers that develop after admission.

Prevalence =

or % people with a pressure ulcer at your facility

Incidence =

or % people who developed a new pressure ucler at your facility

Prevalence rates include all pressure ulcers present in a group of individuals: those that developed during their stay at your facility as well as those that developed before admission.

Incidence rates capture only new pressure ulcers that develop during a patient’s stay at your facility.

24 Healthy Skin

How to calculate pressure ulcer prevalence and incidence To calculate pressure ulcer prevalence and incidence rates, you need to know who has a pressure ulcer and when it developed: a comprehensive skin inspection on every individual. Look carefully for any lesions 1 Perform or discolored areas on the skin and determine whether they are pressure ulcers.

Document the results of the comprehensive skin inspection for all individuals.

Rates are calculated as follows: Prevalence measures the number of individuals with pressure ulcers at a certain point or period in time: • The numerator will be the number of individuals with any pressure ulcer. • Just count individuals; NOT the number of ulcers. Even if someone has four Stage II ulcers, he or she is only counted once. • The denominator is the number of patients during that month. • Divide the numerator by the denominator and multiply by 100 to get the percentage.

Example: 17 individuals with any pressure ulcer ÷ 183 individuals = 0.93 x 100 = 9.3% Incidence measures the number of individuals who developed new pressure ulcers during a specific period in time. • The numerator will be the number of patient who develop a new pressure ulcer after admission. • Just count individuals; NOT the number of ulcers. Even if someone has four Stage II ulcers, he or she is only counted once. • The denominator is the number of all patients admitted during that time period. • Divide the numerator by the denominator and multiply by 100 to get the percentage.

Example: 31 individuals with a new pressure ulcer ÷ 227 individuals = 0.14 x 100 = 13.7% Source: Agency for Healthcare Research and Quality (AHRQ), www.ahrq.gov/research/ltc/pressureulcertoolkit

Improving Quality of Care Based on CMS Guidelines 25

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Students Are Part of the SKIN TEAM:

Pressure Ulcer Prevalence Day By Elizabeth Cotter, PhD, RN-BC and Chenel Trevellini RN, MSN, CWOCN

The nursing profession is responsible for keeping patients safe, providing quality care, reducing errors, and upholding high standards. Healthcare organizations are challenged every day to prevent adverse patient outcomes along with identifying the appropriate staff and practices that will have the biggest impact. At the same time the goal of all nursing educational programs is to prepare students with the skills necessary to provide safe, quality care to their patients. Unfortunately, a gap exists between academia and service in that students are not involved in meeting these challenges until they are well on their way in their profession. Nursing students need to learn the importance of these issues as part of their clinical training. One such issue specific to nursing care is the prevention of pressure ulcers. Gaps between education and clinical practice have been identified relative to pressure ulcers.1 Ayello, Zullowski, and Capenzuti (2010) state that discrepancy between best practice guidelines and the undergraduate education on pressure ulcers still continues today.2 The Essentials of Baccalaureate Education for Professional Nursing Practice provides the educational framework for the preparation of professional nurses. This framework allows for opportunities to build upon baccalaureate education in order

Improving Quality of Care Based on CMS Guidelines 27

Left to right: Kevin Guevara (Molloy nursing student); Mike Eckstein, RN; Joanne Cefalu, RN; Maureen Troise, PCA and Erin Markey, CNS.

to meet the challenges of today’s healthcare industry.3 Nurse educators need to continue to identify and provide opportunities for educational growth for their students. Sherwood and Drenkard (2007) suggest that educators match practice realities with opportunities for student involvement in patient safety initiatives and process improvement activities to ensure quality and safety in nursing education.4 Faculty need to provide opportunities for students to be actively involved in transitioning the theory into practice connection. The opportunity to facilitate evidence-based practice can enhance the students’ ability to draw conclusions and make connections between quality care and the outcomes. St. Francis Hospital, The Heart Center® in Roslyn, NY and Molloy College in Rockville Centre, NY, have a long history of collaboration. The foundation of this partnership is based on respect, trust and a shared commitment to quality patient care and student education. St. Francis Hospital and Molloy College are continuously working together to close the gap between education and clinical practice. The introduction of Nursing Quality Indicators within the clinical setting will serve a dual purpose of improving clinical knowledge and strengthening collaboration between academia and service. Elizabeth Cotter, Assistant Professor of Nursing at Molloy College, identified a need to include additional clinical experiences involving pressure ulcer prevention for her students. She partnered with Chenel Trevellini, Wound Specialist at St. Francis Hospital, inviting Molloy students to participate in Pressure Ulcer Prevalence Day. St. Francis Hospital’s Professional Nursing Practice Model (PNPM) serves as the framework for the educational initiative known as SKIN Champion Program. The characteristics of the St. Francis Hospital PNPM include authority, autonomy, and accountability. The characteristic of authority provides recognition and use of the nurse’s rights, power, and responsibility to use nursing knowledge, skills, and judgments. Autonomy influences independent nursing decisions regarding

28 Healthy Skin

best practices. Accountability focuses on acceptance of responsibility related to nursing assessment, plan, interventions, and judgments. The combination of authority, autonomy, and accountability assists in promoting safety, which positively impacts patient outcomes. Participating in the didactics and hands-on components of the SKIN Champion Program empowers the clinical RN to incorporate critical thinking in the individualization of the interdisciplinary plan of care in preventing and treating pressure ulcers. The SKIN Champion program provides the process and structure required to deliver evidence-based education and policy on pressure ulcer prevention. The program provides an environment that promotes continuous quality improvement, where practitioners are empowered to utilize the nursing process to deliver optimal skin care. During this process, the SKIN champions measure, analyze, track and trend the relationship between nursing care at St. Francis Hospital and Nursing Quality Indicators. This initiative has led to the empowerment of clinical registered nurses and ancillary staff with the knowledge, skills, and tools to provide extraordinary skin care.

By participating in SKIN Champion Prevalence Day the students increased their knowledge on the identification of pressure ulcers, staging, risk factors, product use and preventive measures. Monthly Pressure Ulcer Prevalence Studies SKIN Prevalence Teams are established specifically to conduct monthly pressure ulcer prevalence studies for an entire quarterly data collection period. Each team consists of a clinical nurse specialist, clinical nurses, and ancillary staff. The team begins each prevalence study day with two-hour didactics,

Chart Review Questions • Most recent Braden Score • Most recent skin assessment • I s the patient at risk for pressure ulcer development? • I f yes, is the Pressure Ulcer Prevention Protocol in place? Left to right: Kiera O’Leary (Molloy nursing student) and Nicole Mikicic, RN.

which include skin assessment, staging, and data collection requirements. The teams then proceed to their assigned units and conduct a pressure prevalence study. The day ends with a one-hour post conference. Involving the students to be part of this team gives them the opportunity to experience the practical realities of a nursing career. The students can be a witness to implementation of evidence-based practice and the different research projects that have been conducted to bring us to the point of giving the best care to our patients. Participating in this program also develops the students’ awareness of the responsibilities and professional duty required to participate in creating a safer patient environment. Students see firsthand how the skin tells a story about what is happening to the patient. Pressure Ulcer Training Program The students were also instructed by their professor to navigate through The National Database of Nursing Quality Indicators (NNDQI) website and complete the Pressure Ulcer Training Program and post test to reinforce what they learned during Prevalence Day. The training program included four modules. Module I focused on definition of pressure ulcers, pressure ulcer location, and pressure ulcer staging. Module II described other wound types and skin injuries. Information included a review on arterial, venous, diabetic ulcers, skin tears, and perineal dermatitis. Module III included content related to conducting an NDNQI pressure ulcer survey; suggested training, staging for survey team, and risk assessment and prevention. Module IV focused on differences among community, hospital, and unit-acquired pressure ulcers.5 Each student scored 100% on the test. The goal for this collaborative effort was to improve the accuracy of the students’ data collection ability on hospitalacquired pressure ulcers and allow meaningful comparison of nursing care performance. By participating in SKIN Champion

Prevalence Day the students increased their knowledge on the identification of pressure ulcers, staging, risk factors, product use, and preventive measures. Being active learners in this process allowed the students to learn firsthand what needs to be done to prevent, identify, and care for pressure ulcers. Having the students assist the SKIN team collect and analyze data related to this critical nurse sensitive indicator provides the students with a real –life learning situation. Clinical days that followed included a change in the students’ practice. The students knew to check the patients bathing products to ensure that they were appropriate and located in the basin. The students checked that specialty beds were functioning correctly. The students looked at lab work such as albumin levels and also reviewed the required nursing paperwork relating to skin, including the Braden score, in their documentation. The students have new insight on the importance of pressure ulcer prevention and the role they play. The students also have an increased awareness of “Nurse Sensitive Indicators” and the impact nurses have on patient outcomes and healthcare costs. Student Comments from the Fall 2011 Group Ana Hernandez: I think every hospital should have Prevalence Day. It was a wake-up call for the nursing students on the importance of skin care. Prevalence Day made me feel more confident in my assessment. Kesha Manragh: Being part of Prevalence Day will impact my practice because I feel more comfortable when it comes to preventive measures and pressure ulcer interventions. I also know how important and critical the first nursing assessment (especially skin assessment) is when there is a new admission. I will also make sure that everything is documented upon each assessment in my nursing notes.

Improving Quality of Care Based on CMS Guidelines 29

Prevalence Day at St. Francis Hospital was a thorough representation of the importance of skin assessment and treatment of skin conditions. - Judith Lopez Kevin Guevara: Working with the team helped me see the importance of collaboration. Everyone in the group gave input and opinions as to whether the ulcer was stageable or nonstageable. Was it an injury from pressure or moisture? The group then worked together to obtain the accurate information. Prevalence Day helped me grasp a better understanding of the word teamwork. Judith Lopez: Prevalence Day at St. Francis Hospital was a thorough representation of the importance of skin assessment and treatment of skin conditions. We learned that pressure ulcers are a significant healthcare problem because they increase the amount of nursing care required, the patient’s length of stay, and the healthcare costs, as well as compromise patient health and cause pain. Prevention is the key. Aneta Gorazda: Being part of Prevalence Day increased my knowledge about skin care, which included risks of hospitalacquired breakdowns, use of appropriate devices, and skin care products to prevent the skin from breaking down. I have also gained knowledge to assess and distinguish between different stages of pressure ulcers and suspected deep tissue injury and moisture-related dermatitis. Chelsea Ryan: Being an active part of Prevalence Day showed me how important it is to advocate for patients, provide them with the equipment/products to assist in improving their stay in the hospital, and quality of life. As a student, I think that Prevalence Day has shown me the importance of many aspects of patient care including keeping skin intact, accuracy of the nurse’s assessment, performing a Braden score assessment, and accurate documentation.

30 Healthy Skin

Left to right: Chelsea Ryan (Molloy nursing student) and Laura Gregorovic, CNS.

Kiera O’Leary: This was a great learning experience working as part of the team to prevent and treat pressure ulcers. Natasha Kernahan: This experience confirmed what I learned in my nursing lecture. It gave me the opportunity to witness the preventive methods used to assist in avoiding pressure ulcers. Students’ involvement in Prevalence Day is very important because we are the future. References 1. Gould, D (1992). Teaching students about pressure ulcers. Nursing Standard; 18, 28-31. 2. Ayello, EA, Zullowski, KM,& Capenzuti, E.(2010). Pressure ulcer content in undergraduate programs. Nursing Outlook. 58, 4 3. American Association of Colleges of Nursing (2008). The essentials of baccalaureate education for professional nursing practice. Retrieved from http://www. aacn.nche. edu/Education/pdf/BaccEssentials08.pdf 4. Sherwood, F & Drenkard, K.(2007). Quality and safety curricula in nursing education: matching practice realities. Nursing Outlook. 55, 151-155. 5. American Nurses Association (2011).The National Database of Nursing Quality Indicators (NNDQI) Pressure Ulcer Training retrieved from www.nursing quality .org

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Impact of Pressure Ulcers Across Care Settings

1in25:

number of pressure ulcer hospitalizations that end in death3

Average cost of hospital stay to treat a pressure ulcer2

73% of pressure ulcers occur in persons older than 654

66%

incidence of intraoperatively acquired pressure ulcers6

76%

68%

68% of pressure ulcer patients report pain 2% of those patients receive analgesia8

of nurses in the ED report a knowledge deficit regarding wound care1

In the ICU, 34% of pressure ulcers take more than 6 days to detect7

1in10

number of nursing home residents with a pressure ulcer5

References 1 Niehuser M. Routine Skin and Wound Care in the Emergency Department of Kennestone Hospital. Poster presented at: Southeast Region Wound, Ostomy & Continence Nurses Society 2011 Conference; September 2011; Chattanooga, Tenn. Available at: http://serwocn.org/2011Conf/Images/Poster1.pdf. Accessed January 10, 2012. 2 Center for Medicare & Medicaid Services. Proposed Changes to the Hospital IPPS and Fiscal Year 2009 Rates. Federal Register. 2008;73(84):23550. Available at: http://edocket.access.gpo. gov/2008/pdf/08-1135.pdf. Accessed January 10, 2012. 3 Agency for Healthcare Research and Quality. Pressure Ulcers are Increasing Among Hospital Patients. Available at: http://www.ahrq.gov/research/jan09/0109RA22.htm. Accessed January 10, 2012. 4 Whittington K, Patrick M, Roberts JL. A national study of pressure ulcer prevalence and incidence in acute care hospitals. Journal of Wound Ostomy Continence Nursing. 2000;27(4):209â&#x20AC;&#x201C;215. Available at: http://www.ncbi.nlm.nih.gov/pubmed/10896746. Accessed January 10, 2012.

