Healthy Skin Volume 9 Issue 1 by Medline Industries

JBK_CVR_Layout 1 2/14/11 9:00 AM Page 1

VOLUME 9, ISSUE 1

Improving Quality of Care Based on CMS Guidelines

Free CE Inside!

HEALTHY SKIN

Introducing ...

THE NEW REMEDY WEBSITE www.RemedyAdvancedSkincare.com

Achieve

ZERO Pressure Ulcers

Now you and your family can enjoy professional quality Remedy skin care products at home.

Principles for Achieving Inner Peace

Order online at

www.remedyadvancedskincare.com Save 15% off your first order by using Promo Code “ISaved15” Offer expires 5/31/11.

MKT211020/LIT822/30M/JBK5

www.medline.com

Volume 9, Issue 1

Removing Stress from the QIS

LTC: HOW HEALTHCARE REFORM AFFECTS

YOU Making a Difference in Africa

JBK_CVR1_Layout 1 2/14/11 9:11 AM Page 2

Join the team!

HEALTHY SKIN

Pressure point answers From page 101

1. Lateral malleolus 2. Lateral aspect of foot 3. Lateral aspect of knee 4. Greater trochanter 5. Ribs 6. Shoulder 7. Ear 8. Occiput 9. Ear 10. Elbow 11. Dorsal thoracic area 12. Sacrum/Coccyx 13. Heel 14. Shoulder blade 15. Sacrum/Coccyx

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

16. Ischial tuberosity 17. Posterior knee 18. Foot 19. Medial malleolus

You, our readers, are on the front lines of everything that happens in the healthcare industry – and we want to hear from you! Have you ever wished you could write an article that would be published in a large-circulation magazine? Now’s your chance. Healthy Skin is looking

for writers and contributors. Whether you’d like to try your hand at writing or offer suggestions for future articles, we want to hear what you have to say! You never know – the next time you open an issue of Healthy Skin, it might be to read your own article!

Content Key We’ve coded the articles and information in this magazine to indicate which national quality initiatives they pertain to. Throughout the publication, when you see these icons you’ll know immediately that the subject matter on that page relates to one or more of the following national initiatives: • QIO – Utilization and Quality Control Peer Review Organization • Advancing Excellence in America’s Nursing Homes We’ve tried to include content that clarifies the initiatives or gives you ideas and tools for implementing their recommendations. For a summary of each of the above initiatives, see Pages 6 and 7.

20. Lateral malleolus

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. ©2011 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.

Improving Quality of Care Based on CMS Guidelines 103

jbk_HealthySkin17.3-mag_Layout 1 2/14/11 9:47 AM Page 3

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

44 45

19 30 32 56 69 74

Survey Readiness What’s in Store for QIS and MDS 3.0 Removing Stress from the QIS Prevention 225-Bed Community Hospital Reduces Pressure Ulcers from 9% to 0% in 90 Days Creative Techniques for Preventing Resident Falls in Long-Term Care Improving Hand Hygiene Compliance: A Multi-disciplinary Team Approach Protecting Vulnerable Heels: Tips for Nursing Assistants Easy Does It: Safe and Effective Lifting Practices 5-Step Approach for Avoiding VAP

Page 12

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

36 66

Joyce Norman, BSN, RN, CWOCN, DAPWCA Kim Kehoe, BSN, RN, CWOCN, DAPWCA Elizabeth O’Connell-Gifford, BSN, MBA, RN, CWOCN, DAPWCA

58 83 87

Special Features NE1 Wound and Skin Assessment Tool Award Preparing for Reform in Your Post Acute Setting CE Article Special Insert! Positive or Negative? You Decide: Healthcare Reform’s Impact on Nursing Homes and LTC Facilities Wound Care and Rehab Training in Lesotho, Africa Inspiring Change: The Cozy Project Makes Older Patients More Comfortable Pediatric Pressure Ulcers in the “Darnedest” Places Pink Glove Dance: The Sequel Pink Glove Survey Results

64 78

Caring for Yourself Top Tips for Winter Skin Care 8 Principles for Achieving Inner Peace

11 12 18

Jackie Todd, RN, CWCN, DAPWCA 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

26 49

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

Treatment Osteoporosis in Men The Use of Superabsorbent Containing Fluid Lock Dressing in Hospice Patients

94 95 96 97 99 101

Forms & Tools WHO Glove Pyramid WHO Exam Glove Technique CDC Clean Hands Poster CDC Clean Hands Poster – Spanish Urinary Incontinence Assessment and Implementation How Well Do You Know Pressure Points?

About Medline Medline, headquartered in Mundelein, IL, manufactures and distributes more than 100,000 products to hospitals, extended care facilities, surgery centers, home care dealers and agencies and other markets. Medline has more than 800 dedicated sales representatives nationwide to support its broad product line and cost management services.

Page 26

Page 32

Page 58

Page 83

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

jbk_HealthySkin17.3-mag_Layout 1 2/15/11 4:52 PM Page 4

Healthy Skin Letter from the Editor

e realize that the more opportunities you have to educate yourself about our industry, the latest trends, the constantly changing regulations, the financial challenges, the clinical and quality issues in health care, the more valuable you are to your organization and to your patients. It doesn’t matter what your specialty is, it is part of your responsibility to stay up-to-date on our business.

So, as tax-paying citizens and concerned healthcare professionals, many of you are delving deep into the particulars of healthcare reform and what it means to you and your organization. (Be sure to check out the two articles on healthcare reform in this issue!) As you dig deeper into where the United States stands as a country, you will discover some head-turning data. In 2009, 17.3 percent of the GDP (gross domestic product) in the United States was dedicated to health care. According to the Office of the Actuary in the Centers for Medicare & Medicaid Services (CMS) National Healthcare Expenditure projections, the dollars represented grew from $2.34 trillion in 2008 to $2.47 trillion in 2009—the largest one-year jump since 1960. CMS predicts total U.S. healthcare spending in 2019 will be $4.5 trillion. And yet, as healthcare spending skyrockets, U.S. rankings against other countries are not what you would expect.

our money. And who would have thought that in the category of infant mortality, the United States would rank dead last in this group. But we did. So, there you have it, we are a country in trouble. But what makes it even worse are the statistics for our aging population and what we can expect in the future. If we look ahead to the year 2050, women age 85 and over will be the largest segment of the population. How can we sustain adequate health care for this important part of our population, how can we eliminate waste, how can we adopt better prevention strategies, and how can we improve outcomes? All of these are questions depending on you in part for the answers. You are our future. Read more, learn more—and don’t be afraid to adopt new ideas. Best Regards,

In one study of seven different countries, including Australia, Canada, Germany, Netherlands, New Zealand and the United Kingdom, the United States consistently ranked poorly (in most cases in last place), and yet the cost of healthcare per capita was double that of any of the other countries. So, we spend more and get less for

Sue MacInnes, RD, LD Editor

According to Chip and Dan Heath, authors of the #1 New York Times bestseller Made to Switch: How to Change Things When Change Is Hard, when it comes to change, the rational mind and the emotional mind compete for control. This tension can sabotage efforts to change. In Switch, the Heaths show how real people have brought both parts of the brain together to achieve great results and successful change. To order, visit www.barnesandnoble.com.

Healthy Skin

jbk_HealthySkin17.3-mag_Layout 1 2/14/11 9:48 AM Page 5

Camera not included.

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

Winner of National HCA Innovators Award

Interactive training and online competencies available on-demand at www.medlineuniversity.com To request a sample or additional details, contact your Medline representative or call 1-800-MEDLINE (1-800-633-5463).

Reference 1. Young DL, Esocado N, Landers MR, Black J. A pilot study providing evidence for the validity of a new tool to improve assignment of NPUAP stage to pressure ulcers. Advances in Skin & Wound Care. In press. ©2011 Medline Industries, Inc. NE1 is a trademark of Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc. Patent pending.

jbk_HealthySkin17.3-mag_Layout 1 2/14/11 9:48 AM Page 6

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

QIO Utilization and Quality Control Peer Review Organization 9th Round Statement of Work

Origin:

The QIO Statement of Work is based upon Part B of the Title XI of the Social Security Act. The Medicare-funded “Ninth Scope of Work” plan became effective August 1, 2008 and will remain in effect through July , 2011. Purpose: To carry out statutorily mandated review activities, such as: Stay tuned for • Reviewing the quality of care provided to beneficiaries; details on 10th Round • Reviewing beneficiary appeals of certain provider notices; Statement of Work COMING SOON • 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. 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

Origin:

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.

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.

Healthy Skin

jbk_HealthySkin17.3-mag_Layout 1 2/14/11 9:48 AM Page 7

The 9th Scope of Work Content Themes 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 #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 #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

jbk_HealthySkin17.3-mag_Layout 1 2/15/11 1:58 PM Page 8

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

Medline’s Pressure Ulcer Prevention Program • Average reduction in facility-acquired pressure ulcers: 70.5% • Average annual savings: $306,000 How does it work?

With a compelling combination of products and education: 1. Medline’s strategic product bundle, including skin care and incontinence products 2. Medline’s free educational program for nurses and nursing assistants, including 4 CE credits for nurses plus online, interactive competencies

If you are interested in:

Implementing a program that allows you to achieve these results and sustain them over time Reducing the incidence of pressure ulcers at your facility Learning more about Medline’s Pressure Ulcer Prevention Program

Call Medline Pressure Ulcer Prevention Program Manager Karen Frey at 1-847-643-4805 to get started today!

1. Medline Industries, Inc. Data on file.

jbk_HealthySkin17.3-mag_Layout 1 2/14/11 9:48 AM Page 9

BREAKING NEWS New data released

Pennsylvania Pressure Ulcer Partnership Reduces Pressure Ulcers In early January 2011, the Pennsylvania Pressure Ulcer Partnership released the results of its pressure ulcer reduction project showing collaborative efforts to reduce the rate of pressure ulcers and prevent pressure ulcers from getting worse. Three of the state’s leading healthcare organizations—The Hospital & Healthsystem Association of Pennsylvania (HAP), The Healthcare Improvement Foundation (HCIF), and Hospital Council of Western Pennsylvania (HCWP)—collaborated in 2008 to create the Pennsylvania Pressure Ulcer Partnership for hospitals. The project involved 58 hospitals from across the state. They focused on risk assessments, turning and repositioning, pressure reduction devices and techniques, nutrition, skin cleansing and moisturizing, and diligent wound care. The project was formed because Pennsylvania hospitals recognized that pressure ulcers, are one of the five most common types of harm experienced by patients in healthcare facilities. The nationwide costs associated with pressure ulcers and their complications are approximately $13 billion a year—under Medicare alone.

Findings from the project: • the rate of pressure ulcers that developed decreased by 23% (5.3% to 4.1%) • pressure ulcer risk assessments upon admission improved from 93% to 97% • the rate of pressure ulcers that progressed (worsened) decreased by 81% (2.1% to 0.4%) • ongoing risk assessments improved from 87% to 97% —both statistically significant

The rate of pressure ulcers decreased 23%

The partnership also conducted a baseline and follow-up survey to assess the extent to which participating hospitals had adopted certain practices and strategies. The survey collected information about specific processes identified as important to improvement, including leadership support for pressure ulcer prevention and treatment; organizational policies; monitoring the accuracy of pressure ulcer risk assessments and skin inspections; use of triggers for risk reassessment; documentation; and education and training. Of the 36 hospitals that completed both the baseline and follow-up survey, improvements were achieved in 88% of the 41 questions asked. “As health reform rolls out, Medicare and Medicaid payments to hospitals will be increasingly tied to quality and patient safety outcomes,” said Jane Montgomery, RN, vice president of clinical services and quality for HCWP. “It is critical that hospitals across the state build on their patient care successes in the coming years.” The Pennsylvania Pressure Ulcer Partnership was made possible through funding from Medline Industries, Inc., Capital Blue Cross, Highmark Blue Shield, and the Partnership for Patient Care, an initiative funded jointly by Independence Blue Cross and health systems in southeastern Pennsylvania. Source: The Hospital & HealthSystem Association of Pennsylvania. www.haponline.org

Improving Quality of Care Based on CMS Guidelines 9

jbk_HealthySkin17.3-mag_Layout 1 2/14/11 12:01 PM Page 10

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

Award Winners Honored at Clinical Symposium on Advances in Skin & Wound Care October 2010, Orlando, FL

Elizabeth Ayello wins Sharon Baranoski Founder’s Award

Elizabeth A. Ayello, PhD, RN, ACNS-BC, CWON, MAPWCA, FAAN received the 2010 Sharon Baranoski Founder’s Award. The award honors the overall pursuit of excellence in the field of skin and wound care. The award is named in honor of Sharon Baranoski, MSN, RN, CWOCN, DAPWCA, FAAN, the founder of the Clinical Symposium on Advances in Skin & Wound Care.

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.

Caroline Fife wins Outstanding Peer Reviewer Award

Caroline E. Fife, MD, received the Outstanding Peer Reviewer Award, which honors the Advances in Skin & Wound Care peer reviewer who has made the greatest contribution to furthering the goal of peer review: to provide constructive critiques that assist authors in revising and improving their manuscripts so that they make meaningful contributions to the literature and the skin and wound care field.

Marathon, a cyanoacrylate, bonds to the skin surface, integrating with the epidermis on a molecular level to seal in moisture. While other skin protectants may flake off, Marathon stays in place, offering robust protection and increased wafer wear time.

Stoma site before treatment with Marathon.1

Same stoma site after treatment with Marathon.1

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

10 10 Healthy Healthy Skin Skin

jbk_HealthySkin17.3-mag_Layout 1 2/15/11 1:58 PM Page 11

Treatment

NE1 Wound and Skin Assessment Tool Developer Wins National HCA Innovators Award

Nancy Estocado, PT, CWS Sunrise Hospital and Medical Center Las Vegas, Nev. Nancy Estocado, a physical therapist and certified wound specialist, won the National Hospital Corporation of America (HCA) Innovators Award for her idea “NE 1 Can Stage”— Skin and Wound Assessment Tool. “I could fall out of my chair with how excited I am,” said Estocado. “Because of how many hospitals are in the corporation and how many people entered the contest, to think that mine made it to the top is mindboggling,” she said. Sunrise President and CEO Sylvia Young said employees are celebrating the recognition alongside Estocado. “People are so thrilled that our hospital was selected for this national award and they have such high regard for Nancy,” said Young. “She’s a great caregiver, she’s a real role model, and I think people are just proud to be associated with her and that it started here at Sunrise.” Estocado’s innovative tool provides a simple, easy-touse, economical method for skin and wound assessment and documentation by any care provider at the bedside. The paper, single-use, L-shaped measuring device allows providers to frame the wound, take a photograph and match the picture to the guide’s nationally recognized wound conditions and measurements. This process allows the wound to be properly assessed and provides a standard in care for wounds. “My goal is that this would become the standard of practice for everyone,” said Estocado. “Home health, nursing homes, in the hospital — everyone can be on the same page, measuring and monitoring wounds in the same way.” In previous studies, the average clinician or nurse was only about 30 percent correct when assessing wounds, according to Estocado. When her tool was

used after five minutes of training, she said the results showed nurses and clinicians were 69 percent correct in wound assessments. She said the nurses continue to improve their accuracy the more they use the tool. Estocado’s findings have been approved for publication in Advances in Skin and Wound Care. Nancy Estocado won an HCA Innovators She would like to Award for her NE 1 Can Stage — Skin see the tool pilot- and Wound Assessment Tool. tested at Sunrise and expanded throughout HCA. Medline Industries, Inc. has also picked up the tool to make it available to the public. “I really hope it goes huge,” said Estocado. “I’ve been working on it for almost three years. I didn’t know where it was going to go, but I knew I could help people. I knew I had something.” Estocado said she spent a lot of her own money to create the tool and apply for a patent, so she hopes to use the prize money to pay off some of her debt. She said the entire HCA Innovators Award process has inspired others around her to get creative. “I can’t tell you how many other people have come up to me with ideas. Through this contest and award, it’s motivating people to be innovative. They think, ‘Hey, if she can do it, I can do it.’”

Used by permission from HCA and not intended as an endorsement for Medline Industries, Inc. or any other entity.

Improving Quality of Care Based on CMS Guidelines 11

jbk_HealthySkin17.3-mag_Layout 1 2/14/11 9:49 AM Page 12

Special Feature

R Preparing for EFORM in your post acute setting by Glen Roebuck

12 Healthy Skin

jbk_HealthySkin17.3-mag_Layout 1 2/14/11 9:50 AM Page 13

After years of debate and hand wringing, healthcare reform is here. Though much lamented and often debated, the Patient Protection and Affordable Care Act (PPACA) passed the legislative branch and was signed into law by President Obama in March of 2010. This may prove to be the single most impactful piece of legislation for post acute care field since the Johnson Administration introduced Medicare and Medicaid under the Social Security Amendments of 1965. While the recent mid-term elections have created sidebar conversations regarding potential repeal of certain components of the PPACA, full repeal of the law is unlikely. It is time for responsible and forward-thinking providers in the post acute field to become partners in making this evolution a success for the American people.

Common Reform Strategies Impacting Post Acute Care Four primary initiatives in the PPACA will directly impact how we provide care and remain financially viable in the post acute care sector. These initiatives will create the synergies and efficiencies to improve health care and reduce costs. • • • •

Accountable care organizations (ACOs) Bundling of services Value-added services Performance monitoring and penalties

Most ACOs likely will be formed by hospitals or large physician practice groups. ACOs must be able to provide services for a minimum of 5,000 covered lives. They will become local or regional gatekeepers of the healthcare system and look to establish networks of providers to manage care most effectively and efficiently. They will work within their network of providers to control and manage where patients enter into the healthcare system. As we begin to discuss the other primary initiatives impacting post acute care, the connectivity to one another will be evident. Currently reimbursement is on a fee-for-service basis, with no connectivity or accountability between providers based upon a patient’s care delivery through the system. In the paradigm of bundled services, Medicare pays one entity: the ACO. It will then fall to the ACO to effectively and efficiently manage the patient’s care and direct the patient to the most appropriate level of services to impact effective and efficient care. The ACO then pays the PAC providers.

The bundling of services will revolutionize the reimbursement system for Medicare-certified healthcare providers. Value-added services will be opportunities for ACOs to receive increased reimbursement based upon performance levels for clinical indicators such as lower infection rates and hospital readmission rates. The hospital readmission issue is currently the key touch point where PACs can partner with their current hospital partners (and likely future ACOs). PAC providers who evaluate and improve the management of unplanned hospitalizations will find themselves to be active and value-added partners in the reform-driven healthcare system. Funds for these value-added service incentives likely come from the final component, performance monitoring and penalties. The converse of the value-added incentives, these measures will reduce reimbursement based upon higher infection rates and re-hospitalization rates. It is clearly evident from these initiatives that the ability for a post acute provider to partner and align with local and regional providers will be a prerequisite to continued success in the market.

Becoming a Successful Partner in Healthcare Reform Below are specific steps that must occur for a post acute center to be successful in the reform-driven, ACO world: 1. Post acute centers must become masters of the Medicare system. Becoming a master of the Medicare system will require that providers move from only providing Medicare services for residents who return to their facilities

Improving Quality of Care Based on CMS Guidelines 13

jbk_HealthySkin17.3-mag_Layout 1 2/14/11 9:50 AM Page 14

to becoming market leaders in post acute short-stay rehabilitation. Becoming a leader in this market may be a massive undertaking for your center. If this is not a service you are providing to the community currently, reach to external consultation or management services to assist you in correctly positioning your center in the market. 2. Understand your hospital CEOâ&#x20AC;&#x2122;s world. If you do not have a relationship with the C-Suite staff at your local hospital, you need to cultivate these relationships in earnest. Without these relationships, you will not have the operational agility necessary to be a part of your local network of care. 3. Understand the impact on your physicians. Most physicians with reputable practices have now realized that it is simply financially detrimental to their practice to leave their offices and see patients. We must develop alternative opportunities in partnerships with physiciansâ&#x20AC;&#x2122; groups and ACOs to provide timely quality physician attention to patients, particularly those at risk for re-admission to the acute care setting. Your role as a post acute provider is to work with your physician community now to begin to identify opportunities. This may include the addition of nurse practitioners or physician assistants to support physician presence within your center. 4. Align your medical director leadership for the future. Does your medical director understand, embrace and relish the thought of walking through the fires of reform as your partner? Is he or she an active network member of your local ACO? If you answered no to these questions, it may be time for a change. Your medical director needs to be actively engaged in clinical education, clinical pathway development in alignment with local ACO models, an active liaison to other physicians, and be an active participant in the evolution of medical care in the post acute setting.

