Healthy Skin Volume 9 Issue 3 by Medline Industries

Improving Quality of Care Based on CMS Guidelines

Free CE Inside!

Volume 9, Issue 3

Social Networking for Nurses Reducing Unnecessary Hospital Readmissions Who Will Win the

Pink Glove Dance Competition?

Medline Blankets Keeping Newborns Covered for

50 Years

Whatâ&#x20AC;&#x2122;s New in Ostomy Care

JOIN THE TEAM!

HEALTHY SKIN When it comes to hot topics in long-term care, you’re the experts! You, our readers, are on the front lines of everything that happens in the healthcare industry – and we want to hear from you! Have you ever wished you could write an article that would be published in a large-circulation magazine? 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! Contact us at healthyskin@medline.com to learn more!

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.

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 Senior Writer Carla Esser Lake Creative Director Michael A. Gotti Clinical Team Clay Collins, BSN, RN, CWOCN, CFCN, CWS, DAPWCA

Survey Readiness Understanding the Patient-Family Experience

20 24 50 76 80

Prevention Unlikely Heroes Hospital Readmissions: Facts, Challenges and Real-Life Solutions Hospital-related Infections Drop Under California Initiative Eating & Bowel Control Joint Commission PDF Book: Preventing CAUTI

38 62 68 72

Page 6

Treatment Caring for Persons with Bariatric Health Care Issues: A Primer for the WOC Nurse Framing Expectations for Quality Continence Care in LTC Peristomal Skin Problems Are More Common Than You Think Cyanoacrylates in Neonatal and Infants Peristomal Skin Damage

Lorri Downs, BSN, RN, MS, CIC Cynthia Fleck, BSN,MBA, RN, CWS, DNC, CFCN, DAPWCA, FCCWS Joyce Norman, BSN, RN, CWOCN, DAPWCA Kim Kehoe, BSN, RN, CWOCN, DAPWCA Elizabeth O’Connell-Gifford, BSN, MBA, RN, CWOCN, DAPWCA Jackie Todd, RN, CWCN, DAPWCA Wound Care Advisory Board Christine Baker, MSN, RN, CWOCN, APN Katherine A. Beam, DNP, RN, ACNS-BC

84 86 90

Special Features Pink Glove Dance Movement National Epidermolysis Bullosa Awareness Week Experts Discuss Real Ways to Reduce Medical Errors, HACs A Flexible Approach to the ACO Model Unusual Alliance Slashes Expenses Promote Your Facility Using Facebook An Interview with Nancy Estocado, Developer of the NE1 Wound Assessment Tool Precious Moments Deb and Her Medline Friends Enter the Pink Glove Dance Competition In Celebration of Breast Cancer Awareness: Touring Art Exhibit

9 10

Regular Features Breaking News Two Important Quality Initiatives for Improving Quality of Care

52 92 98

Caring for Yourself Professional Social Networking for Nurses Time Management: How to Stretch Your Time Rubberband Recipe: Apple Crisp

6 13 14 34 47 58 74

Page 24

Page 52

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

101 104 106 107 110

Page 68

Forms & Tools My Heart Failure Knowledge Passport SBAR Communication Tool Heart Failure Care Path PUSH Tool What Should Nursing Home Residents Expect from a Continence Care Program? Page 74

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. ©2011 Medline Industries, Inc. Healthy Skin is published by Medline Industries, Inc. One Medline Place, Mundelein, IL 60060. 1-800-MEDLINE.

Improving Quality of Care Based on CMS Guidelines 3

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Healthy Skin Letter from the Editor

s you smile at the photo on the cover of this issue of Healthy Skin, I hope you’re reminded of what healthy skin can look like — before aging… exposure to the elements… illness. This cover story about Medline’s deep roots in the hospital textile industry is not just a cute story about the Kuddle Up blanket that all three of my children were wrapped in when they came home from the hospital, but hopefully a reminder of the important role you play in the continuum of care and in improving and preserving the care and comfort of the patients you serve. Your patients may not come to you as cute and unadulterated as this precious baby, but, like this baby, many come to you as innocents and all come to you needing care. In this issue, we also talk a lot about heroes. Read the inspiring stories of three unlikely heroes who turned tragedy into inspiration by becoming crusaders for the prevention of hospital associated infections and medication errors after their loved ones were harmed (page 20). Starting on page 6, I hope you’ll be as inspired as I am by reading about the thousands of heroes at nursing homes and hospitals throughout the United States and Canada who donned Medline’s Pink Gloves and shook their groove thing for a good cause. From Raleigh to Rochester, 135 organizations throughout the country participated in Medline’s Pink Glove Dance video competition to raise awareness for breast cancer. You can view the videos at www.pinkglovedance.com. We’ll feature the winning organizations in our next issue. While we hope you’ll find these stories heartwarming, you have to look no further than inside the doors of your own facility, and within your own teams, to find heroism. For the

patients you serve and the caregivers who count on you, you are the embodiment of heroism. Heroism is defined as “of distinguished courage or ability, admired for his/her brave deeds and noble qualities.” I would argue that every person working in your facility, from the CEO to the environmental services staff, is a hero. You are in the business of healing and of caring— there’s no profession more noble or courageous than that. Send me stories and photos showcasing everyday acts of heroism in your facility so we can share them in future issues. smacinnes@medline.com. Best regards,