32 Healthy Skin

5 Park-Lee E & Caffrey C. Centers for Disease Control and Prevention. Pressure Ulcers Among Nursing Home Residents: United States, 2004. Available at: http://www.cdc.gov/nchs/data/ databriefs/db14.htm. Accessed January 10, 2012. 6 Aronovitch S. Intraoperatively acquired pressure ulcers: are there common risk factors? Ostomy Wound Management. 2007;53(2):57-69. Available at: http://www.o-wm.com/content/intraoperatively-acquired-pressure-ulcers-are-there-common-risk-factors. Accessed January 10, 2012. 7 Cox J. Predictors of pressure ulcers in adult critical care patients. American Journal of Critical Care. 2011;20(5):364-374. Available at: http://ajcc.aacnjournals.org/content/20/5/364. full.pdf+html. Accessed January 10, 2012. 8 Gunes UY. A descriptive study of pressure ulcer pain. Ostomy Wound Management. 2008;54(2):56-61.

50% LESS FRICTION than the leading competitor3

Relieve Pressure on Vulnerable Heels HEELMEDIXâ&#x201E;˘ Heel Protector

Pressure relief and skin protection all in one The heels are the most common site for facility-acquired pressure ulcers in long-term care, and the second most common site overall.1 According to clinical experts, the most effective aspect of pressure ulcer prevention for heels is pressure relief, also known as offloading.1,2 Offloading is achieved with the use of pillows or heel protection devices that relieve pressure by elevating the heel. The HEELMEDIX Heel Protector is designed to help eliminate pressure, friction and shear on the skin by elevating the heel. Made of soft, suede-like material on the inside and easy-to-clean nylon on the outside. Adjustable straps are soft against vulnerable skin. Includes a mesh laundry bag with patient ID label to simplify washing and sorting.

Straight-back strapping Criss-cross strapping provides extra room, isolates the foot and ventilation and protection floats the heel against foot drop MENTION THIS AD TO RECEIVE A 10% DISCOUNT ON YOUR FIRST HEELMEDIX HEEL PROTECTOR ORDER 1

Download a QR Code Reader app

2 Launch the QR app 3 Scan this QR Code or visit http://www.medline.com/ heel-and-elbow/ Fowler E, Scott-Williams S, McGuire JB. Practice recommendations for preventing heel pressure ulcers. Ostomy Wound Management. 2008;54(10):42:48. 1

Langemo D, Thompson P, Hunter S, Hanson D, Anderson J. Heel pressure ulcers: stand guard. Advances in Skin & Wound Care. 2008;21(6):282-292. 2

ÂŠ2012 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.

Patented SuperCore® absorbent sheet is thermo-bonded to provide better pad integrity, excellent skin dryness and exceptional absorbency.

AquaShield film traps moisture, providing better leakage protection.

Air-permeable backsheet for better skin comfort and compatibility with under-patient warming

New! ULTRASORBS® AP Dry Sheet for the OR Advanced technology for ongoing moisture management. Introducing Ultrasorbs AP Dry Sheet technology in a larger size (40 x 90) suitable for the OR table. CHALLENGE:

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Perioperative-related pressure ulcers are affected by immobility, pressure and moisture. Incidence of pressure ulcers occuring as a result of surgery has been as high as 66%.1

Ultrasorbs AP has been clinically shown to help maintain skin integrity as part of an overall pressure ulcer prevention program.2 Ultrasorbs AP is now available as a Dry Sheet for the OR.

For a free sample, contact your Medline sales representative

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Survey Readiness Treatment

Butterflies in the Nursing Home Incontinence: Change Your Culture â&#x20AC;&#x201C; Change Your Brief Butterflies go through a process of change or transformation known as metamorphosis. It is through this process that this insect is able to change its appearance becoming the beautiful butterfly we ultimately see and enjoy. Since the federal Nursing Home Reform Lawâ&#x20AC;&#x2122;s enactment in 1987 emphasizing dignity, choice, and self-determination in the care for its residents, we are seeing the culture changing within our nursing homes today. This culture change, like the metamorphosis of the butterfly, is bringing about beautiful new changes or transformations in our nursing homes.

36 Healthy Skin

We are seeing a change from the old institutional nursing home setting to ones with a more home-like, residentcentered living module… Despite these positive changes, one key area that has not caught up to this cultural revolution is the area of incontinence care.

Much like the butterfly going through its changes, we are seeing a change from the old institutional nursing home setting to ones with a more home-like, resident-centered living module. The change is about respecting residents, promoting dignity and individualized care. This new philosophy is shown to help residents function at their highest practicable physical, mental, and psychosocial well-being. Step-by-step, in little ways and big, we’re delivering better care, and granting more autonomy and confidence to our residents. I am seeing beautiful dining rooms with tables set with china and elegant flatware. Residents come to dinner as if they were going out to a fancy restaurant. Residents today have a choice to eat in the facility’s dining area or if they prefer have “room service” deliver their food to their own private rooms. Today’s culture is about making choices based on personal preferences, tastes, likes and dislikes – not a “one-size-fits-all” approach so commonly used in our industry. Despite these positive changes, one key area that has not caught up to this cultural revolution is in the area of incontinence care. Attitudes still pervade the industry that reflect, “This is the way we’ve always done it” with regard to product choices, application of those products, staff and resident education and empathy to those residents afflicted with incontinence. Unfortunately, the “one size fits all” mentality still exists in many

nursing homes when it comes to this important health and quality of life issue. That is not to say nursing home staffs are not well intentioned. They want to do the right thing. They have compassion and pride in doing a great job for our loved ones whom they care for day and night. What is lacking is keeping up with new education and products with regard to “culture change” in incontinence care. Continence management is a vital area that is deficient in practice and should be incorporated into the wave of culture change today. All too often we see residents dress for an elegant dinner, but worry how they will maintain their dignity if they happen to suffer the effects of incontinence. How will they be kept dry while they dine? How will they maintain their comfort while having to wear an incontinence product without it showing or being detected by their friends? Unfortunately these are the questions that keep residents from leaving their rooms in fear of the indignity of incontinence. When it comes to changing an adult brief on a resident while in the bed, most nursing homes still employ an old time bed-making technique that is out-dated and impractical. But there are newer application techniques available that nursing leadership can find by talking with their incontinence supply vendor.

Improving Quality of Care Based on CMS Guidelines 37

By combining better products with educational tools and resources, you will foster a culture

of change

that is designed with each individual’s needs in mind.

Similarly, many adult brief products are still made with a “one size fits all” strategy, which makes it very difficult to maintain a high level of dignity for the resident. Poor fitting products do not promote a high degree of confidence, comfort, and continence management. Ill-fitting products are also uncomfortable and do not keep the resident’s skin dry, which can lead to skin breakdown, wet beds, and increased risk for pressure ulcers. Clearly, “one size does not fit all” when it comes to adult incontinent products. But incontinent products, like resident care techniques and education, are improving. Innovative brief manufacturers are utilizing enhanced technology along with a sharper focus on proper fit and comfort, to design products that work and feel better for the resident. When a resident is properly fitted with an incontinent brief, they will naturally feel a sense of well-being, dignity, and confidence. By combining better products with educational tools and resources, you will foster a culture of change that is designed with each individual’s needs in mind. Moreover, these programs and products will inspire your staff to embrace individualized continence management care, which will lead to enhanced levels of satisfaction for both staff and residents. When administrators and directors of nursing are asked what types of continence management programs or systems are in place, I am usually told, “We don’t really have a system,” or

“We want to implement a system, but I’m too busy right now.” Continence management is far too important of an area to be ignored anymore. In addition, with the recent change to MDS 3.0, facilities are missing the connection that bridges the MDS 3.0 / Section H in implementing an effective individualized continence care program. Often times the facility MDS coordinator is not in coordination with a continence management team in the facility. Not only is this a missed opportunity for improved reimbursement for the facility, but it is also a missed opportunity to bring culture change in this area as well. Culture change with regard to continence management in the nursing home environment is evolving slowly but its time has come. While many facilities are concentrating on physical changes to their building, they must now consider what types of changes will impact something so intimately related to individual residents themselves as continence management. A culture change in continence management in your nursing home will allow your resident to truly participate in life to the fullest inwardly while experiencing your beautifully changing nursing homes outwardly. Debra J Birchman, RN.BS.WCC, is a Clinical Services Manager for the Personal Care Division at Medline Industries, Inc. Printed with permission from Advance for Long-Term Care Management.

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TheraHoney™ Sterile Wound Dressings

The sweet solution for wound care 100% medical grade honey helps promote debridement, moist healing environment, reduced wound odor The high sugar levels (87%) in TheraHoney result in osmotic pressure that helps promote autolytic debridement of necrotic tissue, provides a moist wound healing environment and helps rapidly reduce wound odor. TheraHoney products contain 100% medical-grade Manuka honey, which is derived from the pollen and nectar of the Leptospermum soparium plant in New Zealand. The honey comb is used only one time, and once harvested, the honey is carefully filtered, irradiated and tested in a laboratory.

TheraHoney™ Gel

Use TheraHoney Gel on difficult to dress wounds to promote autolytic debridement and a moist healing environment. Use TheraHoney Gauze to maintain a moist healing environment while permitting the passage of exudate into a secondary dressing.

Available! March 2012

TheraHoney™ Gauze

Change your CULTURE. Change your BRIEF. A culture change is sweeping through long term care. It honors individuals. It’s where “the way we’ve always done it” is replaced by “How would you like us to do it?” The importance of personal choices and care is a central theme of the culture change movement. Asking a resident to fit into your routines is the old way; adapting to fit individual needs is the new way. Medline is proud to provide you videos, tools and educational resources to help you identify and nurture changes that keep your facility moving forward. In continence care, fostering a culture of change means using a brief that is designed with each individual’s needs in mind. It must deliver dignity and comfort. And the idea of “one size fits all” is replaced by choosing one that will FitRight.

Make the change to

FitRight. TM

Skin-Safe Closures Provide secure, safe, and repeated refastenability.

Soft Anti-Leak Guards Reduce leakage and improve containment. Restore patient confidence, impact facility utilization.

4D Core with Odor Protection Wicks fluid away quickly to promote dryness and help maintain skin integrity.

Ultra-Soft Cloth-Like Backsheet Provides a discreet, garment-like, natural feel.

The all-new FitRight brief helps accelerate your culture of patient-centered care. • Designed with individual in mind • More high-tech features for high performance • Discreet, comfortable, garment-like fit and feel • 4D core with odor protection for dryness and dignity

1-800-MEDLINE I www.medline.com Ask your Medline rep for a free sample and more about the FitRight story.

Embracing Change: Promoting a Continence Management Program in Your Facility

42 Healthy Skin

Survey Readiness

The healthcare industry continues to face new challenges with constant pressure to promote individualized care while managing operation costs. With the feeling of near-constant change related to updates in government reimbursements and mandates, it may feel nearly impossible to try to effect change when maintaining status quo is challenge enough. Many nursing homes are concerned about how to maintain quality service while improving clinical outcomes, especially with the recent 11.1% cut in Medicare payments. In the midst of all of this we cannot overlook the importance of assessing our core business values and the required commitment to provide residentcentered care. The transition to the MDS 3.0 platform is an opportunity to ensure we are embracing the goal of changing facilities’ focus from simply managing incontinence to promoting continence. This is an industry change, shifting attention from reacting to the symptom to actually addressing the root of the problem. Although most public initiatives are focused on pressure ulcers, falls, or healthcare-acquired conditions or infections (HAC’s or HAI’s). incontinence is addressed as more of a sidenote to pressure ulcers and falls, for example. Because of this lack of singular focus, many myths about incontinence have been perpetuated, including the concept that incontinence is an inevitable part of aging. This is the time to debunk the myths and embrace culture change. But how does a facility embrace that change, and what might that look like? The overarching goal should be to promote as much continence as possible. For some individuals, this may mean a complete return to continence. For others, even one small improvement can have a large impact on the resident’s quality of life and satisfaction with their care.

Improving Quality of Care Based on CMS Guidelines 43

Start by empowering your staff. Provide them with training to identify factors such as the type of incontinence, proper product usage, and proper sizing techniques. Individualized care plans for each resident will go a long way toward improving outcomes. Standard protocols that recommend simply using one of two different brief sizes paired with checking and changing every two hours will not go far toward promoting your residents’ dignity, nor will they comply with MDS 3.0, Section H.

improved quality of life. A plan that your staff finds impossible to adhere to will fail, and all the best plans profit nothing if in the end they do not benefit your residents. Meet the need to promote as much continence as possible.

As you create your continence management plan, keep in mind the twin goals of staff convenience and residents’

What will your first step be?

Remember, one small change can result in better quality of life for your residents. Decide to make those changes, one clinician at a time, one facility at a time. All it takes is one step forward to make a change.

STEPS for implementing a successful continence management program

everyone on board. Once you decide to implement 1 Get a continence program, everyone’s commitment is crucial to its success. All tiers of the organization, from executives and administrators through all levels of management and staff, must be on board. a continence management team with proactive 2 Assemble nursing leadership. Recommended team members might include: • Facility administrator • Director of nursing • Restorative nurse • Treatment or wound care nurse • Several Lead CNAs Weekly meetings are suggested. To start, you will set up expectations and the philosophy of your continence management program. Once the program has been implemented, you will discuss concerns and make revisions to the program as necessary.

44 Healthy Skin

the nursing staff at all levels regarding: 3 Educate • Types of incontinence • • • •

Behavioral programs Variety of absorbent products available Proper skin care Protocols and procedures for incontinence and where they are located

Important: Be sure to put a system in place to educate new employees as well. a team leader for each unit who will be responsible 4 Select for continence care questions, troubleshooting, training and skin care. This person should receive additional education regarding incontinence and absorbent product selection. Each unit should conduct daily meetings during shift changes, which devote about five minutes to incontinence.

an incontinence product identification system to 5 Create identify the product each resident uses. This information should include the correct size. Consider a discreet sticker system to discreetly identify the size and type of product each individual requires.