Patients who are admitted to a post acute setting on Thursday with a diagnosis of pneumonia simply cannot be readmitted to an acute setting on Saturday withâ&#x20AC;Ś pneumonia.

14 Healthy Skin

5. Understand the impact of healthcare reform on your discharge planners. Be aware that the role of the case manager/discharge planner will evolve and change market to market. If discharge planners are held accountable for re-hospitalization rates, it will be incumbent upon the PAC providers to keep them actively engaged and informed of efforts to manage and control the issues that lead to rehospitalization.

jbk_HealthySkin17.3-mag_Layout 1 2/14/11 9:50 AM Page 15

Performance data will become your best friend or your downfall.

6. Your “competitors” are now your “partners.” If you have not developed close relationships with other post acute setting leaders, the time is now. As ACO networks mature, you will likely receive admissions from sources other than hospitals, including home health, skilled nursing, assisted living, medical homes and hospice. Non-medical support services may report findings to physicians or ACO admissions coordinators who may direct admissions to your setting. 7. Take care of sick people. You may think this sounds silly. But with up to two thirds of re-hospitalizations viewed as preventable, it is not. Patients who are admitted to a post acute setting on Thursday with a diagnosis of pneumonia simply cannot be readmitted to an acute setting on Saturday with… pneumonia. Post acute settings must be prepared to initiate more advanced care such as IV fluids and medications, closely monitoring vitals and changes in condition, and assess potential declines to initiate interventions with the physician early in the process. These measures help avoid unnecessary re-hospitalizations. 8. Assess your clinical prowess and make changes now. To achieve the cultural evolution noted above, the clinical talent and skills of your staff must be assessed and necessary skills must be acquired quickly. This may require additional certification and education, along with re-examination of the distribution of licensed staff, particularly LPNs/LVNs and RNs. These staff members must clearly understand that an unplanned re-hospitalization will be reviewed as a measure of their performance. 9. Monitor your performance and share your results. In the new world of healthcare reform, performance and success will be expanded beyond a successful survey

experience to include the monitoring and analysis of complex and integrated data. Performance data will become your best friend or your downfall. Begin now to develop ways to monitor and track performance data for your post acute center including things such as falls, wounds and re-hospitalizations. Having the tools and knowledge to track and improve these metrics will position you as a valuable partner in health care reform. 10. Educate your direct customers. When these initiatives begin to play out and directly impact the lives of your customers, it will be a time of confusion and angst for many. This presents a tremendous leadership opportunity for you to become a public voice and positive influence. Much will continue to evolve in the months and years to come related to the passage of PPACA. The accompanying regulations are yet to be released as of this writing. Will the three-day required hospital stay be upheld with reform? Where will the rights of patients fall in choosing their post acute service provider? How will your specific healthcare community respond to reform? These issues, and others, will continue to be a part of the changing reform landscape. Your active partnership in leading your post acute setting and your community is critical to your success.

Glen Roebuck is senior vice president of operations for Health Dimensions Group in Minneapolis. He can be reached at 612-770-6163, or via email at glenr@hdgi1.com. Health Dimensions Group is a leading provider of short term consultation and long term management solutions for health care providers. For more information, please contact Glen and visit www.healthdimensionsgroup.com.

Improving Quality of Care Based on CMS Guidelines 15

jbk_HealthySkin17.3-mag_Layout 1 2/14/11 11:47 AM Page 16

TenderWet ACTIVE GENTLY REMOVES

NECROTIC TISSUE & PATHOGENS TenderWet Active TenderWet Active polyacrylate wound dressings rinse and debride necrotic wounds for up to 24 hours! Plus, they won’t stick to the wound bed, reducing patient discomfort at dressing removal. TenderWet Active dressings have a “rinsing” effect as large-molecule proteins found in dead tissue and bacteria are attracted to TenderWet Active's core. We’re confident you’ll find TenderWet Active more effective than wet gauze therapy because TenderWet Active can be left in place for up to 24 hours without drying out while simultaneously removing harmful microorganisms and stubborn necrotic tissue.

For a free trial of TenderWet Active and information on Medline’s complete line of advanced wound care products, contact your Medline representative at 1-800-MEDLINE.

By debriding necrotic tissue, absorbing and retaining pathogens and keeping the wound moist, TenderWet Active helps create an ideal healing environment.

jbk_HealthySkin17.3-mag_Layout 1 2/14/11 9:51 AM Page 17

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

jbk_HealthySkin17.3-mag_Layout 1 2/14/11 11:47 AM Page 18

18 Healthy Skin

jbk_HealthySkin17.3-mag_Layout 1 2/14/11 9:51 AM Page 19

TRUE STORIES

225-BED COMMUNITY HOSPITAL In CounCIl Bluffs, Iowa ReduCes PRessuRe ulCeRs fRom 9% to 0% In 90 days By Beth L. Edwards RN BA Clinical Quality Specialist

Our Hospital

Hospital: Jennie Edmundson Hospital

Location: Council Bluffs, Iowa

Size: 225 licensed beds

Jennie Edmundson Memorial Hospital is an acute care community hospital with 225 licensed beds that provides health care services to Council Bluffs, Iowa and the surrounding community. It is an affiliate of the Nebraska Methodist Health System, and has been serving southwest Iowa since 1887. Today the hospital employs a staff of over 800 and is recognized for its state-ofthe-art Advanced Wound Care Center as well as being the only hospital in Iowa or Nebraska to receive the prestigious Commission on Cancer Outstanding Achievement Award for 2010.

Challenge:

Results: At the conclusion of a 90-day program trial, restricted to the telemetry unit of the hospital, incidence of pressure ulcers was reduced from 2 to 0. This pressure ulcer prevention program has now been activated throughout the hospital. The current rate of incidence remains at zero. Cost savings to the hospital, year to date, are estimated to be $259,080 in nursing time, pharmaceuticals and supplies (based on a projected incidence rate of 6 pressure ulcer cases avoided through this program and using calculations provided by the Centers for Medicare and Medicaid Services).

Our Advanced Wound Care Center opened in February of 2009 and is the only one of its kind in this part of the state. Many of the patients who visit our Center suffer from chronic non-healing wounds due to injury, burns, bedsores or diabetic ulcers. The Center offers wound assessment and care by specially trained staff. It has long been our belief, that skin integrity and the prevention of pressure ulcers is an area of hospital health care where our nurses can really make a difference. We are continually trying to improve on that care. So, in conjunction with the new CMS guidelines, we decided

â&#x20AC;&#x153;

Our Challenge

In January of 2009 we completed incidence and prevalence of pressure ulcers on patients hospitalized on our medical/surgery units, telemetry and ICU. On January 27, 2009, fifty-three hospitalized patients had a skin assessment completed. Nine patients had a pressure ulcer present. On January 31, 2009, twenty-three of the fifty-three patients remained hospitalized and skin assessments were completed. Two patients had new pressure ulcers. This 9% incidence rate was much higher than previous incidence and prevalence assessments. A performance improvement team consisting of myself, Jeri Smith, RN WOCN, Cathy Harvey, RN, Mary Grote, RN, Amy Waldstein, RN, Becky Krauel-Henkel, RN, and Mary Krueger, RN, was formed. Work was started with a goal of addressing and decreasing the incidence of hospital acquired pressure ulcers at Jennie Edmundson. In order to achieve that goal, we realized we were facing three separate challenges. The

We believe that skin integrity and the prevention of pressure ulcers is one area of hospital health care where our nurses can really make a difference. We are continually trying to improve that care.

â&#x20AC;&#x153;

Initiate a systematic approach to reducing hospital-acquired pressure ulcers to zero, utilizing a program of sound wound care principles including staff education and improved skincare products.

to take a closer look at this important opportunity to provide better outcomes for our patients.

Improving Quality of Care Based on CMS Guidelines 19

jbk_HealthySkin17.3-mag_Layout 1 2/14/11 9:51 AM Page 20

TRUE STORIES

first challenge was to provide education to our nursing staff. We wanted a program that would enable us to educate all of the nursing staff including RNs, LPNs, and CNAs. The second challenge was to analyze the kind of skin care products we were using.

In addition to the clinical challenges we faced, we also had some very real financial considerations. It is no secret that the treatment of hospital-acquired pressure ulcers can be very expensive. The CMS (Centers for Medicare & Medicaid Services) estimates the cost of treating a pressure ulcer case at $43,180. More than 50% of those costs are in nursing time, approximately 39% of the costs are pharmaceuticals and 11% are in products. Based on those figures, we were looking at total costs of $86,360 just to treat the two pressure ulcer cases we had at the time. If we could eliminate pressure ulcers in our facility we could realize significant savings over the long term. The Solution

In early January of 2009 our committee met with three different vendor groups and asked each of them to present their educa-

“

tional programs that would assist us in our efforts to eliminate hospital-acquired pressure ulcers. We were looking for learning materials to educate and test our nursing staff on pressure ulcer staging, skin assessment and nursing care. One of those vendors, Medline Industries, Inc., headquartered in Mundelein, IL, introduced us to their Pressure Ulcer Prevention Program (PUPP). Our local Medline reps, Brad Bruner and Allison Ball, “walked” us through the components of their program They had a clinical nurse specialist attend our Pressure Ulcer Committee meeting to outline their program. We soon realized this program had everything we were looking for. It included intensive staff education, a way to evaluate the effectiveness of that training, a specifically designed line of pressure ulcer prevention skincare products and a plan for hands-on implementation utilizing the assistance of Medline personnel and aimed at reducing pressure ulcer incidence levels in our hospital to 0%.

“

The third challenge was to continue assessment of incidence & prevalence to show improvement and prevention of pressure ulcers in patients hospitalized at our hospital.

We concluded that the Medline PUPP program was based on sound wound care principles backed by excellent teaching materials and utilized skincare products with a proven record of success in treating and preventing pressure ulcers. We agreed to a 90-day trial of the Medline PUPP program, starting with an evaluation of their line of pressure ulcer prevention skin care products, including: Remedy skin repair lotion, Remedy NutraShield barrier cream, and Remedy foaming cleanser. At the same time, and for the same 90-day trial period, we agreed to evaluate their premier line of UltraSorb underpads. The educational part of the program would be completed by all nursing staff including registered nurses, licensed practical nurses and certified nursing assistants. The 90-day trial using three Medline skin care products and the UltraSorb underpads would be conducted on one unit. We chose our 28 bed telemetry unit for the trial.

Medline introduced us to their Pressure Ulcer Prevention Program (PUPP) which included intensive staff education and a specifically designed line of pressure ulcer prevention skincare products aimed at reducing our incidence levels to 0%.

20 Healthy Skin

jbk_HealthySkin17.3-mag_Layout 1 2/14/11 9:52 AM Page 21

TRUE STORIES

“

The end goal of this training was to help modify behavior and motivate our nurses and nurse assistants toward improved patient care. But before any of that training could happen, we had to first establish exactly where we were starting from.

We introduced these products into the system and started using them in our targeted test area. Almost immediately we had a number of patients say “I really like this product!” Even our staff commented on how much they liked the smell and the feel of the Medline products. At the same time we were introducing these new products into the system, we kicked off the educational components of the Medline program. We started by administering a “pretest,” provided by Medline, to all of the nursing staff. This pretest was designed to give us an indication of where our staff was starting from in terms of pressure ulcer prevention knowledge. The average scores for this pretest, by nursing group were: RNs and LPNs 79%, and CNAs 64%. Upon completion of the pretest, the nursing staff was provided with either a nursing workbook or a nursing assistance workbook. We would administer a “post test” at the conclusion of the 90day trial period. We would be able to compare the pre and post test results as well as the results from the 90-day trial on one unit utilizing the Medline skin care products, compared to the other units in the hospital. We saw a dramatic improvement in nursing staff scores after the educational training.

“

Implementation

According to a recent CMS roundtable, among the main roadblocks to creating an effective pressure ulcer prevention program are: lack of resources, inconsistent staff education and nonexistent patient and family education. We were determined to start with consistent staff education. Medline’s program addressed these issues by providing clinical and educational resources and assessment tools to our nurses from the beginning. The educational tools they provided were targeted to two primary groups: first, our nursing assistants (CNAs), because they are critical to early detection and prevention of pressure ulcers. They turn the patients, deal with incontinence when it occurs, and otherwise administer creams and lotions for skincare. The second critical element was our RNs and LPNs. The educational component for this group was designed to ensure that these nurses understood their role in assessing and documenting skin condition, nutrition, and overall health improvement of the patient. All nursing personnel included in the 90-day trial satisfactorily completed all phases of the pressure ulcer prevention training. The training materials provided included: a CMS presentation, pressure ulcer prevention workbooks, an instructor’s guide, forms

and tools and, of course, pre and post tests. The workbook Medline created for the CNAs included basic information covering skin care, patient turning, incontinence care and basic nutrition. The workbook created for the RNs and LPNs covered pressure ulcer assessment, skin care, nutrition and documentation. The overall acceptance of the training and of the program was better than we anticipated. One of our LPNs summed it up when she said “The workbooks make it very easy for us to do the right thing!” Everyone who participated in the training received a certificate of completion and a lapel pin signifying they had gone through the training. Our staff’s post test scores (taken after training) were: RNs and LPNs averaged 97% (up 18% over the pretest) and CNAs averaged 93% (up 29% over the pretest). These numbers are significant because they indicate the level of acquired knowledge and hands-on experience our staff had achieved and they give us confidence that going forward the program will experience sustainability for long-term success in our fight to eliminate pressure ulcers in our hospital. Medline supplied the training materials and the management team at Jennie Edmundson provided the encouragement to complete the training, but to a very large extent, the staff took it upon themselves to learn

Improving Quality of Care Based on CMS Guidelines 21

jbk_HealthySkin17.3-mag_Layout 1 2/14/11 9:52 AM Page 22

TRUE STORIES

The Results

At the conclusion of the 90-day trial period, in April of 2009, the PUPP program had lived up to all our expectations. As of May 15, 2009 we had assessed 57 patients and had zero new pressure ulcers. Six months later, on November 6, 2009 we assessed 63 patients hospital wide and again we had no new pressure ulcers. As of the writing of this case study we are still experiencing a 0% incidence rate of new hospital-acquired pressure ulcers. However the real plus is that even the skeptics among our nursing staff have become converts. No change is easy when it comes to nursing care, and our new Pressure Ulcer Prevention Program was not only about change, but also about documenting the results of those changes. And that required some discipline. But as a result of the positive direction this program has taken, I am pleased to say everyone has gotten on board. At this point, our Administrator and our financial management people are in complete support of the program. This, as a result of showing them how by reducing the number of potential pressure ulcers from six (6) to (0) zero over a one year time span we had in fact saved the hospital $247,800 (the number of pressure ulcers reduced multiplied by the average cost to treat one, $41,300, as calculated by CMS).

“

Our results were so good we’ve now gone hospital wide with the Medline PUPP program. We have adopted the Remedy products and UltraSorb underpads throughout the whole facility.

“

the material through reading, memorizing and small study groups.

Future Initiatives

The success Jennie Edmundson has enjoyed as a result of engaging in a systematic approach to the prevention and treatment of pressure ulcers has encouraged us to look at other programs that can improve our patient outcomes through staff and resident education as well as product improvements. One area we are especially interested in is the reduction of catheterassociated urinary tract infections (CAUTIs). Some of these catheter-associated infections may be the result of catheters being placed unnecessarily. Other potential causes for these infections include leaving the urinary catheters in place too long and contamination that can occur during insertion. We are looking at another Medline program, ERASE CAUTI, that we believe may offer the potential to help us reduce the risk of CAUTI in our hospital. The Medline program includes three distinct parts: 1) a new innovative catheter tray design that promotes better processes 2) an educational component that provides strategies to prevent CAUTI in the first place and 3) an awareness campaign, “The Race to ERASE CAUTI,” that we believe would get our nurses on board.

About the Author – Beth L. Edwards, RN BS is the Clinical Quality Specialist at the Jennie Edmundson Hospital in Council Bluffs, Iowa. In this position Beth has responsibility for performance improvement, Joint Commission readiness, and variance event report monitoring. She brings over 25 years of nursing experience to the job, including 5 years in Patient Safety & Quality Improvement and 10 years in clinical research. In addition to nursing, Beth enjoys spending time with her daughter and family, and doing knitting and stitchery.

22 Healthy Skin

jbk_HealthySkin17.3-mag_Layout 1 2/14/11 9:52 AM Page 23

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.

jbk_HealthySkin17.3-mag_Layout 1 2/14/11 9:52 AM Page 24

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.

ÂŠ2011 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.

jbk_HealthySkin17.3-mag_Layout 1 2/15/11 4:55 PM Page 25

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 place in the paper chart or attach to the electronic medical record.

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.

jbk_HealthySkin17.3-mag_Layout 1 2/14/11 9:53 AM Page 26

WOUND CARE AND REHAB TRAINING IN LESOTHO, AFRICA A travelogue by Teresa Conner-Kerr, PhD, PT, CWS, CLT

My name is Teresa Conner-Kerr, and I am a physical therapist, a professor, and chair of the department of physical therapy at Winston-Salem State University. I traveled to the mountainous, rural nation of Lesotho, Africa in June 2010 to explore the possibility of creating a rehabilitation training program at one of Lesothoâ&#x20AC;&#x2122;s nursing schools or at the National Health Training College in Maseru, Lesotho.

Rehab training greatly needed in Lesotho Lesotho has the third highest prevalence of HIV in the world,1 and a significant number of the children and adults have physical disabilities related to HIV/AIDS. Nevertheless, there are currently only six physical therapists and one occupational therapist to serve the entire country. The goal is to find a funding source to assist WinstonSalem State University with establishing a rehabilitation assistant program in Lesotho. The intent is to teach individuals to become rehab assistants so they can provide care for the large numbers of children and adults with disabilities.

Advanced wound care training During the six days I spent in Lesotho, I also trained approximately 20 nursing students, plus adult nurse practitioners and three nursing education faculty at the St. Joseph Nursing College in Roma using prod-

26 Healthy Skin

jbk_HealthySkin17.3-mag_Layout 1 2/14/11 9:53 AM Page 27

Special Feature

ucts and educational materials produced by Medline®. The majority of them had never seen modern wound care products. The only supplies they had on hand were gauze and saline. I mainly discussed pressure ulcers, explaining the principles of wound bed preparation and moist wound healing. I also provided an overview of wound dressing selection and a hands-on demonstration of various Medline dressings. Dressings were passed around for all to see and touch. Some of the supplies included Optifoam®, Optifoam Ag, Puracol®, Puracol Plus, Suresite, bordered gauze, Medfix, Remedy Skin Repair Cream™, Arglaes® powder, Arglaes film, and Marathon®. In addition, I presented Medline wound care education CDs to the nurse educator faculty members to keep in their library at St. Joseph Nursing College. The college is affiliated with St. Joseph’s Hospital, which is run by a board under the Archbishop of Maseru. The hospital, which opened in 1937, is located in the city of Roma, and serves over 100,000 people across the entire nation of Lesotho. About the author

Teresa Conner-Kerr, PhD, PT, CWS, CLT, is a professor and chair of the department of physical therapy at Winston-Salem State University, where she also serves as program director for the doctor of physical therapy program. She holds a PhD in Anatomy & Cell Biology from the Brody School of Medicine, East Carolina University, and a BSPT from the same institution. She is a certified wound care specialist and lymphedema specialist. Her research interests include treatments for antibiotic-resistant bacteria and recalcitrant wounds and the use of simulation technology in product testing and teaching.

Improving Quality of Care Based on CMS Guidelines 27

jbk_HealthySkin17.3-mag_Layout 1 2/14/11 9:53 AM Page 28

nt, with an independe ntainous country ou m a tic is ris o te th ac so ar Le unique ch rnment. It has the ve go c tic bli ra pu oc Re m e de ighbor, th rrounded by its ne su lly ta to ing be of of South Africa.

