Healthy Skin Volume 8 Issue 3 by Medline Industries

Improving Quality of Care Based on CMS Guidelines

Free CE Inside!

Volume 8, Issue 2

Influenza: Prevention Guidelines

Survivors Share Their Stories

TAKE THE PINK GLOVE SURVEY Page 80

How to Prepare for Emergencies & Disasters

The Dance Goes On:

PINK GLOVE DANCE SEQUEL

HEALTHY SKIN Join the team!

CDC CLINICAL REMINDER Use of Fingerstick Devices on More than One Person Poses Risk for Transmitting Bloodborne Pathogens Summary: The Centers for Disease Control and Prevention (CDC) has become increasingly concerned about the risks for transmitting hepatitis B virus (HBV) and other bloodborne pathogens to persons undergoing fingerstick procedures for blood sampling -- for instance, persons with diabetes who require assistance monitoring their blood 1,2,3 glucose levels. Reports of HBV infection outbreaks linked to diabetes care have been increasing . This notice serves as a reminder that fingerstick devices should never be used for more than one person. Background Fingerstick devices are devices that are used to prick the skin and obtain drops of blood for testing. There are two main types of fingerstick devices: those that are designed for reuse on a single person and those that are disposable and for single-use.

Reusable Devices: These devices often resemble a pen and have the means to remove and replace the lancet after each use, allowing the device to be used more than once (see Figure 1). Due to difficulties with cleaning and disinfection after use and their link to numerous outbreaks, CDC recommends that these devices never be used for more than one person. If these devices are used, it should only be by individual persons using these devices for self-monitoring of blood glucose.

When it comes to hot topics in long-term care, you’re the experts! 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? Nowʼs your chance. Healthy Skin is looking

for writers and contributors. Whether youʼd 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 Weʼve 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 youʼll 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 Americaʼs Nursing Homes Weʼve 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.

Single-use, auto-disabling fingerstick devices: These are devices that are disposable and prevent reuse through an auto-disabling feature (see Figure 2). In settings where assisted monitoring of blood glucose is performed, single-use, autodisabling fingerstick devices should be used. Figure 1: Reusable fingerstick devices*

Figure 2: Single-use, disposable fingerstick devices*

The shared use of fingerstick devices is one of the common root causes of exposure and infection in settings such as long-term care (LTC) facilities, where multiple persons require assistance with blood glucose monitoring. Risk for transmission of bloodborne pathogens is not limited to LTC settings but can exist anywhere multiple persons are undergoing fingerstick procedures for blood sampling. For example, at a health fair in New Mexico earlier this year, dozens of attendees were potentially exposed to bloodborne pathogens when fingerstick devices were reused to conduct diabetes screening.

National Center for Emerging and Zoonotic Infectious Diseases Division of Healthcare Quality Promotion (DHQP)

HEALTHY SKIN

Improving Quality of Care Based on CMS Guidelines Editor Sue MacInnes, RD, LD Clinical Editor Margaret Falconio-West, BSN, RN, APN/CNS, CWOCN, DAPWCA Managing Editor Alecia Cooper, RN, BS, MBA, CNOR Senior Writer Carla Esser Lake Creative Director Mike Gotti Clinical Team

Clay Collins, BSN, RN, CWOCN, CFCN, CWS, DAPWCA Lorri Downs, BSN, RN, MS, CIC

Cynthia Fleck, BSN,MBA, RN, CWS, DNC, CFCN, DAPWCA, FCCWS

Joyce Norman, BSN, RN, CWOCN, DAPWCA

Kim Kehoe, BSN, RN, CWOCN, DAPWCA

Elizabeth OʼConnell-Gifford, BSN, MBA, RN, CWOCN, DAPWCA Jackie Todd, RN, CWCN, DAPWCA

Connie Yuska, RN, MS, CORLN Wound Care Advisory Board Zemira M. Cerny, BS, RN, CWS Patricia Coutts, RN

Cindy Felty, MSN, RN, CNP, CWS

Evonne Fowler, MSN, RN, CNS, CWOCN Lynne Grant, MS, RN, CWOCN

Diane Krasner, PhD, RN, CWCN, CWS, BCLNC, FAAN Dea J. Kent, MSN, RN, NP-C, CWOCN

Andrea McIntosh, BSN, RN, APN, CWOCN

Linda Neiswender, BSN, RN, CPN, CWOCN

Laurie Sparks, BSN, RN,CWOCN

Lynne Whitney-Caglia, MSN, RN, CNS, CWOCN Laurel Wiersema-Bryant, RN, ANP, BC

Linda Woodward, BSN, RN, OCN, CWOCN Deborah Zaricor, RN, CWOCN

36 66

Survey Readiness CDC, FDA, CMS Issue Infection Control Guidance Emergencies & Disasters: Preparedness Planning for Long-term Care Facilities

Prevention Save Those Heels! Effective Techniques to Help Avoid Heel Pressure Ulcers Implementing Medlineʼs Pressure Ulcer Prevention Program at Lacombe Nursing Centre Influenza: Prevention Guidelines and Recommendations

58 11

20 32 46 54 13

Treatment MDS 3.0: Revised Guidelines for Pressure Ulcer Risk Assessment and Staging Adult Obesity in the United States: A Growing Epidemic Feeding Dementia Patients with Dignity Foot, Skin and Wound Care from the Other Side of the Bed Rail Case Study: Use of Porcine Urinary Bladder in a Dehisced Wound

80 86 88

Special Features Wound Care Nurses Win Case Study Abstract Award at 2010 WOCN Conference Third Annual Prevention Above All Conference Control Measures for Influenza CDC Forms New Advisory Committee on Breast Cancer in Young Women Take the Pink Glove Survey! The Dance Goes On: Pink Glove Dance Sequel Sharing Stories

74 84 92 94

Caring for Yourself Fail-Safe Strategies to Deal with Difficult People Breast Health Tips Taste the Fountain of Youth Healthy Eating: Tuscan Tomato Soup

14 62 79

96 98 103 105

109

111 114 115

Forms & Tools Announcing New Online Skin & Risk Assessment Competency SKINSAVERS Initiative: A Pressure Ulcer Prevention Tool Impact of Healthcare Reform on Home Health Patient Handout: Medicare and the New Health Care Law – What it Means for You A National Framework and Preferred Practices for Palliative and Hospice Care Quality Ten Tips for Cleaning and Disinfecting Shared Medical Equipment Some Things Should Not be Reused CDC Clinical Reminder: Use of Fingerstick Devices

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.

About Medline

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Meeting the highest level of national and international quality standards, Medline is FDA QSR compliant and ISO 13485 certified. Medline serves on major industry quality committees to develop guidelines and standards for medical product use including the FDA Midwest Steering Committee, AAMI Sterilization and Packaging Committee and various ASTM committees. For more information on Medline, visit our Web site, www.medline.com.

Improving Quality of Care Based on CMS Guidelines 3

HEALTHY SKIN

Letter from the Editor

Dear Reader, September 17th Medline launched the Pink Glove Dance Sequel. If you haven’t seen it, I highly recommend you to go to pinkglovedance.com and take a look.

4,000 people participated. We are thrilled, honored and filled with the hope that this sequel will spur more people to talk about breast cancer, support each other through tough times, and give everyone hope.

The first video, launched in November 2009, now has over 11.5 million hits on YouTube. It has been all over the globe. When it hit the Netherlands and the comments were in Dutch, my daughter and I were so excited. Emily Somers, you see, is the choreographer, and this year she has been super busy traveling for the making of the Pink Glove Dance Sequel. Shortly after the video release last year, both St. Vincent’s Hospital in Portland, Ore., and Medline began receiving countless phone calls and e-mails about people’s experiences with breast cancer.

With so many participants in the film it was hard to condense hours of footage into four short minutes. In order to give everyone a chance to dance, we will be launching an additional video for every hospital that participated, a video for the nursing homes and a video of all of the breast cancer survivors. These will be released the first week of October, to see the schedule go to pinkglovedance.com. It is our goal to spread the word to as many people as possible about saving lives and early detection.

One daughter wrote, my mom has not smiled nor has she gotten off the couch since she was diagnosed. Once she saw the video, she smiled for the first time in months. Another woman said she was getting treatments for stage 4 breast cancer, and the video was so uplifting. Several hospitals and nursing homes asked if we would do a pink glove dance at their facility. So, September 17, 2010, Medline launched the Pink Glove Dance Sequel. Starting at St. Vincent’s in Portland, you will see healthcare workers from 10 hospitals and 3 nursing homes in North America dance, and as a special note of appreciation, you will see breast cancer survivors from coast to coast dance in appreciation of their healthcare workers—caregivers and survivors coming together celebrating. More than

Healthy Skin

On behalf of all the breast cancer survivors and their families, I want to extend a heartfelt thank you to the healthcare workers who continue to show compassion and care for those diagnosed and their families. You are spectacular! Enjoy this edition of Healthy Skin! And, take a moment to reflect on all the good you do. Watch the video, share it with friends and spread the cheer. My deepest thanks to all of you,

Sue MacInnes, RD, LD Editor

“

I want to extend a heartfelt thank you to the healthcare workers who show compassion and care to those diagnosed and their families.

”

Improving Quality of Care Based on CMS Guidelines

Free CE Inside!

Volume 8, Issue 2

Influenza: Prevention Guidelines

Survivors Share Their Stories

TAKE THE PINK GLOVE SURVEY Page 80

How to Prepare for Emergencies & Disasters

The Dance Goes On:

PINK GLOVE DANCE SEQUEL

25th Anniversary

of Breast Cancer Awareness Month

Introducing

Deb! Starring in “The Pink Glove Dance”

Some historical facts

2010 marks the 25th anniversary of Breast Cancer Awareness Month, whose purpose is to remind women about the value of early detection and mammograms.

1993 Evelyn Lauder, senior corporate vice president of the Estee Lauder Companies founded the Breast Cancer Research foundation and began distributing pink ribbons to symbolize breast cancer awareness.

1985 Breast Cancer Awareness Month was created in October 1985 as a collaborative effort among the American Academy of Physicians, CancerCare Inc. and various other sponsors.

Pink was chosen as the breast cancer ribbon color because it symbolizes health and femininity.

www.pinkglovedance.com

In her Generation Pink™ Gloves, pink bouffant cap and scrubs, Deb danced in the Pink Glove Video Sequel. To watch the video, go to www.pinkglovedance.com. To order your own Deb doll, visit www.medline.com/dolls.

Two Important National Initiatives for Improving Quality of Care

Achieving better outcomes starts with an understanding of current quality of care initiatives. Hereʼs 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 9th Round Statement of Work

The QIO Statement of Work is based upon Part B of the Title XI of the Social Security Act. The Medicare-funded “Ninth Scope of Work” plan became effective August 1, 2008 and is a three-year work plan. 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. Goal: In the 9th SOW, the QIO Program has been redesigned with a framework for accountability and also in content. The content now consists of four themes with the goal to help providers, both in long-term care and acute-care facilities, prevent illness, decrease harm to patients and reduce waste in health care. Of note: QIOs will be required to help Medicare promote three overarching themes: adopt value-driven healthcare, support the adoption and use of health information technology and reduce health disparities in their communities. Under the direction of the Centers for Medicare & 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.

Origin:

Quality Improvement Organization Program’s 9th Scope of Work Theme The official Executive Summaries for the 9th SOW Theme are available at: http://providers.ipro.org/index/9SOW_summaries

Advancing Excellence in America’s Nursing Homes

A coalition-based, two-year campaign initiated on September 26, 2006 to improve quality of life for nursing home residents and staff. The coalition has continued the campaign beyond its first-round end of August 25, 2008 for an additional 2 years (until September 26, 2010). Purpose: 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. Goal: 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. Origin:

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. Advancing Excellence The coalition is meeting to consider the following additions for the next two-year campaign: 1. Improving immunizations as a clinical goal 2. Including target setting in all goals 3. Changes to the order in which the goals are presented

Healthy Skin

The 9th Scope of Work Content Themes Theme #4: Prevention Activities will focus on nine Tasks: 1. Recruiting participating practices 2. Identifying the pool of non-participating practices 3. Promoting care management processes for preventive services using EHRs 4. Completing assessments of care processes 5. Assisting with data submissions 6. Monitoring statewide rates (mammograms, CRC screens, influenza and pneumococcal immunizations) 7. Administering an assessment of care practices 8. Producing an annual report of statewide trends, showing baseline and rates 9. Submitting plans to optimize performance at 18 months

Theme #1: Beneficiary Protection Activities will focus on nine Tasks: 1. Case reviews 2. Quality improvement activities (QIAs) 3. Alternative dispute resolution (ADR) 4. Sanction activities 5. Physician acknowledgement monitoring 6. Collaboration with other CMS contractors 7. Promoting transparency through reporting 8. Quality data reporting 9. Communication (education and information) Theme #2: Patient Pathways/Care Transitions Activities will focus on three Tasks: 1. Community and provider selection and recruitment 2. Interventions 3. Monitoring

There will be two periods of evaluation under the 9th SOW. The first evaluation will focus on the QIO's work in three Theme areas (Care Transitions, Patient Safety and Prevention) and will occur at the end of 18 months. The second evaluation will examine the QIO's performance on Tasks within all Theme areas (Beneficiary Protection, Care Transitions, Patient Safety and Prevention). The second evaluation will take place at the end of the 28th month of the contract term and will be based on the most recent data available to CMS. The performance results of the evaluation at both time periods will be used to determine the performance on the overall contract.

Theme #3: Patient Safety Activities will focus on six primary Topics: 1. Reducing rates of health care-associated methicillin-resistant Staphylococcus aureus (MRSA) infections 2. Reducing rates of pressure ulcers in nursing homes and hospitals 3. Reducing rates of physical restraints in nursing homes 4. Improving inpatient surgical safety and heart failure treatment in hospitals 5. Improving drug safety 6. Providing quality improvement technical assistance to nursing homes in need

Focus for the 9th Scope of Work – Move away from projects that are “siloed” in specific care settings – Focused activities for providers most in need – New emphasis on senior leadership (CEOs, BODs) involvement in facility quality improvement programs

Clinical and Operational/Process Goals Clinical Goals: Goal 1: Reducing high-risk pressure ulcers Goal 2: Reducing the use of daily physical restraints Goal 3: Improving pain management for longer-term nursing home residents Goal 4: Improving pain management for short-stay, post-acute nursing home residents

Goal < 10% < 5%

Actual 11% 3%

< 4%

< 15%

19%

Operational/Process Goals: Goal 5: Establishing individual targets for improving quality Goal 6: Assessing resident and family satisfaction with quality of care Goal 7: Increasing staff retention Goal 8: Improving consistent assignment of nursing home staff so that residents receive care from the same caregivers

Goal > 90%

Actual 36.5% 22.5% 13.9% 26.6%

Trends in Goal Selection Each nursing home participating in Advancing Excellence selects a minimum of three goals (outlined above). The goals – and the percentage of participating nursing homes that have selected them – are listed below.

Goal 1: 70.9%

Goal 5: 32.1%

Goal 2: 45.3%

Goal 6: 62.8%

Goal 3: 54.2%

Goal 7: 41.2%

Goal 4: 39.6%

Goal 8: 31.3%

Participating nursing homes: 7,481 Percentage of participating nursing homes:* 47.6% Participating consumers: 2,233 Average number of goals per nursing home: 3.8

Visit this Web site to view progress by state! www.nhqualitycampaign.org/star_index.aspx?controls=states_map *Based on the latest available count of Medicare/Medicaid nursing homes

Improving Quality of Care Based on CMS Guidelines 7

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. For more information visit www.medline.com/ep.

BREAKING NEWS What to Expect This Flu Season Flu season is here, and the Food and Drug Administration has approved eight vaccines made by six companies. One of the eight is a new high-dose version meant for people 65 and older.1 The 2010-2011 vaccine contains killed or weakened forms of three viruses:1 1. Swine flu (technically known as A/California/7/09 (H1N1) 2009 influenza 2. A/Perth/16/2009 (H3N2)-like virus 3. B/Brisbane/60/2008-like virus

FLU FACTS2 • The Centers for Disease Control and Prevention (CDC) announced on June 22, 2010 that it would not be endorsing mandatory influenza vaccinations for healthcare workers this flu season. • The CDC now recommends that healthcare workers wear surgical face masks instead of N-95 respirators when working with influenza patients. • Flu vaccination rates increased by an average of eight percent during the 2009-2010 flu season.

HHS Grants $159.1 Million to Train Healthcare Workers3 The Department of Health and Human Services (HHS) has awarded $159.1 million in grant money to support healthcare worker training to be targeted to nursing and geriatric-targeted programs, as well as Centers of Excellence programs for minority students. The funding is made possible through the American Recovery and Reinvestment Act and Patient Protection and Affordable Care Act. A state-by-state chart of grant award recipients is available at www.hhs.org.

Health Care Spending Among Obese Adults Increases 30 Percent Over 20 Years4 Health care spending per adult grew rapidly among obese patients between 1987 and 2007, according to an analysis recently released by the Congressional Budget Office. Spending per capita for obese adults exceeded spending for adults of normal weight by about eight percent in 1987 and by about 38 percent in 2007. If recent trends continue, the adult obesity rate would rise from 28 percent in 2007 to 37 percent in 2020. Per capita spending on health care for adults would increase by about 3 percent more than it would if the obesity rate were unchanged, CBO estimates.

References 1. Grady D. Flu vaccines are approved and urged for most. The New York Times. July 30, 2010. Available at: http://www.nytimes.com/2010/07/31/health/policy/31flu.html?_r=1&ref=health. Accessed August 9, 2010. 2. Bartlett JG. Need-to-know news about influenza. From Medscape Infectious Diseases. Available at: http://www.medscape.com/viewarticle/725532. Accessed August 4, 2010. 3. Costello MA. HHS awards $159.1 million in heath care workforce grants. AHA News Today. August 6, 2010. 4. How does obesity in adults affect spending on health care? Congressional Budget Office web site. September 8, 2010. Available at: http://www.cbo.gov/doc.cfm? index=11810. Accessed September 10, 2010.

Improving Quality of Care Based on CMS Guidelines 9

What you see... ...is because of what you don't see Happy residents, healthy skin and fewer pressure ulcers are what you want to see in your facility. That's why you should take a look at PUP -- the Pressure Ulcer Prevention program from Medline. One glance shows that this program is comprehensive. It includes: • Curriculum for you to help train your staff: RNs, LPNs, CNAs, MDs • Practical tools to help reduce the incidence of pressure ulcers • Innovative products supported by evidence-based information that results in better patient care

acquired pressure ulcers. By April 2010 they had only six facility-acquired pressure ulcers -- that's an 89 percent reduction in nine months.The number of pressure ulcers decreased another 67 percent by June 2010 after staff completed their PUP education program.1

For more information on the Pressure Ulcer Prevention Program, contact your Medline representative, call 1-800-MEDLINE or visit www.medline.com/pupp-webinar to register for a free informational webinar.

When Tewksbury State Hospital, a 250-bed facility in Massachusetts, began using Medline's Remedy and Ultrasorbs products in June 2009, there were 55 facility-

1. Medline Industries, Inc. Data on file.

MDS 3.0

Revised Guidelines

for Pressure Ulcer Risk Assessment and Staging

The Centers for Medicare & Medicaid Services implemented the Minimum Data Set (MDS) 3.0 on October 1, 2010. MDS 3.0 includes revisions to Section M: Skin Conditions, which changes how wounds are tracked and recorded in Medicarecertified skilled nursing facilities. MDS 3.0 presents pressure ulcer risk in a more sophisticated, thorough and clinically relevant way that requires greater collaboration between caregivers and physicians or primary care providers. The net result is an assessment tool that is more in keeping with residents’ needs.1 The following is a summary of the major changes that apply to pressure ulcer risk assessment and staging. Reverse staging no longer allowed MDS 3.0 illustrates a change in philosophy based on the National Pressure Ulcer Advisory Panel’s (NPUAP) conclusions that applying the pressure ulcer staging system in reverse order is erroneous and can lead to inappropriate wound care and reimbursement. For example, if an ulcer reaches Stage IV and then granulates and epithelializes, it may appear clinically shallow like a Stage II, but it still must be documented as a healing Stage IV.1 (M0300B-G) Now included! Present on admission (POA)/reentry data MDS 3.0 includes new coding for pressure ulcers that are present on admission or upon reentry to the nursing facility. POA ulcers that worsen during the resident’s stay at the nursing facility are then coded at the higher stage and are no longer considered POA. Also, if a pressure ulcer is unstageable at admission, but then becomes visible and stageable, it must then be coded as POA.1

M0610) Now included! Measurement of largest pressure ulcer If the resident has one or more unhealed (non-epithelialized) Stage III or IV pressure ulcers or an unstageable pressure ulcer due to slough or eschar, you must identify the pressure ulcer with the largest surface area (length × width) and record it in centimeters.2 (M0800, M0900) Now included! Tracking of changes in pressure ulcers over time These items document whether overall skin status has worsened since the last assessment. To track increasing skin damage, this item documents the number of new pressure ulcers and whether any pressure ulcers have worsened to a higher (deeper) stage since the last assessment. Most Stage II pressure ulcers should heal in a reasonable timeframe. Full thickness Stage III and IV pressure ulcers may require longer healing times.2 (M0300G) Pressure ulcer blisters associated with signs/symptoms of suspected deep tissue injury (sDTI) must be coded as unstageable sDTIs As of June 2010, MDS 3.0 instructed clinicians to code all blisters related to pressure as Stage II pressure ulcers. These instructions changed in August 2010. Upon consultation with clinicians it was decided to further clarify coding related to pressure ulcer related blisters and sDTIs to emphasize the assessment findings of the wound and the surrounding tissue, rather than the color of the fluid in the blister. The emphasis is on complete and comprehensive assessment of the resident and the type of skin injury rather than just solely on the type of fluid in the blister.3

Improving Quality of Care Based on CMS Guidelines 11

MDS 3.0

Deep tissue injury may precede the development of a Stage III or IV pressure ulcer even with optimal treatment. Quality health care begins with prevention and risk assessment, and care planning begins with prevention. Appropriate care planning is essential in optimizing a resident’s ability to avoid, as well as recover from, pressure (as well as all) wounds. Deep tissue injuries may sometimes indicate severe damage. Identification and management of suspected deep tissue injury (sDTI) is imperative.2 Further understanding of MDS 3.0 For a more in-depth look at MDS 3.0 Section M: Skin Conditions, visit http://journals.lww.com/aswcjournal/pages and search for the articles referenced below. To locate a complete copy of MDS 3.0 and related training materials, go to http://www.cms.hhs.gov/NursingHomeQualityInits/01_Overview.asp#TopOfPage. Section M: Skin Conditions is located in Chapter 3 of the MDS 3.0 RAI Manual.