Determine an incontinence product delivery system. Decide how and when absorbent products will be delivered to each residentâ&#x20AC;&#x2122;s room. Many facilities designate a location in the residentâ&#x20AC;&#x2122;s closet for his or her own absorbent products. Discourage sharing of product. Locking up the incontinence products encourages the team leader (who has the key) to evaluate why a resident may be going through too much product.

a family night meeting to educate residentsâ&#x20AC;&#x2122; 7 Arrange family members and caregivers about incontinence treatments and absorbent product options.

Assess new residents and reevaluate current residents for level of incontinence, sizing, skin condition, and product selection. If a voiding diary has not been completed previously, schedule a 72-hour time frame

to complete one. Then decide whether the resident is a candidate for a toileting program. Also, select appropriate absorbent products, determining the correct size. Implement the treatment program and educate the 9 resident regarding the types of products available and whether they will be participating in a toileting program. Team leaders can be an asset in monitoring and revising continence treatment plans. a good incontinence program by scheduling 10 Maintain regular meetings with team members to discuss problems and address concerns. Determine whether the correct product and size are still being used by selecting a few residents at random to audit. Provide ongoing education regarding product usage and program implementation for all staff. and revise the continence management program as 11 Review necessary to accommodate new staff, new products, new technology and new regulations.

Improving Quality of Care Based on CMS Guidelines 45

Introducing Medline’s New

CONTINENCE MANAGEMENT PROGRAM A wide variety of tools to help you provide individualized continence care Incontinence is one of the most costly and labor intensive issues in nursing homes and long-term care facilities. Despite years of research and clinical efforts to improve it, the prevalence of incontinence remains high. Medline has created this Continence Management Program to help long-term care facilities develop individualized continence programs for residents and comply with Medicare regulations.

Replaces Compass Box F315

The program includes: • RN/LPN workbook with 4 CE credits • CNA workbook • R eproducible care plans, assessment guidelines and other quality assurance tools

Stick with OctylSeal™

Flexible wound closure that’s easy on your budget Introducing Medline’s OctylSeal high viscosity tissue adhesive for closure of simple wounds • Flexible structure moves with the skin, minimizing the chance of cracking • Acts as a barrier to microbial penetration as long as the adhesive film remains intact • 40 percent more glue per container than most other tissue adhesives (0.7 grams versus 0.5 grams) • Easy, versatile application – interchangeable tips (swab and nozzle) included in every package; violet color for easier identification on skin • Metal tube instead of glass ampule means no risk of broken glass entering the wound

Indications for use

Topical application only to hold closed easily approximated edges of wounds from surgical incisions, including punctures from minimally invasive surgery and simple, thoroughly cleansed trauma-induced lacerations. OctylSeal may be used in conjunction with, but not in place of deep dermal sutures. Available by prescription only.

www.octylseal.com

CASE STUDY

Challenges of Preventing Moisture Associated Skin Damage in the Intensive Care Units Using No Sting Spray Skin Protectant* Background The prevention of moisture associated skin damage (MASD) has become a challenge in many intensive care units. When life threatening injuries and conditions arise in ICUs, especially in patients with multiple co-morbidities, moisture/body fluid related skin management issues tend to assume second priority. This occurs sometimes simply because large areas of the skin may not be practically and directly accessible to the nurse in immobile patients who are connected to several life supporting devices at a time. Turning the patients to examine their skin is not an easy option. Under these less than optimal conditions from the perspective of managing skin issues and prevention of skin associated injuries, a skin protective barrier may be deemed to be an effective, practical solution. The proper use of such barriers may protect negative alteration to skin integrity, reduce pain associated with continued moisture/ body fluid damage to denuded skin, and may preserve the healthy surrounding tissue in case of skin damage/wounds that are already present or cannot be prevented. Skin Management Modality Recently we have been interested in testing a non sting spray barrier that utilizes a unique “polymer” formulation. Such polymers form a protective film on the skin upon application. Such a skin barrier is appropriate in our opinion, for general skin protection from moisture/body fluids and irritated incontinence damaged skin, or uncontained body fluids around tubes, fistulas, and also for protecting periwound maceration. In our intensive care unit the population is elderly, immunosuppressed, transplant, cardiac, and DIC patients, who all tend to have very fragile, thin, and often compromised skin. A no sting, affordable, easily applied barrier is highly appropriate. Results and Discussion In each of the patients, resolution of the skin health within reasonable time was observed following the use of the trialed skin spray protectant barrier. Barriers assist with the prevention of stripping of fragile skin by tending to decrease the separation force directly on the skin of adhesive dressings or adhesive trauma. The trialed non sting

48 Healthy Skin

Patient #1 – 3/10/2009 60 y/o male with a history of hepatitis C, cirrhosis and hepatic carcinoma. Liver transplant with recurrent rejection, worsening hepatitis, pancytopenia, CAD, TIA. Presents with melena and BRBPR, as well as lightheadedness. EGD revealed esophageal and gastric varices.

Patient #2 – 11/9/2009 89 y/o female with a history of morbid obesity with restrictive disease, asthma, pulmonary embolism s/p IVC filter, RLE DVT (2010), afib, severe chronic LE edema, and postherpetic neuralgia admitted with atypical chest pain.

Prevention Patient #3 – 2/15/2009 41 y/o female with a past medical history of depression and anxiety. She presents with refractory pneumonia. She developed hypoxemic respiratory failure requiring intubation and ARDS requiring transfer for ECMO.

Denise Robinson, MPH, RN, CHWOCN Juliet Smith, MSN, RN, CWOCN Bernadette Melido, BSN, RN, CWOCN New York Presbyterian Hospital, Columbia University New York, New York

skin protectant was clinically effective as a primary skin management tool to the areas in need of protection. This product provided an alternative to protective creams such as zinc oxide and petrolatum based products one would typically use if such sprayable barriers were not available. One must remember that cream barriers tend to cause overlying adhesive dressing detachment, because the ingredient present in these barriers do not allow efficient attachment of dressing adhesive to skin. In contrast, the spray film protectants of the type tested offer a dry, adherent (to adhesive dressings), and robust platform. Our patients reported comfort in the areas of affected skin, and no pain or stinging was noted during application on the damaged skin areas being subject to the trial spray. This is not surprising given that there is no alcohol in this spray formulation (alcohol is a common stinging ingredient). Healthy at-risk skin was protected in our patients, and no mechanically induced skin stripping was reported on these patients during overlying adhesive dressing removal. In our limited trial on ICU patients, we conclude that the skin protectant trialed, which is based on a unique polymer film forming technology, demonstrated clinically effective results in the management, and protection of skin damage from moisture/body fluids. We think that larger studies on a controlled patient population are warranted for this unique technology. *Sureprep No Sting®, Medline Industries Inc., Mundelein, IL

Patient #4 – 2/22/2008 91 y/o male with a past medical history of chronic kidney disease, coronary artery disease, s/p MI, ischemic CMP, CHF and DM. After complicated CABG course, developed renal failure, vasodilatory shock, enterobacter sepsis, and cardiogenic shock.

Patient #5 – 3/20/2009 62 y/o male presented with a history of diverticulitis, laryngeal CA, melanoma and skin SCC, admitted with chronic diarrhea and failure to thrive. Surgical course colon resection with end colostomy.

References 1. Gray M. Incontinence-Related Skin Damage: Essential Knowledge. http://www.o-wm.com/article/8161. Accessed 4-5-11. 2. Coutts P, Sibbald RG, Queen D. Peri-Wound Skin Protection: A Comparison of a New Skin Barrier vs. Traditional Therapies in Wound Management. Poster at CAWC Meeting, London, Ontario. November 2001. 3. Sibbald RG, MD, Campbell K, Coutts P, and Queen D. Intact Skin – An Integrity Not to Be Lost. http://www.o-wm.com/ content/intact-skin-an-integrity-not-be-lost?page=0,6. Accessed 4-5-11.

Improving Quality of Care Based on CMS Guidelines 49

Total Body Cleansing System

Excellent patient care, soothing comfort ReadyBath Total Body Cleansing System includes pre-moistened disposable washcloths that require no rinsing or drying and offers excellent patient care on a variety of levels. Relieves fear and anxiety. Confined spaces such as shower stalls can be uncomfortable and frightening for elderly patients, especially those with dementia. ReadyBath allows for a calm bathing experience at the bedside. Reduces cross-contamination. ReadyBath improves patient care by eliminating the need for reusable plastic basins that have been shown to increase exposure to harmful bacteria.

To learn more about ReadyBath Bathing products, contact your Medline representative or call 1-800-MEDLINE (1-800-633-5463). To request a sample, email mmalczyk@medline.com.

Improves skin care. ReadyBath contains special cleansers and moisturizers that can help soothe and soften skin. All ReadyBath formulas are pH balanced and have been hypoallergenically tested. ÂŠ2012 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.

Special Feature

Bathing of Older Adults with Dementia

The

By Joanne Rader, MN, RN, Ann Louise Barrick, PhD, Beverly Hoeffer DNSc, RN, FAAN, Philip D. Sloane MD, MPH, Darlene McKenzie PhD, RN, Karen Amann Talerico PhD, RN, Johanna Uriri Glover PhD, RN

Abstract

VERVIEW: Older adults who need assistance with bathing often find the activity to be both O physically and emotionally demanding, as do their caregivers. Research has identified several contributing factors, including pain; fatigue and weakness; confusion; anxiety resulting from being naked in front of strangers, being afraid of falling, and being in a noisy or unfamiliar place; and discomfort from cold or drafty bathing areas or harsh water sprays. The authors of this article make the case for the elimination of forced bathing. Research supports this change in philosophy and practice, whereby bathing is not a task to be performed but rather a human interaction. Inexpensive, practical, and evidence-based alternatives are discussed.

Bathing independently, one of the most personal and complex of the activities of daily living, requires significant cognitive and physical abilities, including dexterity, flexibility, balance, strength, and coordination.1 To the person who requires assistance in bathing, the change can represent a decline in well-being and cause emotional and physical discomfort.2 Indeed, caregivers and recipients alike, in both homes and institutions, often say assisted bathing is difficult and distressing. A significant number of older adults have difficulty or need assistance with bathing. In one study of 626 communitydwelling older adults ages 73 years and over, 195 (31%) met the criteria for “bathing disability” (those “requiring assistance or having difficulty washing or drying the whole body”).1 And according to a report issued by the National Center for Health Statistics, Nursing Homes, 1977-1999: What Has Changed, What Has Not? at least 90% of nursing home residents need some assistance with bathing.3

O ur experience, supported by other research, has shown several factors contributing to bathing difficulties, including1, 4 • pain from musculoskeletal conditions, such as arthritis in the toes, knees, and neck. • fatigue and weakness caused by frailty and other medical conditions. • fear and misunderstanding because of memory loss, cognitive decline, previous negative experience, or a combination of these. • anxiety and apprehension because of such factors as fear of falling, being transported to a noisy area, being naked in front of strangers, and being hoisted high in the air (as on a Hoyer lift). • discomfort from cold, drafty air or harsh shower sprays.

Improving Quality of Care Based on CMS Guidelines 51

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In our series of studies we’ve found nurses to be critical in improving the bathing experience for older adults. In fact, our recent clinical trial tested two person-centered bathing methods (methods tailored to the needs and comfort level of the person being bathed) aimed at reducing discomfort, agitation, and aggression in nursing home residents with dementia, and we found nurses to play a central role.5 And with the growth of the geriatric population, particularly those 85 years old and older, nurses will increasingly need to assist with bathing. Drawing on more than a dozen years of clinical work and research, we suggest the elimination of forced bathing in homes and institutions, a practice we consider on a par with restraint use. Both practices generally went unchallenged and were once thought to be adequate standards of care-some practitioners may still think so-despite the frequent protests and physical resistance of those being restrained or forced to bathe. But solid evidence now disputes the safety and necessity of both of these practices. Bathing people routinely against their wishes-“for their own good”-should become part of nursing history, as personcentered care becomes the norm. We believe that to bathe people against their wishes, unless there is an acute, compelling health reason to do so, constitutes abuse. We hope to encourage nurses to think creatively about how to individualize care and inform and support those who provide direct care.

52 Healthy Skin

Current Bathing Practices In the home. Many community-dwelling older adults adapt their bathing methods as they age or become ill, but those who have dementia and those near the end of life usually require assistance and can be particularly challenging. And trying to bathe a person who is very frail, as people often are at the end of life, in a traditional shower or tub can be physically exhausting or impossible. In the hospital. Since hospital stays have decreased in length and patient acuity has increased, bathing has been less of a focus in facilities. Some acute care facilities are using premoistened, individually wrapped, no-rinse, disposable cloths that can be heated in a microwave oven. Bathing is often delegated to bedside caregivers, with very little professional oversight. Nurses, with their many competing priorities, may not be aware of problems when they arise or are poorly prepared to deal with them. In the long-term care facility. Most nursing homes in the United States schedule routine showers or tub baths for residents at least twice per week. The bathing method and schedule are usually based on the facility’s routine and not on the residents’ preferences. The vast majority are showered.6 In our experience, we’ve found that the shower or tub rooms are often cold and noisy, with tubs and shower equipment that may be unfamiliar or look intimidating. Staff

have reported to us that they feel rushed to get residents up and showered before breakfast. A high proportion of residents have cognitive impairment and may be easily confused or made anxious by being bathed. Pain during bathing is also common in people with dementia. One study found that 88% of 17 subjects had a history of arthritis, osteoporosis, or joint pain.7 The movements required during bathing (such as transferring out of bed into a shower chair and raising and lowering the arms and legs) can cause pain, fear, and discomfort. In our experience it’s not uncommon to hear residents’ screams and profanities from the shower or tub room, and many staff and residents’ families have told us that they believe such behaviors and other signs of discomfort during bathing are inevitable. Caregivers tell us that they worry about ensuring hygiene in a safe and comfortable way. It’s stressful to residents and professional and family caregivers to give care that results in pain, exhaustion, and agitated reactions such as hitting, biting, crying, and screaming.