HIV AND AIDS IN LESOTHO Just under 25 percent of the population in Lesotho currently lives with HIV. In 2009 there were about 23,000 new HIV infections, and approximately 14,000 people died from AIDS. Over half of the 260,000 adults living with HIV in Lesotho are women.1

References 1. HIV and AIDS in Lesotho. AVERTing HIV and AIDs website. Available at: http://www.avert.org/aids-lesotho.htm. Accessed January 18, 2011. 2. UNICEF Executive Director launches “Facts for Life” in Lesotho. UNAIDS website. April 12, 2010. Available at: http://www.unaids.org/en/resources/ presscentre/featurestories/2010/april/20100412unicef Accessed January 18, 2011.

In addition, one in ten children in Lesotho does not survive to see his or her fifth birthday, mostly as a result of AIDS and preventable causes, such as pneumonia and diarrhea, exacerbated by malnutrition.2

Marathon is a registered trademark of Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc. Optifoam is a registered trademark of Medline Industries, Inc. Puracol is a registered trademark of Medline Industries, Inc. Arglaes is a registered trademark of Giltech Limited Corporation Remedy Skin Repair Cream is a trademark of McCord Research Inc.

Lesotho’s AIDS effort is now guided by the National AIDS Policy and Strategic Plan for 2006-2011. The government intends to reverse the epidemic by focusing on HIV prevention through condom promotion, prevention of mother-to-child transmission, and providing antiretroviral treatment for all those in need.1 Considering that more than half Lesotho’s population lives in poverty, declining productivity as a result of HIV/AIDS remains a stark threat to the overall survival of the country. In 2007, Keketso Sefeane, chief executive of the National AIDS Commission in Lesotho, said HIV/AIDS has the potential to “wipe out” the country.1

28 Healthy Skin

Teresa Conne r-Kerr during a one-on-one session with a wound care ed nurse practitio ucation ner from the na tional health se rvice.

jbk_HealthySkin17.3-mag_Layout 1 2/14/11 9:54 AM Page 29

St. Joseph’s Nursing Co llege in Rom one of the o a, Lesotho ldest and la is rgest trainin nurses in Les g facilities for otho.

ollege learn ph’s Nursing C se Jo . St at ts Studen re products nced wound ca va ad e’s lin ed M about and dressings.

St. Joseph’s Hospital in Rom a, Lesotho se over 100,000 rves people across th e entire nation of Lesotho.

Improving Quality of Care Based on CMS Guidelines 29

jbk_HealthySkin17.3-mag_Layout 1 2/14/11 9:54 AM Page 30

Prevention

Creative Techniques for

Preventing Resident Falls in Long-Term Care by Connie Yuska, MS, RN, CORLN

Ensuring the safety of individuals in all healthcare settings has increasingly become a priority for the entire healthcare system. In nursing homes, it is the primary responsibility of both the licensed nurses and unlicensed assistants to ensure the safety of the residents.1 Falls are the most frequently reported adverse events among nursing home residents.1 As many as three out of four nursing home residents fall each year.2 Falls are most commonly caused by an existing health condition, such as muscle weakness or problems with walking, and environmental risk factors, such as wet floors, poor lighting, incorrect bed height, and improperly fitted or maintained wheelchairs.2 Studies have documented various fall prevention strategies, such as providing staff education, reducing risk factors, identifying the need for and providing exercise programming and making modifications in the environment to ensure resident safety.1 Unfortunately, the results of these intervention studies, as measured by a reduction in falls and fall-related injuries have been mixed and have not offered a clear solution to preventing falls in the long-term care setting.1 So what can a facility do to be proactive in ensuring a safe living environment for their residents? Nursing researchers in Ontario, Canada explored the communication patterns among staff working in long-term care settings and found one quite obvious technique that just may help: Get EVERYONE involved.1

30 Healthy Skin

jbk_HealthySkin17.3-mag_Layout 1 2/14/11 9:55 AM Page 31

“

One quite obvious technique that just may help: Get EVERYONE involved.

Falls Prevention Strategies Keeping the general rule of increased communication in mind, some of the following strategies may be employed in your longterm care facility: 1. Incorporate falls risk assessment and facility policies and procedures regarding falls into new staff orientation. 2. Examine how your staff currently communicates falls prevention activities and make sure all members of the healthcare team are included. 3. Include communication strategies about falls in your quality improvement program and include RNs/LPNs and nursing assistants in the development of the plan. 4. Actively engage nursing assistants in the care planning process. 5. Move away from a closed, vertical “chain of command” method of communication to one that is horizontal, open and positive. 6. Stress PREVENTION rather than REACTION in the management of falls incidents. 7. Discuss all of these techniques with your staff and listen to their input. They may have many more ideas that can help prevent falls. By actively engaging all members of the healthcare team in a falls prevention program, you can improve the quality of care provided to your residents, and most importantly — keep them safe from falling.

References 1. Wagner LM, Damianakis T, Mafrici N, Robinson-Holt K. Falls communication patterns among nursing staff working in long-term care settings. Clin Nurs Res. 2010;19(3):311-326. Available at: http:/cnr.sagepub.com/content/19/3/311. Accessed December 21, 2010. 2. Falls in Nursing Homes. Centers for Disease Control and Prevention website. Available at: http://www.cdc.gov/ncipc/factsheets/nursing.htm. Accessed December 21, 2010.

Improving Quality of Care Based on CMS Guidelines 31

jbk_HealthySkin17.3-mag_Layout 1 2/14/11 12:02 PM Page 32

Prevention

Improving Hand Hygiene Compliance A Multi-disciplinary Team Approach By Lorri A. Downs RN, BSN, MS, CIC

Although itâ&#x20AC;&#x2122;s been more than ten years since the Institute of Medicineâ&#x20AC;&#x2122;s eye-opening report To Err Is Human issued its call to action to reduce healthcare errors, improving quality and reducing healthcare-acquired infections continue to be two of the greatest challenges in health care today. We must get healthcare professionals to understand that hands are common vessels for passing pathogens from patient to patient.1 Appropriate hand hygiene is one practice with the potential to prevent a great deal of healthcare-acquired infections. Hand

hygiene, however, appears to encompass the ultimate knowing/doing gap among healthcare professionals. That is to say, they know when they are supposed to wash their hands, yet observed hand-hygiene compliance has been poor; with average baseline rates around 40 percent.2 Known barriers to proper hand hygiene are a lack of knowledge and lack of accessibility to sinks and alcohol-based foam and gels.1

5 actions to help increase hand hygiene compliance1 1

Aggressive, continuous education programs

Ensure alcohol-based hand rubs and lotions are easily accessible

Ensure healthcare workers receive adequate education on proper usage of these products

32 Healthy Skin

4 Empower patients, residents and families to ask caregivers if they have washed their hands 5 To help maintain the integrity of skin, encourage healthcare professionals to use moisturizers and lotions to counteract the drying effects of alcohol-based products

jbk_HealthySkin17.3-mag_Layout 1 2/14/11 9:55 AM Page 33

Survey Readiness

RSV Staphylococcus Influenza

Candida Klebsiella Enterococcus Pseudomonas Improving Quality of Care Based on CMS Guidelines 33

jbk_HealthySkin17.3-mag_Layout 1 2/14/11 9:55 AM Page 34

Steps to improved hand hygiene compliance1 Improving hand hygiene is a daunting task, and using a multidisciplinary approach can address numerous barriers. If your facility is having difficulty focusing on hand hygiene compliance, try implementing the following steps to get your team motivated. 1. Form a multidisciplinary team; include a wide range of staff such as staff nursing, physicians, infection control and quality, and administration. Physician champions can help reach every area quicker. 2. Roll out an aggressive education program with clear expectations for compliance for employees. 3. Partner this campaign with education about hand hygiene Meet regularly to discuss the campaign progress and make improvements. 5. Remove unexpected barriers. What does a successful multidisciplinary hand hygiene campaign look like? The following is an example of one organization’s hand hygiene campaign, as outlined in the American Journal of Infection Control. The interventions were implemented as a way to break down the barriers to hand hygiene compliance.1 Intervention # 1: “You Bugged Me” program. This activity consisted of staff members presenting a “You Bugged Me” card if they witnessed other employees not washing their hands or not following proper infection control practices. The card, which listed the misdoing, was turned in to the employee’s supervisor by the end of the shift. The infection control coordinator was also notified by the individual completing the card. Employees who received three cards were required to present an educational in-service at a staff meeting. Those who received five cards were required to write a research paper. Receiving seven cards meant the employees had to present their research paper to the facility’s policy and quality committee. Finally, employees who received 10 cards were scheduled to meet with the CEO and chief nursing officer (CNO) regarding their noncompliance. Intervention # 2: Hand hygiene education. The hospital’s infection control coordinator attended all the staff meetings in all departments, providing education on proper hand hygiene techniques. One of the tools involved was called Glitter Bug Potion, a fluorescent lotion that is used with an ultraviolet lamp, making it possible to see how well hands are cleaned. After applying Glitter Bug, the employees sanitized their hands, and then placed them under an ultra-

34 Healthy Skin

violet light to see how well they cleaned their hands. Many employees had to repeat this activity two or three times before their hands were adequately washed. Intervention # 3: Proper supplies. All employees and physicians received pocket-sized bottles of hand sanitizing gel to use throughout the day. Alcohol foam dispensers were also placed both inside and outside patient rooms, which addressed a barrier identified in the brainstorming session that the dispensers inside the room were not easily accessible. Signs were placed in patient rooms reminding the staff to wash their hands, and patients were educated to remind the staff to sanitize their hands after they entered the room. Intervention # 4: Hand sanitizing stations. The final part of the intervention was putting hand sanitizing stations in the lobby and waiting rooms on the patient care floors. The nursing staff educated visitors on the importance of hand hygiene and educational handouts were also placed by the hand sanitizing stations. Using these interventions, the hand hygiene compliance rate increased from 66 percent to 90 percent. As hand hygiene compliance improved, it was noted that, during the same time, infection rates decreased. A prospective controlled trial conducted in a hospital nursery, and many other investigations conducted over the past 40 years, have confirmed the important role contaminated healthcare workers’ hands play in the transmission of health care-associated pathogens.3 The time to act is now! We must partner and create multidisciplinary clinical teams to get the message out that this relatively simple process of hand hygiene must be implemented in every healthcare setting and sustained at a compliance level of zero tolerance for poor practices. Our challenge in leadership is to remove barriers, role model best practices and hold our staff accountable. References 1 Helms B, Dorval S, St. Laurent P, Winter M. Improving hand hygiene compliance: A multidisciplinary approach. The American Journal of Infection Control. 2010,38(7):572-574 2 Boyce JM & Pittet D. Guideline for hand hygiene in health-care settings: recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA/ Hand Hygiene Task Force. MMWR. 2002;51(RR16):1-44. 3 Historical perspective on hand hygiene in health care. In: WHO Guidelines on Hand Hygiene in Health Care. 2009:9.

jbk_HealthySkin17.3-mag_Layout 1 2/14/11 9:55 AM Page 35

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.

ÂŠ2011 Medline Industries, Inc. Medline and Epi-clenz are registered trademarks of Medline Industries, Inc.

jbk_HealthySkin17.3-mag_Layout 1 2/14/11 9:56 AM Page 36

36 Healthy Skin

jbk_HealthySkin17.3-mag_Layout 1 2/14/11 9:56 AM Page 37

Treatment

steoporosis in men Osteoporosis is a disease that causes the skeleton to weaken and the bones to break. It poses a significant threat to more than two million men in the United States. One in four men over age 50 will have an osteoporosis-related fracture in their remaining lifetime. Despite these compelling figures, surveys suggest that a ]majority of American men view osteoporosis solely as a “woman’s disease.” Moreover, among men whose lifestyle habits put them at increased risk, few recognize the disease as a significant threat to their mobility and independence. Osteoporosis is called a “silent disease” because it progresses without symptoms until a fracture occurs. It develops less often in men than in women because men have larger skeletons, their bone loss starts later and progresses more slowly, and they have no period of rapid hormonal change and bone loss.

However, in the past few years the problem of osteoporosis in men has been recognized as an important public health issue, particularly in light of estimates that the number of men above the age of 70 will continue to increase as life expectancy continues to rise. Clearly, more information is needed about the causes and treatment of osteoporosis in men, and researchers are turning their attention to this long-neglected group. For example, researchers supported by the National Institutes of Health are studying how much the risk of fracture in men is related to bone mass and structure, biochemistry, lifestyle, tendency to fall, and other factors. The results of such studies will help doctors to better understand how to prevent, manage, and treat osteoporosis in men. This fact sheet describes the highlights of what is already known.

Number of people

(Figures in millions. Figures have been rounded.)

Osteoporosis – Projected Prevalence Age 50 and Older 35 30

Key 2002

2010

2020

25 20 15 10 5 0

Men with osteoporosis

Women with osteoporosis

Men with low bone mass

Women with low bone mass

Source: America’s Bone Health: The State of Osteoporosis and Low Bone Mass in Our Nation. Washington, DC: National Osteoporosis Foundation, 2002.

Improving Quality of Care Based on CMS Guidelines 37

jbk_HealthySkin17.3-mag_Layout 1 2/14/11 10:46 AM Page 38

By age 65 or 70 men and women are losing bone mass at the same rate.

What Causes Osteoporosis? Bone is constantly changing—that is, old bone is removed and replaced by new bone. During childhood, more bone is produced than removed, so the skeleton grows in both size and strength. For most people, bone mass peaks during the third decade of life. By this age, men typically have accumulated more bone mass than women. After this point, the amount of bone in the skeleton typically begins to decline slowly as removal of old bone exceeds formation of new bone. Men in their fifties do not experience the rapid loss of bone mass that women do in the years following menopause. By age 65 or 70, however, men and women are losing bone mass at the same rate, and the absorption of calcium, an essential nutrient for bone health throughout life, decreases in both sexes. Excessive bone loss causes bone to become fragile and more likely to fracture. Fractures resulting from osteoporosis most commonly occur in the hip, spine, and wrist, and can be permanently disabling. Hip fractures are especially dangerous. Perhaps because such fractures tend to occur at older ages in men than in women, men who sustain hip fractures are more likely than women to die from complications.

Primary and Secondary Osteoporosis There are two main types of osteoporosis: primary and secondary. In cases of primary osteoporosis, either the condition is caused by age-related bone loss (sometimes called senile osteoporosis) or the cause is unknown (idiopathic osteoporosis). The term idiopathic osteoporosis is used only for

men younger than 70 years old; in older men, age-related bone loss is assumed to be the cause. The majority of men with osteoporosis have at least one (sometimes more than one) secondary cause. In cases of secondary osteoporosis, the loss of bone mass is caused by certain lifestyle behaviors, diseases, or medications. The most common causes of secondary osteoporosis in men include exposure to glucocorticoid medications, hypogonadism (low levels of testosterone), alcohol abuse, smoking, gastrointestinal disease, hypercalciuria, and immobilization.

Causes of Secondary Osteoporosis in Men • • • • • • • • • • • • • • • • • •

glucocorticoid medications other immunosuppressive drugs hypogonadism (low testosterone levels) excessive alcohol consumption smoking chronic obstructive pulmonary disease and asthma cystic fibrosis gastrointestinal disease hypercalciuria anticonvulsant medications thyrotoxicosis hyperparathyroidism immobilization osteogenesis imperfecta homocystinuria neoplastic disease ankylosing spondylitis and rheumatoid arthritis systemic mastocytosis Continued on page 40

38 Healthy Skin

jbk_HealthySkin17.3-mag_Layout 1 2/14/11 9:56 AM Page 39

Join 100,000 other nurses for free CE courses at

Medline University

w w w w w w

200 courses 20 curriculum tracts Interactive competencies Flexible access: PC, iPhone, iPad Free registration Join today at

www.medlineuniversity.com

ÂŠ2011 Medline Industries, Inc. Medline and Medline University are registered trademarks of Medline Industries, Inc.

jbk_HealthySkin17.3-mag_Layout 1 2/14/11 9:56 AM Page 40

Glucocorticoid medications. Glucocorticoids are steroid medications used to treat diseases such as asthma and rheumatoid arthritis. Bone loss is a very common side effect of these medications. The bone loss these medications cause may be due to their direct effect on bone, muscle weakness or immobility, reduced intestinal absorption of calcium, a decrease in testosterone levels, or, most likely, a combination of these factors. When glucocorticoid medications are used on an ongoing basis, bone mass often decreases quickly and continuously, with most of the bone loss in the ribs and vertebrae. Therefore, people taking these medications should talk to their doctor about having a bone mineral density (BMD) test. Men should also be tested to monitor testosterone levels, as glucocorticoids often reduce testosterone in the blood. A treatment plan to minimize loss of bone during long-term glucocorticoid therapy may include using the minimal effective dose, and discontinuing the drug or administering it through the skin, if possible. Adequate calcium and vitamin D intake is important, as these nutrients help reduce the impact of glucocorticoids on the bones. Other possible treatments include testosterone replacement and osteoporosis medication. Hypogonadism. Hypogonadism refers to abnormally low levels of sex hormones. It is well known that loss of estrogen causes osteoporosis in women. In men, reduced levels of sex hormones may also cause osteoporosis. Although it is natural for testosterone levels to decrease with age, there should not be a sudden drop in this hormone that is comparable to the drop in estrogen experienced by women at menopause. However, medications such as glucocorticoids (discussed above), cancer treatments (especially for prostate cancer), and many other factors can affect testosterone levels. Testosterone replacement therapy may be helpful in preventing or slowing bone loss. Its success depends on factors such as age and how long testosterone levels have been reduced. Also, it is not yet clear how long any beneficial effect of testosterone replacement will last. Therefore, doctors usually treat the osteoporosis directly, using medications approved for this purpose. Recent research suggests that estrogen deficiency may also be a cause of osteoporosis in men. For

40 Healthy Skin

example, estrogen levels are low in men with hypogonadism and may play a part in bone loss. Osteoporosis has been found in some men who have rare disorders involving estrogen. Therefore, the role of estrogen in men is under active investigation. Alcohol abuse. There is a wealth of evidence that alcohol abuse may decrease bone density and lead to an increase in fractures. Low bone mass is common in men who seek medical help for alcohol abuse. In cases where bone loss is linked to alcohol abuse, the first goal of treatment is to help the patient stop, or at least reduce his consumption of alcohol. More research is needed to determine whether bone lost to alcohol abuse will rebuild once drinking stops, or even whether further damage will be prevented. It is clear, though, that alcohol abuse causes many other health and social problems, so quitting is ideal. A treatment plan may also include a balanced diet with lots of calcium- and vitamin D-rich foods, a program of physical exercise, and smoking cessation.

jbk_HealthySkin17.3-mag_Layout 1 2/14/11 12:04 PM Page 41

Smoking. Bone loss is more rapid, and rates of hip and vertebral fracture are higher, among men who smoke, although more research is needed to determine exactly how smoking damages bone. Tobacco, nicotine, and other chemicals found in cigarettes may be directly toxic to bone, or they may inhibit absorption of calcium and other nutrients needed for bone health. Quitting is the ideal approach, as smoking is harmful in so many ways. As with alcohol, it is not known whether quitting smoking leads to reduced rates of bone loss or to a gain in bone mass. Gastrointestinal disorders. Several nutrients, including amino acids, calcium, magnesium, phosphorous, and vitamins D and K, are important for bone health. Diseases of the stomach and intestines can lead to bone disease when they impair absorption of these nutrients. In such cases, treatment for bone loss may include taking supplements to replenish these nutrients. Hypercalciuria. Hypercalciuria is a disorder that causes too much calcium to be lost through the urine, which makes the calcium unavailable for building bone. Patients with hypercalciuria should talk to their doctor about having a BMD test and, if bone density is low, discuss treatment options. Immobilization. Weight-bearing exercise is essential for maintaining healthy bones. Without it, bone density may decline rapidly. Prolonged bed rest (following fractures, surgery, spinal cord injuries, or illness) or immobilization of some part of the body often results in significant bone loss. It is crucial to resume weight-bearing exercise (such as walking, jogging, dancing, and lifting weights) as soon as possible after a period of prolonged bed rest. If this is not possible, you should work with your doctor to minimize other risk factors for osteoporosis.