Sue MacInnes, RD, LD Editor

Improving Quality of Care Based on CMS Guidelines 5

Special Feature

PINK

GLOVE DANCE MOVEMENT Organizations from 40 states enter national Pink Glove Dance video competition

Healthy Skin

“

I wanted you all to know- in my 20 years of mammography I have never seen such an interest in an idea for Breast Center Awareness like the Pink Glove Dance. This is amazing! You all are truly ground breakers- something no one has ever done before. I commend all of you at Medline. I am very proud to have been a part of this!” Marilu C. Kameliski B.S. RT(R)M Parkland Comprehensive Breast Center

More than 135 organizations around the country representing literally tens of thousands of people from hospitals and nursing homes to high schools, fire departments and entire communities are competing in Medline's online nationwide competition to find the best Pink Glove Dance video. The contest is running during October, Breast Cancer Awareness month. • Three winners will be named October 28, 2011 • Winners will receive a donation in their name to their favorite breast cancer charity • Watch the videos at pinkglovedance.com Here are photos and excerpts from the essays from just a few of the contestants. San Juan Medical Foundation, Farmington, NM (Top right) The Pink Glove Dance was filmed throughout our community for three weeks with our finale at the Cancer Walk-A-Thon. We came up with the idea of a “Get Pinked” pep rally, complete with a record for the Guinness Book of World Records: the most people doing the Cupid Shuffle. Thank you for the inspiration!

Westminster Village, West Lafayette, IN (Opposite) One of the most fulﬁlling outcomes in the making of this video is the team building each employee felt when the dance was over. We know and respect each other in a way never before felt among our staff. Each department wanted to participate to do their part in making a difference.

Highland Hospital, Rochester, NY At the end of this video, you’ll see our staff pinning pink ribbons on the survivors who partnered with us. Together we danced for joy, we danced for life, and we danced for the day when a cure for everyone is in our reach.

Improving Quality of Care Based on CMS Guidelines 7

“

It was a lot of fun to make the video. No matter if we win or not, it’s great awareness for Breast Cancer. Way to go!” Sarah Olafson Marketing Assistant Langlade Hospital

Oakwood Care Center, Clear Lake, IA (Two top right) As Oakwood employees learned of Medline’s “Pink Glove” opportunity to raise money for breast cancer research, the excitement of the opportunity traveled quickly throughout the facility. Oakwood employees not only excel in giving care, they welcome opportunities to help others.

Methodist Germantown Surgery Center, Germantown, TN Cancer – this six-letter word – can have such an enormous emotional impact on an individual’s life and on their family’s lives. Since I’ve chosen to view cancer and its effects as a positive experience, I’ve encouraged my coworkers and myself from Methodist Germantown Surgery Center to join me in recording the Pink Glove Dance video in an effort to raise funds and awareness for cancer research and treatment.

Cross Country Stafﬁng, Boca Raton, FL We dance to show that we will never stop until a cure is found! We dance for our mothers, our fathers, our sisters, our aunts, our brothers, and our co-workers. We dance to spread hope and show that we will never give up, ever!

Healthy Skin

BREAKING NEWS HHS launches Million Hearts campaign to prevent heart attacks, strokes The Department of Health and Human Services (HHS) has begun an initiative to prevent one million heart attacks and strokes over the next ﬁve years. The Million Hearts campaign will promote the “ABCS” of clinical prevention: • Appropriate aspirin therapy • Blood pressure control • Cholesterol control • Smoking cessation Promoting a healthy diet and physical activity are also part of the program. The HHS will target $200 million in grants to programs that support these goals. To learn more, visit http://millionhearts.hhs.gov/

Study: Hand hygiene, other practices improve mortality, costs in pediatric ICU1

Joint Commission introduces palliative care certiﬁcation program2,3

According to a three-year study recently published in the journal Health Affairs, improving hand hygiene, oral care and central-line catheter care reduced hospital-acquired infections and improved mortality while reducing costs among children admitted to a large pediatric intensive care unit. Enforcement of strict compliance with hand hygiene standards; implementing the Institute for Healthcare Improvement’s ventilator-associated pneumonia bundle, and ensuring compliance with hygiene standards for central-line catheters were attributed to the improvements. The study took place at a large multidisciplinary pediatric intensive care unit from January 2007 through December 2009. The researchers project the annual savings for the unit to be $12 million. “Used on a larger scale, these quality improvements could save lives and reduce costs for patients, hospitals, and payers around the country, provided that sustained efforts ensure compliance with new protocols and achieve long-lasting changes,” the researchers wrote.