We hope to encourage nurses to think creatively about how to individualize care and inform and support those who provide direct care.

Clinical Trial: Bathing People With Dementia The good news is that the stressors associated with assisted bathing can be modified. Bathing can be pleasant and without harm to older adults in the home, the hospital, and long-term care facility. We recently worked with other members of a research team to study two bathing methods in nursing home residents with dementia.5 We discovered several solutions that benefited both caregivers and residents. (Although we studied people with dementia, most of our ideas and principles are relevant to all older adults who require bathing assistance.) The study was a randomized, controlled trial with two experimental groups and a usual-care control group, conducted in nine nursing homes in Oregon and six in North Carolina. Two interventions were evaluated: person-centered showering and towel bathing in bed. We worked with 73 residents (69 completed the study) and 37 certified nursing assistants (CNAs). To be included in the study, residents had to be age 55 or older, have a diagnosis of Alzheimer disease or other dementia, have moderate or severe cognitive impairment, be able to be showered, and demonstrate agitation or aggression during bathing. The focus of both bathing methods was the resident’s comfort and preferences. Participating CNAs and nurses were encouraged to view resistance and other behavioral symptoms

Improving Quality of Care Based on CMS Guidelines 53

vs. Use no-rinse products to shorten and simplify bathing as expressions of unmet needs. They were taught to employ appropriate communication techniques, apply problem-solving approaches to identify causes of and potential solutions for behavioral symptoms, and adapt the environment to the residents’ comfort and security. Showering uses a wide variety of person-centered techniques, such as covering the resident with towels as much as possible during the shower, distracting the resident with food and interesting objects, using favorite soaps and no-rinse products, modifying the shower spray, and providing choices (such as whether hair is washed first, last, or not at all). The towel bath, a person-centered, in-bed method adapted from the Totman technique in which the caregiver uses a large towel, one or two regular-size towels, washcloths, a bath blanket, norinse soap, and water.8 Many nurses remember this procedure from obstetrics and hospital practice 30 years ago.9 Of the 15 nursing homes participating in our study, five served as control and 10 as experimental homes. Recruited facilities were randomly assigned to three groups of five facilities each. One treatment group received the towel bath during the first intervention period and showering during the second period. The other treatment group received the same interventions in reverse order. In the control group, consent and data collection occurred as in the treatment groups, but no intervention took place. In the 10 treatment facilities, clinicians (a clinical nurse specialist in Oregon and a licensed psychologist in North Carolina) worked with participating CNAs to understand the causes of agitation and

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aggression and to develop an individualized bathing plan designed to address those causes. The clinician and CNAs worked together one or two days per week for four weeks with each resident in the study during each of the two intervention periods. I n conducting the interventions, the team learned the following: Focusing on the person and the relationship rather than the task greatly reduces discomfort and behavioral symptoms. We found that caregivers assisting with bathing often felt rushed and frustrated, while residents felt a loss of control and even attacked. One of us (Rader) was showered in a nursing home during a preliminary study and found the accepted practice to be cold and distressing. Taking the resident’s point of view, we realized that the behaviors we had previously labeled “aggressive” or “resistive” were often defensive actions residents took when feeling threatened and anxious. (For more information, see “Making Sense of Aggressive/Protective Behaviors in Persons with Dementia” by Talerico and Evans in the October-December 2000 issue of Alzheimer’s Care Quarterly.) We found that by shifting the focus to getting to know the resident, communicating clearly (by reassuring or apologizing for any discomfort caused, for example), and thinking creatively, behavioral symptoms lessened. There was a marked reduction in all behavioral symptoms (by 32% in the shower group and 38% in the towel-bath group). Aggression declined by 53% in the shower group, 60% in the towel-bath group, and only 7% in the control group.

It doesn’t take a lot of water to get clean. Dry skin is a problem for about three-quarters of people age 65 or older.10 In planning our study, we knew several of the bathing strategies had the advantage of managing dry skin (for example, reducing the frequency of bathing can prevent scaling or cracking of the skin). First, we reduced the frequency of total-body bathing from twice per week to once per week for most subjects. Second, we switched from standard soaps to a no-rinse cleanser, Septi-Soft, with a soybean-oil base. Third, no rinsing was performed during the towel bath, which further reduced exposure to water. We were concerned that less frequent bathing and using less water in bathing might compromise hygiene. The study demonstrated that the towel bath doesn’t adversely affect skin condition or lead to the accumulation of pathogenic, odor-causing bacteria. Skin condition was significantly improved, in fact, and less debris and dirt were left on the skin. A person doesn’t have to be doused or dunked to be really clean. A bed bath can safely substitute for a shower. There are many ways to meet hygiene needs. Most nurses and CNAs are taught to start a bath at the head and work down because it’s assumed that the head and face are cleaner than other areas. But for people with dementia, water dripping in the face and having the head wet are generally the most upsetting parts of the bath; this causes distress at

the beginning of the bath. One alternative is to wash the face and hair at the end of the bath or at another time. Another is to use no-rinse products that can shorten and simplify bathing. Infection-control concerns can be addressed by the caregiver washing her hands and using a fresh, clean cloth after cleansing a part of the body that might cause contamination. Although many have been taught to cover the person during a shower or tub bath, few actually do this, possibly leaving the person cold and feeling exposed, embarrassed, and without dignity. Covering the person with a towel and washing beneath it alleviates this distress. These changes are simple, practical, and do not increase the length of bathing time. Pain is often the cause of behaviors. The prevalence of pain or potentially painful conditions among institutionalized older adults has been estimated to be between 43% and 71%,11-13 with musculoskeletal conditions the most common source. Many nursing home residents with dementia can’t describe their pain verbally, leading to behavioral symptoms such as aggression, resisting care, and vocalizations. The movements necessary in routine bathing, such as walking, standing, transferring from bed or wheelchair to tub or shower chair, and moving joints and limbs, can often exacerbate chronic pain or precipitate acute pain. We also found that pain is particularly common when washing between the toes, under

Alternative techniques:

Bathing people with dementia Most nurses and CNAs are taught to start a bath at the head and work down. Water dripping in the face and having the head wet are generally the most upsetting parts of a bath. The following alternative bathing methods may help to make bathing more comfortable for the person being bathed: Alternative 1: Wash the face and hair at the end of the bath or at another time. Alternative 2: Use no-rinse products that can shorten and simplify bathing. Alternative 3: Wash the face and hair at the end of the bath or at another time. Alternative 4: Covering the person with a towel and washing beneath it to keeps the person warm, unexposed, and less exposed.

Improving Quality of Care Based on CMS Guidelines 55

the arms, and on sensitive areas such as the genitals and face. In our study, residents’ discomfort declined significantly in both intervention groups, but not in the control group; the largest decline was with the towel-bath intervention (26%).

Practical Approaches To reduce pain associated with bathing, nursing home staff and other caregivers should explore the need for routine analgesia or nonpharmacologic approaches such as applying hot packs to sore joints before a bath. During the bath or shower, caregivers should move the limbs carefully, warn the person before moving or washing a potentially painful body part, and be aware of signs of discomfort. Letting the person assist in cleansing a painful area can diminish aggravation, as well as instill a sense of control that can diminish distress. And while it’s not always practical in all settings, giving a person time to soak in a tub without being rushed can help reduce chronic pain from muscular tension. Also, caregivers in all settings should be familiar with and use universal precautions with any bathing method, wearing gloves when appropriate for protection and infection control. Nurses should think about bathing others as they would think about bathing themselves. When you had a particularly pleasant bath or shower, what made it enjoyable? Conceptualize bathing as a pleasant experience. Nurses should think about bathing others as they would think about bathing themselves. When you last had a particularly pleasant bath or shower, what sensations made it enjoyable? When asked this question in a workshop setting, nurses have mentioned specific preferences: time of day, shower or tub, water temperature, length of shower or bath, music playing (or not), and scent. It’s rare that anyone mentions the process of washing or the goal of getting clean.

This is in stark contrast to the experience of many frail older adults, who depend on others for bathing and whose distress and discomfort can bring them to the point of resistance and aggression. Nurses and other caregivers have traditionally identified these behaviors as the problem and reducing or eliminating them as the goal. But such behaviors should be thought of as symptoms of the real problem: unpleasant bathing. Suggestions for the shower or tub. In the home, if the person is having difficulty getting into and out of the shower or tub, have a physical or occupational therapist perform an assessment. A hand-held showerhead, a bath bench, and properly placed grab bars can be of great help and also foster independence.4 Some spouses report better results when they shower along with the person, if space permits and doing so is customary. When older adults find getting in and out of bathtubs and showers difficult or frightening, despite environmental adaptations, the next step is often to do sponge baths at the sink. Families and other direct caregivers should be made aware of the wide variety of no-rinse products available, since they often make the process quicker, less complex, and less likely to cause agitation. In our study we found that SeptiSoft, when diluted, was useful in shower or tub. The typical plastic-pipe shower chair used in institutions often adds to pain and discomfort in the shower. Such chairs usually have an unpadded seat, a rather large opening, and no support for the feet. One of us (Rader) found that when she was showered in this type of chair, she sank in the opening and her feet dangled unsupported and turned blue-purple from impaired circulation. Before this personal experience, she had assumed that the foot discoloration she’d often observed in frail older adults was the result of irreversible physiologic changes.

Towel-bath interventions resulted in the greatest decline (26%) in discomfort in residents with musculoskeletal conditions 11-13

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vs.

Padded shower chairs make the bathing experience more comfortable.

The typical plastic-pipe shower chair often adds pain and discomfort in the shower.

In a preliminary study we purchased a shower chair with a padded seat and foot support.14 Staff members reported that residents who weren’t cognitively impaired requested this chair specifically once they’d felt how comfortable it was. Since purchasing new shower chairs isn’t always an option, try these adaptations: • Use a small plastic stool (6-in. to 9-in. tall) or an overturned plastic washbasin to support the feet. • Cover the cold, often wet, nylon-mesh chair back with a dry towel. • Cover the arms with closed-cell foam pipe insulation. • Pad the seat using small towels or washcloths, or purchase an inexpensive potty-seat insert and place it in the hole in the shower chair to pad the seat and make the hole smaller. • Disinfect shower chair additions along with the shower chair.

Hospitalized patients, unlike nursing home residents, may wish for more frequent bathing or a soothing bath or shower as a way to feel better. Family members can help with this, which can minimize fear and misunderstandings and also allow the patient to schedule bathing according to his energy level and other preferences. Suggestions for in-room bathing. Professional and family caregivers should consider routine bathing options outside the bath or shower. Here again, the use of no-rinse products can make bathing more pleasant and easier. Prepackaged “bathin-a-bag” products, consisting of up to eight premoistened, presoaped, no-rinse, disposable cloths, can be used in all settings. The following is a checklist for using them: • Heat the package according to instructions. • Check to ensure that the cloths are not too warm. • Remove a cloth and wash the person, using a new cloth for each part of the body.

• Check for small tears or cuts in the surface of the foam or seat insert and replace for infection control.

• Wash under the covers if the person is very sensitive to cold.

In assisted living facilities and nursing homes, a trusted staff member (and the same staff member) assisting with bathing is very important. Think about how difficult bathing would be if someone different were to bathe you each time. If the facility has consistent assignments, and the same person cares for the same resident over time, the caregiver and resident can develop a relationship and tailor the method, time, and frequency of bathing according to the resident’s needs.

Drying isn’t usually required because there’s minimal moisture. A “bath in a bag” does not require water, so a person can be washed in a variety of places. People living at home at the end of life can be adequately bathed while resting comfortably in a recliner. Even the toilet can be an appropriate place for this type of cleansing; for example, if the person has limited energy, requires an extended period on the commode, or feels pain when transferred, this method might be useful.

Improving Quality of Care Based on CMS Guidelines 57

Continuing hair washing in people with dementia is desirable because it’s familiar, enhances the person’s physical appearance, and it gives an opportunity to socialize. If disposable products are too expensive, create the equivalent using a diluted no-rinse product, a number of clean washcloths, and a small plastic bag. Be sure the person is warm and covered before you prepare your equipment: • Place the washcloths in the plastic bag. • Fill a graduate or pitcher with warm water (no hotter than 105ºF). • Add a quarter to half ounce of no-rinse product (such as Septi-Soft) to the water and pour just enough solution into the bag to moisten the washcloths. • Take the bag to the bedside or wherever the washing will take place. • Wash each section of the body, keeping the rest covered and warm. • Place the used washcloths in a second plastic bag. If a more relaxed way of bathing is desired, the towel-bath method can be very comforting and enjoyable (see The Towel Bath, next page). This method can be presented to the person as a “nice, warm massage” in bed rather than a “bath.” Avoiding the words “wash” and “bathe” can be helpful to people with dementia, who often associate the words with a cold, frightening, and uncomfortable experience. Once the caregiver is familiar with the procedures, the towel-bath technique is simple, quick, and easy to perform. In facilities that routinely use this technique, it’s useful to have the bags and towels prepackaged by laundry or central supply and place them in the linen closet for staff use.