How Is Osteoporosis Diagnosed in Men? Osteoporosis can be effectively treated if it is detected before significant bone loss has occurred. A medical workup to diagnose osteoporosis will include a complete medical history, X-rays, and urine and blood tests. The doctor may also order a bone mineral density test. This test can identify osteoporosis, determine your risk for fractures (broken bones), and measure your response to osteoporosis treatment. The most widely recognized BMD test is called a dual-energy X-ray absorptiometry, or DXA test. It is painless â&#x20AC;&#x201C; a bit like having an X-ray, but with much less exposure to radiation. It can measure bone density at your hip and spine.

It is increasingly common for women to be diagnosed with osteoporosis or low bone mass using a BMD test, often at midlife when doctors begin to watch for signs of bone loss. In men, however, the diagnosis is often not made until a fracture occurs or a man complains of back pain and sees his doctor. This makes it especially important for men to inform their doctors about risk factors for developing osteoporosis, loss of height or change in posture, a fracture, or sudden back pain. Some doctors may be unsure how to interpret the results of a BMD test in men, because it is not known whether the World Health Organization guidelines used to diagnose osteoporosis or low bone mass in women are also appropriate for men. Although controversial, the International Society for Clinical Densitometry recommends using separate guidelines when interpreting BMD test results in men.

Improving Quality of Care Based on CMS Guidelines 41

jbk_HealthySkin17.3-mag_Layout 1 2/15/11 2:09 PM Page 42

What Are the Risk Factors for Men? Several risk factors have been linked to osteoporosis in men: • Chronic diseases that affect the kidneys, lungs, stomach, and intestines or alter hormone levels • Regular use of certain medications, such as glucocorticoids • Undiagnosed low levels of the sex hormone testosterone • Unhealthy lifestyle habits: smoking, excessive alcohol use, low calcium intake, and inadequate physical exercise • Age. The older you are, the greater your risk. • Race. Caucasian men appear to be at particularly high risk, but all men can develop this disease.

What Treatments Are Available? Once a man has been diagnosed with osteoporosis, his doctor may prescribe one of the medications approved by the FDA for this disease. The treatment plan will also likely include the nutrition, exercise, and lifestyle guidelines for preventing bone loss listed at the end of this fact sheet.

inadequate, dietary vitamin D intake should be between 600 and 800 IU (International Units) per day. (See Table 1.) The amount of vitamin D found in 1 quart of fortified milk and most multivitamins is 400 IU. • Engage in a regular regimen of weight-bearing exercises in which bones and muscles work against gravity. This might include walking, jogging, racquet sports, climbing stairs, team sports, weight training, and using resistance machines. A doctor should evaluate the exercise program of anyone already diagnosed with osteoporosis to determine if twisting motions and impact activities, such as those used in golf, tennis, or basketball, need to be curtailed. • Discuss with your doctor the use of medications that are known to cause bone loss, such as glucocorticoids. • Recognize and seek treatment for any underlying medical conditions that affect bone health.

Table 1. Recommendations for Calcium and Vitamin D Intake Age

If bone loss is due to glucocorticoid use, the doctor may prescribe a medication approved to prevent or treat glucocorticoid-induced osteoporosis, monitor bone density and testosterone levels, and suggest using the minimum effective dose of glucocorticoid.

Calcium (mg)

Vitamin D (IU)

19 to 30

1,000

600

31 to 50

1,000

600

51 to 70

1,200

600

70+

1,200

800

Source: Institute of Medicine, 2010.

Other possible prevention or treatment approaches include calcium and/or vitamin D supplements and regular physical activity. If osteoporosis is the result of another condition (such as testosterone deficiency) or exposure to certain other medications, the doctor may design a treatment plan to address the underlying cause.

For more information on osteoporosis, visit the National Institutes of Health Osteoporosis and Related Bone Diseases ~ National Resource Center website at www.bones.nih.gov or call 800–624–2663.

How Can Osteoporosis Be Prevented? There have been fewer research studies on osteoporosis in men than in women. However, experts agree that all people should take the following steps to preserve their bone health: • Avoid smoking, reduce alcohol intake, and increase your level of physical activity. • Ensure a daily calcium intake that is adequate for your age. • Ensure an adequate intake of vitamin D. Normally, the body makes enough vitamin D from exposure to as little as 10 minutes of sunlight a day. If exposure to sunlight is

42 Healthy Skin

Article provided by the NIH Osteoporosis and Related Bone Diseases ~ National Resource Center which provides patients, health professionals, and the public with an important link to resources and information on metabolic bone diseases.

jbk_HealthySkin17.3-mag_Layout 1 2/14/11 9:58 AM Page 43

NEW! ULTRASORBSÂŽ UF DRYPADS Dryness & Odor Control In One Ultra-Freshâ&#x201E;˘ Pad

Drier Patients. Fresher Air. Ultrasorbs UF provides the same patented* SuperCoreÂŽ as Ultrasorbs AP. The core draws in moisture, locks it away from the skin and feels dry to the touch in just minutes. In addition, Ultrasorbs UF contains antimicrobial Ultra-Fresh protection to inhibit the growth of bacteria and yeasts that can cause odors. â&#x20AC;˘ Locks odor-causing moisture away in the absorbent core â&#x20AC;˘ Makes for a fresher room â&#x20AC;˘ Clinically shown to help maintain skin integrity as part of an overall pressure ulcer prevention program.1

%&%2%.#% (!../. ! /)% #/./-)# )-0!#4 /& ,42!3/2"39 "3/2"%.4 !$3 ). 02%6%.4)/. /& (/30)4!, !#15)2%$ 02%3352% 5,#%23 ,/"!, %!,4( #/./-)# 2/*%#43 !.$ %7 /2+ %4(/$)34 /30)4!, 2//+,8. !2#( !.5&!#452%$ 5.$%2 0!4%.4 .5-"%2

,42! 2%3( )3 !. %')34%2%$ .4)-)#2/")!, ()3 02/$5#4 $/%3 ./4 02/4%#4 53%23 /2 /4(%23 !'!).34 $)3%!3% #!53).' "!#4%2)! : %$,).% .$5342)%3 .# %$,).% !.$ ,42!3/2"3 !2% 2%')34%2%$ 42!$%-!2+3 /& %$,).% .$5342)%3 .# ,42! 2%3( )3 ! 42!$%-!2+ /& %$,).% .$5342)%3 .# 50%2 /2% )3 ! 2%')34%2%$ 42!$%-!2+ /& # )2,!)$ 3 ,)%334/&&% -" /

Our latest Ultrasorbs innovation. The advanced features of Ultrasorbs AP plus antimicrobial Ultra-Fresh to inhibit bacteria and yeast that cause odor**

To request a free bag of Ultrasorbs UF, send an e-mail to ultrasorbs@medline.com.

jbk_HealthySkin17.3-mag_Layout 1 2/14/11 9:58 AM Page 44

Whatâ&#x20AC;&#x2122;s in Store for

QIS and MDS 3.0 By Dr. Andy Kramer

n case you were wondering, the new minimum data set (MDS) 3.0 will not impact the performance of the Quality Improvement Survey (QIS). However, there are some aspects of the QIS treatment of MDS data that will remain the same going forward and some that will change temporarily.

New QIS software, implemented in November [2010], will still generate random resident census samples and admission samples for the QIS process based on MDS data. Surveyors will continue to require from the nursing facility an alphabetical resident census list of all residents who are in the facility, including those who may be in the hospital or out on a home visit. They will also require the list of recent admissions. Surveyors will also continue to reconcile the software-generated random sample of residents with the alphabetical resident census and new admission list to finalize their samples for survey. What will change, temporarily, is that the QIS software will not calculate or utilize the 44 Quality of Care and Life Indicators (QCLI) that are derived from MDS data. However, almost every

44 Healthy Skin

Care Area has QCLIs mapped to it that originate from one or more of the onsite assessments that are conducted during Stage 1. For example, the Pressure Ulcer Care Area currently has seven QCLIs that are calculated from Staff Interviews, Census Sample Record Reviews, Admission Sample Record Reviews, and MDS. Only two of these are calculated from the MDS items, so the remaining five pressure ulcer QCLIs will be utilized during QIS surveys. The calculation and use of QCLIs based solely on MDS will be on hold until sufficient numbers of MDS 3.0 assessments have been submitted by nursing facilities. Thus, although MDS QCLIs will temporarily not be used to determine triggered Care Areas for a Stage 2 in-depth investigation, these care areas will be included in QIS because of the QCLIs from other sources. Some of the MDS QCLIs that can be calculated from MDS 3.0 data are expected to be used in QIS beginning in early 2011. Printed with permission from Provider magazine.

jbk_HealthySkin17.3-mag_Layout 1 2/15/11 2:09 PM Page 45

SUCCESS STORIES

5HPRYLQJ VWUHVV IURP WKH 4,6 2SHUDWRUV DUH IHHOLQJ PRUH SUHSDUHG DQG FRQILGHQW WKDQNV ODUJHO\ WR DQ LQQRYDWLYH TXDOLW\ DVVXUDQFH WRRO WKDW KHOSV SURYLGHUV DGGUHVV FRQFHUQV EHIRUH WKH\ EHFRPH PDMRU SUREOHPV $%287 7+,6 6(5,(6

5XQQLQJ D ORQJ WHUP FDUH IDFLOLW\ FDQ EH RYHUZKHOPLQJ DQG ORQHO\ %XW WKHUH DUH KHURHV RXW WKHUH VKRZLQJ KRZ VXFFHVV FDQ EH DFKLHYHG (DFK 68&&(66 6725,(6 LQVWDOOPHQW VKRZV KRZ D FROOHDJXH WXUQHG D FKDOOHQJLQJ VLWXDWLRQ LQWR D YLFWRU\

Spokane-based Avalon Care Center at Northpoint is one of many Avalon Healthcare Inc. communities with greater QIS success.

KHQ WKH &HQWHUV IRU 0HGLFDUH 0HGLFDLG 6HUYLFHV DQQRXQFHG SODQV WR LPSOHPHQW 4XDOLW\ ,QGLFDWRU 6XUYH\V ORQJ WHUP FDUH SURYLGHUV ZHUH ULJKWO\ FRQFHUQHG 0DQ\ TXHVWLRQHG ZKHWKHU WKH\ ZHUH WUXO\ UHDG\ ,Q PDQ\ FDVHV VXFK ZRUULHV ZHUH MXVWLÃ&#x20AC;HG Â´3ODQQLQJ DQG SUHSDUDWLRQ LV QHFHVVDU\ IRU DFKLHYLQJ JRRG VXUYH\ RXWFRPHV Âµ QRWHG 0DU\ .DKQ D &06 VSRNHVSHUVRQ Â´%XW LWÒ&#x2039;V DERXW PRUH WKDQ MXVW D VXUYH\ VFRUH ,WÒ&#x2039;V UHDOO\ DERXW PDNLQJ VXUH \RXÒ&#x2039;UH SURYLGLQJ WKH EHVW FDUH SRVVLEOH WR PHHW WKH QHHGV RI >UHVLGHQWV@ Âµ $OWKRXJK WKH IHGHUDO UHJXOD WLRQV DQG LQWHUSUHWLYH JXLGDQFH UHPDLQ XQFKDQJHG WKH QHZ WZR VWDJH FRPSXWHU DVVLVWHG 4,6 SURFHVV LV IDU PRUH GHWDLOHG

Reprinted by permission of McKnightâ&#x20AC;&#x2122;s

WKDQ WKH WUDGLWLRQDO VXUYH\Â²SDU WLFXODUO\ LQ LWV IRFXV RQ UHVLGHQW DQG IDPLO\ PHPEHU VDWLVIDF WLRQ DQG LWV HPSKDVLV RQ FHU WDLQ UHJXODWRU\ DUHDV 7KHVH LQFOXGH TXDOLW\ RI OLIH LVVXHV WKDW IDFWRU LQ GLJQLW\ FKRLFHV DQG RWKHU TXDOLW\ DVSHFWV :KLOH WKH FKDQJHV DUH D SRVLWLYH VWHS IRU HQVXULQJ UHJXODWRU\ FRP SOLDQFH DQG SURPRWLQJ KLJK TXDOLW\ UHVLGHQW FHQWULF FDUH DQ LQFUHDVH LQ GHÃ&#x20AC;FLHQFLHV LV OLNHO\ LI ORQJ WHUP FDUH IDFLOLWLHV DUHQÒ&#x2039;W DGHTXDWHO\ SUHSDUHG IRU WKH QHZ SURFHVV 6\VWHPDWLF VXUYH\ VROXWLRQ $V PDQ\ IDFLOLWLHV WKDW KDYH DOUHDG\ XQGHUJRQH WKH 4,6 SURFHVV FDQ DWWHVW WKH EHVW GHIHQVH DJDLQVW VXUYH\ GHIL FLHQFLHV LV D VWURQJ RIIHQVH )RU 6DOW /DNH &LW\ 87 EDVHG $YD

ORQ +HDOWK &DUH ,QF D VHQLRU KHDOWKFDUH VHUYLFHV SURYLGHU ZLWK IDFLOLWLHV WKURXJKRXW Ã&#x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Â² ORQJ EHIRUH VXUYH\RUV HYHU ZDON WKURXJK WKH GRRU

Improving Quality of Care Based on CMS Guidelines 45

jbk_HealthySkin17.3-mag_Layout 1 2/14/11 9:58 AM Page 46

$KHDG RI LWV -DQXDU\ LPSOHPHQWDWLRQ RI DEDTLV $YD ORQ FUHDWHG D TXDOLW\ DVVXUDQFH WDVN IRUFH WR H[SORUH RSWLRQV DQG GHWHUPLQH ZKLFK VROXWLRQV ZRXOG EHVW KHOS WKHLU FRPPX QLWLHV PHHW WKH PRUH VWULQJHQW UHTXLUHPHQWV XQGHU WKH 4,6 7KH WDVNIRUFH GHWHUPLQHG WKDW WKH DEDTLV V\VWHP ZRXOG EH DQ HVVHQWLDO FRPSRQHQW WR WKH QHZ TXDOLW\ DVVXUDQFH SUR JUDP QRWHG 1DQL *UD\ 9LFH 3UHVLGHQW RI &OLQLFDO 6HUYLFHV IRU $YDORQ +HDOWK &DUH ,QF Â´7KH SURJUDPÒ&#x2039;V DVVLVWDQFH ZLWK WKH 4,6 SURFHVV ZDV FULWL FDO WR RXU SUHSDUDWLRQ DQG VXF FHVV Âµ VKH VDLG %HFDXVH RI DEDTLVÒ&#x2039; HDVH RI XVH $YDORQ VWDII KDV EHHQ DEOH WR TXLFNO\ IDPLOLDUL]H LWVHOI ZLWK WKH SURJUDPÒ&#x2039;V PDQ\ RIIHULQJV DQG IXQFWLRQDO FDSDELOLWLHV 7KH RUJDQL]DWLRQ KDV EHFRPH VR DGHSW LQ LWV XVH RI DEDTLV LQ IDFW WKDW $YDORQÒ&#x2039;V VWDII PHP EHUV KDYH HVVHQWLDOO\ EHFRPH 4,6 OHDGHUV LQ WKHLU UHVSHFWLYH FRPPXQLWLHV %H\RQG WKDW VHD VRQHG VXUYH\RUV KDYH UHDFKHG RXW WR $YDORQ DGPLQLVWUDWRUV WR DVN TXHVWLRQV DQG VHHN FRXQ VHO DFFRUGLQJ WR *UD\ Â´ : L W K D E D T L V Z H K D Y H IRXQG WKDW ZH DUH PXFK EHW WHU SUHSDUHG IRU ERWK 4,6 DQG WUDGLWLRQDO VXUYH\V $V D FRP SDQ\ ZH KDYH H[SHULHQFHG D GHFUHDVH RI ) WDJV RQ DQQXDO VXUYH\V E\ IURP WKH SUHYL RXV \HDU Âµ 7ZR RI WKH Ã&#x20AC;YH VWDWHV LQ ZKLFK $YDORQ RSHUDWHV DUH FXUUHQWO\ FRQGXFWLQJ 4,6 VXU YH\V DQG D WKLUG ZLOO DGRSW 4,6 LQ ,Q &DOLIRUQLD DORQH FLWDWLRQV ZHUH GRZQ 7R IDFLOLWDWH WKH LQWHUYLHZLQJ SURFHVV DQG HQVXUH HIIHFWLYH FRQVLVWHQW GDWD FDSWXUH $YDORQ KDV WDNHQ DQ HQWLUHO\ HOHFWURQLF DSSURDFK (DFK $YDORQ IDFLOLW\ LV RXWILWWHG ZLWK ODSWRS FRP SXWHUV RQ PRELOH FDUWV DORQJ ZLWK D ZLUHOHVV FRQQHFWLRQ WKDW DOORZV VWDII WR LQWHUYLHZ UHVL

By using the same rates and threshold comparisons used by surveyors, abaqis helps take the guesswork out of the survey process.

|, ZRXOG QRW ZDQW WR RSHUDWH D IDFLOLW\ LQ WRGD\ V FOLPDWH ZLWKRXW DEDTLV } 1DQL *UD\ $YDORQ +HDOWK &DUH V 9LFH 3UHVLGHQW RI &OLQLFDO 6HUYLFHV

GHQWV GLUHFWO\ DW WKH EHGVLGH Â´%\ DVNLQJ WKH TXHVWLRQV LQ WKH LQWHUYLHZV VWDII LV PRUH DWWXQHG WR >VSHFLÃ&#x20AC;F DVSHFWV RI FDUH DQG FXVWRPHU VHUYLFH@ Âµ *UD\ FRQ WLQXHG Â´7KH UHVLGHQWV DUH DOVR XVHG WR EHLQJ LQWHUYLHZHG E\ VWDII VR ZKHQ WKH LQWHUYLHZV DUH FRQGXFWHG E\ VXUYH\RUV LW LV QRW D QHZ >H[SHULHQFH@ Âµ 7UDFNLQJ SURJUHVV $YDORQ KDV DOVR EHQHÃ&#x20AC;WHG VLJ QLÃ&#x20AC;FDQWO\ IURP DEDTLVÒ&#x2039; DELOLW\ WR DVVLVW ZLWK RUJDQL]DWLRQ ZLGH FRQWLQXRXV TXDOLW\ LPSURYHPHQW LQLWLDWLYHV 7KH FRPSDQ\ ZKLFK UROOHG RXW DEDTLV DV D FRUH FRP SRQHQW RI LWV FRPSUHKHQVLYH TXDOLW\ DVVXUDQFH SURJUDP UHOLHV RQ DEDTLV WR SURYLGH FOLQL FDO VHUYLFHV VWDII ZLWK WUHQGLQJ UHSRUWV WKDW LQFOXGH ULVN DVVHVV PHQWV IRU 6WDJH ,, WULJJHUV 7KLV IXQFWLRQ DOORZV VWDII WR SURDF

WLYHO\ LGHQWLI\ DUHDV LQ QHHG RI LPSURYHPHQW Â´7KH UHSRUWV JLYH XV D WDU JHWHG WUHQG DV WR WKH VRXUFH RI SUREOHPV Âµ QRWHG *UD\ ,PSURYHPHQWV LQ WKHVH WULJ JHUHG DUHDV FDQ WKHQ EH PHD VXUHG IURP RQH TXDUWHU WR WKH QH[W $YDORQÒ&#x2039;V UHJLRQDO WHDP FRRU GLQDWHV DQ DQQXDO SHHU UHYLHZ DW HDFK IDFLOLW\ LQ ZKLFK D 6WDJH ,, SURFHVV LV UXQ 7KLV SHHU UHYLHZ WKHQ OHDGV WR D VFRUH WKDW EHFRPHV SDUW RI WKH IDFLOLW\Ò&#x2039;V EDO DQFHG VFRUHFDUG Â´7KH UHVXOWV DUH XVHG WR EHQFKPDUN IDFLOLWLHV DQG KHOS WKH FRPSDQ\ LGHQWLI\ DUHDV RI QHHGHG LPSURYHPHQW 7KH DQQXDO YDOLGDWLRQ UHYLHZ UHVXOWV LQ IDFLOLW\ VSHFLÃ&#x20AC;F DFWLRQ SODQV WR DGGUHVV LGHQWLILHG DUHDV Âµ *UD\ H[SODLQHG 7R IXUWKHU PD[LPL]H WKH EHQHÃ&#x20AC;WV RI WKH DEDTLV V\VWHP

$YDORQ HQFRXUDJHV HDFK RI LWV IDFLOLWLHV WR XWLOL]H WKH HQWLUH SUR FHVV Â² LQFOXGLQJ 6WDJH ,, Â² DW OHDVW DQQXDOO\ &HUWLÃ&#x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Ã&#x20AC;GHQFH DQG DVVXUDQFH LQ NQRZLQJ WKDW LW LV SURDFWLYHO\ FDSWXULQJ GDWD WKDW ZLOO KHOS LWV PDQ\ IDFLOLWLHV SURYLGH WKH YHU\ EHVW FDUH SRVVLEOH Â´, ZRXOG QRW ZDQW WR RSHUDWH D IDFLOLW\ LQ WRGD\Ò&#x2039;V FOLPDWH ZLWKRXW DEDTLV Âµ *UD\ DGGHG Q

46 Healthy Skin

jbk_HealthySkin17.3-mag_Layout 1 2/14/11 9:58 AM Page 47

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

jbk_HealthySkin17.3-mag_Layout 1 2/14/11 9:58 AM Page 48

Reduce Survey Deficiencies with abaqis®

The only quality assessment and reporting system for nursing homes that is tied directly to the QIS In a recent survey comparing nursing homes that use abaqis and those that do not, survey deficiencies were 56% lower among abaqis users.