The Joint Commission has launched a certification program to recognize hospital inpatient palliative care programs that demonstrate exceptional patient and family-centered care. Participants must have a formal palliative care program that follows evidence-based practices or guidelines and uses data for performance improvement. Standards for the program are based on the National Consensus Project’s clinical practice guidelines for palliative care and the National Quality Forum’s framework for palliative and hospice care quality. The Center to Advance Palliative Care has developed a guide to help palliative care programs complete the certification process. To download a copy, go to http://www.capc.org/ References 1. AHA News Today. September 3, 2011. Available at: http://www.ahanews.com/ahanews_app/index.jsp. Accessed September 3, 2011. 2. The Joint Commission (TJC) Advanced Certification for Palliative Care Programs. The Center to Advance Palliative Care website. Available at: http://www.capc.org/palliative-care-professional-development/Licensing/jointcommission. Accessed September 14, 2011. 3. The Joint Commission Launches Advanced Certification in Palliative Care Program. The Joint Commission website. Available at: http://www.jointcommission.org/the_joint_commission_launches_advanced_certification_in_palliative_care_program. Accessed September 14, 2011.

Improving Quality of Care Based on CMS Guidelines 9

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: Purpose:

Goal:

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 remained in effect through July, 2011. 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. In the 9th SOW, the QIO Program was 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 10th Round Statement of Work Go to https://www.fbo.gov to view the Draft Statement of Work for Quality Improvement Organizations.

Advancing Excellence in America’s Nursing Homes

Origin: Purpose:

Goal:

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

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

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

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

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

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

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

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

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

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

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

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

Goal 7 – Resident/Family Satisfaction: Almost all Nursing Homes will assess resident and family experience of care and incorporate this information into their quality improvement activities. Goal 8 – Staff Satisfaction: Almost all nursing homes will assess staff satisfaction with their work environment at least annually and upon separation and incorporate this information into their quality improvement activities. Participating nursing homes: 7,418 Percentage of participating nursing homes:* 47.3% Participating consumers: 3,056 *Based on the latest available count of Medicare/Medicaid nursing homes

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

Improving Quality of Care Based on CMS Guidelines 11

MEDLINE’S REVOLUTIONARY SHOW-AND-TELL PACKAGING

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

www.medline.com/ep Reference 1. Kent DJ. Effects of a just-in-time education intervention placed on wound dressing packages. Journal of Wound, Ostomy and Continence Nursing. 2010; 37(6):609-614. ©2011 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.

Special Feature

National Epidermolysis Bullosa (EB) Awareness Week October 25-31, 2011 Debra of America sponsors National EB Awareness Week, a time to increase awareness of EB, to promote the need for a cure, and to spur advocacy on behalf of families suffering with the emotional, ﬁnancial and physical burden of the disease. Frustrated with the lack of available medical information on the disease, Arlene Pessar, whose son was born with epidermolysis bullosa (EB), founded Debra of America in 1980. Throughout its 30 years, Debra has remained committed to funding research toward a cure, while responding to the increased need to provide direct services to patients and their families. For more information on the organization, visit www.debra.org What is epidermolysis bullosa (EB)? Epidermolysis bullosa is a group of inherited disorders in which skin blisters develop in response to minor injury. It can vary from minor blistering of the skin to a lethal form involving other organs. The condition generally starts at birth or soon after. There are four main types of epidermolysis bullosa. All types are usually inherited. Symptoms depend on the type of epidermolysis bullosa, but can include: • Alopecia (hair loss) • Blisters around the eyes and nose • Blisters in or around the mouth and throat, causing feeding problems or swallowing difﬁculty • Blisters on the skin as a result of minor injury or temperature change • Blistering that is present at birth • Dental problems such as tooth decay • Hoarse cry, cough, or other breathing problems • Milia (tiny white bumps or pimples) • Nail loss or deformed nails For heartwarming stories of love and courage, visit a mom’s blog about her twoyear-old son, Tripp, who has EB. http://randycourtneytripproth.blogspot.com/

Improving Quality of Care Based on CMS Guidelines 13

Experts Discuss Real Ways to Reduce Medical Errors, Healthcare-Acquired Conditions Chicago was the epicenter for the nation’s healthcare community, August 21-23, 201. When more than 200 healthcare leaders from around the country gathered to share ideas and learn from the country’s foremost experts on reducing medical errors and healthcare acquired conditions (HACs) at the fourth annual Prevention Above All conference. Clinical and quality leaders from hospitals, nursing homes, surgery centers and other alternate sites heard from national healthcare experts who offered insight and real-life solutions to: • Decreasing Risk by Avoiding Ineffective Practices • Implementing Innovative Practices in Preparation for Value-Based Healthcare • Identifying Important Opportunities for 2011

Couldn’t make the conference? DVD copies of all presentations are available for no charge through your Medline representative, or call 1-800-MEDLINE. For highlights from the conference, visit www.medline.com/events/prevention-above-all/events.asp

Prevention of Performance Loss Due to Lack of Coordination James Avery

MD, CMD, FACP, FCCP, FAAHPM Senior Vice President, Chief Medical Ofﬁcer, Golden Living “Nursing Homes and Hospitals: A Marriage Made in Heaven”