When hair washing is the most dreaded part of bathing, it’s helpful to wash the hair only when it’s absolutely necessary, using a method that has been found to be the most pleasant and tolerable. For example, if you choose to wash the hair as part of a shower or tub bath, wait until the end, cover the person with dry towels, and then wash the hair, as follows: • Use very little water, pouring from a pitcher and carefully deflecting the water away from the eyes with either the hand or a washcloth; or dampen the hair with wet wash cloths. • Use as little shampoo as possible to reduce the need for rinsing. When washing the hair outside of the shower room, a basinand-washcloth method allows the person to remain fully clothed. Here is one: • First place a plastic bag and then a towel around the person’s neck and shoulders. • Dampen the hair with a wet washcloth. • Add a small amount of shampoo. • Massage the head.

Suggestions for hair washing. Going to the beauty parlor or barber is a pleasant experience for many people. Continuing this activity in people with dementia is desirable because it’s familiar, it enhances the person’s physical appearance, and it gives an opportunity to socialize. But a traditional beauty salon may overwhelm a person who has dementia. When a beautician is no longer appropriate or available, separating hair washing from the shower or bath is often useful in preventing agitation.

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• Use the wet washcloth to remove the shampoo from the hair one section at a time, rinsing the cloth in the basin of water frequently. • Gently dry with a towel. An in-bed inflatable basin is useful when hair-washing is performed separately from the bath or shower. Other options include a dry or no-rinse shampoo or a no-rinse shampoo cap.

Working with, Rather Than Against, Resistance Nurses in all settings should work with families so that they can better understand the many ways that hygiene can be maintained. Family members may think the person should be showered or bathed more often than is actually needed, desirable, or is actually tolerable. Without information, family members may see less-frequent showering as a way for nursing home staff to get out of doing the work, for example, rather than as a method of individualizing care. Resources An interactive CD-ROM and video package, Bathing Without a Battle, produced by three of us (Barrick, Rader, and Sloane), was sent to all federally funded nursing homes in January 2004. It is available for purchase online at www.bathingwithoutabattle.unc.edu.4 A book by the same name (and authors) is also available in stores and online.

Improving the Shower or Tub Experience • Switch bathing to a different or familiar time of the day. • Separate hair washing from body washing if either is distressing or overwhelming to the person being bathed. • Cover the person being bathed with a dry towel when using a hand-held shower to prevent the person from being wet, naked, and cold; simply lift up the towel to wash.

References

A caregiver is preparing a nursing home resident for bathing and the resident, an older woman with dementia, is resisting. “You think you know more about my own body,” she says, grabbing at the caregiver’s arms and twisting the collar of her blouse. “You don’t want me to live in my own body.” The caregiver says it isn’t so, and the resident counters with, “Well, why don’t you keep your hands off of me?” This is a scene from a CD-ROM and video package, Bathing Without a Battle: Creating a Better Bathing Experience for Persons with Alzheimer’s Disease and Related Disorders, created by three of us (Rader, Barrick, and Sloane), which depicts actual scenes of assisted bathing that unfold with varying degrees of success. The familiar forms of resistance, such as hitting, biting, and shouting, are shown, as are strategies that caregivers might use.

1. N aik AD, et al. Bathing disability in community-living older persons: common, consequential, and complex. J Am Geriatr Soc 2004;52(11):1805-10. 2. E vans LK. The bath!! Reassessing a familiar elixir in old age. J Am Geriatr Soc 2004;52(11):1957-8. 3. D ecker FH. Nursing homes 1977-1999: what has changed and what has not? Hyattsville, MD: National Center for Health Statistics; 2005. http://www.cdc.gov/ nchs/data/nnhsd/NursingHomes1977_99.pdf . 4. B arrick AL, et al. Bathing without a battle: creating a better bathing experience for persons with Alzheimer’s disease and related disorders [CD-ROM]. Chapel Hill, NC: University of North Carolina; 2003. 5. S loane PD, et al. Effect of person-centered showering and the towel bath on bathing-associated aggression, agitation, and discomfort in nursing home residents with dementia: a randomized, controlled trial. J Am Geriatr Soc 2004;52(11): 1795-804. 6. S loane PD, et al. Bathing the Alzheimer’s patient in long term care: results and recommendations from three studies. Am J Alzheimers Dis Other Demen 1995;10(4):3-11. 7. M iller L, et al. Development of an intervention to reduce pain in older adults with dementia: challenges and lessons learned. Alzheimer’s Care Quarterly 2005;6(2):154-67. 8. Sloane PD, et al. Bathing persons with dementia. Gerontologist 1995;35(5):672-8. 9. Towel-bath-Totman technique [protocol]. St. Louis: Calgon-Vestal Laboratories; 1975.

In another sequence, a caregiver offers a washcloth to an older woman. The woman takes the washcloth and washes her own face. The caregiver then asks the woman’s permission before removing her hospital gown and lets the woman test the temperature of the water before wetting her skin. These actions help the person feel that she has some control, which helps make for a smoother process.

10. Davis G, Luggen A. Geriatric nurse practitioner care guidelines: pruritus and xerosis in the elderly person. Geriatr Nurs 2003;24(4):247-8. 11. Ferrell BA, et al. Pain in cognitively impaired nursing home patients. J Pain Symptom Manage 1995;10(8):591-8. 12. Marzinski LR. The tragedy of dementia: clinically assessing pain in the confused nonverbal elderly. J Gerontol Nurs 1991;17(6):25-8. 13. Parmelee PA. Pain in cognitively impaired older persons. Clin Geriatr Med 1996;12(3):473-87. 14. Hoeffer B, et al. Reducing aggressive behavior during bathing cognitively impaired nursing home residents. J Gerontol Nurs 1997;23(5):16-23.

Reprinted with permission. American Journal of Nursing. 2006; 106(4):40 – 48.

Improving Quality of Care Based on CMS Guidelines 59

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Bath-in-a-Bag Moist Towelette Bathing System Elizabeth O Connell-Gifford, RN, BSN, CWOCN, DAPWCA, MBA

Policy A moist towelette bath will be used on individuals requiring a bed bath, unless contraindicated, and will be available to any other individual. Goal To provide the individuals with a bath that will leave a clean and refreshed feeling while maintaining comfort and dignity. Supplies Bath-in-a-Bag Moist Towelette Bathing System Showerless Shampoo Cap (optional) Warming unit (central supply location) Gloves Bath blanket Clean gown or clothing Towel (optional)

4. Don gloves if necessary. 5. Encourage the individual to participate to the extent that he/she is capable. 6. If giving a shampoo, place the warm cap on the head. 7. Remove the bathing cloth from the package, then reseal package to retain heat. 8. A towel may be used to gently dry areas, especially between skin folds. 9. Discard the used towelette in a trash receptacle. DO NOT FLUSH! 10. Start with the face, neck and chest 11. Right arm and axilla 12. Left arm and axilla 13. Perineal region 14. Right leg

Procedure 1. Knock on the door and identify the individual. 2. Introduce yourself and explain the procedure. • There will be several towelettes for different parts of the body. Show the diagram on the package to the resident, if appropriate.

• The towelettes are saturated with a hydrating no-rinse formula. • There is no need for additional basins, washcloths, or towels. • If you are using a warming method (microwave or warmer), follow instructions for that particular method to warm product.

3. Remove the individual’s gown or clothing and any removable elastic bandages, stockings, or restraints. Provide a bath blanket for privacy and warmth. Use the bath blanket to cover any exposed areas.

15. Left leg 16. Back 17. Buttocks 18. While either bathing or assisting with the bath, assess the individual’s skin for any signs of breakdown or any changes. 19. Finish the shampoo by massaging the head, remove the cap, and then comb out the hair. 20. Dress, or help the individual get dressed, with a clean gown or other appropriate clothing. Reapply any elastic bandages, stockings, or restraints that were removed prior to bathing. 21. Document. Record the date and time of the bath. Note the individual’s tolerance to the bath, any self-care ability, and any unusual

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Prevention

Automated Hand Hygiene Compliance Monitoring Systems Partner or Big Brother? By Marc Lessem

Perhaps you remember your grade school hall monitor. For me, it was Mrs. Angeloni. Amongst us kids, she was anything but an “angel.” She was a tough woman who took her job seriously—maybe too seriously. I don’t think she ever cracked a smile! Years later, I realized it was her obligation to watch over us. She made sure we complied with the class schedule. In hindsight, we should have embraced her resolve, we should have thanked her for enabling us to learn more as a result of her dedication and we should have befriended her instead of fearing and being intimidated by her. It turns out that Mrs. Angeloni, my grade school hall monitor, was an angel of sorts. Though the stakes are much higher, the role of monitor plays a huge part in the daily routine of healthcare professionals. Today, patients’ lives are in the balance, and caregivers rely on monitors to provide useful information such as vital signs and blood glucose levels. And because hand hygiene is one of the most important ways to prevent the spread of infections,1 the most important patient safety monitor might be the hand hygiene compliance monitor. Going all the way back to 1847 when Dr. Ignaz Semmelweis first identified the cause and effect relationship between disease and unclean hands, the goal of 100 percent hand hygiene compliance has been difficult to reach. It is widely recognized that Dr. Semmelweis used his strong personality, and sometimes not so subtle words, to change the behavior of his colleagues. He was the first documented “hand hygiene compliance monitor.” Perhaps he felt he had to be shocking and demonstrative because the science of hand hygiene was unknown. Thankfully, he persevered and the science has evolved. Today, hand hygiene is regarded as the most effective single measure to prevent health care-associated infections.2 And yet, 100 percent hand hygiene compliance remains an elusive goal, and measuring compliance remains a challenge. Many would argue it is time for the science of compliance measurement to evolve as well.

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Table 1. Traditional Methods for Measuring Hand Hygiene Compliance Measurement Methodology

Description

Anonymous (secret shopper)

Observation

observation and recording of hand hygiene events by individual caregiver

Soap and/or sanitizer usage

Consumption

is recorded and compared with census days

Self-Reporting

Merits • Individual accountability • Compliance and technique can be measured • Ability to monitor per WHO “My Five Moments” model

• Relatively simple • Cost effective to implement

Healthcare workers submit

• Low cost to implement

self-evaluations.

• Staff commitment

Traditional methods for measuring compliance Traditionally, hand hygiene compliance has been measured through self-reporting, consumption and/or observation. While each method can provide a quantitative compliance rate for a defined time period, it is the relative change over those defined time periods that is tracked. Interventions are deemed successful if the trend moves in the right direction. Each methodology has both merits and drawbacks, some of which are detailed in Table 1. Is there a better way to measure hand hygiene compliance than with these traditional options? The answer may be yes! New technologies for measuring compliance Electronic hand hygiene compliance measurement systems, such as RFID (radio frequency identification) and RTLS (realtime location system) are now being promoted to infection preventionists and C-suite personnel. In some cases, the systems are part of the nurse call or asset tracking systems already in place. These systems deploy dispensers or alcohol-sensing

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Drawbacks

• Requires dedicated and costly labor resources • “Hawthorn” effect may result in overstated compliance rates

• Cannot measure individual caregiver compliance or technique • Overstated compliance rates unsubstantiated by unbiased observers

devices that interface with healthcare workers’ name badges and remind healthcare workers to cleanse their hands through the use of audible, visual or vibrating cues. The badge or badge holder communicates with a device typically mounted near the doorway or bed of each patient room. For example, a badge may flash “red” if a hand hygiene event has not occurred prior to patient contact and “green” if it has. The “smart” badge also communicates with a data collection server. Through the use of proprietary software, the data is collected and management reports designed to monitor hand hygiene compliance are generated. Depending on the desired reporting and the system capabilities, these reports can be sorted by healthcare worker title (e.g., RNs on 2-West) or by individual (e.g., Sally Johnson). The reports can be used to track compliance to allow for training and education interventions when compliance is lacking and reward and recognition when compliance improves.

Points to consider before implementing an automated compliance system Implementing an automated hand hygiene compliance monitoring system is a complex interdisciplinary decision. Prior to implementation, consider engaging in thoughtful discussion of the following: Expense. Purchased outright, these systems can be costly. By acquiring the system via a monthly service fee, capital expenditures can be avoided. Net cost, however, is dependent on how the impact of healthcare-acquired infections is factored into the equation. A case can be made that with a nominal reduction in HAIs, these systems are a wise investment with an attractive return on investment versus expense. Another case can be made that the money is better spent elsewhere. Individual accountability. Management reports generated from these systems will be used to favorably impact compliance. Some will choose to use the data to reward compliant personnel. Others may use the data for punitive purposes for non-compliant offenders. The impact of labor unions must be considered as well. Unions may desire that the monitoring system be flexible enough to collect data with some degree of anonymity as well as by individual name.

other systems require facilities to use specific soaps with certain levels of alcohol so they can be detected electronically. RFID vs RTLS. These are the two most prevalent technologies. RTLS systems are commonplace for asset tracking, and although it might be tempting to expand on a RTLS platform to leverage that investment, RTLS differs from RFID and a technical capability review is required for accurate hand hygiene monitoring. Most stand alone systems that are designed for the purpose of monitoring hand hygiene compliance utilize RFID. Installation/Maintenance. Some systems are battery-operated and can be installed with double-sided tape, whereas others require a power source, such as AC power, to operate some of the related devices. Installation issues related to facility modification and patient inconvenience must be considered. Furthermore, battery life and/or recharging capabilities must be accounted for as well.

Workflow interruption. Two of the most common obstacles to compliance are lack of time and behavior modification. Sometimes just getting the healthcare worker to the dispenser is deemed a victory. After recognizing the dispenser user via “smart” badge, some automated compliance systems require a second step to verify application of the hand hygiene agent to the hands. Such systems require moderate retraining.