\ 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.

The information presented here was current when this article was published in mid-September 2010.

References 1. Levine JM, Roberson S, Ayello EA. Essentials of MDS 3.0 Section M: Skin Conditions. Advances in Skin & Wound Care. 2010;23(6):273-283. 2. MDS 3.0 RAI Manual August 2010. Centers for Medicare & Medicaid Services. Available at: http://www.cms.gov/NursingHomeQualityInits/45_NHQIMDS30TrainingMaterials.asp#TopOfPage. Accessed September 10, 2010. 3. Ayello EA & Levine JM. CMS updates on MDS 3.0 Section M: Skin Conditions—change in coding of blister pressure ulcers. Advances in Skin & Wound Care. 2010;23(9):394-397.

Stoma site before treatment with Marathon.1

Same stoma site after treatment with Marathon.1

To learn more, visit www.medline.com/skincare.

1. Data on file

12 Healthy Skin

Special Feature

Wound Care Nurses Win Case Study Abstract Award at 2010 WOCN Conference

Left to right: Tricia Corvino, MSN, RN, CWOCN, co-author; Phyllis Bonham, PhD, MSN, RN, WOCN, DPNAP, president, Wound, Ostomy and Continence Nurses Society; Amparo Cano, MSN, RN, CWOCN, co-author; and Margaret Falconio-West, BSN, RN, APN/CNS, CWOCN, DAPWCA, senior vice president, clinical education, Medline Industries, Inc.

Wound care nurses Tricia Corvino and Amparo Cano won a merit award for their case study, “Use of a Porcine Urinary Bladder Matrix (UBM) in a Dehisced Wound Between Stomas Promoted Closure Facilitating Regular Pouch Changes in a Premature Neonate,” which they presented at the 42nd Annual Wound, Ostomy and Continence Nurses Society Conference June 12-16, 2010, in Phoenix, Ariz. Turn to page 54 to review the study.

Improving Quality of Care Based on CMS Guidelines 13

Third Annual Prevention Above All Conference

Strategies for Thriving in the New Era of Healthcare Reform The heat is on in health care like never before. Error prevention, efficiency and cost containment have been top priorities for a very long time, but now, with the introduction of healthcare reform, they are absolutely critical for survival, according to Joint Commission President Mark Chassin, MD, MPP, MPH.

care delivery ideas. Reform will increase federal costs, and there is only one vehicle for cost containment: limiting payment to providers.

What to expect from healthcare reform Dr. Chassin delivered the keynote address at Medline’s 3rd Annual Prevention Above All Conference devoted to sharing new strategies for delivering cost-effective, high-quality, evidence-based health care. An audience of more than 100 hospital CEOs, chief nursing officers and other executives attended the meeting August 16 and 17, 2010, in New York City.

So how do healthcare providers control costs and avoid major payment cuts and benefit reductions while also maintaining quality? Dr. Chassin outlined several keys to survival in today’s era of healthcare reform.

“Today’s message is clear,” Dr. Chassin said. “Solve safety and quality problems. Don’t say you’re trying; just solve them. Take care of 30-plus million more people in your organizations. Become or participate in an accountable care organization. Figure out bundled payments. Adopt electronic medical records quickly. And one more thing. You can’t have any more money.” Overall, Dr. Chassin explained, healthcare reform increases coverage while experimenting with some new payment and

14 Healthy Skin

Dr. Chassin cautioned, “You will never be paid better than you are being paid now. This was true six months ago, it’s true now, and it will be true tomorrow and next week.”

Employ a quality-driven strategy to eliminate overuse of health services. Examples include discontinuing wasteful practices such as prescribing antibiotics for colds and inducing labor earlier than 39 weeks. “This is one part of health policy that has not received any attention,” Dr. Chassin explained. “It’s been overlooked for decades in the research community. We must come together to do this.” Two more keys to survival are eliminating the waste inherent in needlessly complex care delivery processes and putting an end to preventable complications.

Special Feature

Deborah Adler, Trent Haywood, Mark Chassin and Mikel Gray answer questions from the audience at the Third Annual Prevention Above All Conference held at the Hudson Theatre in New York City.

Improving Quality of Care Based on CMS Guidelines 15

A look into the future Speaking from his experience as CEO of New York City’s Mount Sinai Hospital, one of the nation’s largest and busiest hospitals, Wayne Keathley provided a firsthand look at what he predicts will be the norm for the average U.S. hospital amidst the new era of healthcare reform—having to do a lot more with a lot less at average capacity levels of 95 percent.

Left: Keynote speaker Joint Commission President Mark Chassin, MD, MPP, MPH.

“A fair number of you probably don’t recognize the kind of congestion, overcrowding and difficulties with flow that I’m about to describe,” Keathley said. “I would ask you to indulge in a little suspension of disbelief and assume for a minute that as health reform evolves, possibly because of a whole new group of patients who will come to you for care … and more likely because the economics will require you to rethink capacity and the way you manage it — that the situation I’m going to describe for us, in fact has some meaning for you.” Mount Sinai is operating at 95 percent capacity, and they are currently working with GE Healthcare to implement new systems to accommodate this level of activity. Keathley advocates improvement through fixing systems, not by adding more resources. For example, whereas hospitals often rely on intuition and personal judgment when managing patient flow and locating empty beds, Keathley suggests that studying capacity patterns and related data leads to more efficient use of resources. He also encourages collaboration among departments, viewing the hospital as a whole rather than operating as individual silos. “If money were no object, we would add more beds, add more operating rooms, hire more nurses, and we could drive occupancy back down to the ideal 85 percent,” Keathley said. “But I am telling you, that fantasy doesn’t exist.” Prevention Above All Another solution to meeting the challenges of healthcare reform lies in preventing costly medical errors and infections that are indeed preventable. Sue MacInnes, Medline’s Chief Marketing Officer and host of the Prevention Above All Conference, reviewed Medline’s growing offering of preventive strategies for healthcare providers: The Gold Standard Surgical Safety Program to help prevent operating room errors, the Hand Hygiene Compliance Program, the Pressure Ulcer Prevention Program, Educational Packaging, the ClearCount Surgical System to help prevent sponges from being left behind and the Catheter-Associated

16 Healthy Skin

Above (left to right): Medline President Andy Mills, Deborah Adler, Medline Chief Marketing Officer, Sue MacInnes, RD, LD, Atul Gawande, MD, MPH, Medline COO Jim Abrams.

Right: The Third Annual Prevention Above All Conference took place at the historic Hudson Theatre in New York City.

Urinary Tract Infection (CAUTI) Foley Catheter Management System to help prevent CAUTIs. These six strategies are targeted, focused and achievable evidence-based solutions that are also practical. They fit with everyday processes and systems currently in place at most healthcare facilities. MacInnes emphasized, “Sometimes the simplest solutions make the biggest difference.”

What the Experts Are Saying ...

Fife

Yankowsky

Caroline Fife, MD and Kevin W. Yankowsky, JD Lawsuits, Technology and Wound Care: How Electronic Health Records Change Your Legal Risks “Any time a lawsuit is filed, you and your facility and your practitioners lose. The only question is the question of degree ... I would suggest and recommend that you take a moment to focus on how, in addition to improving your clinical care, you can take steps to absolutely minimize your risk of ever being involved in the legal system; of ever being sued in the first place.” - Kevin W. Yankowsky Trent T. Haywood, MD, JD Social Practice: Observation for Understanding and Improving “One of the key things people have taught us in anything that has to do with practice improvement is not really what you don’t know; it’s what you think you know that ain’t so.”

Haywood

Bratzler

Dale Bratzler, DO, MPH Healthcare-Associated Infections and Public Accountability “Clearly, if there is a single practice that we can do better that will dramatically reduce healthcare-associated infections, it would be hand hygiene.” Mikel Gray, PhD, FNP, CUNP, CCCN, FAANP, FAAN Evolution of Evidence: New Models for Demonstrating Effectiveness “Insufficient evidence remains the primary challenge of evidence-based practice; demystification of the research process is urgently needed.”

Gray

Gawande

For video clips of the speakers’ presentations from the 3rd Annual Prevention Above All Conference, visit www.medline.com/media-room. Or contact your Medline representative for a free set of DVDs.

Abdul Gawande, MD, MPH Author, The Checklist Manifesto “What we have today, though, is a volume and complexity of medical discovery that has now exceeded our ability as individual specialized artisans to be able to deliver that care to the right person, the right way, at the right time without waste of resources,” Dr. Gawande said.

Improving Quality of Care Based on CMS Guidelines 17

Bedside Clinicians as Researchers Practicing Advanced Medicine Within Outdated Systems Atul Gawande, MD, a Harvard professor and author of several books, including his most recent, The Checklist Manifesto, addressed the challenges of delivering highly advanced medical care within outdated systems. He pointed out that we’ve entered a complex medical world in which we have 13,600 different diagnoses, 6,000 prescription medications and more than 4,000 medical and surgical procedures. Compounding matters, we’ve inherited a structure from 50 years ago that didn’t have nearly so many diagnoses, drugs and procedures. At that time, the doctor was considered an artisan, and all you really needed was the physician’s brain, along with an operating room, a few simple tools and some skills behind that. “What we have today, though, is a volume and complexity of medical discovery that has now exceeded our ability as individual specialized artisans to be able to deliver that care to the right person, the right way, at the right time without waste of resources,” Dr. Gawande said. The Checklist Manifesto: How to Get Things Right Atul Gawande, MD, MPH We live in a world of great and increasing complexity, where even the most expert professionals struggle to master the tasks they face. Longer training, ever more advanced technologies — neither seems to prevent grievous errors. But in a hopeful turn, acclaimed surgeon and writer Atul Gawande finds a remedy in the humblest and simplest of techniques: the checklist.

Mikel Gray, PhD, FNP, CUNP, CCCN, FAANP, FAAN, editor-in-chief of the Journal of Wound, Ostomy and Continence Nursing, described the research process, focusing on randomized controlled trials, which are considered the gold standard for establishing the efficacy of an intervention. According to Dr. Gray, the primary challenge of evidence-based practice is an overall lack of research. He feels that doctoral prepared researchers from universities are not the only ones qualified to perform meaningful clinical research. And as a way to generate more research, he believes there is an urgent need to demystify the research process to encourage bedside clinicians to conduct studies based on their everyday practice. “Bedside clinicians can and do perform meaningful research if provided proper support, mentoring from sympathetic researchers and adequate resources,” he said. Dr. Gray shared an example of one such clinician, Dea J. Kent, MSN, RN, NP-C, CWOCN, manager of the Wound Ostomy Clinic at Riverview Hospital in Noblesville, IN, who compared the effects of educational materials for wound dressing application that were attached to dressing packaging versus traditional wound care education. The study showed that none of the 139 nurses who used traditional dressing packaging were able to apply the wound dressing correctly. On the other hand, 88 percent of the nurses who used the package with the educational guide attached to it were able to apply the dressing correctly. The study will be published in the November 2010 issue of the Journal of Wound, Ostomy and Continence Nursing. To download a free copy of Kent’s study, “Effects of a Just-in-Time Educational Intervention Placed on Wound Dressing Packages” visit http://journals.lww.com/jwocnonline/pages/default.aspx.

18 Healthy Skin

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* Courses approved for continuing education by the Florida Board of Nursing and the California Board of Reigistered Nursing.

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Treatment

Adult Obesity in the United States A GROWING EPIDEMIC by Cathy S. Birn, RN, MA, CGRN, CNOR

We all intend to eat right and exercise, but life intervenes. Weâ&#x20AC;&#x2122;re too rushed for a real meal and grab something from the vending machine. After a 12-hour shift or a long commute, we crave sleep and comfort food instead of exercise and veggies. The pounds creep up on us despite our best intentions. As nurses, we are used to educating patients about health problems, including excess weight. But for many nurses itâ&#x20AC;&#x2122;s time for a refresher course on the science behind weight gain and loss. The pounds we shed can bring us added energy and better health â&#x20AC;&#x201D; and the pride of accomplishing something important for our own well-being. Losing weight is certainly a hard task, with the inevitable setbacks and frustrations, but a worthwhile one. Anyone who is overweight has lots of company these days. Obesity as a major public health issue has moved to the forefront and for good reason. Obesity among U.S. adults has become epidemic in proportion. Progressively increasing in recent years, American obesity rates are the highest in the world, with 68 percent of adults categorized as overweight, one-third of whom are clinically obese.1,2 Factors that increase the risk of obesity include genetics (affecting the amount and areas of body fat storage), family history (having two obese parents increases the chances of being obese, due to the influence of genetics and learned patterns of behavior) and age (which increases inactivity). A variety of other factors contribute to obesity. At a basic level, obesity is an issue of energy imbalance. Excess weight is the result of the intake of more calories from food than are

expended through activities of daily living plus physical exercise. However, obesity is an expansive and complex health issue that also results from a combination of factors, among them genetics, metabolism, behavior, environment, culture and socioeconomic status.3 Body mass index, also known as the Quetelet index, defines body mass in relation to both height and weight. (BMI is based upon metric measurements, dividing weight in kilograms by height in meters; BMI = weight/height2.) A strong relationship exists between BMI and mortality in adults.4 The most widely accepted obesity scale, the World Health Organization obesity criteria, is based upon BMI and calculates that a BMI of between 25 and 29.9 kg/m2 is overweight, a BMI of between 30 kg/m2 and 39.9 kg/m2 is obese, and a BMI over 40 kg/m2 is severely or morbidly obese.5 The body requires some body fat for insulation and to provide shock absorption and store energy for potential use later. However, along with the cosmetic concerns, too much body fat can have serious health implications, among them the propensity for hypertension, diabetes and cardiac disease. The medical costs directly attributable to obesity are estimated at $147 billion per year.6 Combined with smoking, alcohol use and high levels of stress, excessive weight can have seriously detrimental effects upon the body.

Improving Quality of Care Based on CMS Guidelines 21

I Came, I Saw, I Ate Obviously, diets that include large portions of high-calorie foods contribute to weight gain. Foods high in fat can be heavy in caloric content since fat has more calories per gram than carbohydrate or protein. Foods and beverages such as soft drinks, candy and desserts have not only a high sugar content, but also a high caloric content.

Where’s the Beef? In the United States, society facilitates obesity. Food is readily available and often comes in “super-sized” portions. Passive entertainment has become the norm as the bulk of the population has morphed into a modern cliché, the “couch potato.” Studies have shown that only a small fraction of the population achieves the minimally recommended exercise goals.7 Environment and lifestyle play a significant role in the development of obesity. Obesity is not only a product of our eating habits and exercise patterns, but also a manifestation of our modern lifestyle. More people choose to drive around the block than to walk, to eat in restaurants or order take-out than to cook and to snack on high-caloric vending machine selections than to concentrate on healthier alternatives.7 Cultural background also affects weight. Foods specific to certain cultures may be high in salt and fat. Family gatherings often proffer large quantities of food, along with an excellent excuse not only to socialize, but to overindulge.7 Certain preexisting conditions and illnesses can lead to a propensity for overweight and obesity. Hypothyroidism lowers the body’s metabolic rate, resulting in a slower and reduced expenditure of energy. Cushing’s disease, a hormonal disorder, commonly causes upper-body obesity and increased fat around the neck. Increasing evidence exists that insufficient sleep may lead to weight gain over time as does polycystic ovarian syndrome (which is characterized by high levels of male hormone), irregular or missed menstrual cycles and multiple, small cysts in the ovaries. Certain drugs — such as steroids, some antidepressants and medications used to treat psychiatric illnesses and seizure disorders — may cause weight gain by slowing the metabolic rate, stimulating the appetite or causing water retention.9

22 Healthy Skin

Sedentary people are more likely to gain weight since they are not burning calories through physical activity. Some people gain weight when they quit smoking. Nicotine raises the body’s metabolic rate, resulting in more calories burned. In addition, food typically tastes and smells better after one stops smoking, and eating a natural stopgap for hands and mouths no longer filled with a cigarette.10 In addition, many women find it difficult to lose pregnancy weight after giving birth, contributing to the development of obesity. Also of note is the distribution of body fat as it can have an impact on illnesses that are directly attributable to obesity. Excessive body fat in the abdominal area significantly increases the probability of diabetes mellitus, hypertension and hypercholesteremia.11 Distribution of Body Fat Women typically collect fat in the hips and buttocks, giving them a “pear-shaped” look. Men typically develop more women “pear” of an “apple” shape, generally shape accumulating fat around the abdomen. Women with a waist measurement of more than 35 inches and men with a waist measurement of more than 40 inches run a higher risk of developing weight-related complications related to the distribution of body fat.12

men “apple” shape

People who are obese are more likely to develop a number of significantly serious and chronic diseases. Among these are hypertension; elevated cholesterol levels; diabetes; coronary artery disease; stroke; osteoarthritis, sleep apnea and respiratory difficulties; some cancers (endometrial, breast and colon); nonalcoholic fatty liver disease; endocrine problems; gallbladder disease; and fertility and pregnancy complications. The greater the weight, the more likely a chronic health problem will develop. A reduction of body weight by as little as 5 to 10 percent can significantly improve overall health status.13

It’s Not a Diet — It’s a Lifestyle The goal of any weight loss program is to achieve and maintain a healthy weight. The treatment of choice depends upon the level of obesity and a person’s overall health and readiness to devote the effort to a weight loss plan. Any weight loss regimen should begin with dietary and lifestyle modifications. Weight loss will result primarily from a decrease in overall food intake, which will decrease calorie intake. (A calorie is a unit of energy that is supplied by food.) An excess of about 3,500 calories results in the accumulation of one pound of body fat. Simply by reducing caloric intake by as little as 250 calories per day, a person can loose a half a pound per week. Decreasing intake by 500 to 1,000 calories a day will produce a weight loss of about one to two pounds per week. This can be accomplished by replacing high-calorie food of low nutritional value, typically highly processed foods with a high sugar and solid fat content, with nutritious, low-calorie foods, such as fruits, vegetables and whole grains.14

activity provides both direct and indirect benefits. While increasing energy expenditure and reducing the risk of cardiovascular disease, it also helps preserve muscle mass at the same time it is decreasing body fat. Physical activity can be in the form of walking, running, dancing, gardening or participating in sports. A person should engage in some form of physical activity to achieve an optimally healthy lifestyle. Adults should take part in at least two and a half hours of moderate exercise or one hour and 15 minutes of vigorous, aerobically beneficial exercise every week.15

Physical activity in conjunction with a modified dietary intake plays an important role in preventing overweight and obesity. Although the body burns a certain amount of calories naturally as it cycles through its daily functions of breathing, digestion and activities of daily living, most people still ingest more calories than they expend. To remain in balance, the calories consumed from food must equal the calories expended in physical activity. Too many calories will cause weight gain while too few will lead to a weight loss. Physical

A successful weight loss program requires changes in behavior and more than just the reduction of caloric intake in isolation. A solid weight loss plan consists of alterations in physical activity, as well as a thorough examination of eating habits and realistic and achievable goals. Goals set too high too quickly will result only in failure. Obesity does not have to become a chronic disease. A healthy diet, daily exercise and a strong commitment to a healthy lifestyle can derail obesity and its health complications.

Crash diets are never recommended, because they can compound existing health issues by creating vitamin deficiencies. People can shed weight quickly with very low calorie diets, which consist of 800 calories per day (most adults consume 2,000 to 2,500 calories daily), but they generally regain the weight quickly when they resume a regular diet.14

Continued on page 25

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To request a free sample of Ultrasorbs ES, send an e-mail to scottasmith@medline.com.

The Drugâ&#x20AC;&#x2122;s the Thing The most therapeutic weight loss approach involves a solid diet, exercise plan and behavior modification system set up, ideally, in conjunction with a physician and a nutritional counselor. However, people who have found this approach to be unsuccessful, have a BMI greater than 30 and have developed obesity-related medical complications can explore additional regimens of weight loss. The pharmacological management of obesity has gained attention as a greater portion of the population strives to lose weight. Weight-loss medications should be considered only in conjunction with a diet and exercise plan, and only if lifestyle modifications have not proved to be effective. Medications to treat obesity can be divided into three categories: those that reduce food intake, those that alter metabolism and those that increase energy expenditures. Many medications are sold over-the-counter or by prescription to enhance weight loss in individuals who are obese. Although most weight-loss medications are approved for short-term use only, two that have been approved by the FDA for long-term use are sibutramine (Meridia) and orlistat (Xenical). Sibutramine alters the brain chemistry in the appetite center of the brain by extending the amount of time that serotonin and noradrenaline are free to work. The increased rate of activity of these combined chemicals results in appetite suppression. While its most common adverse effect is hypertension, sibutramine can also cause tachycardia, headaches, dry mouth, constipation and insomnia.17 It should not be used by a person with or at a high risk for cardiovascular disease.