Mark Chassin

MD, FACP, MPP, MPH, President, The Joint Commission "High Reliability in Health Care: What is it and Why You Should Care”

Featured speakers and their topics included: Richard L. Clarke

DHA, FHFMA President and CEO, Healthcare Financial Management Association “The Value Imperative”

Prevention of Barriers to Patient-Centered Care Victoria Nahum

Co-Founder and Executive Director, Safe Care Campaign “Change One Thing, Change Everything”

Jeff Goldsmith

PhD, President, Health Futures, Inc. “Decisions on Payment Models in Value-Based Healthcare; How Accountable Care Organizations Will Impact the Future”

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Sorrel King

Author, Founder - Josie King Foundation “Josie's Story: Family-Centered Approaches to Patient Safety”

Special Feature

Clinical and quality leaders from hospitals, nursing homes, surgery centers and other alternate sites heard from national healthcare experts who offered insight and real-life solutions.

Chicago Mayor Rahm Emanuel delivers opening remarks.

“Once hospitals and nursing homes begin collaborating, quality goes up.” - James Avery

Health care is not about data or the bottom line – it’s about the patient. - Victoria Nahum

Improving Quality of Care Based on CMS Guidelines 15

Prevention of Impediments to Intervention and Integration

Prevention of Theory and Practices That Impact Innovation

Candace Smith

Trent T. Haywood

MPA, RN, NEA- BC, SVP, Chief Nursing Ofﬁcer, Clinical Program Consultant, Medline Industries, Inc. “The Patient Experience: Fundamentals from the Lens of the CMO/CNO”

MD, JD, CEO, Dichotomy Options, LLC “Social Practice: Observation for Understanding and Improving”

Panel Discussion: “Integrating Supply Chain and Clinical Leadership to Improve Outcomes”

Deborah Adler

Principal, Deborah Adler, LLC “Changing Behavior by Design”

Tom Lubotsky

Vice President Supply Chain, Clinical Resource Management, Advocate Health Care

Chris McCarthy Barbara Young

Director of Purchasing/Distribution AtlantiCare Regional Health System

Director, ILN, Innovation Specialist, IC “Kaiser Permanente's Big Idea: The Infrastructure of Design”

Implementation: Positive Outcomes in 2011 Prevention of the Lack of Accountability Carolyn M. Clancy

MD, Director, Agency for Healthcare Research and Quality (AHRQ)

Dr. Dale Bratzler

DO, MPH, University of Oklahoma Health Sciences Center College of Public Health “Healthcare-Associated Infections and Public Accountability”

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Darrell L. Dean DO, MPH, Medical Director of Performance Improvement Floyd Medical Center, Rome, GA “Getting to Zero with CAUTI Prevention”

“Innovation is not a side job.” - Chris McCarthy

“How do we design something so the end user doesn’t feel a sense of loss?” - Trent Haywood

“Design is an iterative process where mistakes have a way of leading to better solutions.” - Deborah Adler

“Respect the wisdom of the front-line caregivers.” - Jackie Medland

“There are ﬁve simple words to avoid communication errors: ‘Tell me what you heard.’” - Carolyn Clancy

Improving Quality of Care Based on CMS Guidelines 17

Experts Discuss Real Ways to Reduce Medical Errors, Healthcare-Acquired Conditions Panel: “Getting to Zero with Pressure Ulcer Prevention”

Beth L. Edwards RN, BA Clinical Quality Specialist, Jennie Edmundson Memorial Hospital, Council Bluffs, IA

Debbie Lygren RN, BS, RHIT, Nurse Consultant, Peak Resources Inc.

Jackie Medland RN, PhD, Chief Nurse Executive, Provena St. Joseph Medical Center, Joliet, IL

Martie Moore RN, BSN, MAOM, CPHQ, Chief Nursing Ofﬁcer, Providence St. Vincent Medical Center, Portland, OR “Fall Prevention Strategies That Work”

Sara Atwell RN, MHA, Chief Quality and Patient Safety Ofﬁcer Oakwood Healthcare System, Detroit, MI “Hand Hygiene; Pulling It All Together and Making It Work”

Lee Sacks, MD Executive Vice President and Chief Medical Ofﬁcer Advocate Health Care, Chicago, IL “Clinical Coordination: The Coordination of Care through Alignment of Hospitals with Physicians to Support Inpatient and Ambulatory Care”

Aron Ralston Author, Between a Rock and a Hard Place: Inspiration for the Film 127 Hours “Making Decisions in the Face of Adversity”

Visit www.medline.com/events/prevention-above-all/events.asp for video clips of conference presentations.