IT involvement. Communications technology and device capabilities are critical. Information technology experts will want to review the hardware required. From a software perspective, most system designs attempt to communicate outside the facility network. This is desirable because it hastens implementation and eliminates security concerns.

Desire to monitor hand washing. While monitoring for the use of alcohol-based hand sanitizer appears achievable for all systems, some automated monitoring systems are limited in their ability to monitor hand washing with soap and water. Some systems are unable to monitor soap and water events, whereas

Measuring to the WHO “5 Moments” Model. Do you wish to monitor healthcare workers as they enter and leave the patient room or do you prefer to monitor within a narrow patient zone around the patient’s bed to more closely approximate the World Health Organization’s “My 5 Moments for Hand Hygiene”3 model?

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Partner or big brother? You decide. After all considerations are evaluated and a decision is made, there remains a single very challenging question to be answered. Are staff and administration ready for the realization that previously reported compliance rates may be grossly overstated? For some facilities that report compliance rates in the 80 to 90 percent range, as calculated by one of the more traditional methods described earlier, it can be a rude wake up call to see how objective reporting from thousands of data points may result in far lower reported compliance rates. How to deal with this from a motivation and compensation perspective requires prospective thought and benevolent senior leadership. The decision to deploy an automated compliance system is highly dependent on the healthcare team’s resources and commitment to hand hygiene. If embraced, these emerging technologies can be a true infection prevention partner in the fight against HAIs. Yet, some healthcare workers might consider them more “Big Brother” and feel threatened. As with any innovative action, implementing an automated hand hygiene compliance monitoring system requires the support of bold leaders who can effectively communicate and motivate. If the end result is improved patient outcomes, could anyone argue that these monitors are as angelic as Mrs. Angeloni? Reference 1. Centers for Disease Control and Prevention. Hand Hygiene Basics. Available at: http://www. cdc.gov/handhygiene/Basics.html. Accessed December 9, 2011. 2. Scheithauer S, Oude-Aost J, Heimann K, Haefner H, Waitschies B, Kampf G, et al. Hand hygiene in pediatric and neonatal intensive care patients: daily opportunities and indicationand profession-specific analyses of compliance. American Journal of Infection Control. 2011; 39(9):732-737. 3. World Health Organization. About SAVE LIVES: Clean Your Hands. My Moments for Hand Hygiene. Available at: http://www.who.int/gpsc/5may/background/5moments/en/index. html. Accessed December 9, 2011.

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As with any innovative action, implementing an automated hand hygiene compliance monitoring system requires the support of bold leaders who can effectively communicate and motivate.

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How Gentle? Remedy with Phytoplex has been tested in NICU, pediatric and adult populations with results like “safe and well tolerated,” “did not cause adverse skin reactions” and “no clinically significant evidence of increases in erythema, edema or dryness.” Ask your Medline rep for study details.

• Hydraguard, a 24% silicone cream that is highly moisture repellent and smooths gently on fragile skin • Nourishing Skin Cream, a blend of emollients including safflower oleosomes, all-natural oils, plant extracts and NO petrochemicals • Z-Guard Protectant Paste, formulated with pure white petrolatum and zinc oxide and without potential irritants such as menthol • Antifungal Clear Ointment, with 2% miconazole nitrate in a clear petrolatum base amended with soothing botanicals. (Not for use on scalp, nails or on children under 2 years of age.)

H O T L I N E

Regular Feature

T O P I C

G N I S ES CE TO R D D A ISTAN OF RES TYPES SSINGS NEW ND DRE ARS WOU SKIN TE FOR

by Elizabeth O’Connell-Gifford BSN, MBA, RN, CWOCN, DAPWCA

Question:

Answer:

I am a director of nursing (DON) in a long-term care facility. After forming a wound team, and developing and implementing protocols, I am frustrated that the staff follows the protocols except when it comes to skin tears. Our nurse aides received many hours of education about moisturizing the skin to prevent skin tears, but we still have a fair number of skin tears.

We receive many calls like this on the hotline from frustrated supervisors, case managers and DONs in long-term care, home care and hospice. Some even relate that the day shift may apply the correct dressing, and then an off-shift nurse may change the dressing to an old style wet to dry “because they don’t believe in all these new fangled dressings.” The staff may also be under fire from relatives or the patients themselves about leaving the wound open to air.

The protocol is to apply a gel dressing every three days. If the wound bed is dry it is covered with a gauze dressing, and if the wound has moderate drainage, it is covered with a foam dressing and changed every five to seven days. Rather then seeing this protocol followed, instead, I consistently find Xeroform or Adaptic with an antibiotic ointment covered with a telfa to be changed daily. This type of dressing puts the facility at risk with the department of health survey team. How can I get my staff to follow the policy?

68 Healthy Skin

Staff not following policies or protocols puts facilities at risk for a deficiency in a department of health survey, and sets the stage for negligence from not following a physician’s orders. When you say you developed and implemented protocols, I am assuming that you had input and final approval from the physician team for the skin and wound care approach you want your team to follow. I recently attended a seminar that discussed the legal implications of wound care. The author discussed several points that seem to apply here.

Regular Feature

Protocols versus guidelines A recommendation was made to change the words “policy, procedure or protocol” to “guidelines,” so that if the staff does not follow the wording of the document exactly they are not setting themselves up for “conduct that falls below the standards of care.”

Having spent several years as a staff development instructor and infection control nurse, I am very aware that what I said is not always what the staff heard. There are several concepts that staff need to understand for them to accept new ideas and new products.

If the protocol indicates the nurse should be applying a gel dressing every three days, and he or she chooses to apply antibiotic ointment and xeroform/adaptic (or use the generic petroleum gauze) without a physician’s order, then that nurse is essentially practicing medicine without a license since antibiotic ointment is an over-the-counter topical drug.

Moist wound healing Early in the 19th century it was common practice to leave smaller lesions, surgical incisions or wounds such as skin tears open to air or to shine a lamp on a wound such as a bedsore using “dry healing” to close an open area. The scab that was formed was thought to be a quality indicator of healing. It wasn’t until the 1960s that scientists discovered that covering a wound up with a moisture retentive dressing such as a film, hydrocolloid and some foams to retain the moisture actually increases the speed of healing. The collection of fluids, or “wound soup,” contains platelets, growth factors, white blood cells, macrophages and components that perform moist healing. Your staff needs to understand and embrace this moist wound healing concept, which has become a standard of care.

You mentioned the extensive education provided. What did it involve specifically? Were the protocols just verbally reviewed during an in-service or was a return demo or competency required to validate the nurses’ knowledge? What about the “new fangled” products? How was the information delivered? Did the staff have a chance to touch and feel the products and ask questions about the mechanisms of wound healing? Did you show your staff photos of a wound after three to five days with the dressing and point out the drainage prior to the wound being cleansed? Does your staff understand the concepts of moist wound healing?

nd care u o w r o ing a skin t or resident? c a f u o y n Are h a patie t i w a m dilem Call Medline’s Educare Hotline at 888-701-SKIN (7546) to discuss a wound care issue with one of our experienced wound care nurses. The hotline is available Monday through Friday, 8 am to 5 pm, Central Time.

1-SKIN (7546) 888-70

In addition, the action of daily dressing changes may cause the patient pain, may expose the wound bed to additional microbes and most likely will decrease the wound bed temperature. Healing will not begin again until the wound bed temperature rises to the patient’s normal temperature. Infection misconception The words we learn in nursing and medical school to identify and explain infection: “red,” “warm,” “local edema” and “pain” are the same clinical markers that describe the inflammatory phase of wound healing. The subtleties are in how pronounced the signs and symptoms present themselves. Often the ingredients in new thin dressings, such as starch molecules in a hydrogel or the carboxymethylcellulose (CMC) of a hydrocolloid, absorb exudate from the wound, and the resultant liquid drainage may appear green or tan in color with a chunky texture and an odor. An inexperienced staff nurse may believe the wound is infected, and he or she may even call the physician to report these findings and suggest that the dressing is changed to an antibacterial, antimicrobial or silver-containing product. These dressings must be re-applied daily because the medication is released in 24 hours, and after that they become ineffective. The nurse may even suggest the patient requires an antibiotic for “cellulitis.”

Improving Quality of Care Based on CMS Guidelines 69

Changing skin tear dressings daily may add to increased overall costs when you calculate supplies, increased time to closure and additional pain medication for the patient.

Nurses are often not educated that a true assessment of the wound bed cannot begin until the wound is cleaned. Then the drainage from the wound and the odor of the wound bed should be noted. So what is all that awful-looking drainage? The odor may be a result of the components of wound fluidcellular waste products, dead cells (cadaverine) and dead fat (putrisene) and components of the product. This is one of the reasons why certain nurses and physicians do not trust new dressings. Education on new types of wound dressings should include the science of what is taking place and how the dressing category works with that physiology. What to do with the “peekers” Medical professionals who continue to subscribe to daily treatments may do so because they do not trust that a dressing can be left in place with nothing bad happening to the wound. They belong to a class of nurses I call “peekers.” Changing skin tear dressings daily may add to increased overall costs when you calculate supplies, increased time to closure and additional pain medication for the patient. An alternative to daily dressings are dressings with silicone borders that allow the staff to peek and re-seal the edges without disturbing the wound bed or dropping the wound temperature. Most wounds initially do not require treatment with a product to protect the wound from bacteria and fungus. The decision to initiate such products should occur when there are signs and symptoms that indicate microbes are impeding healing. In that case, a silver antimicrobial gel or silver foam could be initiated.

\ Cy∙an∙o∙a∙cry∙late \ A fast-acting adhesive that bonds with the skin to create a barrier against moisture and friction.

Problem: Peristomal Irritation Solution: Marathon® Cyanoacrylate Liquid Skin Protectant Peristomal irritation can lead to decreased wear time, pain and embarrassment about leakage. So it only makes sense to do everything you can to protect the peristomal area. Marathon Liquid Skin Protectant helps protect against irritation and maceration by creating a barrier against moisture and chemical assault. Marathon, a cyanoacrylate, bonds to the skin surface, integrating with the epidermis on a molecular level to seal in moisture. While other skin protectants may flake off, Marathon stays in place, offering robust protection and increased wafer wear time.

Stoma site before treatment with Marathon.1

Same stoma site after treatment with Marathon.1

1. Data on file

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MEDLINE’S REVOLUTIONARY SHOW-AND-TELL PACKAGING

Each package is a 2-Minute Course in Advanced Wound Care ™

Medline’s Educational Packaging offers all the information you need, step by step, short and sweet, to help the Medline dressing do its job of healing. In a study involving 139 nurses at eight different facilities, 88% who used a wound care product with an education guide attached were able to apply the dressing to a wound correctly.1

www.medline.com/ep Reference 1. Kent DJ. Effects of a just-in-time education intervention placed on wound dressing packages. Journal of Wound, Ostomy and Continence Nursing. 2010; 37(6):609-614. ©2012 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.

New QA System Improves Resident Quality Care; Builds Staff Morale Innovative quality assurance tool replicates QIS process and empowers staff to improve residents’ quality of life. By Carmen Shell

Our Nursing Facility Morse Geriatric Center is a not-for-profit, mission-driven, 280-bed long-term care facility designed and dedicated to serving the elderly in Florida’s Palm Beach County. Morse Geriatric Center is also a designated teaching nursing home by the Florida legislature. Morse Geriatric Center has received the Gold Seal Award from the State of Florida, Governor’s Panel on Excellence in Long-Term Care. The Gold Seal Award was established in 2002 to recognize Florida nursing homes that consistently demonstrate exceptionally high standards and quality of care.

Our Challenge I guess you could say we’re early adapters at Morse Geriatric Center. In October 2006, Florida was added to the Quality Indicator Survey (QIS) demonstration project to test a statewide implementation approach to prepare for a national QIS rollout. I was selected as the QIS trainer for our facility and subsequently trained all of our corporate staff and key personnel, including administrative staff, nurses, dietitians, housekeepers, certified nursing assistants and social workers. The training opened our eyes to the new QIS, which is radically different than the traditional survey. We immediately realized we needed education and new internal processes to be proactive to the survey

Morse Geriatric Center was an early adapter of the Quality Indicator Survey (QIS), having participated in a demonstration project in 2006 to test a statewide implementation approach for Florida.

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Special Feature

With abaqis, both staff and residents immediately felt the lines of communication open up.

process. Moreover, our past performance on the traditional survey was satisfactory, but we wanted zero deficiencies and our goal is to have our facility operate at the highest level continuously, not just in our survey window.

thresholds and analyses as the QIS to quickly highlight residents at risk. abaqis also would prove to be a tool that could easily be taught to our staff and that allowed me to access reports quickly and easily.

The QIS process is resident-centered, customer service-oriented and designed to more accurately and objectively evaluate facility compliance with federal regulations. The survey sample is randomly selected and uses established threshold markers to consistently identify, and therefore confirm areas of non-compliance.

Replicates QIS Survey The abaqis Stage I Suite examines 125 resident-centered indicators of quality of life (QCLIs) that are used to identify care areas for a Stage II in-depth investigation and possible citations during a QIS.

One of the biggest changes with the new QIS process is that it is designed to be more consistent and less subjective with a resident-centered/customer service focus. As a result of these changes, we needed not only new processes to help us prepare for the survey, but a new quality assurance tool to guide us in reflecting that the resident is the focal point of our business.