Orlistat, on the other hand, prevents absorption of fat in the intestines; fat is eliminated in the stool instead of being absorbed and becoming fat itself. By keeping the body from absorbing dietary fat, orlistat reduces the total amount of energy from calories absorbed by the body and, taken as directed, can block up to 30 percent of ingested fat.18 The adverse effects include oily and frequent bowel movements and diarrhea, as well as a reduction in absorption of essential fat-soluble vitamins and nutrients. Orlistat must be taken with vitamin and nutrient supplements.18 Most FDA-approved weight-loss medications are appetite suppressants not suggested for use for more than 12 weeks. Examples include phentermine (Fastin) and diethylpropion (Tenuate). Other medication classifications that cause weight loss as a side effect include the diabetic medication metformin HCl (Glucophage), antidepressive medications including bupropion (Wellbutrin) and antiseizure medications that include topiramate (Topomax) and zonisamide (Zonegran). Researchers are studying these drugs for their unequivocal usefulness in treating obesity.19 Research is ongoing on the long-term effects of medications prescribed specifically for weight loss. Currently, except for orlistat (released in 2007 in an over-the-counter variety), all weight loss medications are controlled substances because of the potential for abuse and development of dependency. Many people on weight-loss medication are nonadherent with diet and exercise programs because they believe the medication will control their weight for them. However, although many of the adverse effects

Improving Quality of Care Based on CMS Guidelines 25

Big Eyes, Small Stomach

Patients should use caution when considering the many OTC products advertised for weight loss of these medications are mild, rare, serious and even fatal outcomes can and do occur. In addition, when people stop taking these drugs, weight gain tends to reoccur.20 Patients should use caution when considering the many OTC products advertised for weight loss. The FDA issued warnings against more than 70 “tainted weight-loss products” that contained undocumented or dangerous pharmaceutical ingredients. Many contained prescription drugs in amounts that exceeded maximum recommended doses or contained undeclared and dangerous chemical components.21

Weight-loss surgery, known as bariatric surgery, bypass surgery or gastric banding, is recommended for people who have clinically severe obesity (once called “morbid obesity”) and have failed to lose weight through diet and exercise. Weight-loss surgery is suggested for people with a BMI of 40 or greater, men who are 100 pounds or more overweight and women who are 80 pounds or more overweight.22 Surgical intervention provides a medically sustained weight loss for more than five years in most patients.23 However, it is not a miracle cure and still requires a life-long commitment to a healthy lifestyle consisting of a low-calorie diet and a healthy exercise program. Gastric bypass surgeries limit the amount of food a person can consume and digest by surgically altering the anatomy of the GI tract. There are different types of bypass surgeries, and their use depends on surgeon preference and patient requirements. The Roux-en-Y gastric bypass is the most common weightloss surgery in the United States. A surgery that combines the principles of “restriction” and “malabsorption,” it consists of the stapling of a portion of the stomach together to form a smaller pouch that cannot contain a large amount of food at any one time. This limits food intake. In addition, a Y-shaped section of the small intestine is attached to the pouch, which causes food to bypass both the duodenum and the first portion of the jejunum, leading to reduced caloric and nutrient absorption.24 Continued on page 28

26 Healthy Skin

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Gastric banding is a “restrictive” surgical procedure. An adjustable silicone band is placed around the upper portion of the stomach, molding it into two separate but connected chambers. Saline is added or removed from the band through an injection port attached to the abdominal wall underneath the skin and connected to the band with soft, thin tubing. Adding saline to the band through the port increases restriction and limits intake, helping patients feel full sooner with less food. Potential benefits of this procedure include an improved quality of life, improved physical function, improved social and economic opportunities, and improvement of obesity-related comorbidities, including diabetes, hypertension and high cholesterol. The down side is that although the procedure restricts the amount of food that can be ingested at any one time, it doesn’t eliminate the desire to eat. Diet, an exercise plan and behavior modification must still be a definitive part of any surgical resolution of obesity.27 As miraculous as the results of these surgeries may be, they are not without risks and complications. Pneumonia, blood clots and infection can occur after any surgical procedure. Rapid weight lose can predispose a person to gallstones. The gastric bypass itself can cause “dumping syndrome,” which occurs when the contents of the stomach move through the intestines too quickly, resulting in nausea, vomiting, diarrhea, dizziness and sweating.28 A more extensive and complicated gastric bypass surgery is the biliopancreatic diversion. It involves removing the lower portion of the stomach and attaching the small pouch remaining directly to the small intestine, bypassing the entire duodenum and jejunum. Although successful as a weight-loss surgery, it is not extensively performed as it carries a high risk for nutritional deficiencies since so much of the area of the small intestine is not absorbing potentially essential nutrients.25

Weight-loss surgeries can produce dramatic and startling effects not only on a person’s weight, but on his or her overall health status and quality of life. Within the first two years postprocedure, people can shed 50 to 60 percent of their excess weight.12 Dedicated maintenance of a healthy lifestyle will ensure that weight loss is permanent.29

The Invisible Man Sleeve gastrectomy is another example of a “restrictive” bariatric surgery. Typically considered a surgical option for patients who have a BMI of 60 or greater, sleeve gastrectomy involves creating a sleeve-shaped stomach pouch about the size of a banana, larger than the pouch created during a Roux-en-Y bypass surgery. Sleeve gastrectomy is usually the first of a two-part surgical treatment plan that is completed with the performance of a gastric bypass surgery.26

28 Healthy Skin

Obesity carries a negative connotation in numerous societies. Many cultures judge beauty by weight. (Consider the saying “You can never be too rich or too thin.”) Many people view the overweight as slothful, gluttonous and lazy. People who are overweight are often overlooked and ignored. As a result, obesity can have serious psychological, social and economic consequences. Society’s weight bias leaves people who are obese vulnerable to depression, anxiety, lowered self-image and, in some instances, suicidal ideation.

The stigma of obesity affects all areas of a person’s life.30 Under the umbrella of weight bias are employees who are treated poorly by their coworkers and obese students who are ridiculed by their peers. It is no wonder that depression and feelings of inadequacy can result. Unhealthy coping mechanisms can emerge, and people may react to negative stimuli by overindulging on comfort food, isolating themselves or responding negatively to others and refusing to diet. Positive coping mechanisms can include stress management, stimulus control, cognitive restructuring and the cultivation of a strong and supportive social network. A positive self-image that includes developing self-love and acceptance, dieting, refusing to hide and educating others about the very real dilemma of weight bias can go a long way in alleviating the burden of prejudice.31

The Long and Winding Road Weight loss and maintenance are life-long. Management includes the reduction of excessive weight in combination with the maintenance of weight loss and control of any obesity-related comorbidities. It is as much a state of mind as a way of life. Weight loss and maintenance of a healthy weight involve a healthy diet low in fat and high in carbohydrates and a plan for regular physical activity. Successes should be rewarded, but not with food. A person can adjust to smaller portions by eating more slowly and taking smaller bites of food at a time. Weight loss can be charted, and successes can be documented and celebrated. The conscientious monitoring of progress increases motivation.32

Weight loss not only helps control diseases exacerbated by obesity and related to increased mortality rates, but also decreases the likelihood of developing such diseases in the first place. There is no rule of thumb for the treatment of weight loss. Basic principles of obesity therapy and treatment are a “pyramid” with a base of diet, exercise and behavior modification. The next level is pharmacological intervention and, at the top, surgery if necessary. Noninvasive interventions include acupuncture, hypnosis and herbal remedies and supplements. In the end, weight loss and control is a journey, not just a destination, with the goal a comprehensive improvement in overall health. Weight Management and Obesity Resource List • The Obesity Society: www.obesity.org • Obesity Action Coalition: http://obesityaction.org/ home/index.php • CDC resources: www.cdc.gov/obesity/ resources.html About the author

Cathy S. Birn, RN, MA, GRN, CNOR practices endoscopy at memorial Sloan-Kettering Cancer Center in New York, NY; is the cochair woman of the education committee of The Society of Gastroenterology Nurses and Associates and is a former member of the board of directors of the Gastroenterology Nursing Journal.

Improving Quality of Care Based on CMS Guidelines 29

References 1 Flegal KM, Carroll MD, Ogden CL, Curtin LR. Prevalence and trends in obesity among U.S. adults, 1999-2008. JAMA 303(3):235-241, 2010. 2. AOA fact sheets: obesity in the U.S. American Obesity Association Web site. http://www.obesity.org/information/factsheets.asp. Accessed July 8, 2010. 3. Adams KF, Schatzkin A, Harris TB, et al. Overweight, obesity, and mortality in a large prospective cohort of persons 50 to 71 years old. N. Engl J Med. 2006 355(8):763-778. 4. About BMI for adults. CDC Web site. http://www.cdc.gov/healthyweight/assessing/bmi/adult_bmi/index.html. Accessed July 9, 2010. 5. Obesity and overweight for professionals: data and statistics. CDC Web site. http://www.cdc.gov/obesity/data/trends.html. Accessed July 9, 2010. 6. Obesity and overweight for professionals: economic consequences. CDC Web site. http://www.cdc.gov/obesity/causes/economics.html. Accessed July 9, 2010. 7. Caprio S, Daniels SR, Drewnowski A, et al. Influence of race, ethnicity, and culture on childhood obesity: implications or prevention and treatment: a consensus statement of Shaping America; Health and the Obesity Society. Diabetes Care. 2008;(11):2211-2221. 8. Chaput JP, Despres JP, Bouchard C, Tremblay A. The association between sleep duration and weight gain in adults: A six-year prospective study from the Quebec family study. Sleep. 2008;31(4):517-523. 9. Reutsch O, Viala A, Bardou H, Martin P, Vacheron MN. Psychotropic drugs induced weight gain: s review of the literature concerning epidemiological data, mechanisms, and management. Encephale. 2005:507-516, 10. Lerman C, Berrettini W, Pinto A, et al. Changes in food reward following smoking cessation: a pharmacogenetic investigation. Psychopharmacology. 2004;174:571-577. 11. Bessesen DH. Update on obesity. J Clin Endocrinol Metab. 2008;93(6):2027-2034. 12. Guh D, Zhang W, Bansback N, Amarai Z, Birmingham C, Anis A. The incidence of co-morbidities related to obesity and overweight: a systematic review and metaanalysis. MC Public Health Web site. http://www.biomedcentral.com/14712458/9/88. Published March 25, 2009. Accessed July 9, 2010. 13. Shai I, Stampfer MJ. Weight-loss diet: can you keep it off? Am J Clinical Nutrition. 2008;88 (5):1185-1186. 14. Gorin AA, Phelan S, Wing RR, et al. Promoting long-term weight control: does dieting consistency matter? Int J Obes Relat Metab Disord. 2004;28(2):278-281. 15. Physical activity for everyone. Department of Health and Human Services Web site. http://www.cdc.gov/physicalactivity/everyone/guidelines/ adults.html. Accessed July 9, 2010. 16. Bray GA. Lifestyle and pharmacological approaches to weight loss: Efficacy and safety. J Clin Endocrinol Metab. 2008;93(11 Suppl 1):S81-S88.

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17. Wooltorton E. Obesity drug sibutramine (Meridia): hypertension and cardiac arrhythmias. CMAJ. 2002;166(10):1307-1308. 18. Genentech USA Inc. Xenical (orlistal) product information. Xenical Web site. http://www.xenical.com/hcp/3_productinfo.asp. Accessed July 9, 2010. 19. Boss, Olivier; Karl G. Hofbauer. Pharmacotherapy of Obesity: Options and Alternatives. Boca Raton, FL: CRC Press. 2004. 20. Wing RR, Phelan S. Long-term weight loss maintenance. Am J Clin Nutr. 2005; 82(1 Suppl):2225-2255. 21. FDA uncovers additional tainted weight loss products. FDA Web site. http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm149547.htm. Updated March 20, 2009. Accessed July 9, 2010. 22. DeMaria EJ. Bariatric surgery for morbid obesity. N Engl J Med. 2007:356(21):2176-2183. 23. Echols J. Obesity weight management and bariatric surgery case management programs: A review of literature. Prof Case Management. 2010;15(1):17-26. 24. Buchwald H, Olen DM. Metabolic/bariatric surgery worldwide 2008. Weightloss Surgery Vitagarten Web site. Published 2009. Accessed July 9, 2010. 25. Piazza L, Pulvirentil A, Ferrara F, et al. Laparoscopic biliopancreatic diversion: our preliminary experience with 201 consecutive cases. Chir Ital. 2009;61(2):143-148. 26. Sammour T, Hill AG, Singh P, Ranasinghe A, Babor R, Rahman H. Laparoscopic sleeve gastrectomy as a single-stage bariatric procedure. SpringerLink Web site. http://www.springerlink.com/content/3145284114518783. Accessed July 9, 2010. 27. Tice JA, Karliner L, Walsh J, Petersen AJ, Feldman MD. Gastric banding or by pass? A systematic review comparing the two most popular bariatric procedures. Am J Med. 2008;(10):885-893. 28. Apovian CM, Cummings S, Anderson W, et al. Best practice updates for multidisciplinary care in weight loss surgery. Obesity. 2009;17(5):871-879. 29. Farrell TM, Haggerty SP, Overby DW, Kohn GP, Richardson WS, Fanelli RD. Clinical application of laparoscopic bariatric surgery: an evidence-based review. SpringerLink Web site. http://www.springerlink.com/content/ 121234v000452321. Accessed July 9, 2010. 30. Puhl RM, Heuer CA. Obesity stigma: important consideration for public health. Am J Public Health. 2010;100(6):1019-1028. 31. Wardle J, Cook L. The impact of obesity on psychological well being. Best Pract Res Clin Endocrinol Metab. 2005;19(3):421-440. 32. Butryn ML, Phelan S, Hill JO, et al. Consistent self-monitoring of weight: a key component of successful weight loss maintenance. Obesity. 2007;15 (12):3091-3096.

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Treatment

Feeding Dementia Patients With

DIGNITY

By Roni Caryn Rabin

She would chew away at her food, coughing and sputtering and spitting up but swallowing very little, said her daughter, Cyndy Viveiros. And like many relatives caring for patients with advanced dementia, Ms. Viveiros had to decide whether or not to have a gastric feeding tube inserted. This quandary — which usually arises near the end, when Alzheimer’s begins to destroy the part of the brain that controls eating — is often presented as a stark choice between providing nourishment and withholding it. But social workers advising Ms. Viveiros suggested another option: continuing to have her mother carefully fed by hand, giving her only as much as she wanted and stopping if she started choking or became agitated. “I had this realization — wow — that no matter what we did, Mom was never going to get better,” Ms. Viveiros said. “We were just prolonging the inevitable, and potentially causing more suffering. “Mom was already dying. Alzheimer’s is a terminal disease. There’s no stopping it,” she said. Mrs. DeFelice, of Providence, R.I., died about eight months later.

Doctors are calling this new option in palliative care “comfort feeding only.” In a recent paper in The Journal of the American Geriatrics Society, the authors argue that feeding tubes do not necessarily prolong life in patients with advanced dementia, and that surveys indicate that a vast majority of nursing home residents say they would rather die than live with a feeding tube. But medical orders like “no artificial hydration and nutrition” — used to indicate that the patient should not be given a feeding tube — are often interpreted as “do not feed.” And few people can tolerate the idea that a loved one may be starving to death. Comfort feeding offers another alternative. “We believe careful hand-feeding is a much more humane way of taking care of these people, and preserves the patient’s dignity,” said an author of the paper, Dr. Joan Teno, a professor of community health at Brown University’s medical school. “They can still have that human interaction and intimate contact that comes with being fed. “Just imagine someone interacting with the patient, talking to them, cueing them into eating,” Dr. Teno said, “as opposed to someone walking to the bedside and pouring a bottle of Ensure down the feeding tube.”

Improving Quality of Care Based on CMS Guidelines 33

Photo from Shutterstock

Nancy Berlinger, a bioethics research scholar at the Hastings Center, a research institute in Garrison, N.Y., said the feeding-tube dilemma was “not a choice people tend to want to face with reference to their mother, who probably fed them at an earlier age.” Eating is a pleasurable activity, and feeding is associated with love and nurturing, Dr. Berlinger went on, so the question “Should we put a feeding tube in, or do you want to stop feeding her?” is almost like asking, “Do you love your mother or not?” Feeding tubes are used in about a third of all nursing home residents with advanced dementia, in part because the homes worry they could face regulatory scrutiny if their patients are losing weight. Hand-feeding can also be time-consuming and labor-intensive. In addition, the United States Conference of Catholic Bishops issued a directive last year stating that Catholic health facilities have “an obligation to provide patients with food and water, including medically assisted nutrition and hydration for those who cannot take food orally.”

As many as 5.1 million Americans have Alzheimer’s disease, the most common cause of dementia, and the number is expected to rise as the baby boom generation ages. The disease is progressive and terminal, though it may take years to run its course; it is the sixth leading cause of death in the United States, killing more than 71,000 a year, a figure many experts think is understated. Sometimes the ability to eat is lost in the early stages of Alzheimer’s, not toward the end. Seymour Geffner says it was one of the first signs that something was wrong with Blossom, his wife of 63 years. He started feeding her four years ago, while she went through a series of tests to figure out what was wrong. Now that she lives at Schervier Nursing Care Center in Riverdale, in the Bronx, he spends every day there, hand-feeding her lunch and dinner. Each feeding takes 45 minutes to an hour, said Mr. Geffner, 86.

Yet studies suggest that the tubes do not necessarily prolong survival. Nor do they always prevent aspiration in people who have trouble swallowing, since they are at risk of aspirating their own saliva.

“Some days are better than others,” he said. “The food is puréed, and she doesn’t eat a full meal. But I always give her at least half a banana every day, and strawberries in season.”

Moreover, the tubes can be very uncomfortable, and people with dementia must often be physically restrained or sedated to prevent them from yanking the tubes out.

“The bottom line is she doesn’t go hungry,” he said. “She looks good.”

From The New York Times, © August 3, 2010 The New York Times All rights reserved. Used by permission and protected by the Copyright Laws of the United States. The printing, copying, redistribution, or retransmission of the Material without express written permission is prohibited. Photos published here did not run with the original New York Times article.

34 Healthy Skin

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Medline’s OptiumEZ Blood Glucose Monitoring System, manufactured by Abbott Diabetes Care, uses TrueMeasure® Technology to minimizes the potential interfering effects of many common medications.* In addition, the OptiumEZ system features no coding, simple 2-step testing with results in 5-seconds and an easy to read display with backlight. The OptiumEZ Blood Glucose Test Strip are individually foil-wrapped to protect against air and moisture. Advanced Technology Made Simple™ for the Post Acute Care Professional. • No coding required • Simple two-step testing • Results in five seconds • Small blood sample size – 0.6 µl

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Survey Readiness

CDC, FDA, CMS ISSUE

INFECTION CONTROL GUIDANCE Point of care testing in healthcare settings The Centers for Disease Control and Prevention (CDC) recently released new guidelines regarding blood glucose monitoring and insulin administration when people are assisting others, (i.e., in healthcare settings). Not all of the CDC information is new; however, it clarifies how to prevent infection when using a glucose monitor. Some of this information has been available from the CDC since 2005. The latest language states:

tration. In the last 10 years alone, there have been at least 15 outbreaks of HBV infection associated with providers failing to follow basic principles of infection control when assisting with blood glucose monitoring. Due to under-reporting and under recognition of acute infection, the number of outbreaks due to unsafe diabetes care practices identified to date are likely to be underestimated.

CDC is alerting all persons who assist others with blood glucose monitoring and/or insulin administration of the following infection control requirements:

Although the majority of these outbreaks have been reported in long-term care settings, the risk of infection is present in any setting where blood glucose monitoring equipment is shared or when those assisting with blood glucose monitoring and/or insulin administration fail to follow basic principles of infection control.

• Fingerstick devices should never be used for more than one person • Whenever possible, blood glucose meters should not be shared. If they must be shared, the device should be cleaned and disinfected after every use, per the manufacturer’s instructions. If the manufacturer does not specify how the device should be cleaned and disinfected, then is should not be shared. • Insulin pens and other medication cartridges and syringes are for single patient use only and should never be used for more than one person. An underappreciated risk of blood glucose testing is the opportunity for exposure to bloodborne viruses, such as hepatitis B virus (HBV), hepatitis C virus and HIV through contaminated equipment and supplies if devices used for testing and/or insulin administration are shared. Examples of these devices include blood glucose meters, fingerstick devices and insulin pens. Outbreaks of HBV infection associated with blood glucose monitoring have been identified with increasing regularity, particularly in long-term care settings, where residents often require assistance with monitoring of blood glucose levels and/or adminis-

36 Healthy Skin

For example, at a health fair in New Mexico in 2010, dozens of attendees were potentially exposed to bloodborne viruses when fingerstick devices were inappropriately reused for multiple persons to conduct diabetes screening. In addition, at a hospital in Texas in 2009, more than 2,000 persons were notified and recommended to undergo testing for bloodborne viruses after individual insulin pens were used for multiple persons.