“

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

We use abaqis.” abaqis is an online system sold exclusively through Medline. Learn more about it when you register for a free webinar demo at www.medline.com/abaqisdemo or call Shawn Scott at 847-643-4892.

Sherri Dahle, RN, DNS Director of Nursing Central Healthcare LeCenter, MN

jbk_HealthySkin17.3-mag_Layout 1 2/14/11 9:59 AM Page 49

Special Feature

Inspiring change:

The Cozy Project makes older patients more comfortable By Tina Weitzel MA, RN-BC

Improving Quality of Care Based on CMS Guidelines 49

jbk_HealthySkin17.3-mag_Layout 1 2/14/11 9:59 AM Page 50

While Rosemary Muller, 82, was hospitalized with pneumonia, she often complained about feeling cold. One evening she told her nurse that she couldnâ&#x20AC;&#x2122;t go to sleep because she was too cold. The temperature of her room was 23[degrees] C (74[degrees] F), but Mrs. Muller was still uncomfortable, despite being covered with three blankets. In an effort to help her relax and sleep, her nurse gave her a p.r.n. sedative. During the night, Mrs. Muller woke up because she needed to urinate. Feeling light-headed and confused, she fell when she got out of bed to go to the bathroom. The Professionals Improving Care for Health System Elders (PICHE) group at our hospital recognized that being cold was a risk factor for older adults such as Mrs. Muller. We questioned why hospitalized older adults are dressed in short-sleeved, open-backed gowns that cover far less of the body than clothing worn at home. The amount and type of clothing selected by older adults may be related to changes in thermoregulation, which cause them to feel cold in an environment thatâ&#x20AC;&#x2122;s comfortable for younger people. The PICHE nurses decided to investigate.

Reading up The first step was to review the literature to better understand physiologic changes that contribute to older adults feeling cold. We discovered that their response to cold is affected by a decrease in their abilities to produce and conserve heat. Age-related changes in the temperature-regulating center in the hypothalamus as well as decreased vasoconstrictor response lead to less heat production and decreased ability to maintain body heat in cooler environments.1 Researchers compared older adults with younger adults and measured each groupâ&#x20AC;&#x2122;s response to decreases in ambient room temperature. Although core body temperature remained stable for the younger subjects, older subjects experienced progressively lower core temperatures.2 Other researchers found that increasing skin temperature as little as 0.4[degrees] C led to decreased nocturnal wakefulness.3 Hospitalized older adults are likely to have chronic illnesses that may contribute to thermoregulatory problems. Those who are malnourished will have even less subcutaneous fat, which may contribute to less ability to maintain warmth. Disorders such as hypothyroidism and hypoglycemia may affect the shivering response, and immobility associated with conditions such as stroke, arthritis, and parkinsonism may lead to decreased heat production. Continued on page 52

50 Healthy Skin

jbk_HealthySkin17.3-mag_Layout 1 2/14/11 9:59 AM Page 51

“

“Excellent. 40 FREE NAB-approved credits now available at Medline University.

Visit www.medlineuniversity.com for 24 nursing home administrator courses. Topics include: • QIS • Diabetes • Infection Control • Pressure Ulcer Prevention • Spend Management • Wound and Skin Care

www.medlineuniversity.com

Access courses on your computer, iPhone or iPad.

jbk_HealthySkin17.3-mag_Layout 1 2/14/11 9:59 AM Page 52

Medications for pain, depression, or anxiety can diminish the shivering response or act as vasodilators, further increasing discomfort in a cool environment.4 When the thermostat can’t be adjusted, older adults need extra clothing and bedcovers to trap warm air next to their body.

nurse and said they were much more comfortable. One of the patients with dementia seemed very pleased and said, “I have one just like this at home.” Patient ages ranged from 75 to 89, beds had 2 to 4 blankets, and room temperature ranged from 74[degrees] F to 77[degrees] F.

Introducing the Cozy Project

After the intervention, the nurses documented nonverbal behavior. Notes included the words smiling, quiet, and sleeping. We discovered that when the older women were offered a long-sleeved shirt, they often refused, but when we called it a long-sleeved blouse, they usually accepted the garment.

The PICHE group decided to investigate whether warmer clothes could make a difference in the comfort of our older patients, starting with donated “gently worn” long-sleeved turtleneck shirts. We decided to evaluate the effectiveness of the Cozy Project in a trial of patients with these characteristics: women age 75 and older in a medical unit who said they’re cold and uncomfortable and were observed to be restless or fidgeting. The women who met these criteria were offered a warm garment. For patients with I.V. devices, the garment was cut up the back to make it easier to get on and off and to facilitate changing the devices and dressings.

The story of one patient demonstrates the effectiveness of our project. This patient, 88, said she was cold and tired but couldn’t go to sleep. She was covered with two blankets, and her room temperature was 77[degrees] F. During the first observation period, the nurse noted that the patient constantly fidgeted. Ten minutes after the nurse helped her put on a long-sleeved turtleneck, the patient was sleeping. Continued on page 54

We decided to systematically collect data for the PICHE group to analyze. The RNs who participated and documented their observations attended a 2-hour educational session that included the opportunity to practice taking notes while watching a videotaped patient-interaction scenario. Before and after the intervention, the nurses were asked to: • describe the patient and the setting • note all actions, gestures, and nonverbal behaviors • include the room temperature and the number of blankets on the bed. When they documented the situation, the nurses were encouraged to include (in parentheses) their feelings, ideas, and impressions about what they observed. The data were reviewed by the PICHE group.

Comforting results We evaluated the results based on notes about the first five women who were identified as patients who might be more comfortable wearing a long-sleeved turtleneck. Immediately after their shirts were put on, three of the patients thanked their

52 Healthy Skin

jbk_HealthySkin17.3-mag_Layout 1 2/14/11 10:00 AM Page 53

Changing your look just got more affordable New lower prices on all your favorite brands! At www.Scrubs123.com, finding quality scrubs in a variety of brands and styles to match your individual look and professional style is as easy as 1-2-3! And now itâ&#x20AC;&#x2122;s more affordable with new lower prices and low flat rate shipping. Pay only $6.95 shipping on any size order and get FREE shipping on purchases over $99.

All Medline scrubs are 15% off when you enter promo code Healthy Skin 11 at checkout.

ÂŠ2011 Medline Industries, Inc. Medline is a registered trademark and Remedy is a trademark of Medline Industries, Inc

jbk_HealthySkin17.3-mag_Layout 1 2/14/11 10:00 AM Page 54

This project indicates that this simple intervention can improve comfort in older adults. The PICHE group decided to solicit additional donations of gently worn long-sleeved turtlenecks and expanded our project to additional units. These donated turtlenecks were laundered and then stored in a designated bin on the nursing units. Nurses could take a turtleneck and cut it as needed; for example, to accommodate any venous access devices. The garment would then be discarded when it was soiled or when the patient was discharged. We placed a collection box near the cafeteria and requested donations in the hospital newsletter. Very quickly, the collection box was filled. When supplies get low, we place another request in the hospital newsletter. We’ve had no difficulty obtaining long-sleeved turtlenecks.

In a previous study in our hospital, blankets from a blanket warmer were also found to improve the comfort level of older adults.5 The long-sleeved garments may be an additional simple intervention to enhance warmth. Florence Nightingale wrote that nurses should provide comfort through proper use of “fresh air, light, warmth, cleanliness, quiet, and the proper selection and administration of diet.”6 Making a patient comfortable has always been an integral component of nursing.

References 1. Talley HC, Talley CH. AANA Journal course. Update for nurse anesthetists. Evaluation of older adults. AANA J. 2009;77(6):451-460. 2. Degroot DW, Kenney WL. Impaired defense of core temperature in aged humans during mild cold stress. Am J Physiol Regul Integr Comp Physiol.

Understanding the implications Feeling cold may aggravate pain for those who suffer from arthritis or any other musculoskeletal illness. Patients who are recovering from surgery and report acute pain may also benefit from wearing long-sleeved garments because the warmth may decrease muscle tension.

2007;292(1):R103-R108. 3. Raymann RJ, Swaab DF, Van Someren EJ. Skin deep: enhanced sleep depth by cutaneous temperature manipulation. Brain. 2008;131(Pt 2):500-513. 4. Halter J, Ouslander J, Tinetti M, et al., eds. Hazzard'sGeriatric Medicine and Gerontology. 6th ed. Chicago, IL: McGraw-Hill; 2009. 5. Robinson S, Benton G. Warmed blankets: an intervention to promote comfort for elderly hospitalized patients. Geriatr Nurs. 2002;23(6):320-323. 6. Nightingale F. Notes on Nursing: What It Is and What It Is Not. London, England: Harrison and Sons; 1860.

Older patients may sleep better if they’re comfortably warm. Because the rooms, hallways, and diagnostic areas in the hospital are generally cool, nurses need to be sure that older adults are covered sufficiently.

54 Healthy Skin

Printed with permission from Nursing2011. 41(1):18-19.

jbk_HealthySkin17.3-mag_Layout 1 2/14/11 10:00 AM Page 55

50% less friction than the leading competitor3

Relieve Pressure on Vulnerable Heels HEELMEDIXâ&#x201E;˘ Heel Protector Pressure relief and skin protection all in one The heels are the most common site for facility-acquired pressure ulcers in long-term care, and the second most common site overall.1 According to clinical experts, the most effective aspect of pressure ulcer prevention for heels is pressure relief, also known as offloading.1,2 Offloading is achieved with the use of pillows or heel protection devices that relieve pressure by elevating the heel. The HEELMEDIX Heel Protector is designed to help eliminate pressure, friction and shear on the skin by elevating the heel. Made of soft, suede-like material on the inside and easy-to-clean nylon on the outside. Adjustable straps are soft against vulnerable skin. Includes a mesh laundry bag with patient ID label to simplify washing and sorting.

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

2 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.

ÂŠ2011 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.

2 Strapping Methods

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

jbk_HealthySkin17.3-mag_Layout 1 2/14/11 10:00 AM Page 56

Prevention

Protecting Vulnerable Heels Tips for Nursing Assistants

By Evonne Fowler, MSN, RN, CNS, CWOCN

Patients who spend long periods of time in bed can be especially susceptible to pressure ulcers and other injuries to their heels. Heel pressure ulcers are a serious health concern for patients. Besides being painful, they can possibly lead to infection, cellulitis, osteomyelitis, septicemia, limb amputation and even death. Pressure ulcers often form on the heel because: • It has a bony prominence • There are no oil glands, so the skin gets dry1 Heel pressure ulcers can also be very expensive for facilities. They’re the most common facility-acquired pressure ulcer in long-term care facilities and the second most common among all healthcare settings. And complex heel pressure ulcers are among the most costly complications for the elderly.2

56 Healthy Skin

jbk_HealthySkin17.3-mag_Layout 1 2/14/11 10:01 AM Page 57

You can help prevent heel pressure ulcers by turning patients regularly and by making sure they’re wellnourished and well-hydrated. There are also many helpful products available for heels.

Pillows The National Pressure Ulcer Advisory Panel (NPUAP) recommends the use of pillows. Pillows are an easy and cost-effective way to elevate the heels of cooperative individuals. 3 But pillows are not recommended for patients who might move the leg off the pillow or if the leg must be elevated longer than 24 hours. For these patients, it’s best to use a product that stays on the foot during movement, such as a heel offloading device, or heel boot.4 Tip: For best results, place pillows lengthwise under the calf with the heel suspended in the air.3

Moisturizers and padding devices Padding devices (sheep skin or bunny boots) and moisturizers help minimize friction and shear, but they don’t provide protection from excessive pressure.5 Tip: Look for moisturizers with nourishing topical nutrients and ingredients that add a layer of protection on top of the skin, such as dimethicone. Despite the best efforts of caregivers, some patients still experience heel pressure ulcers. When you find a heel pressure ulcer, contact your facility’s wound care or treatment nurse, as these wounds often require specialized care. Heel pressure ulcers can pose a significant threat to your patients’ health and your facility’s bottom line. However, there are steps you can take to reduce heel pressure ulcers.

Heel offloading devices Often shaped like a large boot, heel offloading devices surround the foot and ankle on all sides and leave space for needed air flow. Benefits of heel offloading devices: • Stays in place • Pressure redistribution • Friction and shear reduction • Ankle separation and protection • Foot drop prevention

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.

Tip: Remove heel offloading devices every shift and inspect the patient’s skin for redness.

Improving Quality of Care Based on CMS Guidelines 57

jbk_HealthySkin17.3-mag_Layout 1 2/14/11 10:03 AM Page 58

Special Feature

e r u s s e r P c i r t Pedia e h t n i s r e c l U s e c a l P ” t s “Dar nede by Margie Rodriguez, RN, MSN, WCC

Pediatric pressure ulcers have been somewhat overlooked by the medical community as an area of concern for patient safety. Although there is little data regarding the extent of the problem, there is anecdotal evidence that critically ill children are at greater risk for pressure ulcers than the general pediatric population. I am finding more and more that children do get pressure ulcers, and I must add — in the “darnedest” places.

Skin breakdown in children Key factors that contribute to skin breakdown in children differ from those for premature infants or adults.1 Many children in the special needs pediatric population acquire pressure ulcers that are related to the use of equipment, and it takes very little time to produce a pressure-related injury. The application of pressure on the skin of a special needs child with risk factors such as supplemental nutrition, chronic illness, limited mobility or increased mobility or incontinence is just as detrimental as it is in the geriatric population. Children with special needs often lack the ability to clearly communicate their needs, especially when it comes to identifying discomfort. If a child demonstrates any verbal or non-verbal signs or symptoms of discomfort, a head-to-toe skin assessment should be performed immediately to check for discoloration and signs of skin breakdown – likely precursors to pressure ulcers. Continued on page 60

58 Healthy Skin

jbk_HealthySkin17.3-mag_Layout 1 2/14/11 10:02 AM Page 59

SAFER CATHETERIZATION FOR KIDS Pediatric Catheter Tray

Children’s Activities

Introducing Medline’s new Pediatric Catheter Tray. The latest addition to the innovative ERASE CAUTI product line.

You trust Medline for clinical innovations, such as our industry-leading catheter tray design. Now, we can be your patient’s buddy, too.

I’

But it’s more than just fun. There’s published evidence that distraction helps children tolerate unpleasant procedures better than adult reassurance does.

ra mB v

Sometimes, you just need a buddy. Buddy the Brave lion cub is here to help your youngest catheter patients. Along with some serious patient (and parent) education resources, you’ll find some upbeat fun and even a bravery award sticker in every tray.

Bud

Bravery Sticker

To learn more about Medline’s ERASE CAUTI program and alternatives to catheterization, visit http://erasecauti.com.

jbk_HealthySkin17.3-mag_Layout 1 2/15/11 2:31 PM Page 60

A pressure ulcer is a localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction. A number of additional contributing or confounding factors are also associated with pressure ulcers; the significance of which is yet to be elucidated.2

Confounding factors A majority of the special needs population are subject to skin issues related to the use of medical devices, alternate feeding modalities, cognitive impairment (congenital or pathological), metabolic compromise, neurological deficits and chronic illness, making this population vulnerable to pressure ulcers during their childhood years and into adulthood—basically for their entire lifetime. Technological advancements in the care of critically ill infants and children has undoubtedly saved lives and greatly extended the life span among many children. However, these successes have posed unforeseen challenges as these individuals enter adulthood.3 Pressure ulcers in the pediatric special needs population and/or chronically ill child can be acquired at home, during hospitalization, or during an extended stay at a rehabilitation or long-term care facility. In my experience, children are no different from adults regarding the most common areas of the body where pressure ulcers form, such as the coccyx, sacrum, ischial tuberosities, heels, and over bony prominences, to name a few. In addition, because of children’s fragile, vulnerable, compromised and not yet matured skin, pressure ulcers also appear in the “darnedest” places and for many different reasons.

Stage III just below the occipitus/present upon admission

Unstageable (eschar) on the first digit of the foot/unknown etiology

Stage IV on the lateral side of the malleolus/status post hospitalization

Unstageable

60 Healthy Skin

jbk_HealthySkin17.3-mag_Layout 1 2/14/11 10:05 AM Page 61

The greater the neurological deficit the child presents, the more likely that signs of discomfort will be difficult for caregivers to interpret. Caregivers of children with significant neurological deficits must be sure to assess skin meticulously and use extra caution when placing equipment. The caregiver must always check, check and recheck these children’s equipment for safe placement.

Abdominal pressure ulcers Healing Stage II on the heel over calloused skin/cast

Mucosal pressure ulcers The pediatric population is not exempt when it comes to newly recognized mucosal pressure ulcers. According to the National Pressure Ulcer Advisory Panel (NPUAP) position statement,4 mucosal pressure ulcers are found on mucous membranes where a medical device has been in use. These include ulceration of the nare/septum or any mucous membrane site due to the insertion of catheters.

I have also seen in my practice that the abdomen is a common site for the development of pressure ulcers among children with special needs. For example, the gastrostomy tube when first placed, often comes with a retainer disk. The retainer disk keeps the internal balloon that forms a stoma sealed at the level of the abdomen. It is placed as close as possible to the abdomen to keep the tube in place as it forms a track and allows for healing to occur. This close placement, however, can also contribute to Stage II pressure ulcers.

NPUAP states pressure ulcers found on mucous membranes are not to be staged according to the usual pressure ulcer staging system. Although it is understood that these ulcers may indeed be due to pressure, anatomically analogous tissue comparisons cannot be made. Further, it is NPUAP’s position that mucosal pressure ulcers not be classified as partial or full thickness, because clinical assessment of the tissue does not allow for the distinction. Therefore, NPUAP’s position is to label pressure ulcers on mucous membranes as mucosal pressure ulcers without a stage identified.4 In my experience, the pediatric population is at higher risk for these types of mucosal ulcerations in part because children cannot always follow the clinician’s instructions not to touch a device. Many children instead arrange and rearrange devices for comfort or play, unaware that they could be harming themselves.

Improving Quality of Care Based on CMS Guidelines 61

jbk_HealthySkin17.3-mag_Layout 1 2/14/11 10:05 AM Page 62

Even though children can suffer from pressure ulcers, very little research is available regarding the prevalence, incidence and risk factors associated with pressure ulcers among the pediatric population.1 Despite the lack of available research, suffice it to say there is a possibility we are not reaching far enough in pursuit of this data, which encompasses not just the acute care setting but all spectrums of care. Evidencebased clinical practice guidelines for prevention and treatment of pressure ulcers specifically addressing the unique needs of the neonatal and pediatric population are needed. This population is especially deserving of the time it would require to gather such data and develop clinical practice guidelines. I know from my own clinical experience that chronically ill children and those with special needs are at risk for pressure ulcers and in fact acquire them not only in all the same areas as adults, but also in the “darnedest” places.