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Prevention

Unlikely Heroes Tragedy inspired three women to become infection prevention pioneers

Sorrel King

When a family member goes into the hospital, your expectations are that your child, husband or parent will receive excellent, safe care, recover and go home. Unfortunately, this isn’t always the case. In fact, 4,600 patients become infected each day from a healthcare complication. And 271 patients die each day as a result of a facility-acquired infection.1 Human lives are cut short because of a horriﬁc, widespread and preventable problem. The hospitals where these tragedies occur also suffer the consequences of their mistakes. Bad press and lawsuits emerge from the anger and confusion of frustrated families seeking answers. However, there’s hope in the form of three unlikely heroes: Sorrel King, Victoria Nahum and Deborah Adler. Each woman, in her own way, is pioneering patient safety efforts inspired by extremely painful personal experiences.

Sorrel King A little more than 10 years ago, Sorrel King’s daughter, Josie, was admitted to the hospital for second-degree burns she suffered from hot bath water. Two days before her scheduled return home, she died from severe dehydration and misused narcotics. Josie King was just 18 months old, and her heart stopped from an avoidable misunderstanding. Following their tragedy, Sorrel King and her husband, Tony, founded the Josie King Foundation. They began working with hospitals across the country with the goal of promoting patient safety. Sorrel King has traveled every corner of the country to create a culture of patient safety, and her innovations have redeﬁned how medical errors are prevented. Through the Josie King Foundation, she has established safety programs in hospitals, “care journals” for patients and families to record information, a research project on therapeutic writing for nurses, book clubs based on her book, Josie’s Story, and nursing awards to promote good practices.

Sorrel King and daughter, Josie

Deborah Adler

Victoria Nahum

Deborah Adler

As if one tragedy is not enough for one person to bear, Victoria Nahum saw the same misfortune play out three times. A close relative, Nahum herself, and Nahum’s son were each infected in just 10 months’ time, ending with the death of Victoria’s son, Josh. He was 27. Angered and ultimately inspired by the loss of their son, Nahum and her husband, Armando, founded the Safe Care Campaign to focus on infection prevention and identify and implement solutions to save lives. Safe Care works with hospitals to change current practices for enhanced patient safety. The initiative also works with patients to help them understand what is safe and what kinds of practices to look for.

Deborah Adler’s grandmother, Helen, accidentally swallowed her husband’s medication because she could not clearly identify her own pill bottle among the many bottles in her medicine cabinet. Fortunately, Helen was not severely harmed by the accident. At the time, Adler was persuing her Master of Fine Arts (MFA) at the School for Visual Arts in New York City. The incident inspired her to create not only a more attractive pill bottle, but a safer prescription packaging system that clearly communicates the necessary information to patients so they know exactly what they are taking. Adler’s design included color-coded labels to personalize prescriptions for each member of a household. She took her design ideas to Target, and they quickly saw the enormous beneﬁts. Her ClearRx® prescription-packaging system is now standard in Target pharmacies across the country.

Deborah Adler and grandmother, Helen

Victoria Nahum’s husband, Armando, and son, Josh

Improving Quality of Care Based on CMS Guidelines 21

These women have a message that goes beyond a lack of precision due to human error. Their message is one of caring.

These women have a message that goes beyond a lack of precision due to human error. Their message is one of caring. Their stories are exactly what anyone within the health care needs to hear because simply, they’re stories anyone can understand.

ClearRx® prescription drug packaging

“ClearRx is raising awareness in the medical community, the design community, and in popular culture,” Deborah said. “People are paying closer attention to what the patient gets at the end of the day. Throughout this process, I have learned first hand that design has the power to make a difference.” Adler also works with Medline to design packaging for its clinical products and programs to help clinicians use products correctly and reduce variance in the procedure. Specifically, she has assisted in the development of clinical programs to aid in reducing healthcare-acquired conditions, including catheter-associated urinary tract infections and ventilator-associated pneumonia. Each of these women took her heartbreak and decided to help fix a broken system. Rather than passively grieving their losses, King, Nahum and Adler are taking action. Rather than ignoring or circumventing the healthcare hierarchy, they partner with it. Rather than burying their feelings, they share their ideas in efforts to make health care as transparent as it should be. They each travel across the nation armed with their stories, their insights and their passion to fight an uphill battle against dangerous apathy.

These women weren’t activists or philanthropists before their tragedies. King and Nahum were mothers and Adler was a student. King says in her book, Josie’s Story, “I am not a doctor or a nurse and I knew absolutely nothing about the health care industry. All I knew was that Josie died from medical errors— a breakdown in the system—poor communication, and I was determined one way or another to prevent that from happening to anyone else.” These women are people who didn’t think twice about trusting their children to men and women in scrubs; they were people with tragedies that didn’t have to be. They preach the message of prevention with an empirical appeal, but they also preach (and practice) the message of getting people to care about this pervasive problem. Reminding doctors and nurses of the essence of their profession—that prevention is the best medicine, the best step towards truly improving patient safety.

Reference: 1. Infection facts you need to know. Safe Care Campaign website. Available at: www.safecarecampaign.org/Welcome.html. Accessed August 12, 2011. Clearrx® is a registered trademark used for Retail Pharmacy Services and owned by Target Brands, Inc..