Fingerstick devices should never be used for more than one person. Full guidelines can be found at http://www.cdc.gov/injectionsafety/blood-glucose-monitoring.html. The Food and Drug Administration (FDA) recently posted a Safety Alert on reusable fingerstick devices and point of care testing devices. They stated that fingerstick devices should never be used for more than one person. When possible, POC blood testing devices, such as blood glucose meters and

PT/INR anticoagulation meters, should be used only on one patient and not shared. If dedicating POC blood testing devices to a single patient is not possible, the devices should be properly cleaned and disinfected after every use as described in the device labeling. The full alert can be found at: http://www.fda.gov/Safety/MedWatch/SafetyInformation/SafetyAlertsforHumanMedicalProducts/ucm224135.htm?sms_ss=email

If shared, blood glucose meters should be cleaned and disinfected after every use. Similar to the CDC and FDA, the Centers for Medicare & Medicaid Services (CMS) issued a memo in late August 2010 regarding infection control standards for nursing homes. The memo is a reminder: • not to reuse fingerstick devices for more than one resident • not to use a blood glucose meter or other point-of-care device for more than one resident without cleaning and disinfecting it after each use Also, if the manufacturer does not specify instructions for cleaning and disinfection between uses of a point-of-care device, then the device should not be used for more than one resident. CMS also clarifies that reuse of fingerstick devices for more than one resident should be treated as immediate jeopardy. Failure to clean and disinfect blood glucose meters used for more than one resident is a deficiency in infection control that warrants corrective action; however, it may not constitute immediate jeopardy. A copy of the CMS memo to state survey agency directors is located at www.cms.gov/surveycertificationgeninfo/downloads/SCLetter10_28.pdf. Turn to the Forms & Tools section at the back of the magazine for pullout fact sheets on the topics mentioned in this article.

PERIOPERATIVE PRESSURE ULCER EDUCATION. MORE IMPORTANT THAN EVER BEFORE

“

I have seen an increase in the number of legal issues linking facility-acquired pressure ulcers to post-surgical patients. A pressure ulcer program for the OR is more critical than ever.” Diane Krasner, PhD, RN, CWCN, CWS, BCLNC, FAAN

Medline’s Pressure Ulcer Prevention Program now has a component designed specifically for the perioperative services. The easy-to-use interactive CD addresses the following: • Hospital-acquired conditions • CMS reimbursement changes • Best practices for pressure ulcer prevention • Perioperative assessment tools • Critical patient and equipment risk factors

To learn more about Medline’s Pressure Ulcer Prevention Programs for long-term care, acute care and perioperative services, call your Medline representative or visit www.medline.com/pupp-webinar.

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INFECTION PREVENTION PROGRAM

Prevention

Continuing Education Article

VE EFFECTI S UE TECHNIQ OID AV TO HELP SURE ES HEEL PR S ULCER

SAVE THOSE

HEELS!

by Alecia Cooper, RN, BS, MBA, CNOR

With their drier skin and bony prominences, the heels are particularly vulnerable to injury. People with medical conditions requiring them to spend long periods of time in bed are especially susceptible to heel injuries â&#x20AC;&#x201C; particularly pressure ulcers â&#x20AC;&#x201C; in the absence of proper prevention strategies. In addition, the soles of the feet have no sebaceous glands, resulting in a lack of skin lubrication. This makes the heels vulnerable to dryness and damage from friction, another precursor to pressure ulcers.1

Complex heel pressure ulcers represent one of the most costly complications in the elderly.2 They are the most common facility-acquired pressure ulcers in long-term care facilities and the second most common among all healthcare settings. In fact, long-term care facilities have reported pressure ulcer prevalence rates as high as 27.3 percent, with 23.6 percent of the ulcers occurring on the heels. In acute care and mixed acute care/long-term care settings, heel pressure ulcers account for approximately one third of all pressure ulcers.

Improving Quality of Care Based on CMS Guidelines 39

They can be physically debilitating and painful, possibly leading to serious complications, including infection, cellulitis, osteomyelitis, septicemia, limb amputation, and even death.3

Risk assessment To avoid these complications, it is best to prevent heel pressure ulcers altogether. And with appropriate preventive care, most heel pressure ulcers can be avoided.3 Prevention begins with a thorough assessment to determine which individuals are at greatest risk. The most effective assessment of pressure ulcer risk blends the results of general screening tools, knowledge of common risk factors and nursing judgment.4 The Braden Scale is a widely used risk assessment tool that screens for the individual’s degree of sensory perception, exposure to moisture (usually caused by incontinence), amount of activity, degree of mobility, nutrition level and amount of exposure to friction and shear. Each of these areas is scored numerically, with lower numbers indicating greater risk. A copy of the Braden Scale is available online at www.bradenscale.com/images/bradenscale.pdf. Preventive interventions should focus on specific Braden categories in which the patient has a low score. For example, if a patient scores low under exposure to friction and shear, interventions should focus on ways to minimize friction and shear. Preventive measures also should be pursued in patients whose total score indicates they are at risk.5 A total score of 18 or less indicates a person at risk for developing pressure ulcers.

40 Healthy Skin

Risk factors Certain physical conditions also increase the risk for pressure ulcers, including:6 • Decreased circulation and low blood pressure • Being obese or underweight • Advanced age • Specific illnesses • Medications Decreased circulation and low blood pressure. Blood supplies the body’s tissues with oxygen and nutrients, so when blood flow is blocked or reduced, the tissues can literally starve. The result is the death of skin cells, which can lead to the development of pressure ulcers. People with diabetes often experience decreased circulation, particularly in the legs and feet, making it more difficult for a sore or infection to heal. Proper foot care is essential for these individuals and necessary to prevent foot ulcers and infection. Preventive measures include inspecting feet daily for any cuts, sores, blisters or calluses. Feet should be washed in warm water and dried thoroughly.7 Being obese or underweight. Two body types are at increased risk for pressure ulcer development: people who are obese and those who are extremely underweight. Obesity causes higher risk because blood circulation to fatty tissue is not as good as circulation to leaner muscular tissue. The poor circulation means less oxygen and fewer nutrients, which can lead to pressure ulcers. Very thin people are at risk as well be-

“

Heel pressure ulcers are the most common pressure ulcers in long-term care facilities.

”

cause they have less fatty tissue to cushion bony prominences.

mal heel could be one that is pink, red, blistered or containing an existing pressure ulcer.9

Advanced age. Age is an uncontrollable risk factor for pressure ulcers. Older skin tends to be drier and thinner. It also breaks down more easily and forms new cells more slowly.

Tools for prevention

Specific illnesses. Specific medical conditions also put individuals at greater risk for heel pressure ulcers. The following groups of patients have the highest risk:8 • Those who cannot move their legs because of fractured hips, joint replacement surgery, spinal cord injury, Guillainbarre syndrome, stroke or another medical condition. • People with diabetes and peripheral neuropathy, which lessens the feeling of pressure or pain in the feet. • Individuals with dementia who are confused and distraught may inadvertently rub their heels on the bed, causing heel abrasions from shear and friction. These abrasions can result in pressure ulcers. Medications. The side effects of certain medications can also put individuals at increased risk for pressure ulcers. For example, long-time use of steroids for the treatment of asthma and other chronic respiratory disorders have a tendency to thin the skin. Once you have identified an individual at risk for heel pressure ulcers, the next step is to create a personalized prevention plan, including a thorough skin assessment with results documented in the chart. When assessing heels, a normal heel may be defined as clean and dry with intact skin. An abnor-

In addition to basic pressure ulcer prevention techniques, such as regular turning and making sure the patient is well-nourished and hydrated, there are several products that can aid in preventing pressure ulcers on the heels. Preventive devices should be selected on the basis of effectiveness, ease of use, and cost. For preventing heel pressure ulcers, the best products achieve the following:5 • Reduce pressure, friction and shear • Separate and protect the ankles • Maintain heel suspension • Prevent foot drop In patients at risk, the primary goal is to reduce pressure, friction and shear on the heels. Several types of products are available to achieve one or more of these objectives. Some examples include: pillows, heel offloading devices, padding devices, moisturizers and pressure-relieving mattresses. Pillows. The National Pressure Ulcer Advisory Panel (NPUAP) recommends the use of pillows as an effective, convenient and cost-effective way to elevate the legs of cooperative individuals for short periods of time. Raising the heel off the bed with pillows is best achieved when the pillow is placed longitudinally underneath the calf with the heel suspended in air.3 Pillows are not recommended, however, for individuals who are at risk for moving the leg off the pillow or in cases when the leg(s) must be elevated longer than 24 hours. For these Continued on page 43

Improving Quality of Care Based on CMS Guidelines 41

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 in all healthcare settings.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 off the bed or other surface.

Open back provides maximum ventilation

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. Mention this ad to receive a 10 percent discount on your first order. Contact your Medline sales representative or call 1-800-MEDLINE. 1

Fowler E, Scott-Williams S, McGuire JB. Practice recommendations for preventing heel pressure ulcers. Ostomy Wound Management. 2008;54(10):42:48.

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.

ÂŠ2010 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.

patients, it’s best to use a product that stays on the foot during movement – perhaps in the form of a heel offloading device.4 Heel offloading devices. The type of product most often used to elevate the foot and keep it in place is called a heel offloading device. Heel offloading devices can be more efficient than pillows because they can remain in place around the clock.3 Look for a device that is comfortable for the patient, easy for the caregiver to use and permits repositioning without increasing pressure in other areas. Most are shaped like a large boot, surrounding the foot and ankle on all sides, but also allowing open spaces for needed air flow. The advantage of these devices is that they both relieve pressure and greatly reduce friction and shear on the skin. They also separate and protect the ankles and prevent foot drop. One area of caution: remember to remove protective boots routinely (i.e., every shift) to inspect the individual’s skin for redness. To help determine the effectiveness of heel offloading devices as a way to prevent heel pressure ulcers, Meyers studied 53 sedated ICU patients at high risk for pressure ulcers. All 53 wore a heel offloading device. As a result, none of the patients developed a hospital-acquired heel pressure ulcer.9 Padding devices. Padding devices such as sheep skin and “bunny boots” protect the heels from friction and shear but do not remove pressure. Moisturizers. Moisturizers also minimize friction. In addition, they may contain topical nutrients to nourish the skin and/or ingredients such as dimethicone, which adds a layer of protection on top of the skin. Moisturizers do not, however, provide any protection from excessive pressure.5 Pressure-reducing mattresses. Air fluidized beds consistently reduce heel pressure below minimal capillary pressure. However, some benefit may be lost if the head of the bed is elevated to 30 degrees – a technique recommended to prevent pressure ulcers on the upper body.5 Also, make sure the mattress is positioned properly. Many pressure-reducing mattresses have a definitive head and foot. Placing the mattress upside down on the bed, so that the individual’s feet are resting on the head portion, can lead to heel problems.

Conclusion With heel pressure ulcers being the most common type of pressure ulcer in long-term care and the second most common in all healthcare settings, there is still much to be learned

about prevention. Overall, information on the prevention of heel pressure ulcers is lacking; however, medical needs are changing. Higher patient acuity and the growing elderly population will continue to keep this issue in the forefront.10 Further studies are needed to document the effectiveness of existing interventions and develop new ones. References 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. Walsh JS. Keeping heels intact: using a nursing professional practice model can improve outcomes. Advance for Nurses. 2010; 8(24):25. 3. Fowler E, Scott-Williams S, McGuire JB. Practice recommendations for preventing heel pressure ulcers. Ostomy Wound Management. 2008;54(10). Available at www.o-wm.com/content/practice-recommendations-preventingheel-pressure-ulcers. Accessed August 25, 2010. 4. Cuddigan JE, Ayello EA, Black J. Saving heels in critically ill patients. WCET Journal; 28(2):2-8. 5. FAQs: Preventing heel pressure ulcers in immobilized patients. Advances in Skin & Wound Care; 18(1):22. 6. Pressure Ulcer Prevention Program Nurse Workbook. 2nd edition. Medline Industries: Mundelein, IL. 2010. 7. Saccomano SJ. Handle with care: proper foot and skin care are necessary to prevent complications in diabetic residents. Advance for Long-Term Care Management. July/August 2010:24-26. 8. Black J. Preventing heel pressure ulcers. Nursing. 2004; 34(11):17. 9. Meyers TR. Preventing heel pressure ulcers and plantar flexion contractures in high-risk sedated patients. Journal of Wound, Ostomy and Continence Nursing. 2010; 37(4):372-378.

Improving Quality of Care Based on CMS Guidelines 43

CE TEST

SAVE THOSE HEELS!

Effective Techniques to Help Avoid Heel Pressure Ulcers True/False 1. People who spend long periods of time in bed are more susceptible to heel pressure ulcers. T F 2. Obesity increases an individualâ&#x20AC;&#x2122;s risk for developing pressure ulcers. T F 3. Heel pressure ulcers are the most common facility-acquired pressure ulcers in long-term care. T F 4. Heel pressure ulcers account for approximately one half of all pressure ulcers in acute care and mixed acute care/long-term care settings. T F 5. People with diabetes often experience decreased circulation, especially in the legs and feet. T F Multiple Choice 6. A low score on the Braden Scale means the individual is a. At lower risk for pressure ulcers b. At higher risk for pressure ulcers c. Anemic d. None of the above

Multiple Choice (cont) 8. Which of the following devices protect heels from friction and shear but do NOT remove pressure? a. Sheep skin b. Heel offloading devices c. Moisturizers d. Both a and c 9. Heels are more prone to pressure ulcers than other parts of the body because a. They have bony prominences b. The skin lacks sebaceous glands and tends to be dry c. They are usually covered with shoes and socks d. Both a and b 10. Heel pressure ulcers are the second most common type of pressure ulcers among a. All healthcare settings b. Home health care c. Hospitals d. Day care centers

7. Which of the following is NOT a common risk factor for developing heel pressure ulcers? a. Guillain-Barre syndrome b. Joint replacement surgery c. Dementia d. Urinary tract infection

Submit your answers at www.medlineuniversity.com and receive 1 FREE CE credit

Courses approved for continuing education by the Florida Board of Nursing and the California Board of Reigistered Nursing.

44 Healthy Skin

Snug-fitting sheets for healthier skin. SoftSpan sheets with spandex fit snugly on the bed to comfort and protect the skin. A patented blend of cotton, polyester and spandex provides softness and a non-abrasive surface, along with better air circulation for skin health.

Call your Medline representative or 1-800-MEDLINE to trial two dozen SoftSpan fitted sheets for the same price you’re paying for your current sheets.

Independent laboratory studies1 showed that SoftSpan fitted sheets had 260% stretch in the width and 98% stretch in the length, compared to a regular knit sheet, which has 104% stretch in the width and 45% in the length. Regular woven sheets have no stretch at all. More stretch means a tighter, smoother fit, and no wrinkles. Mayo Clinic and other healthcare experts recommend keeping the bottom sheet pulled tight to prevent wrinkles and bunching, which can cause pressure that contributes to skin breakdown.2,3

References 1. Diversified Testing Laboratories, Inc. ASTM D 6614-07, “Standard Test Method for Stretch Properties of Textile Fabrics – CRE Method.” July 29, 2009. Data on file. 2. Mayo Clinic. Bed sores (pressure sores). Available at http://www.mayoclinic.com/health/bedsores/DS00570. Accessed on February 5, 2010. 3. Oregon Department of Human Services. Pressure Sores: A Self-Study Course. 2008. Available at: http://www.oregon.gov/DHS/spd/provtools/nurs

Treatment

by Cynthia Ann Fleck RN, BSN, MBA, CWS, DNC, CFCN

In January, I had what I like to describe as Extreme Makeover — Foot Edition. While my show didn’t include Ty Pennington’s yelling from his megaphone, rebuilding homes for deserving folks on a Sunday night, I couldn’t take the agony of da feet any more and needed more than just my custom orthotics. I needed something drastic to alleviate the years of pain and suffering my poor peds had endured. I was a ballerina growing up, then spent my teenage and youngadult years as a competitive long-distance runner. This, coupled with some genetics from my maternal grandmother Florence, left me with some motor changes in my feet and pain that became increasingly worse — to the point that walking through an airport or standing to give a presentation in anything other than sneakers became excruciating!

46 Healthy Skin

Reprinted with permission from AAWC News. www.aawconline.org

Improving Quality of Care Based on CMS Guidelines 47

Looking back at my grandmother’s things when she passed and helping clean out her home, I found all sorts of concoctions, bunion pads, foot creams, etc. It was all-too reminiscent of the 2 x 2 hydrocolloids and special skin creams always in my handbag, medicine cabinet, and suitcase when I need to pad the many hot spots on my feet. So, I finally took the plunge and had my foot deformities surgically corrected (on my right foot) by my friend, Larry Huels, DPM, a foot and ankle surgeon (see Figure 1). Five surgeries on one foot (see Figure 2) meant I was on the OR table almost 4 hours. A tough recovery brought along nausea, vomiting, pain, immobility, 4 weeks non-weight-bearing, and 12 weeks in a walking cast (see Figure 3). My husband Joe was a saint — I fell several times and was quite a handful, I’m sure. I was back out on the road traveling, flying, and working after only 4 weeks. I’m still in the midst of 9 months of using my bone-growth stimulator daily. On the whole, my foot feels and works great now. I am back in normal shoes — with my orthotics, of course. And I was back to speed walking on the treadmill after only a few months. The only complaint: Some inflexibility remains due to hardware in several toes. Can’t wait until January to get the other foot done (ugh!), but all good things come with pain and sacrifice, right? Enough about that. This is a story about taking care of feet, wounds, and skin from the patient’s perspective. For me, nothing was more important as a patient than having a total experience that let me be independent, moving about, taking

Figure 1. Dr. Larry and Cynthia’s foot.

48 Healthy Skin

a shower, working, and relieving my pain. I will share some insight into what worked. Sometimes it’s not just about evidence-based medicine, nursing, and outcomes — but rather about patient choice, consumer satisfaction, and overall experience. Isn’t that what life is about, anyway: the experience? So, here’s what we did. I had three osteotomies, some hardware, an implanted xenograft, and five incisions, so infection was a concern. Right out of surgery, a silver transparent film was applied to reduce my chances of succumbing to a surgical site infection (see Figure 4). The remarkable thing about the silver transparent film is that it liberated ionic silver to all my sites, and I was able to shower the next day. The dressing didn’t have to be removed for 7 days, which dramatically decreased my pain since there was no manipulation of the tender incision sites. Keep in mind, the most frequent time patients experience wound pain is at dressing change.1 One of the best parts is that the silver transparent film let me and my surgeon view the incision lines without removing the dressings. A plus for nurses is that it’s often a nursing decision to use such a dressing. When my dressing and sutures were removed, I immediately moved to a cyanoacrylate monomer protectant that remained in place an average of 5 to 7 days (see Figure 5). This cousin of Dermabond ® has 510(k) approval as a device so it’s another nurse-mediated dressing. The nurse pinches the little, glow-stick-like device to activate it, then paints it directly on and around the wounds and incisions. I simply reapplied when I no longer could see the lavender color. It chemically

Figure 2. Cynthia’s edematous post-op foot.

Figure 3. Cynthia on a tricycle offloader.

bonded to my incisions, protecting them and allowing them to gain strength. Another key advantage was that it reduced pain from socks and hosiery, the water from the shower, etc. The protectant is removed only by epidermal turnover. I’ve progressed greatly at the 6-month mark and am now cleansing, moisturizing and protecting daily with a nutritional skin care line that is free of soap and surfactants, and contains antioxidants and breathable silicones. The products also have ingredients that offer topical nutrition via amino acids, vitamins, and a proprietary blend of methylsulphonmethane to reduce stinging and pain. As a result, my scars are fading beautifully (see Figure 6). Maybe it’s due to having gone soap-free. Perhaps it’s the antioxidants and nutritional blend that are helping the scars fade. It could also be the breathable blend of silicones that decrease transepidermal water loss. These are some of the same products that facilities nationwide are using to reduce pressure ulcers and skin tears. Post-op skin needs the same nutrition and coddling, however. Was my surgery a success? Absolutely! I’m happy with the result. And, further, my experience was as positive as feasible because my satisfaction, comfort, and choice were important to my surgeon, who acted additionally as my cooperative partner. Gallup World Poll researchers have found that happiness is likely to be associated with how well one's psychological and

Figure 4. Nurse Shelly changes Arglaes® silver transparent dressing.

“

Being a patient made me think about the experience of each and every person I treat. I hope that, as a result, I’m a better caregiver.

”

social needs are being met.2 In other words, it’s all about the experience. Why not consider making every patient experience as optimistic, pain-free, and supportive as possible? Think beyond your chronic wounds to your post-op patients like me. After all, people remember the experience. Of course, kindness, respect, and gentle, reassuring care didn’t hurt. Patients return for care and refer future business when you use products that offer a satisfying and atraumatic experience. Plus, it’s the right thing to do. This positive experience tied a big bow on an already-beautifully wrapped package: my brand new, now-pain-free foot! Here’s to life on the other side of the bed rail, treatment table, podiatric chair, or OR table. Being a patient made me think about the experience of each and every person I treat. I hope that, as a result, I’m a better caregiver. References 1. European Wound Management Society Position Document: Pain at Wound Dressing Changes. London, UK: Medical Education Partnership Ltd., 2002:2,8. Available at www.aawconline.org (accessed July 19, 2010). 2. Levy F. The World's Happiest Countries. Forbes. Available at http://travel.yahoo.com/pinterests-35010143 (accessed July 19, 2010).

Figure 5. Marathon® skin sealant protects the new incision lines on Cynthia’s foot.

Figure 6. Remedy® Skin Repair Cream is applied to nourish the skin and smooth the scars.

Dermabond is a registered trademark of Johnson & Johnson Company. Marathon and Remedy are registered trademarks of Medline Industries, Inc. Arglaes is a registered trademark of Giltech Limited Corporation

Improving Quality of Care Based on CMS Guidelines 49

Treatment

Implementing Medlineâ&#x20AC;&#x2122;s Pressure Ulcer Prevention (PUP) Program at Lacombe Nursing Centre Lacombe Nursing Centre is a 98-bed family-owned longterm care and rehabilitation facility in Louisiana. Rehabilitation represents the fastest growing segment of the care they provide. The facility employs 26 registered nurses and 38 certified nursing assistants (CNAs). They also have a treatment nurse. Staff members completed Medlineâ&#x20AC;&#x2122;s Pressure Ulcer Prevention (PUP) program in May 2010 and celebrated their newfound knowledge with the awarding of certificates and pins. The Pressure Ulcer Prevention Program includes a strategic product bundle consisting of skin care products and incontinence garments to assist in reducing or preventing pressure ulcers and incontinence-associated skin conditions.