References 1 Suddaby EC, Barnett S, Facteau L. Skin breakdowns in acute care pediatrics. Pediatric Nursing. 2005; 31(2):132-138. 2 National Pressure Ulcer Advisory Panel (2009). Prevention of Pressure Ulcers: Quick Reference Guide. 3 Gray M. Context for WOC practice – urban myths and the randomized control trial. 2010. JWOCN; 37(6):583–585. 4 National Pressure Advisory Panel. (Dec. 2010). Mucosal Pressure Ulcers: A NPUAP Position Statement.

62 Healthy Skin

About the author

Margie Rodriguez, RN, MSN, WCC, is a wound care nurse at the Elizabeth Seton Pediatric Center, a pediatric long-term care facility for palliative, rehabilitation and longterm care services in New York City. Her accomplishments include creating a skin care program, publishing articles, and in 2010, working with NPUAP to help revise definitions for pressure ulcer staging. She is also on faculty for the Beth Israel School of Nursing. You can reach her at margie.rodriguez@setonpediatric.org.

jbk_HealthySkin17.3-mag_Layout 1 2/14/11 10:05 AM Page 63

Medline University Introduces ...

iPhone® App At home, at work or on the go… earn free CE credits It’s even easier to maintain licensure and certification and validate competencies! All Medline University courses are now available as free iPhone® and iPod touch® apps that can be downloaded from The Apple® Store. As always, you can also access courses online on your computer and download podcasts to your MP3 player. New courses and competencies are more interactive with graphics, sound and animation to make learning fun. Nurses Are Getting WIRED In a recent poll of 762 Medline customers and subscribers of The OR Connection and/or Healthy Skin magazine: • 41 percent were RNs • 10 percent own an iPhone Of those who own an iPhone: • 89 percent said they would download available content from Medline • 88 percent have downloaded content from the iTunes store • 64 percent were 40 or older • 30 percent currently use their iPhone as a reference at work

Visit www.medlineuniversity.com today and start earning CE credits* – FREE.

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

jbk_HealthySkin17.3-mag_Layout 1 2/14/11 10:05 AM Page 64

Caring for Yourself

Top Tips for Winter Skin Care You may not realize the health threats associated with the glaring sun and bitter cold air of the winter season. By itself, dry skin isn’t a medical worry, but serious cases can result in cracking, inflammation, serious burns and skin conditions such as eczema.1 If you do nothing else for your skin during the winter, be sure to protect it from the cold, dry air and moisturize as often as possible. Granted, choosing a moisturizer can be confusing. The number of choices seems endless. One reason for the development of so many moisturizers is the continuing search for a mix of ingredients that holds in water like petroleum jelly, yet allows for air circulation and feels nicer on the skin. 2 One such ingredient is dimethicone, a silicone-based substance that forms a protective layer on top of the skin while also allowing oxygen to reach the skin cells underneath. Regardless of which moisturizer you choose, almost all will help with dry skin. In most cases, the choice simply comes down to whether you like the feel and the fragrance. It’s best to apply moisturizer right after a bath or shower while your skin is still damp to help seal in your own natural moisture. References 1 Dos and don’ts for winter skin: winterize your skin. American Society for Dermatologic Surgery. Available at: www.asds.net/dosanddontsforwinterskin.aspx. Accessed January 14, 2011. 2 Tips for soothing dry winter skin. News from Harvard Health. Available at: www.health.harvard.edu/press_releases/tips-for-dry-skin. Accessed

64 Healthy Skin

more ways to keep your skin healthy: 1 Use a humidifier to put moisture back in the air. 2 Turn down the thermostat. Hot air is often very dry. 3 Bundle up with a scarf, hat and gloves to protect your face, scalp and hands from harsh winds. 4 Remember to wear sunscreen and lip balm with SPF, especially when participating in outdoor winter sports. Ultraviolet rays are still present even during the winter. 5 Avoid hot showers and baths. Hot water can strip the skin of the fatty substances (lipids) that help it retain water. 6 Skip the soap. Soaps, especially deodorant bars, can be drying and harsh. Use mild cleansers or moisturizing body washes instead. 7 Drink plenty of water. Hydrating from the inside as well as the outside helps keep your skin healthier. 8 Eat right. A balanced diet rich in vitamins and nutrients also helps promote healthy skin.

jbk_HealthySkin17.3-mag_Layout 1 2/14/11 10:05 AM Page 65

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. ÂŠ2011 Medline Industries, Inc. Medline and Medline Remedy are registered trademarks of Medline Industries, Inc.

jbk_HealthySkin17.3-mag_Layout 1 2/14/11 10:06 AM Page 66

CASE STUDY

The Use of Superabsorbent Containing Fluid Lock Dressing* in Hospice Patients INTRODUCTION

The management of exudating wounds presents challenges in the hospice environment, where the focus is on the comfort of the resident and the elevation of quality of life factors. In our practice, we have sought the use of absorbent dressings that are versatile on wound exudate, emerge at variable rates depending on the type of wound, and act as a single product across the spectrum of exudation levels. Such optimization is desirable because it allows us to focus more energy on the patient rather than on managing the choice and inventory of many different dressings for various types of wounds. We chose patients who suffered from exudating wounds, with some wounds being more exudative than others, even within the same patient. The purpose of this limited trial was to check if a new variety of superabsorbent particle containing dressings were versatile enough on this vulnerable population, and whether the dressings had any undesirable properties such as tendency to leak, or to cause discomfort during removal. This new superabsorbent dressing consists of a contact layer that has special microchannels that allow directional fluid flow, from the wound into superabsorbent particles dispersed inside an internal core layer. Laboratory data shows that these dressings, when subjected to pressure, still allow fluid absorption. Compression on the dressings leads to minimum fluid loss. These properties are thought to be significant in managing periwound maceration. Because maceration of periwound skin is a major problem in hospice patients with exudating wounds, and all too frequent dressing changes impact cost and quality of care. This trial also examined whether the new superabsorbent dressing can alleviate care and cost concerns in a hospice environment.

METHODOLOGY In this safety and effectiveness study, a convenience sample of three patients with multiple wounds were chosen. In all cases, the dressings were changed as needed based on visual observation of the dressing saturation and potential exudate overloads. More frequent change was not needed during use. CASE DETAILS AND OBSERVATIONS Case 1: DG is a 74-year-old female, admitted to our program with multiple Stage lll and lV pressure ulcers. Her terminal diagnosis is AFTT. Her albumin level was 2.4. During her hospital stay just prior to her hospice admission, lab cultures revealed MRSA in her ulcers and at one point she was treated for septicemia. Initially, while in hospice care she required dressing changes as frequently as 2 times a day for several of the pressure ulcers with foam dressings. When the new superabsorbent dressing was introduced, dressing change frequently decreased considerably. The trial with the new product was started with two of her pressure ulcers. The high capacity of the dressing contributed to our patient’s comfort by reducing occasions of dressing change, and proportionally reduced the caregiver’s time which then impacted the cost of care. Case 2: JH is a 68-year-old female who was admitted to our program with a terminal diagnosis of pancreatic cancer. She presented on admission with four ulcers, which were identified as being Pyoderma Gangrenosum in etiology. We used the superabsorbent dressing on a highly exudating wound on her right hip. The new dressing managed exudate without any maceration to periwound skin. Case 3: MKL, an 84-year-old female, was admitted to our program with a terminal diagnosis of vascular dementia. She presented with two venous leg ulcers. The foam dressings in use initially were replaced with the new superabsorbent dressing. Compared to the frequency of the foam dressing change, the number of dressing changes was greatly reduced, increasing our patient’s comfort and freeing up the caregiver to focus on patient comfort.

66 Healthy Skin

jbk_HealthySkin17.3-mag_Layout 1 2/15/11 2:27 PM Page 67

Treatment

P. Sue Hashley, RN, CWS, FACCWS St Francis Hospice Honolulu, HI

RESULTS AND CONCLUSION The use of a superabsorbent based dressing on our patients was a new and valuable experience for us. We found that the use of these products on wounds whose exudate level ranged from low (Case 2) to high (Cases 1 and 3) produced excellent results. Minimal or no periwound maceration, with no accidental strike through, and no adhesion of the dressing to the wound site was observed, even on the low exuding wound (Case 2). There was no leakage of the superabsorbent particles from the dressing into the wound during use, even when the dressing was used on the coccyx of a patient (Case 1) and the dressing was sporadically subject to the weight of the patient. Patients reported no discomfort during dressing use. Since the dressing has no observable adhesion there was also no pain reported during dressing removal. This was especially notable in the patient with Pyoderma Gangrenosum. In our view, the availability of this affordable product to potentially replace more expensive products represents a step in the right direction both in product performance, as well as in terms of reducing cost and time for care in this hospice environment. References 1. Sibbald Gary et al. The role of moisture balance in wound healing. Advances in Skin and Wound Care: 2007: 20:39-53. 2. Steinlecher E, Rohrer C, Abel M. Absorbent dressings with superabsorbent polymers â&#x20AC;&#x201C; a new generation of wound dressings. Poster 374. 18th Conference of the European Wound Management Association.

*OptiLockâ&#x201E;˘, Medline Industries, Inc. Mundelein, IL OptiLock is a trademark of Medline Industries, Inc.

Improving Quality of Care Based on CMS Guidelines 67

jbk_HealthySkin17.3-mag_Layout 1 2/14/11 10:06 AM Page 68

OPTILOCK™ Super Absorbent Wound Dressing

Gentle on wounds, tough on exudate OPTILOCK’s superabsorbent polymer core absorbs moderate to heavy exudate, locks in fluid—even under compression— and protects periwound skin from maceration. Non-adherent contact layer prevents the dressing from sticking to the wound. Gentle removal and fewer dressing changes mean greater patient comfort. To learn more or request a sample, contact your Medline representative or call 1-800-MEDLINE (1-800-633-5463).

jbk_HealthySkin17.3-mag_Layout 1 2/14/11 10:06 AM Page 69

Prevention

EASY DOES IT Safe and Effective Lifting Practices A major issue in nursing homes is the frequent lifting and repositioning of residents who exceed the lifting capacity of most caregivers. Numerous studies have shown that training caregivers how to use proper body mechanics to lift residents is not an effective prevention measure because lifting the weight of adult patients is intrinsically unsafe. Factors that contribute to the difficulty of lifting and moving a resident include the size and weight of the resident, combativeness and propensity to fall or lose balance. In addition, performing resident transfers in small bathrooms and rooms cluttered with medical equipment and furniture works against the caregiver being able to use good body mechanics. When lifting or repositioning a resident in bed, the bed generally prevents caregivers from bending their knees to assume the proper posture for lifting. The forward bending required for many patient lifting and moving activities places the caregiverâ&#x20AC;&#x2122;s spine in its most vulnerable position. Even under ideal lifting conditions, the weight of any adult far exceeds the lifting capacity of most caregivers, 90 percent of whom are female. These conditions contributed to the 211,000 occupational injuries suffered by caregivers in 2003.1 Because of the rapidly expanding elderly population in the United States, employment for nursing aides, orderlies and attendants is projected to increase by 25 percent between 2002 and 2012, adding an estimated 343,000 jobs.2 Due to the ongoing demand for skilled care services, musculoskeletal injuries to the back, shoulders and upper extremities of caregivers are expected to increase.

Improving Quality of Care Based on CMS Guidelines 69

jbk_HealthySkin17.3-mag_Layout 1 2/15/11 2:27 PM Page 70

Research has shown that safe resident lifting programs reduce resident-handling workers’ compensation injury rates by

61%

How effective is mechanical lifting equipment in preventing injuries to caregivers? Safe resident lifting programs can be highly effective in reducing a healthcare worker’s exposure to heavy loads and awkward working postures that contribute to back and other musculoskeletal injuries. Research has shown that safe resident lifting programs reduce resident-handling workers’ compensation injury rates by 61 percent, lost work day injury rates by 66 percent, restricted work days by 38 percent, and the number of workers suffering from repeat injuries.3 Similar findings have been reported by other investigators.4,5,6 Furthermore, this research has shown an increase in caregiver job satisfaction and a decrease in “unsafe” patient handling practices performed. Nurses ranked lifting equipment as the most important element in a safe lifting program.5,6 The increase in bariatric residents has also led lifting equipment manufacturers to develop equipment with higher lifting capacities to accommodate the special needs of some bariatric residents. How does lifting equipment benefit nursing home residents? Although some residents may be reluctant to try new lifting devices, the use of mechanical lifting equipment increases a resident’s comfort and feelings of security when compared to manual methods.7 The findings from one study

70 Healthy Skin

Healthy Skin

indicated that residents’ acceptance of a safe lifting program was moderate when the program was first implemented but high at the end of the research study. 5,6 Injuries to residents are also reduced because the mechanical lifts protect residents from being dropped. Anecdotal information indicates that a reduction in skin tears and bruises may result when residents are handled mechanically rather than manually.8 Does it take more time to use a mechanical lift to move a resident than to manually transfer the resident? It is quicker to manually transfer a resident. However, using a mechanical lift is much safer for the caregiver and provides a more comfortable and secure transfer for the resident. The long-term health and wellness of the caregiver will be much greater over the long term by taking a few extra minutes to lighten the daily burden of work. Much of the extra time to use a mechanical lift is spent in locating and bringing the lift to the bedside. Convenient storage and adequate numbers of mechanical lifts greatly reduce the time required to move a resident and increase staff adherence to the program. Ceiling-mounted lifts address the concern of bringing the lift to the bedside because they are conveniently stored in the resident’s room.

jbk_HealthySkin17.3-mag_Layout 1 2/15/11 2:27 PM Page 71

How can nursing home management motivate staff to use lifting equipment initially and maintain long-term commitment? • Provide sufficient training on lift usage so that caregivers learn how to properly operate the equipment. Training should be provided to all newly hired caregivers, and a plan should be in place to assess competency in use of the equipment at least annually. • Post a graph to show caregivers the decrease in injuries after the lifts are being used routinely. • Do not permit manual lifting except in life-threatening circumstances. • Include caregivers and residents in the selection of lifting equipment. • Allow caregivers the opportunity to work with different mechanical lifts. Some vendors will allow equipment to be evaluated on a short-term trial basis. • Ask maintenance and housekeeping staff to provide their opinion and input on the equipment being considered. • Ensure that all shifts are covered by an adequate number of caregivers who have been trained to use the lifts to help decrease injuries. • Follow up to check if lifting equipment is being used properly. • Keep equipment readily available and accessible. The number of lifts required will depend on the level of physical dependency among the residents. As a general rule, one full-body lift should be provided for every eight to 10 non-weight bearing residents and one stand-up lift should be provided for every eight to 10 partially weight bearing residents. • Provide back-up battery packs as needed so that lifts can be used 24 hours per day while batteries are being recharged. • Ensure that sufficient slings of the proper size are available. • Consider a single-patient-use disposable sling for each resident; reimbursement may also be available. • Store equipment in a convenient location. • Implement a routine maintenance program to ensure equipment is kept in good working order. The maintenance program should include tag-out and repair procedures for broken equipment. • Provide training to a knowledgeable person with enthusiasm and leadership capabilities on each shift to serve as a peer safety leader. A peer safety leader can provide education, bedside assessments and training/re-training on lifting equipment.

One full-body lift should be provided for every to non-weight bearing residents

8 10

Improving Quality of Care Based on CMS Guidelines 71

jbk_HealthySkin17.3-mag_Layout 1 2/14/11 10:07 AM Page 72

What kind of training is necessary to ensure all caregivers are prepared to use lifting equipment? Training should focus on how to use the lifting equipment for residents with a range of physical limitations and should include hands-on practice. Caregivers should be required to demonstrate that they are proficient in the use of the lifting equipment for residents with a range of disabilities. Training is generally provided by the lifting equipment manufacturer when equipment is purchased; however, a member of the care giving staff and/or peer safety leaders should be trained in all aspects of lifting equipment usage and should be prepared to provide periodic refresher training to newly hired and existing staff.

What approaches promote the effective implementation of a safe resident lifting program? It is important to include caregivers and staff from all departments in the program development. Keeping the staff trained and competent in the use of the mechanical lifting equipment is a key component of a successful program. Lack of compliance may result if newly hired employees do not know how to use the equipment. Adapted from “Safe Lifting and Movement of Nursing Home Residents,” Department of Health and Human Services.

Is it helpful to have a written resident lifting policy? Yes. A written policy establishes: • Manual lifting is unsafe for residents and staff and is not permitted • Minimum standards for the lifting program • The transferring needs of each resident are assessed and reassessed as a resident’s transferring needs change • The amount of lifting equipment required • Requirements to select appropriate lifting methods • Training requirements for caregivers • Responsibilities for all caregivers What if a resident refuses to be lifted by a mechanical lift? Upon admission, explain to incoming residents that your facility has a policy requiring the use of a mechanical lift for non-weight bearing residents. It should be explained that the lift is for the safety of the resident and the caregiver. If caregivers are injured, it will compromise the nursing home’s ability to provide quality care. If a resident refuses to be lifted with a mechanical lift, the caregiver, therapy staff and the social worker should spend extra time with the resident to secure their trust and to help them understand that the lifts increase resident and staff safety. The social worker, administrator, nurse manager or therapy staff can intervene with the resident’s family by explaining the benefits of lifts for the resident and the caregivers. Offer to demonstrate the lift using a family member and explain that the use of the lift will not compromise the resident’s dignity. Furthermore, the resident’s comfort and security may be improved, while reducing the risk of injury.

72 Healthy Skin

References 1. U.S. Department of Labor Bureau of Labor Statistics. Total Recordable Occupational Injury Cases in Nursing and Residential Care Facilities. 2003. Available at http://www.bls.gov/data/home.htm. Accessed January 14, 2011. 2. U.S. Department of Labor, Bureau of Labor Statistics. February 2004. Monthly Labor Review, Table 4 – Occupations with the largest job growth, 2002-2012. Available at: http://www.bls.gov/data/home.htm, http://www.bls.gov/emp. Accessed January 14, 2011. 3. Collins JW, Wolf L, Bell J, Evanoff B. An evaluation of a “best practices” musculoskeletal injury prevention program in nursing homes. Injury Prevention. 2004; 10(4):206-211. 4. Tiesman H, Nelson A, Charney W, Siddharthan K, Fragala G. effectiveness of a ceiling-mounted patient lift system in reducing occupational injuries in long term care. Journal of Healthcare Safety. 2003; 1(1):34-40. 5. Nelson A, Fragala G, Menzel N. Myths and facts about back injuries in nursing. American Journal of Nursing. 2003; 103(2):32-40. 6. Nelson A, Matz M, Chen F, Siddharthan K, Lloyd J, and Fragala G. Research report: a multifaceted ergonomics program to prevent injuries associated with patient handling tasks in the VHA. Occupational Safety and Health Administration website. 7. Zhuang Z, Stobbe TJ, Collins JW, Hsiao H, Hobbs G. Psychophysical assessment of assistive devices for transferring patients/residents. Applied Ergonomics. 2000; 31(1):35-44. 8. Garg A. Long-term effectiveness of “zero-lift program” in seven nursing homes and one hospital, Contract No. U60/CCU512089-02. 1999.

jbk_HealthySkin17.3-mag_Layout 1 2/14/11 10:07 AM Page 73

“

Oh Yeah!