Read Josie’s Story Medical errors are a leading cause of death in the United States, but the subject has long been taboo. All that changed after Sorrel King’s 18-month-old daughter, Josie, died in the hospital after a series of medical errors. Josie’s Story is an account of one woman’s unlikely path from full-time mom to nationally renowned patient advocate and an inspirational chronicle of how a mother—and her unforgettable daughter—are transforming the face of American medicine.

22 Healthy Skin

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Medline’s Pressure Ulcer Prevention Program If you are interested in:

• Average reduction in facility-acquired pressure ulcers: 70.5% • Average annual savings: $306,000

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VIEW A PRESSURE ULCER PREVENTION PROGRAM SUCCESS STORY 1

Download a QR Code Reader app

2 Launch the QR app 1. Medline Industries, Inc. Data on ﬁle.

3 Scan this QR Code or visit http://www.medline.com/ qr-code/jennie-edmundson/

Prevention

by Margaret Falconio-West, BSN, RN, APN/CNS, CWOCN, DAPWCA

According to the Medicare Payment Advisory Commission, nearly one-ďŹ fth of Medicare beneďŹ ciaries (a total of about two million) discharged from the hospital return within 30 days. The readmissions are both planned and unplanned, and they may or may not be related to the original reason the patient came to the hospital. 1 The easiest unnecessary readmissions to avoid are those that are unplanned and related to the initial admission. The reason is because they most likely involve factors that can be controlled, including better follow-up care after the patient goes home. 1

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It has been shown that reducing avoidable hospital readmissions can improve healthcare quality and lower spending, leading policymakers to begin developing ways to reduce readmissions. One way is by publicly posting data on readmissions rates. In 2009 hospitals began voluntarily reporting readmission rates for heart attack, heart failure and pneumonia to the Centers for Medicare and Medicaid Services (CMS), and those rates are publicly posted on the Hospital Compare website (http://www.hospitalcompare.hhs.gov). Beginning in 2013, CMS will penalize hospitals for high rates of readmissions.1

tions, including information about worsening symptoms, diet, drug interactions, follow-up appointments and weight monitoring. Inadequate follow-up care from post-acute and long-term care providers. These providers may send patients back to the hospital because they lack the skill or resources to provide the appropriate level of care. They may also lack sufﬁcient information about the patient’s condition, which can stem from a poor or lacking discharge summary from the hospital, as mentioned above. Family caregiving. Family members play an important role in caregiving when the patient goes home or is admitted into a post-acute or long-term care setting. One study showed that patients with greater caregiver support are at less risk for hospital readmission than those who live alone. Another study suggests less likelihood of hospital readmission when patients and their caregivers received after care training during the discharge process.

Factors that lead to readmissions for Medicare beneﬁciaries 2 Poor communication by those who plan discharges Poor patient compliance

Deterioration of the patient’s medical condition. In most cases, natural deterioration of an acutely ill or very frail elderly patient cannot be avoided, even when carefully following the treatment plan. No matter how many times these patients return to the hospital, the majority will not get better. Alternative care settings, including hospice, could reduce this kind of readmission.

Inadequate follow-up care from post- acute and long-term care providers Insufﬁcient use of support from family caregivers Deterioration of the patient’s medical condition Hospital-acquired illness or injury during an initial admission

Poor communication of medical- and care-related discharge information to patients, caregivers and/or post-acute providers: Medicare requires participating hospitals to have a discharge planning process for all patients. The plan must include an evaluation of post-acute services the patient will require, and the discharge planner must provide the patient with a list of home health agencies or skilled nursing facilities available to the patient after discharge from the hospital. Although physicians have indicated that a discharge plan should include the patient’s diagnosis, physical ﬁndings, lab and procedure results and medication; these key pieces of information are often missing from physician discharge summaries. Similarly, studies have shown that no more than one-third of physicians treating a patient after hospital discharge have a copy of the patient’s discharge summary. Poor patient compliance. It is challenging to make sure patients take their medications, keep follow-up appointments with their physicians and properly follow discharge instructions after they go home. They may not understand what they are supposed to do, or perhaps instructions are not communicated to them before they leave the hospital. For example, one study of patients with heart failure showed that only 68 percent received all discharge instruc-

Hospital-acquired illness or injury. Medical errors, particularly those related to surgery and administration of medications, often require a patient to be readmitted to the hospital to correct the mistake or treat a new condition caused by the error.

Are readmissions always a bad thing?1 Not all experts agree that readmission rates are valid measures of quality. Multiple patient characteristics and patterns of care can cloud the picture, and a review of published research shows mixed evidence connecting readmissions rates with the care patients receive during their initial hospital stay. Factors such as socioeconomic status also contribute to whether a patient will be readmitted to the hospital. And then there’s the evidence showing an inverse relationship between readmissions and mortality, which is difﬁcult to rectify. Overall, more research is required to determine all the factors that drive readmissions and to have a better understanding of when readmission is necessary and appropriate for safe patient care and when it is not.