50 Healthy Skin

Lacombe PUP Program Test Scores Compared to National Averages CNAs and nurses at LaCombe scored higher than the national averages on the PUP program pre- and post-tests.1 PUP Pre-Test %

Posttest %

Certified Nursing Assistant (NA) Average Lancombe CNA Average

58 71

80 90

Nurse Average Lancombe Nurse Average

78 82

88 90

Prevention

WHEN PREVENTION BUNDLES (toolkits) are employed, pressure ulcers are reduced.2 The program also packages education and training tools together with the products to allow healthcare teams to implement an effective pressure ulcer prevention program and immediately begin reducing the incidence of healthcare-acquired pressure ulcers. Training may be completed on a selfstudy basis or conducted classroom style by staff at the facility. Included are workbooks, patient and family education brochures, a CD with printable electronic forms and tools, and a staff rewards program.

Lacombe nurses proudly display their PUP certificates.

In addition, the MD Education DVD includes everything the physician needs to recognize, assess and document present–on–admission (POA) indicators for Stage III and IV pressure ulcers. There is also a separate version of the PUP program specifically for home care and hospice. Lacombe was uncertain at first about trying the program, mainly because purchasing the Remedy® Skin Repair Cream would add significantly to their supply costs. Once they moved forward, however, they learned that the product cost was not even a factor because of the savings achieved by no longer having to treat as many pressure ulcers or buy additional wound care products. 50 percent reduction in pressure ulcers Within 90 days of implementing the PUP educational program and product bundle, Lacombe saw a 50 percent reduction in pressure ulcer incidence. Residents were selected to participate in the program based on particular medical factors, including diabetes, peripheral vascular disease, history of skin tears, poor nutrition status and/or low Braden Scale scores. Residents experienced increased skin integrity and also benefited from one-on-one social interaction with the nurses as

Graduates of the PUP program celebrate with cake.

CONTINUOUS PROFESSIONAL development trains staff members on an ongoing basis in their work setting and results in confirming current practice, changing current practice or causing the learner to seek more information.2

they applied the Remedy Skin Repair Cream. Staff said residents enjoy spending those 20 minutes talking and sharing with the nurse as they feel the soothing touch and breathe in the aromatic citrus fragrance of the cream. In addition, residents with diabetes showed significant improvement in redness and scaling on their legs.

Improving Quality of Care Based on CMS Guidelines 51

CNA pride and accomplishment For the education portion of the PUP program, registered nurses at Lacombe studied the workbook and completed the course on their own, and Assistant Director of Nursing Sheila Smith conducted classroom style sessions for the CNAs. The CNAs especially praised the program for its focus on topics that were not covered as part of their professional training. They liked the PUP class so much that they encouraged each other to sign up. “You should have seen the smiles on the faces of our CNAs when they received their PUP pins,” Smith said. “They were so proud.”

CLOSE TO 40 PERCENT of the facilities participating in the PUP program are nursing homes or LTCs.1

CLINICIAN TRAINING AND education is an ideal opportunity for the wound care community to partner with associations or industry to develop appropriate programs and materials that can be implemented quickly.2

Each nurse and CNA who completes the PUP program receives a personalized certificate and a paw print (“PUP”) lapel pin from Medline. They display their pins on their ID badges. Good patient care Overall, the administrators at Lacombe said they believe in the PUP program because it represents good patient care. Developing pressure ulcers limits residents’ ability to socialize and participate in activities, affects their appetite and increases their physical pain. “Anything we can do to minimize poor outcomes and enhance residents’ enjoyment of life is a good thing,” said Lacombe Administrator Gwen Aucoin. “Not only does the PUP program contribute to good patient care, it is also valuable for staff development. So there’s a double reason to participate in PUP because it’s good for patients and it’s good for staff.” References 1 Medline Industries Inc. Pressure Ulcer Prevention (PUP) program. Data on file. 2 Armstrong DG, Ayello EA, Capitulo KL, et al. Opportunities to improve pressure ulcer prevention and treatment: implications of the CMS inpatient hospital care present on admission (POA) indicators/hospital acquired conditions (HAC) policy. Adv Skin Wound Care. 2008;21(10):469-78. Remedy is a registered trademark of Medline Industries, Inc.

Left to right: Gwen B. Aucoin, Administrator; Shiela Smith, Assistant Director of Nursing; Mona Soileau, Medline Wound Care Representative; Chrystal Wust, LPN Restorative Nursing.

52 Healthy Skin

Medline Remedy

ÂŽ

Serious care.

Serious results.

Nosocomial pressure ulcers reduced by 50% after 3 months1

Nosocomial pressure ulcers reduced to zero after 8 months1

Estimated cost savings of $6,677.11 per patient1

Independent outcomes research1 was conducted in an acute care facility where, after implementation of a prevention program, the only additional change during the reduction period was the focus of improving skin care by using Medline Remedy products exclusively, as part of a formal skin care regimen. The results were amazing!

To receive a FREE TRIAL of our effective Remedy skincare products, contact your Medline representative.

1. Shannon RJ, Coombs M, et al. Reducing hospital-acquired pressure ulcers with a silicone-based dermal nourishing emollient-associated skincare regimen. Adv Skin Wound Care, 2009;22:461-7. ÂŠ2010 Medline Industries, Inc. Medline and Medline Remedy are registered trademarks of Medline Industries, Inc.

CASE STUDY

Use of Porcine Urinary Bladder Matrix (UBM)* in a Dehisced Wound Between Stomas Promoted Closure Facilitating Regular Pouch Changes in a Premature Neonate PROBLEM

PAST MANAGEMENT

Maintaining pouch adherence over neonates’ stomas after laparotomy for Necrotizing Enterocolitis (NEC) challenges the NICU staff. The likelihood of achieving a seal decreases when the pouching surface is an open wound. A typical case of a NEC patient is LG, who is a five week old female born at the gestational age of 29 weeks, 4 days with a birth weight 690 gm. At 36 days of age, a laparotomy was performed and the wound dehisced eight days later. The dehisced abdominal wound, located between the ileostomy and the mucus fistula, measured 1.5 cm by 2.5 cm, and was approximately 20 percent of the total abdominal surface area. The goal was to close the wound as quickly as possible in order to provide a flat pouching surface. This led to a search for a dressing that promoted wound closure.

Two other patients with NEC (Patient A and Patient B) born at 30 weeks and 32 weeks 2 days, respectively, experienced dehisced wounds similar to LG’s wound described above. The dehisced wounds of both were treated with a Hyrdofiber® dressing and hydrocolloid dressing or tape strips followed by pouch application. Although both patients’ wounds closed completely, the dressing often failed to contain effluent and resulted in skin irritation and wound contamination, necessitating daily or more frequent pouch and dressing changes. Average closure time was 23.5 days.

CURRENT APPROACH Porcine UBM was selected because of its ability to manage wounds, and its composition that contains collagen, elastin, glyscosamionglycans and other materials associated with wound closure. Wound management consisted of application of porcine UBM covered with a perforated silicone sheet that was cut to circumscribe the stoma, followed by the pouch application. The dressing was changed twice a week, except for one time when the dressing had to be changed one day ahead of schedule.

OUTCOMES Complete wound closure was achieved in 17 days of implementation of porcine UBM. Additionally, the perforated silicone sheet helped to increase pouch adherence over the open wound, decreasing the number of pouch changes.

9-2-2009

9-24-2009 54 Healthy Skin

9-28-2009

9-30-2009

Amparo Cano, MSN, RN, CWOCN Patricia Corvino, MSN, RN, CWOCN Broward General Medical Center and the Chris Evert Childrenâ&#x20AC;&#x2122;s Hospital Fort Lauderdale, FL

CONCLUSIONS AND DISCUSSION

ACKNOWLEDGEMENT

Wound closure was achieved with the use of porcine UBM, allowing better pouch adhesion and increased wear time in this premature neonate. Although the study sample size was small, it is worth noting that the patient who was treated with UBM was gestationally the youngest, had the lowest birth weight and the largest open wound, yet the closure was the most rapid of this group. This type of advanced material, UBM, is widely used for management of chronic wounds; however we believe that this is the first instance where the use of this material in the management of an acute wound in neonates has been reported. It is possible that LG had better results due to reduced pouch change related disturbance of the wound site, coupled with the use of the advanced UBM material. Clinical trials with greater sample sizes are recommended.

The authors would like to acknowledge the NICU Nursing and Medical staff at Broward General Medical Center and the Chris Evert Childrenâ&#x20AC;&#x2122;s Hospital for their care of this and all neonates and for their contributions to this poster.

Gestational Age Date of Birth Birth Weight Laparotomy Date Dehiscence Date Measurements Date Closed Dressing Used

Patient A 30 weeks 11-12-07 1400 gm 12-7-07 3w, 4d after birth 12-13-07 6 days post op 0.9 x 1.5 cm 1-3-08 3 weeks Hydrofiber+

10-5-2009

Patient B 32 weeks, 2 days 5-15-09 1030 gm 6-9-09 3w, 4d after birth 6-16-09 7 days post op 2 x 1 cm 7-12-09 3 weeks, 5 days Hydrofiber+

REFERENCES 1. Angel, C., Daw, S., Phillipe, P, et al. (1992). Pig in a pouch: A technique for the management of complete wound dehiscence after Laparotomy for neonatal necrotizing Enterocolitis. Journal of Pediatric Surgery, 27(1), 67-69. 2. Brown B, Lindberg K, Reing J, Stolz D.B., Badylak S.F. The basement membrane component of biologic scaffolds derived from extracellular matrix. Tissue Eng., 12(3):519-526. 3. Hocevar, B., (2005). Home care management of an ostomy within a dehisced abdominal wound. Journal of WOCN, 32(3), 202-204. 4. WOCN. Best practice: Troubleshooting pediatric Ostomies. http://www.wocncenter.com/uploaded_documents/pdf/Ped.Trouble.Shooting.9.10.08.pdf. Accessed October 28, 2009,

LG 29 weeks, 4 days 8-8-09 690 gm 9-13-09 5w, 1d after birth 9-21-09 8 days post op 1.5 x 2.5 cm 10-8-09 2 weeks, 3 days UBM*

10-8-2009

* Urinary Bladder Matrix (UBM), MatriStem is a Registered Trademark of ACell, Columbia, MD. MatriStem is distributed by Medline Industries, Inc. Mundelein, IL. +Hydrofiber. Aquacel is a Registered Trademark of E. R. Squibb & Sons, L.L.C.

10-29-2009

Improving Quality of Care Based on CMS Guidelines 55

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• Online interactive courses and competencies

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• Podcasts for downloading to your mp3 player

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* Courses approved for continuing education by the Florida Board of Nursing and the California Board of Registered Nursing

Prevention

Influenza: Prevention Guidelines and Recommendations Infection Control Measures for Preventing and Controlling Influenza Transmission in Long-Term Care Facilities

58 Healthy Skin

Influenza is a contagious respiratory disease that can cause substantial illness and death among long-term care facility residents and illness among personnel in long-term care facilities. Influenza vaccination of health care personnel and long-term care facility residents combined with basic infection control practices can help prevent transmission of influenza. Every effort should be made to ensure compliance with influenza vaccination recommendations each season. However, because influenza outbreaks can still occur among highly vaccinated longterm care residents, long-term care facility personnel should be prepared to monitor personnel and residents each year for influenza and promptly initiate measures to control the spread of influenza within facilities when outbreaks are detected. This document provides general guidance for prevention and control of influenza transmission in long-term care facilities.

[Transmission] Influenza is primarily transmitted from person to person via large virus-laden droplets that are generated when infected persons cough or sneeze; these large droplets can then settle on the mucosal surfaces of the upper respiratory tracts of susceptible persons who are near (e.g., within about 6 feet) infected persons. Three feet has often been used by infection control professionals to define close contact and is based on studies of respiratory infections; however, for practical purposes, this distance may range up to 6 feet. The World Health Organization defines close contact as “approximately 1 meter”; the U.S. Occupational Safety and Health

Administration uses “within 6 feet.” For consistency with these estimates, this document defines close contact as a distance of up to approximately 6 feet. Transmission may also occur through direct contact or indirect contact with respiratory secretions, such as touching surfaces contaminated with influenza virus and then touching the eyes, nose or mouth. Adults may be able to spread influenza to others from 1 day before getting symptoms to approximately 5 days after symptoms start. Young children and persons with weakened immune systems may be infectious for 10 or more days after onset of symptoms.

Prevention and Control Measures Strategies for the prevention and control of influenza in long-term care facilities include the following:

1 2 3

Annual influenza vaccination of all residents and healthcare personnel Implementation of Standard and Droplet Precautions when a person is suspected or confirmed to have influenza Active surveillance and influenza testing for new illness cases

4 5 6

Restriction of ill visitors and personnel from entering the facility Administration of influenza antiviral medications for prophylaxis and treatment when influenza is detected in the facility Other prevention strategies, such as respiratory hygiene/cough etiquette programs

Improving Quality of Care Based on CMS Guidelines 59

[Vaccination] Health care personnel (e.g., all paid and unpaid workers who have contact with residents and visitors, including volunteer workers) and persons at high risk for complications from influenza, including all residents of long-term care facilities, are recommended to receive annual influenza vaccination according to current national recommendations. Vaccination is the primary measure to prevent influenza, limit transmission, and prevent complications from influenza in long-term care facilities. Vaccination of persons 65 years and older does not prevent 100 percent of influenza infection, but can reduce serious complications from influenza in this population. Vaccination rates of 80 percent and higher among residents have been shown to decrease influenza outbreaks in long-term care facilities. Inactivated influenza vaccine or live attenuated influenza vaccine may be used to vaccinate most healthcare personnel. Inactivated influenza vaccine (LAIV) may be given to healthcare personnel younger than 50 years who do not have contraindications to receiving this intranasal vaccine. Healthcare personnel who may receive LAIV include those who care for immunocompromised patients who do not require care in a protective environment. Healthcare workers who care for patients with severely weakened immune systems (i.e., patients who have recently had a hematopoietic stem cell transplant and require a protected environment) and who receive LAIV should refrain from contact with severely immunosuppressed patients for 7 days after LAIV vaccination.

The following persons should

NOT receive LAIV...

■ Persons with a history of hypersensitivity, including anaphylaxis, to any of the components of LAIV or to eggs ■ Persons aged 2-4 years who have recurrent wheezing and healthy persons 50 years and older ■ Persons with asthma, reactive airways disease, or other chronic disorders of the pulmonary or cardiovascular systems ■ Persons with other underlying medical conditions, including metabolic diseases such as diabetes, renal dysfunction, and hemoglobinopathies; or persons with known or suspected immunodeficiency diseases or who are receiving immunosuppressive therapies ■ Children or adolescents receiving aspirin or other salicylates (because of the association of Reye’s syndrome with wild-type influenza infection) ■ Persons with a history of Guillain-Barré Syndrome

Source: Centers for Disease Control and Prevention

■ Pregnant women

60 Healthy Skin

■ Administration of LAIV should be postponed among persons with a fever or significant nasal congestion that may interfere with delivery of the LAIV although persons with mild respiratory illness can receive LAIV

Patient Safety is in Your Hands Epi-clenzâ&#x201E;˘ Gel Instant Hand Sanitizers contain 70% v/v ethyl alcohol to disinfect hands of most common disease-causing germs. They also contain aloe vera and vitamin E to care for and soothe the skin. The Breesia formula is a desirable option if a mild, pleasant fragrance is preferred.

Also available in a foaming formulation.

For a FREE case of our 16 oz. Epi-clenz (MSC097032) to get you started, e-mail Lynsey Wolfe at lwolfe@medline.com.

ÂŠ2010 Medline Industries, Inc. Medline and Epi-clenz are registered trademarks of Medline Industries, Inc.

Special Feature

Control Measures

for Influenza

In addition to influenza vaccination, the following infection control measures are recommended to prevent person-to-person transmission of influenza and to control influenza outbreaks in long-term care facilities.

2. Standard Precautions

During the care of any resident with symptoms of a respiratory infection, healthcare personnel should adhere to Standard Precautions:

1. Educatio n

Educate per sonnel abou t the import of vaccinatio ance n, signs and symptoms o influenza, co f ntrol measu res and indic tions for obta aining influen za testing.

62 Healthy Skin

a. Wear gloves. b. Wear a gown. c. Change gloves and gowns after each resident encounter and perform hand hygiene. d. Decontaminate hands before and after contact with a sick resident. e. Wash visibly soiled or contaminated hands with soap (either plain or antimicrobial) and water. f. If hands are not visibly soiled, use an alcohol-ba sed hand rub for routinely decontaminating hands.

ygiene/ H y r o t a ir p s 3. R e og rams never residr P e t t e u iq t iquette whe Cough E t ene/cough et

n to preven spiratory hygi iratory infectio Implement re sp re of s om -term care have sympt ctions in long fe in t ents or visitors ac tr ry e: irato on of all resp grams includ etiquette pro the transmissi h ug co e/ en piratory hygi facilities. Res rsons who sidents and pe re g in ct ru st ey have sual alerts in personnel if th re ca a. Posting vi th al he ho em to inform ging those w accompany th and discoura n io ct fe in ry respirato symptoms of y. ting the facilit tors who are are ill from visi dents and visi si re to ks as outh and tissues or m cover their m n ca b. Providing ey th at eezing so th coughing or sn on rubs in comm nose. l-based hand ho co al d an tissues c. Providing here ting rooms. e available w areas and wai ndwashing ar ha r fo s lie pp l-b at su alcoho ased d. Ensuring th dispensers of g in id ov pr d ted an sinks are loca . other locations t at least 3 hand rubs in coughing to si e ar ho w s of ng person ith symptoms e. Encouragi . Residents w rs he ot m g fro in et us to about 6 fe ouraged from should be disc n io ct fe in ry respirato le. s where feasib common area

[Other Considerations] A. If influenza is suspected in any resident, influenza testing should be done promptly. Confine symptomatic residents with suspected or confirmed influenza and their exposed roommates to their rooms or on one unit for 5 days following the onset of symptoms. Personnel should work on only one unit, if possible. B. Patients receiving antiviral treatment for influenza should continue to be confined until treatment is completed because patients may still be infectious and rarely may be shedding antiviral resistant viruses.

ns for Ill 5. Restrictio alth care e H ll I d n a s Visitor Inf luenza n e h w l e n n o Pers ing in the r r u c c O is y Activit ommunity C g in d n u o r Sur tices) that via posted no

4. Droplet Precautions Health-care workers should adhere to Droplet Precautions during the care of a resident with suspected or confirmed influenza for 5 days after the onset of illness: a. Place resident in a private room. If a private room is not available, place suspected influenza residents with other residents suspected of having influenza; residents with confirmed influenza with other residents confirmed to have influenza. b. Wear a surgical or procedure mask upon entering the residentâ&#x20AC;&#x2122;s room. Remove the mask when leaving the residentâ&#x20AC;&#x2122;s room and dispose of the mask in a waste container. c. If resident movement or transport is necessary, have the resident wear a surgical or procedure mask, if possible.

rs (e.g., a. Notify visito s should not iratory symptom sp re ith w ts adul d children with y for 5 days an visit the facilit the onset days following 10 r fo s om pt sym e of illness. ould not com symptoms sh ith w s ee oy pl b. Em ize and to work. ability to social s' nt de si re e n th g c. To maintai rtunities durin bilitation oppo ha re to ss ce ely have ac ions are unlik influenza infect n he w ds rio ed pe confirm , suspected or is za en flu in infections and no of respiratory s om pt m sy ls residents with in group mea to participate ed itt rm pe can be to about 6 be placed 3 n ca ey th if and activities n adhere to dents and ca si re r he ot m feet fro etiquette. giene/cough hy ry to ira sp re ers fo Source: Cent

r Disease Cont

rol and Preven

tion

Improving Quality of Care Based on CMS Guidelines 63

[Control of Influenza Outbreaks

in Long-term care Facilities

]

Definitions Cluster: Three or more cases of acute febrile respiratory illness (AFRI) occurring within 48 to 72 hours, in residents who are in close proximity to each other (e.g., in the same area of the facility). Outbreak: A sudden increase of AFRI cases over the normal background rate or when any resident tests positive for influenza. One case of confirmed influenza by any testing method in a long-term care facility resident is an outbreak. The outbreak control measures described below should be promptly implemented in the event of any clustering or an outbreak of AFRI, or any case of laboratory confirmed influenza: • Inform local and state health department officials within 24 hours of outbreak recognition. Determine if the health department wants clinical specimens or viral isolates. • Implement daily active surveillance for respiratory illness among all residents and healthcare personnel until at least 1 week after the last confirmed influenza case occurred. • Identify influenza virus as the causative agent early in the outbreak by performing rapid influenza virus testing of residents with recent onset of symptoms suggestive of influenza. In addition, obtain viral cultures from a subset of residents to confirm rapid test results (both positive and negative) and to determine the influenza virus type and influenza A subtype. Ensure that the laboratory performing the tests notifies the facility of tests results promptly.