The Solution The introduction of the new QIS coincided with our mission to improve customer service. Our priority was to first find a continuous quality assurance tool to help us achieve these goals. We knew if we could better identify quality and customer service issues, we could directly affect our day-to-day outcomes and survey results. In the winter of 2007, we were exposed to a new quality assurance tool for nursing homes that was tied directly to the QIS called abaqis. Marketed and distributed exclusively by Medline Industries, Inc., abaqis is a web-based tool that uses the same calculations,

These indicators are contained in six modules that replicate exactly the QIS assessments conducted on site during the survey, plus one module that uploads and reviews MDS data. The modules are: • Resident Interview • Family Interview • Staff Interview • Resident Observation • Census Sample Record Review • Admission Sample Record Review • MDS Data Just one month to implement abaqis system wide Once we learned about the abaqis system, we trained the key people at our facility who would be implementing the new tool, including administrative assistants, clinicians, dietitians, housekeepers and social workers. The training was not difficult and took about one month in total to get our facility trained and ready to implement abaqis.

Improving Quality of Care Based on CMS Guidelines 73

Because abaqis asks residents questions about how they feel they are being treated in specific areas of their care such as food preparation, daily activities or even what time they go to bed, both staff and residents immediately felt the lines of communication open up. Residents sensed a greater voice and staff had an evidence-based platform to direct care and services. The goal is to have the resident, family and staff interviews completed quarterly by an administrative assistant, dietitian, unit manager or a social worker. Chart reviews are on the same timeline, but are usually conducted by the clinicians. We then have QA meetings on a monthly basis to review performance measures and areas for improvement.

Real change to improve care Our previous QA system often did not enable us to easily drill down to find the heart of a problem. It seemed our audits were all retrospective. abaqis is real-time, and upon completion of all Stage I and Stage II modules, we were able to determine if the problem was a structure, process or outcome issue.

Like the QIS survey, abaqis also uses laptop computers or tablet PCs to capture data. Early on we used traditional pen and paper, and then entered the data into a central computer. But now we are making the transition to computers or WOWs (workstations on wheels), which reduces administrative time substantially and allows us to utilize abaqis and our staff more efficiently.

Similarly, with QIS and abaqis redefining what quality assurance means to our facility, our staff now has a renewed sense of empowerment and team building. They ask our residents what they want and how they feel, and if a resident wants something changed, our staff has the real sense that they can improve our residents’ lives.

‘Real-time’ summary reports reveal deficiencies The data from our facility is aggregated on a central file so we can review summary reports on the entire facility. This enables us to determine our progress and what action steps need to be taken. For instance, we can view reports that show how many residents still need to be interviewed, what areas could be flagged for deficiency or what trends are developing in specific areas or facility wide.

Asking the resident and family interview questions has forced us to take a hard look at ourselves and ask the hard question, “Are we truly meeting the needs and choices of our residents and families?” The interviews, as well as resident observations, can really reveal a facility’s weak spots.

Another key benefit of abaqis is that it lets us see results in real time. As soon as the data is entered into the computer, we are able to access it on our computers, analyze it and identify areas of concern.

Results Staff attitude shifts to resident-centered care At first, many of our staff did not feel they had time to implement a new ongoing QA process. They were hesitant and reluctant to change. Fortunately, soon after the staff started using abaqis, saw the results, and realized the benefits, they became believers in our new continuous quality improvement tool.

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After several months using abaqis and employing ongoing quality assurance, our line staff felt prepared for the QIS survey and confident they knew what to expect. About the Author Carmen Shell, RN, CDONA has served, since 2000, as the Vice President of Clinical Services at MorseLife, a comprehensive senior care community located in Palm Beach County. Ms. Shell has clinical and operational responsibility for Nursing, Social Services, Admissions, Rehabilitation and Therapeutic Recreation for the campus which includes more than 400 SNF/IL/AL beds and a staff of 800+ employees.

NO CATHETER CATHETER IS THE THE BEST CATHETER IS

ERASE CAUTI ERASE CAUTI

速

www.erasecauti.com

Caring for Yourself

FEAR: HOW TO KILL IT

DEAD! 76 Healthy Skin

By Wolf J. Rinke, PhD, RD, CSP

Erik Weihenmeyer successfully climbed Mt. Everest and four of the worlds’ tallest peaks. No big deal, right? Wrong! It’s a very big deal because Erik is BLIND! Contrast that to the fact that many of us have difficulty tackling even the most mundane challenges. For example you may be afraid of asking for that raise you know you have earned. If you’ve had a disagreement with your boss you may be afraid to talk to her about it. Or you may be avoiding to get in touch with that wonderful young man you met at the party last weekend. What prevents most of us from being more like Erik? It’s that dirty four letter word: FEAR! Here are six specific strategies you can use to help you get rid of fear.

Improving Quality of Care Based on CMS Guidelines 77

e It

1. Acknowledg

Acknowledging that fear of failure is normal allows us to see ourselves as typical human beings instead of “chickens.” It provides us with the mechanism for getting off our case. For most of us, we are the ones who hold us back more than anything or anyone else. Some time ago I shared a taxi with a young man on my way from Chicago’s O’Hare airport to downtown Chicago. He told me that he worked for CBS and was on his way to make a big presentation to the CBS board of directors. When I told him that I was a professional speaker, management consultant, and author he got excited. He immediately began to quiz me on how he could be a more effective presenter for this big meeting he had coming up. I asked him what he wanted to improve. After some prying, he told me he wanted to be less nervous. I asked him why he wanted to do that. When he gave me a funny look that said: Wonder what kind of professional speaker this guy is? I explained that speakers who are not nervous are terrible speakers because they are deadly. (Remember that professor that put you to sleep during every lecture?) I assured him that being nervous is a benefit, provided the nervous energy is channeled in the right direction. After coaching him, I left him with a thought that he eagerly wrote down: “Every speaker has butterflies. Excellent speakers make the butterflies fly in formation.” One week later he sent me a note together with an order for my book and audio program. In his note he told me that he had made his butterflies fly in formation and that he had made the best presentation of his life. (If you’d like help with this read Knock’em Alive Presentation Skills: How to Make an Effective Presentation for 1 or 1,000, 2nd Edition, (C208), 20 CPEUs, available at wolfrinke.com/CEFILES/cepd.html#C208, or in an e-course format at wolfrinke.com/CEFILES/ecourses. htm#C208.)

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ou Fear Y g in h T e th o 3. D

2. Ignore othe

I have found over the years that the minute I announce an innovative idea, a new business venture, a great suggestion for an outing, or anything else that is different, there are innumerable people who tell me that it won’t work, is not feasible, or is too risky. The naysayer song goes on and on. If you have worked in a traditional healthcare organization, I know that you too have heard that song many times. That type of advice used to slow me down. It made me cautious, made me rethink my original thoughts, caused me to worry, and led me to focus on all the reasons why something could not work, dissipating my energy to the point that I could no longer see all the reasons why it could work. Before I knew it, I gave up on what might have been a milliondollar idea. Not anymore. I have developed a simple but powerful strategy to silence the naysayers by saying: “I appreciate your concern. Have you yourself done this before?” If the answer is no, I thank them for their interest and ignore their advice. On the other hand, if the answer is “yes” I listen attentively so that I can learn from their mistakes. I firmly believe that only the people who have taken the journey and who have experienced the risks are able to provide you with meaningful advice. Most of the others want to be sure that you remain one level below them so that they can feel OK about themselves. After all, if you succeed too much, it might lower their self-esteem.

Think about what you fear the most, and do it. Probably the biggest confidence builder in your life is to do the thing you fear. It may be quitting your current job, jumping out of an airplane (do put on a parachute first, and, while you are at it, get some decent instructions too), living in the wilderness, scuba diving, or giving a speech. Do your homework, get yourself mentally and physically conditioned, and break the task into small, doable steps so that you can benefit from the principle of incremental success. For example, tightrope walkers start low to the ground. After they have it mastered at that height, they go up a little bit at a time. When they get dangerously high, they add a safety net. Only after they have mastered the task to the point that they could do it in their sleep do they remove the safety net. After experiencing incremental successes at whatever you are afraid of, you will be able to do it, and will no longer be afraid of it. Most importantly, it will empower you and put you in charge of your life, providing you with the confidence of a supremely successful human being.

4. Conduct a W orst-Case Analysis Whenever I am presented with a challenge that scares me, I ask myself, “What is the worst thing that can possibly happen?” After I identify that, I ask myself, Can you live with that? If the answer is yes, I forget the worst case, visualize myself succeeding, and go for it. If that does not work for you, do a basic Ben Franklin decision making analysis. (Actually Plato came up with it first.) For each option, list the “Pros” and “Cons.” Now pick the option that has the greatest number of Pros and the fewest Cons, and go for it with gusto. (For other useful decision making strategies go to http://en.wikipedia.org/ wiki/Decision_making.)

Improving Quality of Care Based on CMS Guidelines 79

esire

r with D a e F e c la p e R . 5

All of us are motivated by two very powerful human emotions: fear and desire. Both are extremely powerful and both work equally well, although in opposite directions. To overcome fear, we must recognize that the human mind can only hold one major thought at a time. To take advantage of this phenomenon, we must get in the habit of substituting desire for fear when we communicate with ourselves and with others. Instead of programming our mind with the things we do not want to have happen we must use the same creative energy to tell ourselves what it is that we want to have happen. Telling ourselves what we want should be supplemented with visualizing what we desire in clear, vivid, dramatic pictures. Once you have formulated that picture in your mind, think of all the positive consequences associated with succeeding. That way you will be focusing on the rewards of success instead of the penalties of failure.

6. PIN it The PIN technique will help you focus on the positive instead of the negative, see the opportunity instead of the risks, and generally minimize “stinking thinking.” Internalizing and consistently applying the PIN technique has enabled me to transform myself from a perpetual pessimist into an eternal optimist. The PIN technique consists of a three-step mental process that you

80 Healthy Skin

can use to first focus on what is positive (P), then on what is interesting or innovative (I), and last on what is negative (N). By PINing it, instead of NIPing it, you will provide yourself with the ability to focus your vast mental energies on positive thoughts instead of squandering them on negative and nonproductive ideas. NIPing it closes the proverbial mental shade whereas PINing it allows you to go beyond your customary response pattern and provides you with a technique that will let you see the hidden opportunities and focus on desire instead of fear. For other empowering strategies read or listen to Make It a Winning Life: Success Strategies for Life, Love or Business available at http://wolfrinke.com/MIWL.html or if you need CPE credits devour How to Maximize Professional Potential and Increase Your Earning Power (C187) approved for 30 CPEUs, available at http://www.wolfrinke.com/CEFILES/cepd.html#C187.) © 2011 Wolf J. Rinke

Dr. Wolf J. Rinke, RD, CSP is a keynote speaker, seminar leader, management consultant, executive coach and editor of the free electronic newsletter Read and Grow Rich, available at www.easyCPEcredits.com. In addition he has authored numerous CDs, DVDs and books including Make It a Winning Life: Success Strategies for Life, Love and Business, Winning Management: 6 Fail-Safe Strategies for Building High-Performance Organizations and Don’t Oil the Squeaky Wheel and 19 Other Contrarian Ways to Improve Your Leadership Effectiveness; available at www.WolfRinke.com. His company also produces a wide variety of quality pre-approved continuing professional education (CPE) self-study courses, available both in print and electronic formats at www.easyCPEcredits.com. Reach him at WolfRinke@aol.com.

Camera not included.

NE1™ Wound Assessment Tool

Accurate identification, consistent documentation Wound measurement made easy The NE1 Wound Assessment Tool is a proven way to accurately measure and record wound characteristics, featuring a unique right angle design to see length and width measurements at the same time. It also contains areas to record the type of wound, plus the date, time and clinician’s name. Key benefits • Increase accuracy of wound assessment by more than 100 percent1 • Standardize wound documentation • Drive appropriate reimbursement due to more accurate wound assessment

Winner of National HCA Innovators Award

Interactive training and online competencies available on-demand at www.medlineuniversity.com

NEW 10 pack Reference 1. Young DL, Esocado N, Landers MR, Black J. A pilot study providing evidence for the validity of a new tool to improve assignment of NPUAP stage to pressure ulcers. Advances in Skin & Wound Care. In press. ©2012 Medline Industries, Inc. NE1 is a trademark of Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc. Patent pending.

available! www.medlinene1.com

Yes, They’re Genuine. Only Medline’s Pink Pearl™ gloves combine aloe, nitrile and breast cancer awareness.

pinkglovedance.com

Special Feature

Congratulations

Lexington Medical Center for taking first place in Medlineâ&#x20AC;&#x2122;s first Pink Glove Dance Competition

$10,000 to Lexington Medical Center Medline Chief Marketing Officer Sue MacInnes presents a check for the Vera Bradley Foundation for Breast President and CEO Michael J. Biediger. The money was donated to Cancer, Lexingtonâ&#x20AC;&#x2122;s chosen charity.

Improving Quality of Care Based on CMS Guidelines 83

First Place Winner

Lexington Medical Center

61,054 Votes

Featuring hospital CEOs with “moves like Jagger,” a dancing janitor, and octogenarians popping wheelies in their wheelchairs, Medline’s first national Pink Glove Dance video competition was a hit by any measure. With more than half a million votes in and counted, Lexington Medical Center in West Columbia, S.C., won first place with 61,054 votes — more than four times the population of their entire city (14,061). Their creative video features a dancing environmental services assistant, as well as hundreds of hospital staff, including a number of breast cancer survivors, all dancing in pink gloves to Katy Perry’s hit song “Firework” — all in the name of breast cancer awareness. A very close second place was captured by Highland Hospital in Rochester, N.Y., with almost 58,000 votes, followed by Victoria Hospital, Prince Albert Parkland Health Region in Prince Albert, Saskatchewan, Canada, who took home third place honors with more than 38,000 votes.

What did you like best about participating in the Pink Glove Dance Competition?

“

this event promoted I loved the camaraderie spital from EVS among everyone in our ho right up to the CEO.

“

84 Healthy Skin

” ”

Creating the video wa s so much fun and supporting br east cancer awareness was truly special.