“

Learning opportunities for CNAs at Medline University

Online CNA courses available at

www.medlineuniversity.com. Visit today to learn more about: • Hand hygiene • Incontinence • Skin care • Long-term care • Pressure ulcers

Access courses on your computer, iPhone or iPad.

jbk_HealthySkin17.3-mag_Layout 1 2/14/11 10:07 AM Page 74

Ventilator-associated pneumonia (VAP) is a hospital-acquired infection that occurs in up to 27 percent of all mechanically ventilated patients. 1 It is specifically defined as an airway infection that develops more than 48 hours after a patient is intubated.2

Five Step Approach for Avoiding

VAP 74 Healthy Skin

Among ICU patients, nearly 90 percent of episodes of hospital-acquired pneumonia occur during mechanical ventilation.1 Because half of all episodes of VAP occur within the first four days of mechanical ventilation, it is especially critical to prevent the condition all together.1 Reducing mortality due to ventilator-associated pneumonia requires an organized process that guarantees early recognition of pneumonia and consistent application of evidence-based practices.2 The Institute for Healthcare Improvement (IHI) advocates use of a bundle approach to help fight VAP. The ventilator bundle is a series of interventions related to ventilator care that, when implemented together, achieves significantly better outcomes.2 The five components of the (IHI) Ventilator Bundle are:2 1. Elevating the head of the bed 30 degrees 2. Daily â&#x20AC;&#x153;sedation vacationsâ&#x20AC;? and assessment of readiness to extubate 3. Peptic ulcer disease prophylaxis 4. Deep vein thrombosis prophylaxis 5. Daily oral care with chlorhexidine

References 1. Kollef MH. What is ventilator-associated pneumonia and why is it important? Respiratory Care. 2005;50(6):714-724. Available at: www.rcjournal.com/contents/06.05/06.05.0714.pdf. Accessed November 4, 2010. 2. Implement the Ventilator Bundle. Institute for Healthcare Improvement (IHI) website. Available at: www.ihi.org/IHI/Topics/CriticalCare/IntensiveCare/Changes/ImplementtheVentilatorBundle.htm. Accessed November 4, 2010.

jbk_HealthySkin17.3-mag_Layout 1 2/14/11 10:07 AM Page 75

Prevention

Tips 1. Elevating the Head of the Bed 30 Degrees • Implement a mechanism to ensure head-of-the-bed elevation, such as including this intervention on nursing flow sheets and as a topic at multidisciplinary rounds. • Create an environment where respiratory therapists work collaboratively with nursing to maintain head-of-the-bed elevation. • Involve families in the process by educating them about the importance of head-of-the-bed elevation and encourage them to notify clinical personnel when the bed does not appear to be in the proper position. • Use visual cues to easily identify when the bed is in the proper position. • Include this intervention on order sets for initiation and weaning of mechanical ventilation, delivery of tube feedings, and provision of oral care.

2. Daily “Sedation Vacations” and Assessment of Readiness to Extubate • Implement a protocol to lighten sedation daily at an appropriate time to assess for neurological readiness to extubate. Include precautions to prevent self-extubation such as increased monitoring and vigilance during the trial. • Include a “sedation vacation” strategy in your overall plan to wean the patient from the ventilator; if you have a weaning protocol, add “sedation vacation” to that strategy. • Assess that compliance daily during multidisciplinary rounds. • Consider implementation of a sedation scale (e.g., the Riker Scale) to avoid oversedation.

for Complying with the VAP Prevention Bundle

3. Peptic Ulcer Disease Prophylaxis • Include peptic ulcer disease prophylaxis as part of your ICU order admission set and ventilator order set. Make application of prophylaxis the default value on the form. • Include peptic ulcer disease prophylaxis as an item for discussion on daily multidisciplinary rounds. • Empower pharmacy to review orders for ICU patients to ensure that some form of peptic ulcer disease prophylaxis is in place at all times.

4. Deep Venous Thrombosis Prophylaxis • Include deep venous prophylaxis as part of your ICU order admission set and ventilator order set. Make application of prophylaxis the default value on the form. • Include deep venous prophylaxis as an item for discussion on daily multidisciplinary rounds. • Empower pharmacy to review orders for ICU patients to ensure that some form of deep venous prophylaxis is in place at all times.

5. Daily Oral Care with Chlorhexidine • Educate registered nurses (RNs) about the rationale supporting good oral hygiene and its potential benefit in reducing ventilator-associated pneumonia. • Develop a comprehensive oral care process that includes the use of 0.12% chlorhexidine oral rinse. • Schedule chlorhexidine as a medication, which then provides a reminder for the RN and triggers oral care process delivery. Source: www.ihi.org/IHI/Topics/CriticalCare/IntensiveCare/Changes/ImplementtheVentilatorBundle.htm

Improving Quality of Care Based on CMS Guidelines 75

jbk_HealthySkin17.3-mag_Layout 1 2/14/11 10:07 AM Page 76

Ventilator-Associated Pneumonia can be deadly. VAPrevent can be easy. Convenient, space-saving packaging

VAPrevent follows IHI Ventilator Bundle guidelines. With this checklist, you can too.

Sequential dispensing system and thumb grip for easy, one-at-a-time access â&#x20AC;&#x201D; in the right order

jbk_HealthySkin17.3-mag_Layout 1 2/14/11 10:07 AM Page 77

Evidence-based innovation in oral care for ventilator patients VAPrevent is a comprehensive system to give your staff the tools to deliver excellent oral care. And for ventilator patients, excellent oral care may be part of the difference between ventilator-associated pneumonia and staying healthy. The three parts of the VAPrevent program you’ll want to know:

Product Only Medline gives you these three options for oral care: IHI-recommended chlorhexidine gluconate (CHG), the alcohol-free moisturizing of Biotene®, or the proven antisepsis of hydrogen peroxide. Procedure kits feature innovative components, like graduated suction catheters and toothbrushes with integrated gum and tongue scrubbers. Breakthrough package design communicates and educates, all while leaving less waste behind. And the intuitive stack-pack design with its one-at-a-time dispenser makes it easy for caregivers to stay on track with care protocols.

Clear visuals let you identify the right kit quickly for your patient’s needs

Program When your staff knows how to use a product appropriately, its effectiveness increases greatly. That’s why Medline developed the Medline VAP program, which helps build knowledge and clinical skills with educational modules for both novice and experienced clinicians, as well as an online interactive competency for oral care. A program manager helps you implement your program and stays active as you progress, providing 90-day reports to help you track your incidence of VAP.

Price If you expected a VAP program this innovative would come at a price premium, you’re in for a pleasant surprise. VAPrevent from Medline comes to you for five to ten percent lower than competitors. In a tough, pay-for-performance environment, VAPrevent represents a major value.

To schedule your evaluation of the VAPrevent System, contact your Medline representative or call 1-800-MEDLINE (633-5463).

References 1 Bingham M, Ashley J, De Jong M, Swift C. Implementing a unit-level intervention to reduce the probability of ventilator-associated pneumonia. Nursing Research. 2010; 59(1): S40-S47. 2 Trouillet J, Chastre J, Vuagnat A, Joly-Guillou M, Combaux D, Dombret M, et al. Ventilator-associated pneumonia cased by potentially drug-resistant bacteria. Am J Respir Crit Care Med. 1998. 157(2):531-539. ©2011 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.

jbk_HealthySkin17.3-mag_Layout 1 2/14/11 10:08 AM Page 78

78 Healthy Skin

jbk_HealthySkin17.3-mag_Layout 1 2/14/11 10:08 AM Page 79

Caring for Yourself

8 Principles For Achieving Inner Peace by Wolf J. Rinke, PhD, RD, CSP Travel alerts, seemingly never ending natural and manmade disasters, cranky patients bugging you…stress accelerating at logarithmic speed! We certainly live in a very unsettling and stressful time. A time where achieving inner piece seems totally out of reach. And yet I have found that you can attain it by relentlessly practicing the eight principles that follow.

1. Be honest BP, politicians, clergy … do I need to say more? But before you get too smug, better look at the face in the mirror. Study after study has shown that most people lie. We inflate our resumes, fudge our accomplishments and exaggerate even inconsequential events. And when we lie there is no trust, and without trust you can’t have solid relationships, without relationships there is no love, and without love you won’t have inner peace. Call me old-fashioned; I believe there is no excuse for lying … none. There is not even a good reason for exaggerating. Because if you do, you will have to talk from the head, always checking your memory to make sure you are consistent. And who can keep track of that, when most of us have trouble remembering where we put our car keys. Only by getting in the habit of always telling the truth—especially if it is at your own expense—will you be able to talk form the heart and that will set you free. This in turn will enhance your leadership skills because people follow people they can trust. And it will put you on the fast track in any endeavor. It will also enrich your personal relationships and, most importantly, will get you to like and respect yourself—the foundation for achieving inner peace.

2. Think empowering thoughts As a man thinkest, so he becomes, says the Bible. And yet most of the time we are totally inattentive to our thoughts. It’s almost like they run amok—totally out of control—doing their own thing. To achieve inner peace requires us to first become aware of our thoughts—instead of just letting them ruminate at the subconscious level. Second we must ask ourselves: is this a thought that empowers me and makes me stronger, or does it make me feel mad, bad or sad? And third we must become aware that at any one nanosecond our minds can hold only one thought. It can be a positive thought that gives us inner peace and improves our quality of life, or it can be a negative thought that does just the opposite. It’s so simple, yet difficult, to develop this powerful new awareness and transform it into a habit.

3. Take advantage of the abundance all around you When we are struggling and having trouble making ends meet, it is really difficult to see the abundance. What we see instead—almost oppressively—is scarcity. I know firsthand. Having been born right after World War II in Germany, with my parents losing all their earthly possessions—yes, everything—we had less than scarcity, we had desperation. Finding enough food and shelter to keep us alive is what consumed my parents. Then some 17 years later—when I immigrated to the United States—scarcity, although not as extreme, reared its ugly head again. Basi-

Improving Quality of Care Based on CMS Guidelines 79

jbk_HealthySkin17.3-mag_Layout 1 2/14/11 10:08 AM Page 80

8 Principles For Achieving Inner Peace

cally I only spoke a few words of English, had $20 in my pocket and the proverbial shirt on my back. And I certainly had trouble finding all “the milk and honey” that supposedly was just waiting for me. However, it was all around me, and over time I learned to find it by internalizing a powerful concept that I learned from several different mentors: If you want more of something, you have to give it first. I know it sounds counterintuitive. (By the way, lots of things are…otherwise men would ride sidesaddle. If that didn’t at least make you smile, you’re taking this much too seriously.) Here is how it works: If you want more love in your life, give more love. If you want to be happier, make others happy. If you want people to trust you, give unconditional trust. Of course the only way you can take advantage of this principle is to internalize the next one.

4. Take really great care of #1 first Gotcha! Especially if you are a cynic. Those who are cynics immediately translate this into selfishness, conceit and greed. Nothing; however, could be further from the truth. (Why do you suppose that in an emergency, you are told to put your oxygen mask on first, before you help anyone else, even your own child?) It’s also important to remember that you can’t give away what you don’t own. Going back to the previous paragraph. If you want to love someone you must first love yourself, if you want to be happier you must choose to be happy. It you want to trust someone…I’m sure by now you’re catching on. Achieving inner peace requires you to begin to love who you are, not who you ought to be…by someone else’s standard, whether that’s your parents, spouse or friend. The unvarnished fact is that at this very nanosecond you are who you are. And no wishing, hoping or praying is going to change that one iota. Now, who you will become in the future will be determined by your thoughts (see Principle #2), which in turn will drive the actions you take.

80 Healthy Skin

So begin right now to become your own best friend, because if it is not you, who is it going to be? In addition to taking really great care of your thoughts, also take extraordinary care of your body. And if you want to avoid psychosomatic illnesses—which, as you probably know, account for the majority of illnesses in this country—then you must eat right—which means you learn to stop when it tastes the best. Get adequate rest—seven to eight hours of sleep is a great start—and do 25-30 minutes of aerobic exercise three times per week, alternating with strength training for the other three days. (Go ahead and take Sunday off.) It also means that you don’t put stuff into your body that does not belong there—read drugs and nicotine. (Please don’t yawn. This is important. You only will be given one body—a the one you’ve got is it. So treat it accordingly.)

5. Become your own creator Movie directors, such as James Cameron of Avatar, are geniuses at creating exciting “realities.” You can be your own “creator” once you realize that there is no reality. There is only perception. (No, I haven’t lost it.) Let me explain with a wonderful story: A young man was interviewing for his dream job. He had done his homework. He spent hours on the Internet learning all he could about the hospital of his choice and the people he was going to be interviewing with. He had read the last three annual reports and knew the hospital’s mission, vision and core values by heart. In short he was ready to ace this interview. On the big day, he entered the impressive lobby of the hospital and had to check in with the security guard to get his visitor badge. Wanting to leave no stone unturned he said to the elderly gentleman behind the desk, “Sir, I’m interviewing for my dream job today. Tell me about the people at this hospital. What are they like?” The elderly man replied with a question. “Tell me young man, what were the people like at the last hospital you worked for?” “Oh, they were deceitful, unsupportive and mean. There simply was no vestige of teamwork or joy. In fact that’s why I left.” “Well,” the security guard answered, “I believe you will find the same kind of people here.”

jbk_HealthySkin17.3-mag_Layout 1 2/14/11 10:08 AM Page 81

Just about an hour later the scene repeated itself all over again. Except this time it was a young lady who was also interviewing for the same job. She, too, had done her homework and wanted to make a great impression. She also asked the security guard, “What are the people like around here?” In turn, he asked, “What were they like where you came from?” The vivacious young lady answered, “Oh, I just loved the people at my former hospital. They were kind, supportive and hardworking. Everyone worked together as a team. We cared so much for each other that I developed some of the best friendships. It’s really a shame that my husband is relocating to this area. I just hate to leave all those wonderful people behind.” “Well,” the wise elderly man answered, “I believe you will find the same kind of people here.”

6. Let go of the past It’s amazing how much we mental energy we spend in a place over which we have absolutely no control—the past. It was Dr. Wayne Dyer who likened our past to a bag of manure that we carry around with us. We keep putting more and more manure into the bag. Once in a while we put the bag down, reach in and smear manure all over

us. And then, we wonder why our life stinks. Part of what we carry around in our bag is resentment, hate and blame. All of these emotions will attack our souls and diminish the quality of our spirit and our physiology. Instead, go ahead pay tribute to your past. Visit it. And then toss it in the trash. You can make that happen by taking ownership of all that is going on in your life. Your life is not a function of what other people have done to you; it is today what it is because of the choices you have made in the past. And if your feelings of resentment, hate and blame are attributed to the actions of others, then you have to wait for those people to change—which may never happen. And don’t even try to change them! Think about how many of us have difficulty changing ourselves, let alone others. Instead live by the axiom: If it is to be it is up to me. Once you’ve done that, you are ready to take it to the next level by substituting the emotions of love, empathy and kindness for resentment, hate and blame, which will put you on the fast track to inner peace. And while you are at it, force yourself to get off your case, quit living in the past, and become future-oriented by learning from every action. If an action gives you the results you desired, keep doing it. If the action did not accomplish the intended result,

Improving Quality of Care Based on CMS Guidelines 81

jbk_HealthySkin17.3-mag_Layout 1 2/14/11 10:08 AM Page 82

8 Principles For Achieving Inner Peace

review what happened; make a commitment to do it differently in the future, then quit doing it and let it go. No wait, I mean really let it go. Get on with your life by refocusing your thoughts on the only moment you and I have any control over, the now. 7. Kill your ego Ego, right along with greed and envy, is one of the most powerful destroyers of inner peace. A look at history confirms that these emotions are responsible for more evil. Think Napoleon, Stalin and Hitler—and more corporate catastrophes. Think Toyota’s and even venerable Johnson & Johnson’s recent recalls—as well as relationship killers. And yet we can get rid of our ego with just five powerful phrases expressed liberally and from the heart: • You are right about that. Any time you get into a conflict, use this phrase and you will have no more conflict— guaranteed! • I’ve made a mistake. This phrase helps you get off your high horse gracefully. All human beings make mistakes— and since you are a…I think you get it. There is only one omnipotent force in the universe—and it is not you. So quit defining unrealistic expectations for yourself. • I changed my mind. You are an evolving human being, one who is like red wine and gets better all the time. That means you have to let go of your past beliefs. (Remember that the only person who can change his/her mind is the one who has one.) • I don’t know. Admit it. You don’t know everything. It lets other people know that you have high levels of self-esteem. (Only people who are OK inside of their own skin can admit they don’t know everything.) • Let’s agree to disagree. The phrase to use if all else fails. By the way, do try all five of these at home; the positive results will astound you.

82 Healthy Skin

8. Never give up on your dreams The purpose of life is not to make it safely to the grave. Pursue your dreams no matter how late or how “weird.” Let me share an example. Doris Haddock had a passion. She felt that Congress needed to get off their duff and change the campaign finance laws! Unlike most of us; however, Doris did not sit around and complain and whine. Instead, Doris started to walk from Pasadena, Calif.; walking 10 miles a day, every day. Fourteen months and 3,200 miles later she arrived in Washington, DC. Now, here comes the startling part of the story. Doris, better known as Granny D, had a severe case of arthritis, wore a brace and turned 90 years “young” while on the trail. And for an added measure, she was arrested twice demonstrating for her beliefs. Why? Because she had a dream and a passion. So whatever you do, don’t ever give up on your dreams, it’ll make you cranky. Instead, get off your butt and act on your dreams today, and you, too, will be on the road to achieving the most coveted of all possessions—inner peace. © 2011 Wolf J. Rinke

Dr. Wolf J. Rinke, RD, CSP is a keynote speaker, seminar leader, management consultant, executive coach and editor of the free electronic newsletter Read and Grow Rich, available at www.easyCPEcredits.com. In addition he has authored numerous CDs, DVDs and books including Make It a Winning Life: Success Strategies for Life, Love and Business, Winning Management: 6 Fail-Safe Strategies for Building High-Performance Organizations and Don’t Oil the Squeaky Wheel and 19 Other Contrarian Ways to Improve Your Leadership Effectiveness; available at www.WolfRinke.com. His company also produces a wide variety of quality pre-approved continuing professional education (CPE) self-study courses, available at www.easyCPEcredits.com, including his Beat the Blues: How to Manage Stress and Balance Your Life, approved for 28 CPEUs, from which this article was extracted. Reach him at WolfRinke@aol.com.

jbk_HealthySkin17.3-mag_Layout 1 2/14/11 10:08 AM Page 83

Special Feature

PGD2

Pink Glove Dance: The Sequel From Halifax, Novia Scotia to San Francisco, California, Medline traveled across North America in 2010 showcasing the spirit of breast cancer survivors and caregivers who performed in the Pink Glove Dance: The Sequel. To see videos of Pink Glove Dancers in action visit www.pinkglovedance.com. Thank you, Pink Glove Dancers, for welcoming us to your city! • New York, NY • La Jolla, CA • Chicago, IL • Portland, OR • San Francisco, CA • New Orleans, LA • Indianapolis, IN • Denver, CO • Minneapolis, MN • Halifax, Novia Scotia • Richmond, VA • Plano, TX • Tallahassee, FL • Baltimore, MD • Newark, NJ

Pink Gloves for a Cause Our goal is to create a Pink Glove Nation – that is, get as many people as possible talking about breast cancer and to raise awareness for early detection. To that end, medline donates partial proceeds from our pink gloves and other pink ribbon products to the National Breast Cancer Foundation (NBCF) to help fund mammograms for women who cannot afford them.

Improving Quality of Care Based on CMS Guidelines 83

jbk_HealthySkin17.3-mag_Layout 1 2/14/11 10:09 AM Page 84

Pink Glove Dance: The Sequel

San Francisco Survivors at the Golden Gate Bridge. San Francisco, CA

Providence St. Vincent Medical Center. Portland, OR

University of Minnesota Medical Center, Fairview. Minneapolis, MN

84 Healthy Skin

jbk_HealthySkin17.3-mag_Layout 1 2/14/11 10:09 AM Page 85

Thibodaux Regional Medical Center. Thibodaux, LA

Burgess Square Healthcare and Rehab Centre. Westmont, IL

Isabella Geriatric Centre. New York, NY

Improving Quality of Care Based on CMS Guidelines 85

jbk_HealthySkin17.3-mag_Layout 1 2/14/11 10:09 AM Page 86

New York City Survivors at Times Square. New York, NY

Capital Health. Halifax, Nova Scotia

DID YOU KNOW? Medline has donated over half a million dollars to the National Breast Cancer Foundation (NCBF) since 2005.

Providence St. Vincent Medical Center. Portland, OR

86 Healthy Skin

jbk_HealthySkin17.3-mag_Layout 1 2/14/11 10:09 AM Page 87

And the winning pink glove ad is… Yes, They’re Genuine. Only Medline’s Pink Pearl™ gloves combine aloe, nitrile and breast cancer awareness.

Precious. And Pink.

only wear Pink Pearls.

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.

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.