• If other patients become symptomatic, cancel common activities and serve all meals in patient rooms. If patients are ill on specific wards, do not move patients or personnel to other wards, or admit new patients to the wards with symptomatic patients. • Limit visitation, exclude ill visitors, consider restricting visitation of children via posted notices. • Monitor personnel absenteeism due to respiratory symptoms and exclude those with influenza-like symptoms from patient care for 5 days following onset of symptoms, when possible. • Restrict personnel movement from areas of the facility having outbreaks to areas without patients with influenza. • Limit new admissions. • Administer the current season’s influenza vaccine to unvaccinated residents and health care personnel as per current vaccination recommendations for nasal and intramuscular influenza vaccines. • Administer influenza antiviral chemoprophylaxis and treatment to residents and health care personnel according to current recommendations. • Consider antiviral chemoprophylaxis for all health care personnel, regardless of their vaccination status, if the health department has announced that the outbreak is caused by a variant of influenza virus that is a suboptimal match with the vaccine.

[Additional Resources] The following resources provide information about preventing the spread of influenza in health care facilities:

• Implement Droplet Precautions for all residents with suspected or confirmed influenza.

Sneller VP, Izurieta H, Bridges C, Bolyard E, Johnson D, Hoyt M, Winquist A. Prevention and control of vaccine-preventable diseases in long-term care facilities. JAMDA

• Confine the first symptomatic resident and exposed roommate to their room, restrict them from common activities, and serve meals in their rooms.

2000;Sept-Oct:S1-S37.

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Bradley SF. Prevention of influenza in long-term-care facilities. Long-Term Care Committee of the Society for Healthcare Epidemiology of America. Infect Control Hosp Epidemiol 1999;20:629-37.

THE CHOICE IS YOURS. Medline’s comprehensive line of face masks was designed to meet a variety of needs and preferences, but all of our masks are united by a common trait — quality. Every mask we manufacture — from our fluid-resistant masks to our spearmint-scented masks — is backed by Medline’s quality guarantee and designed to exceed expectations for comfort and protection. • Fluid resistant • Fog-free • Spearmint-scented • Chamber style • Isolation • Procedure • N95 respirator • Face shield • Protective eyewear

Survey Readiness

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Emergencies & Disasters Preparedness Planning for Long-Term Care Facilities By Guy Robertson, MLS

Long-term care facilities need to have a formal working plan to handle emergencies and disasters before they take place. The following article was originally published by the Long Term Care Association of Ontario and gives an overview of risk factors for facilities to review and have practical contingency plans for. Improving Quality of Care Based on CMS Guidelines 67

Have A Plan Assume that 20 minutes from now, a fire breaks out in a building down the street from your facility. Flames burst from the windows while black smoke shrouds the neighborhood. A firefighter appears at your reception desk and says that he might ask you to evacuate your staff and residents shortly, “depending on the toxic fume hazard.” Are you prepared for such an event? Many long-term care facilities aren’t, despite occasional fire drills and binders crammed with instructions from emergency response agencies.

Check List !

What risks threaten your facility?

Best ways to mitigate them.

Emergency Response Plan.

Many organizations rely on business resumption (or continuity) plans to resume and restore your administrative operations

A good emergency plan starts with a summary of the risks that prevail at your facility. Every region has its natural risks, from high winds and winter storms to flooding to earthquakes. Heat waves and freak storms are increasingly common across North America. Any of these risks can lead to property damage, power outages and supply problems for care facilities. Technological risks include computer failures and data loss, toxic spills, electrical fires and explosions. Contrary to popular opinion, these risks prevail just as often in less populated rural regions as in cities and towns. Technological problems often result from human error. Somebody pushes the wrong button or forgets to push the right one, and the lights go out all over town. Somebody else trips over a cable in the server room, disables an entire network and you lose access to your electronic files, including those pertaining to essential resident care.

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While human error is unintentional, some harmful actions are purposeful. These are security risks: theft, sabotage, vandalism and fraud. A thief could steal cash, drugs and residents’ valuables. A prankster might leave a bomb threat on your voice mail or hack into your website and tamper with its contents. Crooks have been known to get vulnerable long termcare facility residents involved in different kinds of bogus financial schemes. While some neighborhoods are more secure than others, security risks prevail wherever there are people. Make a list. What risks threaten your facility? Remember that risks at nearby sites can threaten you directly. For example, an accident on an adjacent roadway could isolate your facility for hours. A fuel spill at the local gas station could lead to an explosion that cuts your power. And then there’s the fire in the building down the street that’s making your eyes water. Some of your residents are starting to cough. Nearby threats are called proximity risks, and every property manager should be aware of them.

Once you’ve determined the risks to your facility, consider the best ways to mitigate them. There are always means of dealing with a risk so that it’s less likely to disrupt your operations. For example, high winds and severe winter weather may be unavoidable, but if your building has a good preventative maintenance program in place, you’ll experience fewer problems from roof leaks and heating problems. If you’re concerned about power failures, investigate the feasibility of a backup generator. Ask your staff and residents to report any facility problems promptly. You should be able to mitigate most of your risks to the point where they no longer pose serious threats to your facility.

But occasionally risks turn into emergencies. You need an emergency response plan to deal with the real thing. You don’t need a huge binder to tell you

how to evacuate your building or restore your power. Often a small brochure containing the standard procedures is more useful than a binder that only a few of your staff members have studied carefully. Besides, you don’t want to start leafing through a binder when a fire threatens your facility and the smoke gets in your eyes. As for reviewing emergency response procedures during a power outage, forget it. You’ll have other uses for those flashlights — if you can find them.

Natural Disasters

Cyclones, typhoons, hurricanes, tornadoes, hailstorms, snowstorms and droughts

Meteorological Disasters

Land slides, avalanches, mud flows and floods

Topological Disasters You can create a small brochure on your office workstation and reproduce your fire department’s advice to meet the specific needs of your facility. You can print separate brochures for staff and residents. You can include handy reminders and space for notes and personal information, including room numbers, addresses, family contacts and the locations of refuge areas and safe gathering sites. Brochures can be designed to fit in a wallet, coin purse or pocket. When they’re attractively laid out and contain concise, practical response measures, brochures are ideal tools for emergency orientation and procedural training. They’re also much less expensive than those binders. After an emergency, how can you resume adequate levels of service and restore your administrative operations? Many organizations rely on business resumption (or continuity) plans, which contain solutions to problems that arise after the storm has died down or the fire has been extinguished. Often a resumption plan begins with a damage assessment checklist, which guides you through your facility and points out those areas where different kinds of damage can occur. Has a storm damaged your roof? Here’s what to look for: cracks, pools of water, debris from trees and neighboring structures, broken wires, leaky skylights. Even if you’re not a trained property manager, your damage assessment checklist will help you to make a record of any damage to a roof or any other part of your facility’s structure. A key component for any care facility’s resumption plan is a strategic alliance program. After an emergency, you might have difficulty obtaining supplies that in normal circumstances you would take for granted. What if severe weather puts your usual delivery service out of action for a few days? Fortunately, you’ve organized an alliance with a local taxi firm, which will pick up medications, groceries and office

Earthquakes, volcanic eruptions and tsunamis (seismic sea waves, also known as tidal waves)

Disasters that Originate Underground

Communicable disease epidemics and insect swarms (locusts)

Biological Disasters

Man-made Disasters Conventional warfare (bombardment, blockade and siege) Non-conventional warfare (nuclear, chemical and biological)

Warfare

Civil Disasters

Riots and demonstrations, strikes Bomb threat/incident; nuclear, chemical, or biological attack; hostage incident

Criminal/Terrorist Action

Transportation (planes, trucks, automobiles, trains and ships) Structural collapse (buildings, dams, bridges, mines, and other structures) Explosions, fires, chemical (toxic waste and pollution) Biological (sanitation)

Accidents

Improving Quality of Care Based on CMS Guidelines 69

equipment from suppliers and deliver them to you as soon as possible. Taxis can also serve as couriers and help staff members get to and from your facility if the roads are closed. Taxi companies use radio communications to receive information regarding road closures and other lifeline problems, and are often better prepared to travel in disaster areas than local police and firefighters. Your residents might be frightened or disoriented by an emergency. To restore their good morale, you should include normalization guidelines in your resumption plan. Getting residents to talk about their experience during an emergency is one way to ease their anxiety. Another is to hold a “closure party,” during which staff and residents are served refreshments and given a chance to celebrate the conclusion of events relating to the emergency. Sometimes facilities bring in trauma counselors to address individual concerns or ongoing fears. But residents are not always disturbed by emergencies. After a fire near a Vancouver care facility that resulted in an evacuation, some residents told their caregivers that they enjoyed the excitement. “It was a nice break from the usual TV game show,” one resident said. Your resumption plan can contain advice concerning alternative sites for residents, a list of post-emergency service priorities, a summary of emergency team activities and advice regarding the auditing and testing of the plan. Since each care facility is unique, each should have an emergency plan customized to meet its specific needs. A template plan will not necessarily give you the most effective guidance. It’s up to you to ensure that your facility has a plan that takes into account characteristics that make it different from a facility in a different part of the country, city or neighborhood. You have only three minutes until that fire breaks out down the street and you hear the wail of the sirens. Fortunately this is only an imaginary scenario. But next time it might be the real thing. Isn’t it time that you developed a real emergency plan for your facility? About the author

Guy Robertson, MLS, is an emergency management consultant based in Vancouver, British Columbia, Canada. He has over 20 years of experience working with financial institutions (e.g. credit unions), insurance companies, hospitals, libraries, and private and public archives. He regularly writes for various professional associations’ journals and magazines. His knowledge is often presented with humor and anecdotal examples, making him a sought-after public speaker. To contact him, send an e-mail to guy_robertson@telus.net.

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Benefits Of A Great Work Environment By Greg Smith

Businesses can improve retention and make their organization the good place to work by following the five-step PRIDE model:

P R I D E

– – – – –

Provide a positive working environment Recognize, reinforce, and reward individual efforts Involve and engage everyone Develop the potential of your workforce Evaluate and hold managers accountable

Source: http://workz.com/content/view_content.html? section_id=531&content_id=6965

Medline Named One of Becker’s

100 Best Places to Work in Healthcare Becker’s recognizes company for “Excellence in Promoting Teamwork, Professional Development” Medline Industries, Inc. has been named one of the “100 Best Places to Work in Healthcare” for 2010 by Becker's ASC Review and Becker's Hospital Review, well respected industry publications. According to Becker’s, the list was developed “through nominations, recommendations and research, and the organizations were selected for their demonstrated excellence in creating a work environment promoting teamwork, professional development and quality patient care.”

“ How do we improve our resident and familycentered quality of care and prepare for QIS?

We use abaqis.” Sherri Dahle, RN, DNS Director of Nursing Central Healthcare LeCenter, MN

The new Quality Indicator Survey (QIS) for nursing homes is more resident-centered, with more information obtained from direct questioning of residents and families. In fact, 60 percent of facilities have had more deficiencies in QIS than in the prior traditional survey, often in regulatory areas such as quality of life that were not as fully investigated in the traditional process.

That gives you a unique advantage in preparing for your survey – and in meeting your resident’s needs. abaqis® is sold exclusively through Medline. Learn more by signing up for a free webinar demo at www.medline.com/abaqisdemo.

abaqis is the only quality assessment and reporting system for nursing homes that is tied directly to the QIS, and its quality assessment modules reproduce the same forms, analysis and thresholds used by State Agency surveyors. Rich reporting capabilities on 30 care areas guide you to what surveyors will be targeting in your facility.

“

Oh Yeah!

“

New learning opportunities for CNAs

For the first time ever, Medline University introduces online CNA courses at www.medlineuniversity.com. Visit today to learn more about: • Diabetes • Hand hygiene • Incontinence • Indwelling urinary catheters • Skin care • Skin tears • QIS

ME DLINE

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“

“Excellent.

NAB-approved courses now available at Medline University. Visit www.medlineuniversity.com for an all-new way to earn nursing home administrator certification credits — for FREE. QIS topics: • Understanding the Survey • The Seven Mandatory Facility-Level Tasks • The Five Triggered Tasks • Activities of Daily Living and Range of Motion • Critical Elements for Activities • Critical Elements for Pain Management • Federal Tag 441 – Infection Prevention and Control Plus, • Diabetes Education for Long-Term Care Administrators • Hand Hygiene Improvement Strategies Register today!

www.medlineuniversity.com Access courses on your computer or iPhone.

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Caring for Yourself

Fail-Safe Strategies to Deal with

DIFFICULT PEOPLE By Dr. Wolf J. Rinke, RD, CSP

Let’s face it. Certain people just like to make your life difficult. Maybe it’s a patient who seems to get his jollies from making you miserable. Or a team member who refuses to perform at an acceptable level. Or what about your colleagues who drive you nuts? Any of these can be a huge challenge and cause you a great deal of difficulty and stress. But don’t despair. There are specific steps you can take to deal more effectively with these kinds of people. 74 Healthy Skin

The Most Powerful Stress Control System of All Time But first let me share with you what I consider the most powerful stress control system of all time. It’s very simple—only three steps, but if you can master it, your ability to deal with all types of stress and conflict, not just difficult people, will be significantly enhanced. Here they are: 1. Change the Changeable. Don’t like something? Change it! Don’t fret, complain or whine … just do it! (I know you’ve heard that before.) Remember, you don’t have to do anything you don’t want to do. Alright, you caught me. There is one thing you have to do—die. No choice—not yet. Everything else is a choice. And no matter how badly other people behave, you always are able to control your response to their behavior. Notice I said you can control your response, but you cannot control them or their behavior, so quit wasting time trying to do the impossible.

2. Remove Yourself from the Unacceptable Find something or someone unacceptable? Get out of the way. Sitting with someone who is bitching and griping? Get up and sit somewhere else. Working for a toxic boss? Start shopping for a new one. About to be sucked into another conversation with an employee who is always complaining about his team members? Tell him you are busy and that you prefer that he talk to the other party directly instead of coming to you. Can’t remove yourself? Minimize the time you are exposed to unacceptable people. Whatever you do, just do it without fretting and whining … I know you’re catching on!

Improving Quality of Care Based on CMS Guidelines 75

3. Accept the Unchangeable There are lots of things beyond your control, such as your parents. No matter how much you would like them to be different, they won’t be. So love them the way they are, not the way they ought to be. (By the way, that is a great prescription for getting along with all people!) Bad weather? Get a grip. Deal with it. Learn to associate any type of bad weather with prior positive events in your life. For example, when it is rainy, misty or foggy, I’ve taught myself to think back to my days in Germany. When it is freezing cold, I think of cuddling in front of a toasty warm, roaring fireplace with Superwoman – my wife and lover of 42 years. Getting older? Accept it. You are beautiful just the way you are! A wise person once remarked, “God doesn’t make junk.” In fact, evaluating both my physical and emotional health, I have never felt better in my life as I do right now. (I’m 66—thanks for asking.) One reason is that I have never been as content and at peace as I am right now. So don’t sweat your chronological age—something you can’t change. Instead, take care of your body … that’s something you can have a positive impact on right now. Difficult people? Accept that some people like to be miserable. Just don’t try to take it away from them. (I hope you are smiling. Otherwise you are taking this much too seriously.) Accept them just the way they are, and minimize the time you spend with them. If they report to you make sure that you do not place them in patient sensitive positions, and do your best to get them out of your team or organization as soon as possible.

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Ten Fail-Safe Strategies to Deal with Difficult People After you have mastered these three biggies, let’s take a look at what other strategies you can use to make your life less aggravating:

1. Change your response to the other person. As I mentioned earlier, you are the only one you can change. (And most of us have lots of difficulty achieving that!) In dealing with difficult people, don’t try to change the other person; you will only get into a power struggle, cause defensiveness, invite criticism or otherwise make things worse. It also makes you a more difficult person to deal with. On the other hand you can always control your response to the other person. So don’t let negative people live in your head rent free. 2. Manage your perceptions. Remember that most relationship difficulties are due to a dynamic between two people rather than one person being “bad.” In other words it takes two to tango. This is one thing that has been driven home to me time and time again as a result of my coaching and consulting experiences. I listen to one person and they tell me in excruciating detail how

badly someone else has behaved. In fact, because of their vivid descriptions I’m often tempted to take their word for it. Until … wait for it … I talk to the other person, and then I find out that their reality is diametrically opposite of the other party, and by the way, equally as convincing. In other words there is no reality, there are only perceptions, and we all create our own. The fastest way to begin to no longer perceive people as “difficult” is to look for what they are doing right. And then let them know about that. In other words, look for the positive aspects in others, especially when dealing with the important people in your life, and focus on those things. The neat part of this is that over the long run we all tend to find what we are looking for. (Read that again!) And before you know it, the other person will feel more appreciated, and you will begin to develop a more positive relationship. 3. Minimize the time you spend with difficult people. I know I’ve mentioned this before so this must be a biggie, especially for people in leadership positions. Time and time again I find that managers, supervisors and team leaders tend to spend a disproportionate amount of time with trouble makers. What they don’t get is that their time is a reward. This means that they will get more trouble. Remember: Whatever you reward is what you will get more of. Instead, if you want peak performance, then you should spend the greatest share of your time with the “water walkers”—the people who make you look good.

5. Don’t beat yourself up. Avoid blaming yourself or the other person for negative interactions. It may just be a case of two personalities being like “oil and water.” Remember that you don’t have like everyone; just being polite goes a long way toward getting along and appropriately dealing with difficult people. 6. Respond with a sense of humor. Much can be solved by just lightening up. Somehow a sense of humor often lowers the intensity of a difficult situation and allows both of you to laugh instead of continuing to escalate the situation. 7. See it through the other persons’ eyes. As cliché as this may sound, we tend to forget that we become blindsided when we are angry or stressed. Instead put yourself in the other person’s position and consider how you may have hurt their feelings. This understanding will give you a new perspective, may help you to become more rational, and help you develop compassion for the other person.

What about the other difficult people in your life? Know when it’s time to distance yourself, and do so. If no matter what you do, the other person still antagonizes you, minimizing your exposure may be the key. If they’re continually abusive, it’s best to cut ties and let them know why. Explain what needs to happen if there ever is to be a relationship, and then let them go. If the difficult person is your boss it may be time for you to find another job. We spend far too great a portion of our life at work to be miserable. Life is simply too short to work for a toxic boss or organization. 4. Avoid discussing divisive issues. Issues such as religion and politics, or other topics that push certain people’s “buttons” are best avoided. If the other person tries to engage you in a discussion that has the potential to become an argument, change the subject or remove yourself.

Improving Quality of Care Based on CMS Guidelines 77

8. Hang out with positive people. Negative people drain your battery. Positive people charge your battery. So minimize the time you are together with “stinking thinking” people and cultivate other more positive relationships in your life to offset the negativity of dealing with difficult people. (If you would like to know more about this, read my Beat The Blues: How to Manage Stress and Balance Your Life CPE program. It’s available at www.easyCPEcredits.com.) 9. Don’t fight fire with fire. When you interact with someone who is going into attack mode or becoming excessively defensive, recognize that it is useless to argue with him. Realize the other person may be behaving in this way because he is feeling very insecure. Don’t continue to push or attempt to convince him because he will only get more difficult. Let it go, and come back at another time. 10. Make the other person right. I’ve left the best for last. The most effective way you can deal with difficult people is to make them right by expressing the most powerful conflict resolution phrase of all time: “You are right about that.” (Try it in any situation that appears to be spinning out of control.

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What you will find will amaze you. It literally makes any type of conflict evaporate. It’s so powerful that Superwoman and I no longer even use the five words, we just hold up our hand with all five fingers extended.) Or express agreement in any other way you wish. For example you might say, “I see why you feel that way;” or “I can understand why you are upset,” or “That’s an interesting perspective.” (The words are not important as long as you express agreement.) If you find yourself arguing for the sake of being right, ask “Does it matter if I am right?” If yes, then ask “Why do I need to be right? What will I gain?” In virtually all situations you will find that the only reason you feel a need to be right is to satisfy your ego. If that still does not let the “hot air out of the balloon” find something, no matter how small, to agree on. And if nothing else works you can at least agree to disagree, and get on with your life. © 2010 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 newsletters Make It a Winning Life and The Winning Manager, available at www.WolfRinke.com; and a new electronic newsletter Read and Grow Rich, targeted specifically to nutrition professionals, 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; all available at www.WolfRinke.com. His company also produces a wide variety of quality pre-approved continuing professional education (CPE) self-study courses, available at www.easyCPEcredits.com, including his latest Delegation and Coaching: High Impact Strategies for Doing More with Less, approved for 15 CPEUs, from which this article was extracted. Reach him at WolfRinke@aol.com.

Special Feature he Centers for Disease Control and Prevention (CDC) has just announced the establishment of the Advisory Committee on Breast Cancer in Young Women.

CDC Forms New Advisory Committee on Breast Cancer in Young Women

The committee has been established to assist in creating a national evidence-based public education and media campaign to provide age-appropriate messages and materials to: 1. Increase awareness of good breast health habits 2. Identify risk factors based on familial, racial, ethnic and cultural backgrounds 3. Encourage young women and healthcare professionals to increase early detection of breast cancers 4. Increase the availability of health information and other resources for young women diagnosed with breast cancer For more information, contact Ena Wanliss, MS, Lead Public Health Advisor, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Division of Cancer Prevention and Control, 4770 Buford Highway, Mailstop K-57, Chamblee, GA 30316. (770) 488-4225.

Source: Federal Register June 24, 2010. Available at http://edocket.access.gpo.gov/2010/2010-15293.htm. Accessed July 9, 2010.

Improving Quality of Care Based on CMS Guidelines 79

Special Feature

Take the Pink Glove Survey! Precious. And Pink. Soft and shimmery. Layered with organic aloe. Fashioned from nitrile.

1 2

The Pink Pearl.

To take the survey, go to www.medline.com/healthyskin/survey or complete the business reply card.