Improving Quality of Care Based on CMS Guidelines 25

TIPS

for Reducing Unnecessary Hospital s3 Readmission

1 Dictate discharge summaries within 24 hours of discharge – not within the current standard 30 days. Information needs to be available to the patient and clinicians at the time of discharge. 2 Lengthen the handoff process by staying in communication with the skilled nursing facility or home health provider throughout the patient’s

hospital stay; and not just waiting for discharge to communicate. 3 Make sure to provide a 30day medication supply or prescription when discharging patients. Also be sure patients are able to take the medications on their own and receive recommended follow-up. 4 Make follow-up appointments with the patient’s physician and other aftercare healthcare service providers before the patient is discharged. 5 Make use of telehealth and wireless technology to monitor patients’ vital signs after discharge.

6 Research hospital records to identify those patients at greatest risk for readmission, and expend extra resources for those patients. For example, a cohort of hospitals in Los Angeles discharges homeless patients to a halfway house to ensure a safer environment as they recover. 7 Understand what happens after discharge by careful follow-up with patients and caregivers after discharge. Use your ﬁndings to streamline care by identifying cracks in the system that cause patients to return to the hospital.

8 Make sure patients understand all discharge instructions. One recommended way to accomplish this is by having the patient and his caregivers repeat back the instructions. 9 Focus efforts on helping end-of-life palliative patients put together a care plan with their healthcare provider that outlines the patient’s end-oflife wishes, avoiding painful hospital admissions for treatment the patient does not care to receive. This counseling can be provided in the emergency room to help redirect patients toward more appropriate care.

REDUCING UNNECESSARY HOSPITAL READMISSIONS AMONG CONGESTIVE HEART FAILURE PATIENTS IN MICHIGAN

“Patients who have chronic disease like heart failure are a vulnerable group. At the hospital, they receive 24-hour monitoring, so if there is any change, the doctors and nurses can respond immediately. Yet when they are discharged home, they are pretty much on their own.” -Sarwat I. Chaudhry, MD, assistant professor, Yale School of Medicine

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Burcham Hills Center for Health and Rehabilitation, East Lansing, MI. Operations director Jennifer Pruitt, of Burcham Hills Retirement Community, improved hospital readmissions among short-term rehabilitation patients with either a primary or secondary diagnosis of heart failure (HF). According a study by Jencks published in The New England Journal of Medicine in 2009, hospital readmissions among patients with HF are 26.9 percent, higher than for any other single diagnosis. 3 Pruitt began her involvement with reducing readmissions among patients with HF when Burcham Hills and 17 other facilities in the greater Lansing, MI, area were tasked with creating a system for reducing unnecessary hospitalizations among HF patients as part of their participation in the Care Transitions Program through the Centers for Medicare and Medicaid Services (CMS) and Michigan’s QIO.

In the process, the group developed a tool called “My Heart Failure Passport,” a guideline and educational resource for patients to use as they transition through various healthcare settings. The 15-page document contains areas to record the patient’s name and address and key healthcare information such as physician names and phone numbers, medications, recent hospitalizations and doctor appointments. It also includes several pages of specific instructions and education to help the patient manage his/her condition after leaving the hospital, including symptoms to watch for and circumstances when the patient needs to seek medical assistance. (For sample pages from the passport, turn to the Forms and Tools section at the back of this magazine, or download a complete copy at: www.mpro.org/HFPassport.htm. The passport is available in both English and Spanish.) Following completion of her work with the Care Transitions program, Pruitt used the passport as part of a six-month cohort she conducted at Burcham Hills. Use of the passport, along with several additional interventions outlined below, resulted in a lower (7 percent) rate of readmission among Burcham Hills patients with heart failure who participated in the study. (Baseline data from before the cohort was not collected.) The cohort focused on short stay rehabilitation patients recovering from various conditions who also had a diagnosis of HF. Participants received a thorough introduction to the heart failure passport, which included instructions on how to monitor their weight, recognize edema and take their medications appropriately. The study paid close attention to the slightest details, including making sure patients were steady enough to stand on the scale on their own. If not, modifications were made to ensure the patients’ success both at Burcham Hills and when they went home. A dietitian also met with the patients, teaching them how to read labels and cut down on sodium intake. For patients who were not capable of absorbing the education, either because of cognitive decline or feeling overwhelmed after their hospital stay, their home caregivers and/or family received instruction. Before patients went home, Burcham Hills scheduled a follow-up appointment with each patient’s primary care provider to take place within five to seven days of discharge. For those who required it, Burcham Hills also scheduled home health services to begin within 24 hours of discharge. All pertinent patient information was faxed in advance to the primary care provider and/or home health agency. Three days after discharge, Burcham Hills placed a follow-up phone call to each patient, asking how they were doing and if they had any concerns. Another called was placed 30 days after discharge to find out if the patient had been back in the hospital within that time frame.