139 Teams Competed to Raise Breast Cancer Awareness

In all, 139 teams from hospitals, nursing homes, schools and other organizations from 40 U.S. states and Canada participated in the three-week competition during Breast Cancer Awareness Month in October. More than 17,000 people were featured in the videos, which are all available for viewing at pinkglovedance.com.

Second Place Winner

Highland Hospital

58,000 Votes

Sponsored by Medline, the manufacturer of the pink gloves, the inaugural competition quickly became a social media phenomenon with more than 1.2 million views, half a million votes and thousands of tweets, blogs and texts. For winning first place, Medline donated $10,000 to Lexington Medical Center’s breast cancer charity of choice, the Vera Bradley Foundation for Breast Cancer. Medline donated $5,000 on behalf of Highland Hospital to the Breast Cancer Coalition of Rochester; and Victoria Hospital earned a $2,000 donation from Medline to the Saskatoon Cancer Agency. Medline’s original Pink Glove Dance video premiered in November 2009 and featured more than 200 workers from Providence St. Vincent in Portland, Ore. wearing pink gloves and dancing in support of breast cancer awareness and prevention. Today the video has more than 13 million views on YouTube® and has spawned hundreds of pink glove dance videos and breast cancer awareness events across the country and around the world. Throughout the year, for every case of Medline’s Generation Pink® gloves purchased, Medline will donate $1.00 to the National Breast Cancer Foundation (NBCF) to fund free mammograms for underserved women. To date, Medline has donated more than $800,000 to the NBCF.

Third Place Winner

Victoria Hospital, Prince Albert Parkland Health Region

38,000 Votes We asked the 139 contestants:

What impact did the Pink Glove Dance have on your facility? More than 80 percent of participants said that staff morale and satisfaction increased at their facility.

Improving Quality of Care Based on CMS Guidelines 85

Healthy Eating

Nutrition Information Servings: 4 Calories: 197 Fat: 7.2 g Sodium: 80 mg Fiber: 7.1 g

Roasted Winter Vegetables Ingredients 2 tablespoons olive oil 1 cup baby carrots 1 large onion, coarsely chopped 1 medium sweet potato, peeled and cut into 1-inch cubes 2 large beet, peeled and cut into 1-inch cubes 2 parsnips, peeled and cut into 1-inch cubes ¼ cup minced parsley Salt and pepper

Directions: Preheat oven to 500 degrees. Pour oil into large roast pan or jelly roll pan. Place pan into oven until oil is hot, about 1 minute. Add vegetables to hot pan and roast for 20-30 minutes, stirring every 10 minutes until vegetables are golden brown and sweet potato mashes easily when pressed. Season with salt and pepper and garnish with parsley. Diane Christensen, RN, is a clinical coordinator in the Quality division at Medline’s corporate headquarters in Mundelein, IL. She began learning how to cook at age 8, after her father

86 Healthy Skin

passed away and her mother was working long hours. Diane started out helping prepare meals, and before long she was a full-fledged cook. “I still like cooking, and I am always looking for new things to try. Anytime I come across a new recipe, I adjust it to make it my own,” Diane said.

The Medline employee cookbook is $10. To purchase your own copy, please e-mail Judy at jdesalvo@medline.com.

Forms & Tools

The following pages contain practical tools for implementing patient-focused care practices at your facility.

Infection Control Cover Your Cough..............................................................89 Physical Fitness Supporting Your Employeesâ&#x20AC;&#x2122; Physical Activity Goals.........90 Sharps Safety Safe Disposal of Needles and Other Sharps........................91 Device Safety Device Decision Guide....................................................92-95

Improving Quality of Care Based on CMS Guidelines 87

Introducing the new BioConâ&#x201E;˘- 700 The future of bladder ultrasound technology Minimize unnecessary catheterization Research has shown that 80 percent of urinary tract infections acquired at healthcare facilities are associated with an indwelling urethral catheter.1 This type of infection is known as CAUTI, or catheter-associated urinary tract infection. Avoiding unnecessary catheter use is a primary strategy for preventing CAUTI, and clinical guidelines recommend the consideration of alternatives to catheterization.2 Bladder scanners accurately assess bladder volumes, and many urinary catheterizations can be avoided.3

1. Lo E, Nicolle L, Classen D, Arias A, Podgorny K, Anderson DJ, et al. SHEA/IDSA practice recommendation: strategies to prevent catheter-associated urinary tract infections in acute care hospitals. Infect Control Hosp Epidemiol. 2008;29:S41-S50. 2. Stokowski, LA. Preventing catheter-associated urinary tract infections. Medscape Nursing Perspectives. February 3, 2009. 3. Stevens E. Bladder ultrasound: avoiding unnecessary catheterizations. Med/Surg Nursing. 2005; 14(4):249-253.

www.erasecauti.com/bladder-scanner

ÂŠ2012 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.

Cover Your Cough

Forms & Tools

Stop the spread of germs that can make you and others sick!

Cover your mouth and nose with a tissue when you cough or sneeze. Put your used tissue in the waste basket.

If you donâ&#x20AC;&#x2122;t have a tissue, cough or sneeze into your upper sleeve or elbow, not your hands.

You may be asked to put on a facemask to protect others.

Wash hands often with soap and warm water for 20 seconds. If soap and water are not available, use an alcohol-based hand rub.

CS208322

Improving Quality of Care Based on CMS Guidelines 89

Forms & Tools

Physical Activity Goals

Everyday Fitness Ideas from the National Institute on Aging at NIH www.nia.nih.gov/Go4Life

Supporting Your Employees’ Physical Activity Goals Physical activity is one of the most effective ways of staying healthy.

It can improve strength and endurance, reduce the risk of heart disease, and improve overall well-being. Here are a few tips to help employees be more physically active. Create a supportive atmosphere. l Make sure management (including the top boss) supports efforts to promote physical activity. Management can do this by: – Coming to employee sporting or physical activity events. – Being physically active themselves. – Encouraging and congratulating employees in internal publications or meetings. l Join forces with community programs that promote physical activity. l Invite a local health and fitness expert to make a presentation or give a demonstration. l Invite families to worksite physical activity events like softball games. l Use the free materials on the Go4Life website, such as tip sheets, posters, and newsletter articles. Make physical activity happen. l Organize a group walk during the lunch hour or form after-work sports leagues. l Provide information about nearby fitness centers, walking trails, and sports fields. l Make it easy for people to be physically active at your worksite: – Provide secure bike racks in convenient locations. – Make sure the stairs are safe and inviting to use. – Consider flexible scheduling so that employees can be active during the day. – Host active meetings. Encourage people to stand when they speak or provide mini-exercise breaks during meetings.

National Institute on Aging National Institutes of Health U.S. Department of Health & Human Services

90 Healthy Skin

Quick Tip Lead by example. Be a “physically active” role model for your co workers.

VIsIt

www.nia.nih.gov/Go4Life l l

Print useful tools. Order free exercise guides, DVDs, posters, and bookmarks.

“Playing softball with my coworkers keeps me active and builds teamwork. Plus, we have a ball!” — Patty, age 66

Sharps Safety

Forms & Tools

DO’s and DON’Ts

Safe Disposal of Needles and Other Sharps Used At Home, At Work, or While Traveling

Do • Immediately place used needles and other sharps in a sharps disposal container to reduce the risk of needle-sticks, cuts, or punctures from loose sharps. • Use an FDA-cleared sharps disposal container, if possible. If an FDA-cleared container isn’t available, some organizations and community guidelines recommend using a heavy-duty plastic household container (i.e. laundry detergent container) as an alternative. • Make sure that if a household disposal container is used, it has the basic features of a good disposal container. (See box at right for more info.) • Be prepared — carry a portable sharps disposal container for travel. • Follow your community guidelines for getting rid of your sharps disposal container. • Call your local trash or public health department (listed in the county and city government section of your phone book) to find out about sharps disposal programs in your area.

All sharps disposal containers should be:

• Ask your health care provider, veterinarian, local hospital or pharmacist o where and how you can obtain an FDA-cleared sharps disposal container, o if they can dispose of your used needles and other sharps, or o if they know of safe disposal programs near you. • Keep all needles and other sharps and sharps disposal containers out of reach of children and pets.

• able to close with a tight-fitting, puncture-proof lid, without sharps being able to come out;

Don’t

Best Way to Get Rid of Used Needles and Other Sharps:

• Throw needles and other sharps into the trash. • Flush needles and other sharps down the toilet. • Put needles and other sharps in your recycling bin — they are not recyclable. • Try to remove, bend, break, or recap needles used by another person. This can lead to accidental needle sticks, which may cause serious infections. • Attempt to remove the needle without a needle clipper device because the needles could fall, fly off, or get lost and injure someone.

• made of a heavy-duty plastic;

• upright and stable during use; • leak-resistant; and • properly labeled.

Step 1: Place all needles and other sharps in a sharps disposal container immediately after they have been used. Step 2: Dispose of used sharps disposal containers according to your community guidelines. For more information visit, www.fda.gov/safesharpsdisposal.

Safe Disposal of Needles and Other Sharps www.fda.gov/safesharpsdisposal

Improving Quality of Care Based on CMS Guidelines 91

92 Healthy Skin

Page 1 of 4

Completed By:

Resident Name/Room Number:

Device is not a restraint. If device is used: - Do not code MDS P4 Proceed to Step 2 - Care plan for use/ impact, even if not a restraint.

YES

Does device/situation restrict movement or access to oneâ&#x20AC;&#x2122;s body? - Determine if device prevents resident from performing movement otherwise capable. - Does device restrict residentâ&#x20AC;&#x2122;s ability to reach their legs or toes (if capable)?

Does resident have cognitive AND functional ability to remove device? Resident removes device purposefully.

YES

Does resident have functional ability to alter position?

A device may be a restraint for one resident, but not for another. At this point do NOT consider intent or reason (enabling/safety) for device use.

STEP 1: Determine Restraining Effect

YES

Date:

Device is a restraint. If device is used: - Code MDS P4 Proceed to Step 2 - Care plan for use/ impact.

Complete all 3 STEPS in order given to determine if device is a restraint and/or enabler as well as potential hazards. After completing these initial 3 steps any device must be care planned in STEPS 4-8. If device is not used, document rationale and care plan for alternatives.

DEvicE DEciSiON GuiDE: Restraint, Enabler, and Safety Hazard

Forms & Tools Device Decision Guide

Page 2 of 4

Resident Name/Room Number:

If no enabling qualities, device is not an enabler. If device is used: Proceed to Step 3 - Care plan for use/impact

Enabling Qualities 1. Does the device allow the resident to do something that would improve quality of life? 2. Does it allow the resident to participate in an activity otherwise incapable of? 3. Does it improve physical or emotional status?

Consider the following questions and include in care plan:

STEP 2: Determine Enabling Qualities

YES

Date:

If any enabling qualities, device is an enabler. - If device is only an enabler, statement of medical necessity not required. Proceed to Step 3 - Care plan for use/impact

Complete only after STEP 1. A device may have both restraining and enabling qualities or it may have qualities of one, but not the other. Consider all possible effects.

DEvicE DEciSiON GuiDE: Restraint, Enabler, and Safety Hazard

Device Decision Guide Forms & Tools

Improving Quality of Care Based on CMS Guidelines 93

94 Healthy Skin

Page 3 of 4

Resident Name/Room Number:

There are no safety risks. If device is used: Proceed to Step 4 - Care plan for use/impact

- Asphyxiation - Entanglement - Pain from lack of movement - Skin tears/scrapes/bruises - Decreased bone density/ increased fractures

- Residents using Speciality Mattress: Compression of mattress widens gap between mattress and rail. As resident changes position, mattress may inflate and trap head, chest, neck, or limbs between mattress and side rail resulting in fractures, asphyxiation and death. - Follow manufacturer recommendation for inflation based on resident’s weight.

- Delirium - Uncontrolled body movements *These conditions may cause resident to move about and exit from a device or bed.

- Confusion - Fecal Impaction

3. Is resident at risk for entrapment?

• Elderly or frail residents with: - Agitation - Pain

- Residents most at risk:

- Depression - Loss of muscle tone - Loss of Dignity - Strangulation - Agitation - Incontinence - UTIs - Constipation - Decreased mobility - Pressure Ulcers - Injury from devices not adapted or fitted to resident - Injury from defective or improperly used devices

2. Does the device place the resident at risk for:

Date:

YES

Evaluate each hazard. Weigh against benefit. If device is used: Proceed to Step 4 - Care plan for use/impact, hazard avoidance

1. Is resident vulnerable to hazard? Vulnerability changes. Risk factors: resident’s function, medical condition, cognition, mood, and treatments (e.g., medications), etc.

STEP 3: Determine Safety Hazards

Consider all possible negative effects and safety hazards of the device. Devices can be therapeutic and beneficial; but may not be risk free. If resident found in an at risk position with device, discontinue use and reevaluate with team.

DEvicE DEciSiON GuiDE: Restraint, Enabler, and Safety Hazard

Forms & Tools Device Decision Guide

We’ve tried to include content that clarifies the initiatives or gives you ideas and tools for implementing their recommendations. For a summary of each of the above initiatives, see Pages 6 and 7.

JOIN THE TEAM!

Healthy Skin

When it comes to hot topics in long-term care, you’re the experts! Date:

STEP 6: care Plan - Treatment and Management

STEP 5: Diagnosis and identify cause a. Identify likely causes (medication side effects or environmental factors) of

Page 4 of 4

Resident Name/Room Number:

STEP 7: Monitoring

STEP 4: Assessment and Problem Recognition

Device care Planning Process

Device Decision Guide Forms & Tools

Improving Quality of Care Based on CMS Guidelines 95

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Improving Quality of Care Based on CMS Guidelines

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