Medline’s newest Generation Pink glove. Supporting the National Breast Cancer Foundation.

Answer these questions: A. What does the Pink Glove Dance mean to you? B. Do you think pink gloves get people talking about breast cancer?

AD 1 I only wear Pink Pearls.

Yes, They’re Genuine.

Only Medline’s Pink Pearl gloves combine aloe, nitrile and breast cancer awareness.

Take a look at the Pink Pearl ads on the next three pages and pick your favorite.

Only Medline’s Pink Pearl gloves combine aloe, nitrile and breast cancer awareness.

AD 2

AD 3

Participate today! The first 1,000 readers to respond will receive the new Deb doll!

www.PinkGloveDance.com 80 Healthy Skin

Precious. And Pink. Soft and shimmery. Layered with organic aloe. Fashioned from nitrile. The Pink Pearl.™ Medline’s newest Generation Pink glove. Supporting the National Breast Cancer Foundation.

Improving Quality of Care Based on CMS Guidelines 81

I only wear Pink Pearls.

Only Medline’s Pink Pearl™ gloves combine aloe, nitrile and breast cancer awareness. ©2010 Medline Industries, Inc. Medline is a registered trademark and Pink Pearl is a trademark of Medline Industries, Inc.

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

3 Improving Quality of Care Based on CMS Guidelines 83

Caring for Yourself

Breast Self-Examination 1. In the Shower Fingers flat – move gently over every part of each breast. Use your right hand to examine left breast, left hand to examine right breast. Check for any lump, hard knot or thickening. Carefully observe any changes in your breast. 2. Before a Mirror Inspect your breasts with your arms raised high overhead. Next, place your arms at your sides. Look for any changes in contour of each breast; a swelling, a dimpling of skin, or changes in the nipple. Then rest palms on hips and press firmly to flex your chest muscles. Left and right breasts will not match exactly. Few women’s breasts do match. 3. Lying Down Place pillow under right shoulder, right arm behind your head. With fingers of left hand flat, press right breast gently in small circular motions, moving vertically or in a circular pattern covering the entire breast. Use light, medium and firm pressure. Squeeze nipple, check for discharge and lumps. Repeat these steps on your left breast.

Mammograms

Save Lives The U.S. Preventive Services Task Force (USPSTF), a group of health experts that reviews published research to make healthcare recommendations, points out that women who have screening mammograms die of breast cancer less frequently than women who do not get mammograms. Although the USPSTF recently changed their breast screening guildelines, recommending mammograms to be performed every two years beginning at age 50. The American Cancer Society (ACS), Mayo Clinic, and others, however, have not changed their recommendations. • The ACS and Mayo Clinic continue to recommend yearly mammogram screening beginning at age 40 for women at average risk of breast cancer. • ACS says breast self-exams are optional; however, Mayo Clinic recommends breast self-exams to allow women to identify breast abnormalities and become familiar with their breasts so they can tell their doctor about any changes. If you are confused about any of these recommendations, it is best to talk to your doctor to learn what’s right for you based on your individual risk factors. Source: Pruthi S. Mammogram guidelines: what’s changed? Mayo Clinic website. Available at: http://www.mayocliic.com/health.mammogram-guidelines/AN02052. Accessed July 30, 2010.

Recommended Reading Dr. Susan Love’s Breast Book Susan M. Love, MD Da Capo Press, 2005 Everything you wanted to know about breasts and breast cancer. Each treatment option is reviewed with realistic outcome statistics. Also check out Dr. Love’s website www.dslrf.org/breastcancer.

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The Breast Cancer Survival Manual: A Step-by-Step Guide for the Woman with Newly Diagnosed Breast Cancer John Link, MD Henry Holt and Company, 2000 A complete guide on how to survive a diagnosis of breast cancer: how to pick a team of specialists, diagnostic tests, adjuvant therapy choices, management of side effects and diet.

How 4 square inches of Puracol® Plus changed chronic wound care. Forever.

Look closely. It’s not a bandage. It’s Puracol Plus MicroScaffold , made entirely of pure native collagen. ™

™

Chronic wounds tend not to heal when unbalanced levels of elastase and MMPs (inflammatory enzymes) destroy the body’s own collagen and growth factors.1 But apply Puracol Plus and help restore nature’s balance.

This is Puracol Plus MicroScaffold as seen through an electron microscope. Its open, cellular structure allows easy fibroblast migration.2 The high strength of the MicroScaffold2 also assists in establishing a fresh wound bed.

1. Schultz GS, Mast BA. Molecular analysis of the environment of healing and chronic wounds: Cytokines, proteases, and growth factors. Wounds. 1998;10 (6 Suppl): 1F-9F. 2. Data on file.

In vitro studies show that Puracol Plus has the ability to reduce the levels of elastase and MMPs from surrounding fluid.2

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

Special Feature

The Dance Goes On:

Pink Glove Dance Sequel Never in our wildest dreams did we think a video of a few hundred people dancing in pink gloves at Providence Medical Center in Portland, Ore., St. Vincent would become an Internet sensation, generating more than 11 million views on YouTube and launching a wave of awareness. Medline created the original Pink Glove Dance video to help get people talking about breast cancer early detection and to spotlight the healthcare workers who are taking care of breast cancer patients. The video went viral and Medline received a flood of calls and e-mails from hospitals and breast cancer

survivors around the country expressing their gratitude for the video and how much they want to participate in the next video. So this summer, the Pink Glove Dance crew traveled the nation, stopping at 11 hospitals, three nursing homes and five survivor sites, including New York City, New Orleans, Chicago, Denver and San Francisco, to film healthcare workers and breast cancer survivors dancing in pink gloves and sharing their message of joy, support and caring.

Here is just a sampling of the comments we heard on the road:

â&#x20AC;&#x153;

Thanks for bringing so many people together, I am so happy to have been able to participate. It just goes to show there is nothing we can't do to raise awareness. - Veronique Nikki Thomas, Chicago shoot

I absolutely loved partaking in the Pink Glove Dance sequel video in Times Square. Thanks again for the opportunity to be part of something so wonderful and the chance to speak about something so important to me. - Lisa Kisternberg-Solomon, New York City survivor shoot

I encourage ANY and ALL Survivors to participate. As a Breast Cancer Survivor myself, this was an event that I will never forget. - Beth Parrish, Portland survivor shoot

What an awesome time, experience and memory. This amazing experience will stay with me forever. Thank you for including Chicago. - Tammy Moletz, Chicago shoot

â&#x20AC;?

Watch the Pink Glove Dance sequel at pinkglovedance.com. About 200 healthcare workers and breast cancer survivors danced at the Chicago shoot.

Follow Medline and Breast Cancer Awareness on Facebook at www.facebook.com/medlinebreastcancerawareness and on Twitter at twitter.com/medlineindustr.

Special Feature

Sharing Stories More than 4,000 breast cancer survivors and healthcare workers participated in the making of the Pink Glove Dance sequel. During that time, we heard many powerful and inspiring stories of survivorship and hope. Thank you to the survivors and their families for allowing us to share a few of their stories.

The following is a letter from a woman who saw the original Pink Glove Dance featured on the news and was inspired to share the story of her mother's final few days battling breast cancer.

To the Pink Glove Crew (aka Staff of Providence St. Vincent Medical Center) This evening, as I was watching ABC World News Tonight with Charles Gibson, I heard him mention two of the worst words I have ever heard: Breast Cancer. These words leave a huge lump in my stomach and can almost instantaneously bring a tear to my eye. It is because these two horrific words took my mama, Eleanor Margaret Strelecky away from me August 30, 2004 at 7:45 a.m. She was a mere 56 years of age. I was lucky enough to say goodbye, but not willingly. My mother was amazing. By amazing, I mean she was both warm and loving. Don’t get me wrong, she was by no means perfect, and, at times, she drove me up a wall! She always encouraged me to try at everything though. I loved to perform and she got me on every stage she possibly could. I made up silly dances and songs and she would sit in her recliner any time I needed an audience. She laughed so hard and would applaud every time. My mother was so sarcastic. When I would cry and get whiney, she would come at me as if to comfort me, and then start applauding announcing I had won the award for best dramatic performance! She had a lust for life, and I know that she was so cheated by breast cancer. She had battled it on and off for four years. She knew way before I did that this little terrorist was going to win, but she stood strong in silence.

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A week before her passing, I found out through my stepfather, that she did not have much time left. I scurried to buy a plane ticket from Iowa down to Georgia where she lived. In transit, I wrote down as many memories as I could think of between her and me. Some of them were the stupidest jokes, but I did not want to forget a thing. The day before she passed, I walked into her bedroom where she lay in a semi-conscious state. She was heavily sedated and the cancer had metastasized to her liver, lungs, and brain. I sat in a chair by her bed and read her all of the memories I had written down, trying hard to enunciate through the ever-growing tears in my eyes that caused my voice to quiver. When I was done reading them, I kissed my mother’s hand and told her over and over again how much I loved her. This wasn’t enough though; I had to hug her. I carefully sat down on her bed and as I leaned in to embrace her frail body, I saw a tear from her eye. I knew seeing her tear I was going to lose it completely and become hysterical. At the brink of this happening, my mother became completely coherent, opened her eyes wide and said, “And the award for best dramatic performance goes to: Bwinny (her nickname for me)!” She then laughed, gave me a look of “Oh please,” and said, “Now get off the bed. There isn’t much room as it is!” I took a step back and was stunned, but then began to laugh uncontrollably at my mother’s comic relief in such a sad moment as saying a final goodbye! There was my mama, in all her glory, being a smart-ass just as if it was any other day.

“

When I saw the brief [Pink Glove Dance] clip on ABC World News, I smiled and shivers ran down my spine.

”

When I saw the brief [Pink Glove Dance] clip on ABC World News, I smiled and shivers ran down my spine. It was the same feeling that came over me that day in my mother’s bedroom. I quickly jumped on YouTube and watched the video in its entirety. I cried the entire way through, but tears of joy. And I laughed. As I laughed, I looked up at the sky and said to my mama: I know you are thinking this is hilarious! The point of this letter was not to ramble on and on, but to thank you for making such a funny video and for everyone’s commitment to participating in something that is sure to increase breast cancer awareness. The choreography was like nothing I’ve ever seen, and I think you have some future Broadway dancers on your hands! You made me laugh in a time when Christmas is around the corner and I begin missing my mother more than ever. Most importantly, you provided me with a laugh that I shared with my mother up in heaven and for that, I am forever grateful because I just received the best Christmas present ever! Happy holidays to each and every one of you at that hospital and keep donning those pink gloves because they suit you all very well. I send the biggest hug to every star in that video! All my love, Melinda Sara Crane Wellman, Iowa

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Sharing Stories Below is an e-mail from a Medline sales representative whose 36-year-old sister has stage 4 breast cancer. She and her three-year-old daughter (see accompanying photo), danced in New Yorkâ&#x20AC;&#x2122;s Times Square for the sequel.

Thank you for everything you did last Saturday for my sister, niece and family. To see my sister and niece smiling meant everything to me and my family. I can not express my gratitude enough through words. But again, thank you. They truly had a blast and my niece loves her Deb doll. What you guys and Medline are doing is so awesome and is touching the lives of so many. It makes me proud to say I work for Medline. Hank Israel Medline Sales Representative Ft. Lauderdale, Florida

Margaret Smith lost her battle with breast cancer on July 5, 2010. She participated in the original Pink Glove Dance while being treated at Providence St. Vincent's Medical Center. Following is a note from her family:

That video was such a special thing for Mom â&#x20AC;&#x201C; something so unique and different than anything she would have ever done! After spreading her ashes at the coast, we played the Pink Glove Dance song and danced to it in the parking lot. I think she would have enjoyed it. John Smith Susan, Tim, Stephanie and Rachael Burke Jay and Carmel Charland

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Below is an e-mail from a Medline employee in the Information Services department. She and her five sisters tested positive for the breast cancer gene and each underwent treatment. She danced in Chicago for the sequel.

I am lucky thanks to early detection â&#x20AC;&#x201D; without it, I would still have breast cancer. Breast cancer runs in my family. I have two sisters who were diagnosed and treated within two years of each other. Their doctors suggested that they be tested for the BRCA gene to see if that was going to be an issue in the family. They were both tested and both were positive for the BRCA-II gene. At that point, the doctors suggested the family be tested. Let me tell you, I am one of 12 children in my family. I tested positive for the BRCA-II gene as well as five of five sisters tested. It was recommended that I have a hysterectomy (full) to reduce my chances of getting breast cancer from 80% to 40%. I got the hysterectomy and two years later (almost to the day), I was back on the table for a lumpectomy. It was biopsied and was positive for cancer.

Participating in the Pink Glove Dance was AWESOME! It was a great day and it felt wonderful to be with so many others who had similar stories and the people who helped us (the patients) through it all. When the healthcare workers were dancing with us, we were high-fiving them and thanking them for everything they do. I am so lucky to have known about the breast cancer early and to be working at Medline. Helen Franklin Medline Information Services Mundelein, Illinois

Improving Quality of Care Based on CMS Guidelines 91

Taste the

Fountain ofYouth 92 Healthy Skin

Caring for Yourself

Want to fight the effects of aging? Add these powerful foods to your diet! 1. Fatty fish. Mackerel, bluefish,

6. Green tea. This traditional Asian

salmon and tuna are rich sources of omega-3 fatty acids, which improve circulation, reduce inflammation and reduce the risk of heart disease.

drink has been shown to have anti-cancer properties. It also contains theanine, an amino acid known for its relaxation benefits.

2. Whole grains. Pass up the

7. Mangosteen. Never heard of it?

white bread, and fill your plate with whole grains, an excellent source of B-complex vitamins, including riboflavin and niacin, which are essential for optimal energy metabolism.

Never mind. Just give it a try. This small, purplish fruit from Southeast Asia contains anti-inflammatory compounds known as xanthones, which have been shown to improve gastrointestinal function, control pain and reduce markers of inflammation in the blood, such as C-reactive protein. The mangosteen is best in juice form.

3. Low-fat dairy products. Drink your skim milk, and eat plenty of yogurt to receive the anti-aging benefits of calcium and vitamin D. Not only are they good for your bones, calcium also helps boost your metabolic rate, and vitamin D exhibits anti-cancer activity.

8. Exotic spices. Jazz up your recipes with turmeric, curry, cumin and ginger, which have profound anti-cancer properties. Used in Indian and Thai cuisine, each of these spices has been linked with prevention and accelerated healing of cancers of the mouth, throat and gastrointestinal tract.

4. Green leafy vegetables. Never underestimate the power of spinach and salad greens. Green leafy vegetables are terrific sources of fiber, calcium and beta-carotene, an important antioxidant that protects the skin from the effects of ultraviolet radiation.

9. Citrus fruits. Whether it’s oranges, lemons, limes, grapefruit or tangerines, citrus fruits are a rich source of vitamin C. Plus, the white underside of the peels is a source of specialized flavanoids known as poly-methoxylated-flavones (PMFs), which have been shown to reduce stress hormones and cholesterol levels.

5. Berries. Try them all – strawberries, blueberries, raspberries. They are rich in flavonoids, which have been shown to help reduce the risk of heart disease, cancer and diabetes. Source: Talbott S. Anti-aging power foods slideshow. HealthyAging. Available at http://healthy-aging.advanceweb.com. Accessed May 16, 2010.

10. Red wine. Sip a glass of your favorite Merlot, and reap the benefits of resveratrol, a flavanoid found in the skins of red grapes. Animal studies have shown that diets high in resveratrol are associated with a unique set of anti-aging benefits. Studies of resveratrol’s effects on humans are underway.

Improving Quality of Care Based on CMS Guidelines 93

Healthy Eating

Nutrition Information Servings: 6 Calories: 271 Fat: 3.38 g Sodium: 579 mg Fiber: 4.9 g

Tuscan Tomato Soup (6 servings) • 1 teaspoon olive oil • 1 clove garlic, minced • 2 cups (1-inch cubes) country style bread (only hearty dense bread will do)

• 3 pounds ripe tomatoes, cut into quarters • ¼ cup loosely packed fresh basil leaves, chopped

Directions: In a small skillet, heat oil on medium heat until hot. Add garlic and cook for one minute – stirring constantly. Remove from heat. In a food processor with knife blade attached, pulse bread until coarsely chopped. Add tomatoes and garlic. Pulse until mixture is almost a puree. Pour soup into a bowl and stir in chopped basil, sugar and salt. Serve warm or chilled. Operations analyst Mary Lanciloti, who works at Medline’s Vernon Hills, Ill. office, won a bronze medal for this recipe in the International Cookoff during Employee Appreciation Week.

• 1 teaspoon sugar • ¼ teaspoon salt

She subscribes to lots of different magazines, and always scans them for new recipes to try. This one caught her eye because it’s quick, easy and nutritious. She also noted that it’s perfect for anyone who is trying to drop a few pounds because it’s low in calories and very filling. “I’m a big gardener, so this recipe gives me a chance to use fresh tomatoes and basil from my own garden,” Mary said. “Of course, you can always find good summer tomatoes at the local farm stand or supermarket, too.” Mary shared that she likes to cook and loves to bake. She took it up based on her grandmother’s advice that if you like to cook and bake and sew, you’ll land yourself a good husband. “I guess it wasn’t the greatest advice,” Mary said. “Because I’ve always been single! Oh, well.”

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FORMS & TOOLS

The following pages contain practical tools for implementing patient-focused care practices at your facility. Pressure Ulcer Prevention Online Skin & Risk Assessment Competency ................96 SKINSAVERS Initiative: A Pressure Ulcer Prevention Tool ................................................................98 Healthcare Reform Impact of Healthcare Reform on Home Health ............103 Patient Handout: Medicare and the New Health Care Law â&#x20AC;&#x201C; What it Means for You ..............................105 Palliative Care A National Framework and Preferred Practices for Palliative and Hospice Care Quality ............................109 Infection Control Ten Tips for Cleaning and Disinfecting Shared Medical Equipment ......................................................111 Some Things Should Not be Reused ..........................114 CDC Clinical Reminder: Use of Fingerstick Devices ......................................................115 Improving Quality of Care Based on CMS Guidelines 95

Announcing New Online Skin & Risk Assessment Competency The Latest Addition to Medline’s Pressure Ulcer Prevention Program Medline’s Pressure Ulcer Prevention Program – an educational initiative aimed at reducing the incidence of pressure ulcers – has added an interactive online competency to allow nurses to demonstrate what they’ve learned in a virtual clinical setting. This approach provides consistency, as each learner performs the same assessments.

The learner proceeds through the competency using the computer mouse to complete each step – from dispensing hand sanitizer at the wall unit to pulling back the bed linens and patient gown, performing assessments on three separate patients. An illustrated hand replaces the usual mouse arrow on the screen.

James is a 44-year-old male who is recovering from a heart attack.

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Prevention

Sarah is in a coma with a naso-gastric feeding tube. She has a visible wound on her right arm.

When the learner clicks on Sarahâ&#x20AC;&#x2122;s arm, a close-up photograph of her wound and a related multiple choice question appear on the screen.

At the end of each skin assessment, the learner completes the Braden Scale to determine the patientâ&#x20AC;&#x2122;s level of risk for pressure ulcers.

The only way to access the Skin and Risk Assessment Competency is by joining the Pressure Ulcer Prevention Program. Visit www.medline.com/PUPP-webinar to sign up for an informational webinar to learn more. (See back cover for webinar dates.)

Improving Quality of Care Based on CMS Guidelines 97

Forms & Tools

SKINSAVERS Initiative

SKINSAVERS Initiative A pressure ulcer prevention tool By Feddy S. Emmanuel, RN, MSN, FNP-BC, CWOCN

Pressure ulcers are a great health concern with considerable financial implications and ability to cause considerable pain and suffering. Accordingly, the SKINSAVERS initiative was put into place at Lutheran Medical Center in Brooklyn, NY, and includes the following: • WOCN consultation of all patients with pressure ulcers stage II and greater • Standardization of skin and advanced wound products • Staff education on skin and wound product utilization • Braden Scale risk assessment performed on admission and daily • Recruitment, training, empowerment of SKINSAVERS RN unit champions • Implementation of SKINSAVERS bundle for pressure ulcer prevention

SKINSAVERS Bundle

S K I N S A V E R S

– Side lying positioning at 30-degrees – Keep HOB at 30 degrees – Inspect skin daily & at every turn – Nutrition & hydration improvement/nutrition consult – Suspend heels – Apply moisture barrier after incontinence episodes – Vigilant skin care & moisturizer – Encourage mobility – Reposition at least every 2 hours – Support surfaces: bed & chair

Since its implementation the initiative has shown considerable reduction in the incidence of pressure ulcers. Ongoing staff education is an essential part of the program. With increased knowledge comes increased compliance and subsequently improved patient outcomes. © 2010 Feddy S. Emmanuel. Printed with permission.

About the author

Feddy S. Emmanuel, RN, MSN, FNP-BC, CWOCN is a practicing WOC Nurse Practitioner at Lutheran Medical Center in Brooklyn, NY. She earned her Master of Science degree and Family Nurse Practitioner certificate in 2008 from SUNY Downstate Medical Center in Brooklyn, NY, and is board certified by the ANCC. She obtained her WOCN certificate from Albany Medical Center WOCNEP in 1998, has been board certified by the WOCNB for 11 years and holds a certificate in HBOT. She has been a registered nurse for over 30 years with experience in acute care, critical care, long-term care, home health and outpatient services.

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BioConâ&#x201E;˘- 500 Bladder Scanner Safely Measures Bladder Volume 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

To learn more about CAUTI prevention, visit www.medline.com/erase or contact your Medline sales representative.

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.

ÂŠ2010 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.

What did we do after designing a revolutionary new catheter tray system?