The results are in! We’ve tallied your votes and compiled your thoughts about Medline’s pink gloves and the Pink Glove Dance. Thank you for your heartfelt comments and participation in last issue’s survey. Turn the page to find the winner! Improving Quality of Care Based on CMS Guidelines 87

jbk_HealthySkin17.3-mag_Layout 1 2/14/11 10:10 AM Page 88

59% Voted for Pearls! Yes, They’re Genuine. Only Medline’s Pink Pearl™ gloves combine aloe, nitrile and breast cancer awareness.

88 Healthy Skin

jbk_HealthySkin17.3-mag_Layout 1 2/14/11 10:10 AM Page 89

Pink glove survey

What our readers said:

It means unity, joy, excitement, a cause “on the go” for all involved. Shannon Sessoms, RN, BSN, CNOR Southeast Missouri Hospital Cape Girardeau, MO

The Pink Glove Dance shows how teamwork is effective whether it’s a family team or a team that helps patients with their journey. Christina Zoltowski, RN Greenville Memorial Hospital Greenville, NC

I thought it was excellent – tears to my eyes.

What does the Pink Glove Dance mean to you?

Steve Hoffarth Lake Regional Healthcare Corp. Fergus Falls, MN

It is a fun but touching video that shows the true concern healthcare workers have for people with breast cancer. Holly Creel, RN The Kirklin Clinic Warrior, AL

Improving Quality of Care Based on CMS Guidelines 89

jbk_HealthySkin17.3-mag_Layout 1 2/14/11 10:10 AM Page 90

What does the Pink Glove Dance mean to you?

Bay Radiology Associates, Panama City, FL. Pictured, left to right. Front row: Virginia Dunn, Kristie Willoughby, Janice Skipper, Linda Pitts. Back row: Marian Hamilton, Janice Mulligan, Dr. James Strohmenger, Rhonda Miller, Jennifer Valle.

We together will beat breast cancer. We are not alone. Cory Pritchett, RNC, ADON Mallard Bay Care Cambridge, MD

It is inspirational! R. Peter Rossi, RN, BS Halifax Regional Medical Center Roanoke Rapids, NC

It shows how caring healthcare workers

of ALL types are towards supporting the cause!

Those with cancer are not alone. We are out there standing beside them and showing our support. Kathleen Ingraham FirstHealth Moore Regional Hospital Pinehurst, NC

People from all different walks of life coming together for a common cause â&#x20AC;&#x201C; fighting breast cancer. Sue Montgomery, RN Foothill Presbyterian Hospital Glendora, CA

Helen Aylward, RN, BSN, L.Ac. Maine Medical Center Portland, ME

It made me cry to see the teamwork that went into making it. Iâ&#x20AC;&#x2122;m a breast cancer survivor. Carolyn Meyer, RN, BSN, CNOR St. John Medical Center Bartlesville, OK

I believe that it shows we are all in this together. Benna Coleman Covenant Hospital Levelland Levelland, TX

90 Healthy Skin

The Breast Health Center at Excela Health Westmoreland, Greensburg, PA. Pictured, left to right. Front row: Joleen Brewer, Linda White. Middle row: Candy Suarez, Nancy Pavlik, Shirley Coulson. Back row: Michelle Kelley, Cindy Clair, Margaret Clark, MD, Sue Cholock, Karen Smith.

jbk_HealthySkin17.3-mag_Layout 1 2/14/11 10:10 AM Page 91

The dance demonstrates the joy of living while increasing awareness about breast cancer. Paula Bishop, RN, MSN, CNOR Aultman Hospital Canal Fulton, OH

Lorien Health Systems Maryland Nursing care staff members boogie to the beat during the filming of the Pink Glove Dance: The Sequel.

A hospital works as a unified unit to complete its mission. Colleen Witt, RN BSN Roswell Park Cancer Institute Buffalo, NY

People getting involved to bring awareness to breast cancer. Darlene McCraney, RN South Central Regional Medical Center Laurel, MS

It energizes you and makes you want to move, especially when you see everyone working toward the same goals. Jerlene McClain, RN, BSN, MHR, CNOR Reynolds Army Community Hospital - Fort Sill Lawton, OK

Wonderful healthcare providers, not professional dancers, working hard to spread the word about breast cancer awareness. Mary Valley, RN, CNOR Frisbie Memorial Hospital Rochester, NH

Joy for cancer survivors and hope for more. Carol Athey, RN, MSN, CNOR Woodland Heights Medical Center Lufkin, TX

It makes me smile. Debra Ann Caise, RN, BSN Provena St. Maryâ&#x20AC;&#x2122;s Hospital St. Anne, IL

Improving Quality of Care Based on CMS Guidelines 91

jbk_HealthySkin17.3-mag_Layout 1 2/14/11 10:10 AM Page 92

Healthy Eating

Nutrition Information Servings: 6 Calories: 749 Fat: 19.5 g Sodium: 1427 mg Fiber: 21.8 g

Crock Pot Chili 1 lb. lean ground beef 1 lb. lean ground turkey 4 teaspoons chili powder 1 teaspoon ground cumin 1 large onion, chopped 2 jalapeno peppers, chopped

1 green pepper, chopped 4 teaspoons minced garlic 1 16-ounce can tomato sauce 1 16-ounce can diced tomatoes 1 15-ounce can chili with beans 1 6-ounce can tomato paste

Directions: Place ground beef and ground turkey in a large skillet, along with 1 teaspoon chili powder and 1 tsp. ground cumin. Cook until crumbled and brown. Drain and place in crock pot. Spray empty skillet with cooking spray. Saute onion, garlic, jalapenos and green pepper until tender. Place in crock pot. Add tomato sauce, diced tomatoes, beer, chili with beans and tomato paste. Simmer 20 minutes on high setting. Add kidney beans, chili beans, 3 teaspoons chili powder, pepper and hot sauce and simmer at least 30 minutes.

92 Healthy Skin

1 15-ounce can kidney beans 1 15-ounce can spicy chili beans 1 bottle beer 1 teaspoon black pepper (or to taste) Hot sauce to taste

recipe in Medline’s 2010 Chili Cookoff. She offers product expertise for Medline customers, sales representatives and customer service reps in the areas of diabetic testing, diagnostics, sharps containers, over-the-counter medications, enterals, oral care, ReadyBath and wet wipes. Jennifer originally found her chili recipe in one of her husband’s fitness magazines, and they have tweaked it a little over the years to get it just right. “It’s a healthier chili recipe, made with lean meat,” she said. You’ll also notice that the onions and peppers are sautéed with cooking spray rather than oil.

“I find the longer it simmers, the better the taste, so after the last round of ingredients are added, I let it simmer on low for 6 to 8 hours,” Jennifer said.

Jennifer has always enjoyed cooking, having learned by watching her mother from the age of six. Her favorite meals include seafood with lots of butter and garlic.

Senior Product Specialist Jennifer Sutschek, who has worked Medline’s corporate headquarters in Mundelein, Ill. since 1998, won second place for this

In addition to cooking, Jennifer, who lives on Illinois’ Chain O’Lakes with her husband and two children, enjoys water sports, such as boating, and in the winter months, she enjoys snowmobiling and skiing.

jbk_HealthySkin17.3-mag_Layout 1 2/14/11 10:10 AM Page 93

FORMS & TOOLS

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

Hand Hygiene WHO Glove Pyramid……………………………………….94 WHO Exam Glove Technique……………………………..95 CDC Clean Hands Poster………………………………… 96 CDC Clean Hands Poster – Spanish……………………. 97 Incontinence Urinary Incontinence Assessment and Implementation………………………………………. .99 Pressure Ulcers How Well Do You Know Pressure Points?..................... 101

Improving Quality of Care Based on CMS Guidelines 93

jbk_HealthySkin17.3-mag_Layout 1 2/14/11 10:10 AM Page 94

Forms & Tools

WHO Glove Pyramid

The Glove Pyramid â&#x20AC;&#x201C; to aid decision making on when to wear (and not wear) gloves Gloves must be worn according to STANDARD and CONTACT PRECAUTIONS. The pyramid details some clinical examples in which gloves are not indicated, and others in which examination or sterile gloves are indicated. Hand hygiene should be performed when appropriate regardless of indications for glove use.

STERILE GLOVES INDICATED Any surgical procedure; vaginal delivery; invasive radiological procedures; performing vascular access and procedures (central lines); preparing total parental nutrition and chemotherapeutic agents.

EXAMINATION GLOVES INDICATED IN CLINICAL SITUATIONS Potential for touching blood, body fluids, secretions, excretions and items visibly soiled by body fluids. DIRECT PATIENT EXPOSURE: Contact with blood; contact with mucous membrane and with non-intact skin; potential presence of highly infectious and dangerous organism; epidemic or emergency situations; IV insertion and removal; drawing blood; discontinuation of venous line; pelvic and vaginal examination; suctioning non-closed systems of endotrcheal tubes. INDIRECT PATIENT EXPOSURE: Emptying emesis basins; handling/cleaning instruments; handling waste; cleaning up spills of body fluids.

GLOVES NOT INDICATED (except for CONTACT precautions) No potential for exposure to blood or body fluids, or contaminated environment DIRECT PATIENT EXPOSURE: Taking blood pressure, temperature and pulse; performing SC and IM injections; bathing and dressing the patient; transporting patient; caring for eyes and ears (without secretions); any vascular line manipulation in absence of blood leakage. INDIRECT PATIENT EXPOSURE: Using the telephone; writing in the patient chart; giving oral medications; distributing or collecting patinet dietary trays; removing and replacing linen for patient bed; placing non-invasive ventilation equipment and oxygen cannula; moving patient furniture.

All reasonable precautions have been taken by the World Health Organization to verify the information contained in this document. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World Health Organization be liable for damages arising from its use.

94 Healthy Skin

jbk_HealthySkin17.3-mag_Layout 1 2/14/11 10:10 AM Page 95

WHOâ&#x20AC;&#x2C6;Exam Glove Technique

Forms & Tools

Technique for donning and removing non-sterile examination gloves

Improving Quality of Care Based on CMS Guidelines 95

96 Healthy Skin

Influenza

www.cdc.gov/handhygiene

Klebsiella

RSV

Enterococcus

Pseudomonas

Staphylococcus

Candida

Protect patients, protect yourself

Forms & Tools

Alcohol-rub or wash before and after EVERY contact.

CENTERS FOR DISEASE CONTROL AND PREVENTION

DEPARTMENT OF HEALTH AND HUMAN SERVICES

CLEAN HANDS SAVE LIVES

jbk_HealthySkin17.3-mag_Layout 1 2/14/11 10:36 AM Page 96

Hand Hygiene Poster

Candida

Klebsiella

www.cdc.gov/handhygiene www.cdc.gov/handhygiene

VSR

Enterococo

Pseudomonas

Estafilococo

Gripe

Proteja a los pacientes, protéjase usted

Hand Hygiene Poster - Spanish

Lávese o frótese con alcohol antes y después de CADA contacto.

CENTERS FOR DISEASE CONTROL AND PREVENTION

Departamento de Salud y Servicios Humanos

LAS MANOS LIMPIAS SALVAN VIDAS

jbk_HealthySkin17.3-mag_Layout 1 2/14/11 10:37 AM Page 97

Forms & Tools

Improving Quality of Care Based on CMS Guidelines 97

jbk_HealthySkin17.3-mag_Layout 1 2/14/11 10:11 AM Page 98

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.

ÂŠ2011 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.

jbk_HealthySkin17.3-mag_Layout 1 2/14/11 10:11 AM Page 99

Forms & Tools

Urinary Continence Assessment and Implementation Resident ______________________________________________

Room #___________

Assessed by _______________________________________________________________

Date: ___________________

Current Product Information: Size: ______ Type: ________

Frequency of Leakage: ________ times/week

1. Determine Type of Incontinence

None

See Tab 2 (Survey Readiness Resource Book)

QUESTIONS CHART

proceed to section 2 stress urge urge urge overflow overflow transient

Is the incontinence related to something other than urinary tract, such as inability to undo a zipper? . . . . . . . . . . . . . . . . . . . . . . . . . . N Does the resident have a postvoid residual greater than 200 cc? . . . . . . N Does the resident take stool softeners, antipsychotic, anticholergenic, narcotic analgesics, or other drugs that may affect continence? . . . . N

Y Y

functional overflow

further evaluation may be necessary

Female Is there presence of pelvic prolapse or other abnormal finding? . . . . . . . N Is the vaginal wall reddened and/or thin? . . . . . . . . . . . . . . . . . . . . . . . . N Is there abnormal discharge? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . N

Y Y Y

stress transient transient

Male Is the foreskin abnormal (difficult to draw back, reddened)? . . . . . . . . . . . N Is there drainage from the penis? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . N Is the urethral meatus obstructed? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . N

Y Y Y

transient transient overflow

PHYSICAL

N N N N N N N N

Y Y Y Y Y Y Y Y

Resident is continent . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Do you leak when you cough, sneeze, exercise, laugh? . . . . . . . . . . . . . Do you need to rush suddenly to toilet? . . . . . . . . . . . . . . . . . . . . . . . . . Do you sometimes not make it to the toilet? . . . . . . . . . . . . . . . . . . . . . . Do you urinate more than 7 times/day or 2 times/night? . . . . . . . . . . . . Do you have a weak stream of urine? . . . . . . . . . . . . . . . . . . . . . . . . . . . Do you have frequent dribbling? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Do you have burning or blood in urine? . . . . . . . . . . . . . . . . . . . . . . . . .

Select (circle) the type of incontinence that most fits the resident based on answers above: Urge Sudden urge, large amounts, can’t get to toilet in time

Stress Leakage when coughing, standing up, sneezing

Mixed Combination of urge and stress symptoms

Overflow Weak stream, dribbling, incomplete voiding

2. Determine Resident’s Voiding Pattern

Functional Unable to get to toilet without assistance (mobility)

Transient Temporary or recent onset, variety of causes

See Tab 3 (Survey Readiness Resource Book)

Every resident should have a completed voiding diary upon admission and with significant changes in condition. Voiding diary scheduled (date) ________________________ Did the resident have a pattern? _______

Date completed _______________________

Initials__________

For pattern, see voiding diary.

3. Evaluate for Behavioral Program

See Tab 4 (Survey Readiness Resource Book)

What is the MDS coding for item B0800 (Ability to understand others)? If 0, 1

If 2, 3

Consider MDS coding on G0110, 1-I (self performance/toileting)

Scheduled Voiding

If 0, 1, 2

If 3, 4

Bladder Rehabilitation or Pelvic Floor Rehab

Prompted Voiding

Residents with the following conditions could still benefit from participating in a prompted or scheduled voiding program: • Those who cannot feel “urge” to urinate • Agitated or disoriented residents • Bedridden residents or those with mobility limitations

Based on above, the resident may be a candidate for _______________________________________________________________________________ Resident is not a candidate for a bladder program due to: Use of appliances No bowel or bladder pattern Other ______________________

Improving Quality of Care Based on CMS Guidelines 99

jbk_HealthySkin17.3-mag_Layout 1 2/14/11 10:11 AM Page 100

Forms & Tools

Urinary Continence Assessment and Implementation

4. Determine Appropriate Absorbent Product

See Tab 5 (Survey Readiness Resource Book)

Minimum Data Set (MDS) Version 3.0 — Section H 0300 & 0400, Bladder and Bowel

Always Continent

Occasionally Incontinent

Frequently Incontinent

Always Incontinent

H0300 & H0400

Bladder—less than 7 episodes of incontinence

Bladder—7+ episodes, at least 1 episode of continence

Bladder—No episodes of continent voiding

Bowel—1 episode of incontinence

Bowel—2+ episodes, at least 1 continent bowel movement

Bowel—No episodes of continent voiding

Ambulatory Weight-bearing

Liner

Heavy Liner

Bladder Control Pad: (females without bowel incontinence episodes) Liner

Nonambulatory Contracted Chronic diarrhea Combative Low air loss mattress

Adult Brief Heavy/Overnight Brief Ultrasorbs Dry Pad

Protective Underwear

Adult Brief Ultrasorbs Dry Pad (on a low air loss mattress)

Daytime selection: _____________________________________

(on a low air loss mattress)

Overnight protection: __________________________________

5. Determine Sizing of Absorbent Product

See Tab 6 (Survey Readiness Resource Book)

Determine and document the size by selecting the larger of the hip or waist measurement, or use sizing matrix reference based on gender/weight. Gender: M F

Weight ___________________

Hip measurement ________

Waist measurement ________

ADULT BRIEF

MOLICARE BRIEF WITH STRETCH BACKING Small: Blue backing

20" – 34"

Medium/Large: White backing

27" – 47"

Large/X-Large: Blue backing

39" – 59"

Small: Green backing

20" – 31"

Medium: White backing

32" – 42"

Regular: Purple backing

40" – 50"

KNIT PANTS FOR TWO-PIECE SYSTEMS

Large: Blue backing

48" – 58"

Med/Large: Blue/Brown thread at waist

20" – 60"

X-Large: Beige backing

59" – 66"

X-Large: Green thread at waist

45" – 70"

XX-Large: Green backing

60" – 69"

XX-Large: Purple thread at waist

50" – 75"

Bariatric: Beige or Green backing

65" – 94"

XXX-Large: Red thread at waist

65" – 85"

5. Catheterization

See Tab 7 (Survey Readiness Resource Book)

Catheter — Type ____________________________________ Size: ____________________________ Medical Justifications • Urinary retention that cannot be treated medically or surgically, related to: - Post void residual volume over 200 ml - Persistent overflow incontinence - Inability to manage retention/incontinence - Symptomatic infections with intermittent catheterization - Renal dysfunction • Contamination of stage III or IV pressure ulcers with urine which impeded healing. • Terminal illness/severe impairments – which makes positing/changing uncomfortable or associated with intractable pain. ©2010 Medline Industries, Inc.

100

Healthy Skin

jbk_HealthySkin17.3-mag_Layout 1 2/15/11 2:27 PM Page 101

Forms & Tools

Pressure Point Quiz

How well do you know

Pressure Points? 6

Feel free to use this quiz for skill fairs, training and in-services.

7 1

Choose from (some may be used twice) Dorsal thoracic area Ear Elbow Foot Greater trochanter Heel Ischial tuberosity Lateral aspect of foot Lateral aspect of knee Lateral malleolus Medial malleolus Occiput Posterior knee Ribs Sacrum/Coccyx Shoulder Shoulder blade

1. _____________________

2. _____________________ 3. _____________________ 4. _____________________

5. _____________________ 6. _____________________ 7. _____________________ 8. _____________________ 9. _____________________ 10. _____________________

11. _____________________ 12. _____________________ 13. _____________________ 14. _____________________ 15. _____________________ 16. _____________________

Answer key to quiz on page 103

17. _____________________ 18. _____________________ 19. _____________________ 20. _____________________

Improving Quality of Care Based on CMS Guidelines 101

jbk_HealthySkin17.3-mag_Layout 1 2/14/11 10:11 AM Page 102

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.

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. ™

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.

JBK_CVR1_Layout 1 2/14/11 9:11 AM Page 2

Join the team!

HEALTHY SKIN

Pressure point answers From page 101

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

16. Ischial tuberosity 17. Posterior knee 18. Foot 19. Medial malleolus

20. Lateral malleolus

PERIOPERATIVE PRESSURE ULCER EDUCATION. MORE IMPORTANT THAN EVER BEFORE

“

Improving Quality of Care Based on CMS Guidelines 103

JBK_CVR_Layout 1 2/14/11 9:00 AM Page 1

VOLUME 9, ISSUE 1

Improving Quality of Care Based on CMS Guidelines

Free CE Inside!

HEALTHY SKIN

Introducing ...

THE NEW REMEDY WEBSITE www.RemedyAdvancedSkincare.com

Achieve

ZERO Pressure Ulcers

Now you and your family can enjoy professional quality Remedy skin care products at home.

Principles for Achieving Inner Peace

Order online at

www.remedyadvancedskincare.com Save 15% off your first order by using Promo Code “ISaved15” Offer expires 5/31/11.

MKT211020/LIT822/30M/JBK5

www.medline.com

Volume 9, Issue 1

Removing Stress from the QIS

LTC: HOW HEALTHCARE REFORM AFFECTS

YOU Making a Difference in Africa