We found THREE more ways to make it even better. Weâ&#x20AC;&#x2122;re obsessed with engineering new and better technology for healthcare workers. So after we revolutionized the outdated Foley catheter tray with a unique, one-layer system design, we immediately turned our attention to addressing how we could make it even easier to use. We studied how the tray was being used in the field. The result was three more great improvements.

Combined with the previous innovative tray redesign and comprehensive ERASE CAUTI education, these three new features help to improve patient safety and quality, while reducing avoidable costs associated with waste and urinary tract infections. To learn about the ERASE CAUTI system, as well as other strategies for minimizing the risk of CAUTI, sign up for a free Innovation in the Prevention of CAUTI webinar at www.medline.com/erase/webinar.

ÂŠ2010 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.

Real photography on the outside – so you know exactly what’s inside A photo on the package helps identify the contents of the kit, serves as an educational tool for the clinician and can be used to discuss the procedure with the patient. Also, the label opens up to a booklet with step-by-step instructions and helpful tips for the clinician.

A checklist that fits better in the medical record The reformatted checklist is smaller, making it easier to fit in the patient chart or medical record. It is also available as an attachment for electronic documentation.

Education you’ll want to present to your patient There’s nothing like the new Patient Education Care Card. Designed to look and feel like a “Get Well Soon” card, it tells patients about catheterization so they know you are providing them the best care possible.

ÂŠ2010 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.

Impact of Health Care Reform on Home Health

Forms & Tools

Tip Sheet

Impact of Health Care Reform (The Patient Protection & Affordable Care Act) on Home Health Care Agencies and Nurses

Joan M. Marren, RN, MA, MEd, Chief Operating Officer, Visiting Nurse Service of New York / President, VNSNY Home Care Payment Changes Reduces reimbursement to home care by $39.7 billion over 10 years beginning in 2011. Home health agencies will be under great pressure to manage costs, including nursing costs, case mix and utilization closely. This raises concerns about the potential impact on access to and quality of home care. Mandates two studies - first (due 1/2015) to assess the impact of home care reductions on access, quality and number of agencies and types; second (due 3/2014) to evaluate costs to serve low income, complex care patients and their patterns of admission to home health care. The Act authorizes up to $500million, based on study findings, for demonstrations to see if changes to PPS reimbursement will improve access for high need patients. Take Away Message: Home health agencies, and their nurses in particular, serving high cost, complex care patients have a unique opportunity to articulate the characteristics and needs of these patients and to participate in demonstrations to assure their access to care.

Quality Reporting & Incentives/Value Based Purchasing Requires development of a national strategy and action plan to improve health service delivery, outcomes and population health with emphasis on managing high cost chronic illness, reducing preventable hospital admissions and decreasing health disparities Implements value based purchasing/pay for performance Take Away Message: A national health care improvement strategy can raise awareness of the role and contributions of home health nurses to management of chronic illness and avoidance of hospitalization. Success in a value based purchasing model will highlight the impact of home care nurses on quality of care but nurses must be sure that measures are properly risk adjusted and within the home care agenciesâ&#x20AC;&#x2122; and nursesâ&#x20AC;&#x2122; control. Chronic Care Coordination & Service Innovation Improving Quality of Care Based on CMS Guidelines 103

Forms & Tools

Impact of Health Care Reform on Home Health

Establishes Federal Coordinated Health Care Office and creates a Center for Medicare and Medicaid Innovation to better integrate Medicare/Medicaid strategy at the federal and state level and to test new payment and service delivery models for elderly and chronically ill. Proposes demonstration programs to reduce cost and improve coordination and quality for the chronically ill by expanding medical and health care homes (Independence at Home/Medicaid “health homes”), developing new models and incentives for improved cross continuum collaboration (Community Care Transitions Program and “bundled payment”), and sharing savings with accountable, collaborative, multi-provider organizations (Accountable Care Organizations). Take Away Message: Proposed initiatives present many opportunities for home health care nurses and nurse practitioners, as lead providers and in partnership with others, to play a greater role in the care management of chronic illness patients in the community.

The CLASS Act Creates a new federally administered, voluntary insurance program that supports community living for beneficiaries with long term cognitive or functional impairments Provides a modest benefit to cover non medical ADL services and support. Take Away Message: Program could expand the market for community based assessment, care management and direct care services provided or supervised by home health care nurses.

Expansion of Medicaid & Long Term Care Home and Community Based Services Proposes various models and incentives that expand Medicaid coverage and promote community based care in lieu of nursing home placement. Take Away Message: More insured individuals and emphasis on access to community care options will probably create greater demand for home care services. This will drive demand for skilled home care nurses to deliver services and to train and oversee paraprofessional home care workers. Workforce Development Authorizes grants and training programs for “community health workers”, “community based long term care entities” and health professionals who provide direct care Focuses particular emphasis on targeting training programs to serve underserved, high risk communities and populations. Take Away Message: Access to increased numbers of well prepared home care nurses and paraprofessional staff will be essential to meet anticipated demand from demographic changes in the population and from health care reform’s emphasis on building community care options and capacity.

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Medicare and Health Care Reform – Patient Handout

Forms & Tools

CENTERS

SERVICES

FOR

MEDICARE & MEDICAID

MAY 2010

Medicare and the New Health Care Law — What it Means for You A Message from Kathleen Sebelius, Secretary of Health & Human Services The Affordable Care Act passed by Congress and signed by President Obama this year will provide you and your family greater savings and increased quality health care. It will also ensure accountability throughout the health care system so that you, your family, and your doctor—not insurance companies—have greater control over your care. These are needed improvements that will keep Medicare strong and solvent. Your guaranteed Medicare benefits won’t change—whether you get them through Original Medicare or a Medicare Advantage plan. Instead, you will see new benefits and cost savings, and an increased focus on quality to ensure that you get the care you need. This brochure provides you with accurate information about the new services and benefits to help you and your family now and in the future. The Centers for Medicare & Medicaid Services (the federal agency that runs the Medicare, Medicaid, and Children’s Health Insurance Program) will continue to provide you with up-to-date information about these new benefits and will ensure that your personal information is safe. Remember—rely on your trusted sources of information when it comes to accurate information about Medicare, and don’t hesitate to call 1-800-MEDICARE or go on-line at Medicare.gov if you have questions or concerns. Don’t give your personal Medicare information to anyone who isn’t a trusted source.

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Forms & Tools

Medicare and Health Care Reform – Patient Handout

HEALTH CARE LAW

2 What Stays the Same The guaranteed Medicare benefits you currently receive will remain the same. During open enrollment this fall, you will continue to have a choice between Original Medicare and a Medicare Advantage plan. Medicare will continue to cover your health costs the way it always has, and there are no changes in eligibility. But, there are some important benefits that you and your family can take advantage of starting this year. Look for more details in your Medicare and You Handbook coming this fall.

Improvements in Medicare You Will See Right Away More Affordable Prescription Drugs • If you enter the Part D “donut hole” this year, you will receive a one-time, $250 rebate check if you are not already receiving Medicare Extra Help. These checks will begin mailing in mid-June, and will continue monthly throughout the year as beneficiaries enter the coverage gap. • Next year, if you reach the coverage gap, you will receive a 50% discount when buying Part D-covered brand-name prescription drugs. • Over the next ten years, you will receive additional savings until the coverage gap is closed in 2020.

Important New Benefits to Help you Stay Healthy • Next year you can get free preventive care services like colorectal cancer screening and mammograms. You can also get a free annual physical to develop and update your personal prevention plan based on current health needs.

Improvements to Medicare Advantage • Today, Medicare pays Medicare Advantage insurance companies over $1,000 more per person on average than Original Medicare. These additional payments are paid for in part by increased premiums by all Medicare beneficiaries—including the 77% of seniors not enrolled in a Medicare Advantage plan. • The new law levels the playing field by gradually eliminating Medicare Advantage overpayments to insurance companies. • If you are in a Medicare Advantage plan, you will still receive guaranteed Medicare benefits. • Beginning in 2014, the new law protects Medicare Advantage members by taking strong steps to ensure that at least 85% of every dollar these plans receive is spent on health care, rather than administrative costs and insurance company profits.

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HEALTH CARE LAW

3 Improvements in Medicare You Will See Soon Better Access to Care • Your choice of doctor will be preserved. • The law increases the number of primary care doctors, nurses, and physician assistants to provide better access to care through expanded training opportunities, student loan forgiveness, and bonus payments. • Support for community health centers will increase, allowing them to serve some 20 million new patients.

Better Chronic Care • Community health teams will provide patient-centered care so you won’t have to see multiple doctors who don’t work together. • If you’re hospitalized, the new law also helps you return home successfully—and avoid going back—by helping to coordinate your care and connecting you to services and supports in your community.

Improvements Beyond Medicare That You and Your Family Can Count On Improves Long-Term Care Choices • New tools and resources in the Elder Justice Act, which was included in the new law, will help prevent and combat elder abuse and neglect, and improve nursing home quality. • The new law creates a new voluntary insurance program called CLASS to help pay for long-term care and support at home. • Individuals on Medicaid will receive improved home- and communitybased care options, and spouses of people receiving home- and communitybased services through Medicaid will no longer be forced into poverty.

Helps Early Retirees • To help offset the cost of employer-based retiree health plans, the new law creates a program to preserve those plans and help people who retire before age 65 get the affordable care they need.

Helps People with Pre-existing Conditions • The new law provides affordable health insurance through a transitional high-risk pool program for people without insurance due to a pre-existing condition. • Insurance companies will be prohibited from denying coverage due to a pre-existing condition for children starting in September, and for adults in 2014. • Insurance companies will be banned from establishing lifetime limits on your coverage, and use of annual limits will be limited starting in September.

Expands Health Coverage for Young People • Young people up to age 26 can remain on their parents’ health insurance policy starting in September.

Improving Quality of Care Based on CMS Guidelines 107

Medicare and Health Care Reform – Patient Handout

Forms & Tools

HEALTH CARE LAW

4 The New Law Preserves and Strengthens Medicare New Tools to Fight Fraud and Protect Your Medicare Benefits • The new law contains important new tools to help crack down on criminals seeking to scam seniors and steal taxpayer dollars. • It reduces payment errors, waste, fraud, and abuse to make Medicare more efficient and return savings to the Trust Fund to strengthen Medicare for years to come. • You are an important resource in the fight against fraud. Be vigilant and rely only on your trusted sources of information about your Medicare benefits. • Call 1-800-MEDICARE if you have any questions or want to report something that seems like fraud.

Keeps Medicare Strong and Solvent • Over the next 20 years, Medicare spending will continue to grow, but at a slightly slower rate as a result of reductions in waste, fraud, and abuse. This will extend the life of the Medicare Trust Fund by 12 years and provide cost savings to those on Medicare. • In 2018, seniors can expect to save on average almost $200 per year in premiums and over $200 per year in co-insurance compared to what they would have paid without the new law. • Upper-income beneficiaries ($85,000 of annual income for individuals or $170,000 for married couples filing jointly) will pay higher premiums. This will impact about 2% of Medicare beneficiaries.

For More Information For more information about the new health care law now, visit www.medicare.gov. If you have any questions, call 1-800-MEDICARE (1-800-633-4227) or your State Health Insurance Assistance Program (SHIP). Visit www.medicare.gov or call 1-800-MEDICARE to get their telephone number. TTY users should call 1-877-486-2048. If you need help in a language other than English or Spanish, say “Agent” at any time to talk to a customer service representative. Visit the Eldercare Locator at www.eldercare.gov to find out how to access home- and communitybased services and benefits counseling, transportation, meals, home care, and caregiver support services. You can also call 1-800-677-1116. The Eldercare Locator, a public service of the U.S. Administration on Aging, is your first step for finding local agencies in every U.S. community.

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CMS Product No. 11467

Preferred Practices – Palliative & Hospice Care Quality

A National Framework and Preferred Practices for Palliative and Hospice Care Quality A National Quality Forum (NQF) Consensus Report

Forms & Tools

Center to Advance Palliative Care 1255 Fifth Avenue, Suite C-2 New York, NY 10029 Phone 212.201.2670 Fax 212.426.1369 www.capc.org

The National Quality Forum has recently identified palliative care and hospice care as national priority areas for healthcare quality improvement. The highly influential NQF report provides TM a framework and set of NQF-endorsed preferred practices that focus on improving palliative care and hospice care across the Institute of Medicine’s six dimensions of quality – safe, effective, timely, patient-centered, efficient, and equitable. The preferred practices mark a crucial step in the standardization of palliative care and hospice. Preferred Practices… 1. Provide palliative and hospice care by an interdisciplinary team of skilled palliative care professionals, including, for example, physicians, nurses, social workers, pharmacists, spiritual care counselors, and others who collaborate with primary healthcare professional(s). 2. Provide access to palliative and hospice care that is responsive to the patient and family 24 hours a day, 7 days a week. 3. Provide continuing education to all healthcare professionals on the domains of palliative care and hospice care. 4. Provide adequate training and clinical support to assure that professional staff is confident in their ability to provide palliative care for patients. 5. Hospice care and specialized palliative care professionals should be appropriately trained, credentialed, and/or certified in their area of expertise. 6. Formulate, utilize, and regularly review a timely care plan based on a comprehensive interdisciplinary assessment of the values, preferences, goals, and needs of the patient and family and, to the extent that existing privacy laws permit, ensure that the plan is broadly disseminated, both internally and externally, to all professionals involved in the patient's care. 7. Ensure that upon transfer between healthcare settings, there is timely and thorough communication of the patient's goals, preferences, values, and clinical information so that continuity of care and seamless follow-up are assured. 8. Healthcare professionals should present hospice as an option to all patients and families when death within a year would not be surprising and should reintroduce the hospice option as the patient declines. 9. Patients and caregivers should be asked by palliative and hospice care programs to assess physicians'/healthcare professionals' ability to discuss hospice as an option. 10. Enable patients to make informed decisions about their care by educating them on the process of their disease, prognosis, and the benefits and burdens of potential interventions.

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Forms & Tools

Preferred Practices â&#x20AC;&#x201C; Palliative & Hospice Care Quality

A National Framework and Preferred Practices for Palliative and Hospice Care Quality (continued) 11. Provide education and support to families and unlicensed caregivers based on the patient's individualized care plan to assure safe and appropriate care for the patient. 12. Measure and document pain, dyspnea, constipation, and other symptoms using available standardized scales. 13. Assess and manage symptoms and side effects in a timely, safe, and effective manner to a level that is acceptable to the patient and family. 14. Measure and document anxiety, depression, delirium, behavioral disturbances, and other common psychological symptoms using available standardized scales. 15. Manage anxiety, depression, delirium, behavioral disturbances, and other common psychological symptoms in a timely, safe, and effective manner to a level that is acceptable to the patient and family. 16. Assess and manage the psychological reactions of patients and families (including stress, anticipatory grief, and coping) in a regular, ongoing fashion in order to address emotional and functional impairment and loss. 17. Develop and offer a grief and bereavement care plan to provide services to patients and families prior to and for at least 13 months after the death of the patient. 18. Conduct regular patient and family care conferences with physicians and other appropriate members of the interdisciplinary team to provide information, to discuss goals of care, disease prognosis, and advance care planning, and to offer support. 19. Develop and implement a comprehensive social care plan that addresses the social, practical, and legal needs of the patient and caregivers, including but not limited to relationships, communication, existing social and cultural networks, decision making, work and school settings, finances, sexuality/intimacy, caregiver availability/stress, and access to medicines and equipment. 20. Develop and document a plan based on an assessment of religious, spiritual, and existential concerns using a structured instrument, and integrate the information obtained from the assessment into the palliative care plan. 21. Provide information about the availability of spiritual care services, and make spiritual care available either through organizational spiritual care counseling or through the patient's own clergy relationships. 22. Specialized palliative and hospice care teams should include spiritual care professionals appropriately trained and certified in palliative care. 23. Specialized palliative and hospice spiritual care professionals should build partnerships with community clergy and provide education and counseling related to end-of-life care. 24. Incorporate cultural assessment as a component of comprehensive palliative and hospice care assessment, including but not limited to locus of decision making, preferences regarding disclosure of information, truth telling and decision making, dietary preferences, language, family communication, desire for support measures such as palliative therapies and complementary and alternative medicine, perspectives on death, suffering, and grieving, and funeral/burial rituals. 25. Provide professional interpreter services and culturally sensitive materials in the patient's and family's preferred language.

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Cleaning and Disinfecting

Forms & Tools

Ten Tips for Cleaning and Disinfecting Shared Medical Equipment

1 Make a list of every piece of shared medical equipment. (Assign appropriate staff to help identify and generate the equipment list.) 2 Assign the cleaning and disinfection responsibility to the type of healthcare worker who will be performing the task within your policy. 3 Communicate this administrative decision to all members of your staff, both written and verbally, and document. 4 Educate and train staff on proper care, maintenance, cleaning and storage of each piece of equipment. At a minimum, provide this education upon initial employment, when the equipment is replaced with a newer model and annually. Document that this training has occurred. 5 Select easy-to-use, EPA-registered hospital grade disinfectants and cleaning products. Make sure the products list which microorganisms and viruses it kills. Common cleaners are sodium hypochlorite (bleach solution) or quaternary ammonium products. However, to help avoid warranty issues or equipment damage, be sure to follow manufacturers’ recommendations regarding which cleaning products to use.

6 Clean medical device surfaces when visible blood or bloody fluids are present by wiping with a cloth dampened with soap and water to remove any visible organic material, and then disinfect. 7 If no visible organic material is present, disinfect the exterior surfaces after each use using a cloth or wipe with either an EPA-registered detergent/germicide with a turberculocidal or HBV/HIV label claim, or a dilute bleach solution of 1:10 to 1:100 concentration. 8 Note that alcohol also is not an EPA-registered detergent/disinfectant. 9 Disposable professional grade wipes with a short “kill time” (60 seconds after application) can make the time spent cleaning equipment quick and easy. 10 All cleaning should be done in well-ventilated areas with gloves to protect healthcare workers’ hands.

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EDUCATIONAL OPPORTUNITIES FOR LONG-TERM CARE PROFESSIONALS

Making Sense of the New Quality Indicator Survey Two free online courses available at www.medlineuniversity.com

The Role of the CNA in Resident-Centered Care and the New Quality Indicator Survey

Understanding the Quality Indicator Survey Designed for: Long-Term Care Administrators

Designed for: Nurses and CNAs You’ll earn: One Administrator Credit You’ll earn: One Continuing Education Credit* This course covers:

• How the state survey process has evolved into the new Quality Indicator Survey (QIS) • The importance of the CNA in QIS and resident-centered care

• How the Quality Indicator Survey (QIS) process evolved to standardize state surveys in accordance with federal guidelines

• The different aspects of QIS, including the resident interview, resident observations and family interviews

• The top six objectives of the QIS

• How the CNA can help improve the overall quality of care in long-term care facilities

• How the QIS differs from traditional state surveys

* Courses approved for continuing education by the Florida Board of Nursing and the California Board of Reigistered Nursing.

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Approved by the National Association of Long-Term Care Administrator Boards (NAB), this course covers:

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• How surveyors in all states are being trained in a structured and consistent manner

LEARN MORE ABOUT THE ONLY INTEGRATED SOLUTION FOR SURVEY READINESS IN NURSING HOMES

Quality Assurance System Webinar

This webinar gives a QIS overview and demonstration on how the abaqis® system can help prepare for both the traditional and QIS survey processes. This demonstration also highlights how abaqis® provides: • Rich reporting capabilities to identify which care areas to target for quality improvement • Root cause analysis on a facility-wide or individual-resident basis, enabling prioritization and focusing of interventions for maximum impact • Emphasis on information reported by residents and families to help identify the needs of residents, aiding your efforts to improve consumer satisfaction Now with the new Stage 2 module featuring: • A dashboard view of triggered care areas based on data collected using abaqis® Stage 1 Suite • Investigative tools to determine deficiencies in triggered care areas

Free Webinar at www.medline.com/abaqisdemo Improving Quality of Care Based on CMS Guidelines 113

Some things should not be reused About the One & Only Campaign The goal of the One & Only Campaign is to improve safe injection practices across healthcare settings. The practices within an organization are highly influenced by its culture or are an expression of its culture. Thus, through education, outreach, and grassroots initiatives, the One & Only Campaign will seek to influence the culture of patient safety. The One & Only Campaign is an education and awareness campaign aimed at both healthcare providers and the public to increase proper adherence to safe injection practices to prevent

disease transmission from the misuse of needles, syringes, and medication vials in outpatient settings. While the campaign will be initially rolled out in targeted locations, the vision is to develop a concept that can be replicated nationwide. For more information, please visit:

www.ONEandONLYcampaign.org. Safe Injection Practices Coalition partners include the following organizations: Accreditation Association for Ambulatory Health Care (AAAHC), American Association of Nurse Anesthetists (AANA), Ambulatory Surgery Foundation, Association for Professionals in Infection Control and Epidemiology,

www.ONEandONLYcampaign.org

Inc (APIC), BD (Becton, Dickinson and Company), Centers for Disease Control and Prevention (CDC), CDC Foundation, HONOReform Foundation, Nebraska Medical Association (NMA), Nevada State Medical Association (NSMA), and Premier Safety Institute.

HEALTHY SKIN Join the team!

Figure 2: Single-use, disposable fingerstick devices*

National Center for Emerging and Zoonotic Infectious Diseases Division of Healthcare Quality Promotion (DHQP)

VOLUME 8, ISSUE 2

Improving Quality of Care Based on CMS Guidelines

Free CE Inside!

Volume 8, Issue 2

Influenza: Prevention Guidelines

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Survivors Share Their Stories

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How to Prepare for Emergencies & Disasters

The Dance Goes On:

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