As mentioned previously, only seven percent of the patients were re-hospitalized within 30 days after discharge from Burcham Hills. Half of the patients said they continued to use their passport, and 75 percent followed up with their primary care provider. Burcham Hills continues to record readmission data, and they have been able to maintain a low rate of readmissions for patients with HF. Next, they will begin looking at ways to reduce readmissions among patients with respiratory conditions and pneumonia. Metro Health Hospital, Wyoming, MI. 2 Within six months of beginning its CHF readmissions program, Metro Health Hospital cut its readmissions rate from 15.5 percent to 7.4 percent. The hospital used the following interventions to keep patients on the right track: 1. They established a specialized CHF unit of nurses with advanced training in CHF care. The nurses developed patient education materials outlining diet and other self care guidelines, which they review with patients during their hospital stay. 2. Secretaries on the unit schedule primary care follow up appointments for each patient before they leave the hospital, making sure to provide the primary care provider with detailed instructions about each patient. All appointments are scheduled to take place within seven days after hospital discharge. 3. Hospital case managers arrange home health services for patients requiring more intensive after care. They also follow up with every patient within 48 hours of discharge to make sure they are following discharge instructions and keep their physician appointments.

HOW WINCHESTER TERRACE NURSING HOME REDUCED HOSPITAL READMISSIONS by Casey King, LNHA, Administrator About three years ago we instituted a program to prevent rehospitalizations of our skilled patients. To do that, we had to look at all of our processes, particularly communication, which I have learned is the key to a lot of things. We discovered an issue with the way our nurses were communicating with physicians about problems that would arise with patients. It’s so easy when you’re the physician and you’re getting very little information to say, “just send the patient back to the hospital.” To counter that problem, we began working with some tools, some similar to those used by hospitals, such as the SBAR form.

Improving Quality of Care Based on CMS Guidelines 27

(See sample copy in the Forms and Tools section at the back of this issue.) We used open access materials from the Georgia’s QIO IMPACT program, which we modified for our specific purposes as a nursing home and to properly communicate to the physicians. We’ve also had to educate the physicians as to what materials and services we can offer as a nursing home to try to prevent or forestall having to send our patients to the ER. The new process has functioned tremendously well. In conjunction with the physicians who practice at our home, we have developed clinical pathways for different types of common illnesses. Are pathways are based on open access materials from the American Medical Directors Association and input from our medical director and Director of Nursing Tammy Mejia. (Turn to the Forms and Tools section at the back of this issue for a sample copy of one for Winchester Terrace’s clinical pathways.) We have trained the nurses on the pathways, and the physicians have a high level of confidence in the nurses’ ability to implement the steps. So, the confidence level in our nurses has risen, and with that, it has helped us to reduce our rehospitalizations to a very low level. We wanted to start this process a few years back when we heard that the Centers for Medicare and Medicaid Services (CMS) was going to begin reducing payments to hospitals because of nursing homes that continue to send people back rather than care for them in-house. It’s helped us, certainly, and it’s very, very beneficial to the patient who can be treated for an acute episode in their home so to speak – the nursing home where they are living – surrounded by people they know and trust. And it has certainly helped Winchester Terrace, because every time patients leave the facility, it gives them and their family an opportunity to decide to take them elsewhere. So, I think it’s a win-win for everybody.

When we were first developing our rehospitalization program, we met with the leaders at our local hospital – the chief medical officer, head of the hospitalists and ER physicians, to find out what they wanted to see in our program and to make sure they were aware of what we were doing. We emphasized that we were on the same team, working to try to help them reduce readmissions and the pending CMS penalties they will face as a hospital. It has helped us, this partnership, because we’ve begun a dialogue of sharing information and that communication didn’t really exist before we started the program and began using our data. Because we are measuring our data, the outcomes are no longer anecdotal. Rather than merely surmising that the patients are doing really well and it looks like we have a good rate, now we are using statistical analysis to determine whether we are making progress toward our goals and whether there are areas that need improvement. Our readmissions program has helped our quality improvement process tremendously, which has helped us achieve a national quality award from the American Healthcare Association. Winchester Terrace is a 100-bed skilled nursing and rehabilitative center owned by Levering Management of Mount Vernon, OH. Winchester Terrace is located in Mansfield, OH. Casey King has been with Winchester Terrace since 1998. She is responsible for overall operation of the facility, ensuring that residents receive the best possible care to help them achieve their goals. In 2009, King was named the Ohio Health Care Association’s Long Term Care Administrator of the Year, and she is responsible for spearheading the national Advancing Excellence Campaign at her facility. You may contact her at casey@leveringmanagement.com.

Winchester Terrace

Winchester Terrace Skilled Rehospitalizations per 1000 Patient Days

Total Rehospitalizations per 1000 Patient Days

Residents Hospitalized

2.5

2 1.5

1.4 1.38

1.2

0.5

January

February

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March

April

2011

2009

Residents Hospitalized

2010

2011

12 10 8 6 4 2 0

Jan Feb Mar Apr May Jun Jul Aug Sept Oct Nov Dec

HOSPITAL READMISSIONS:

CE Test

FACTS, CHALLENGES AND REAL-LIFE SOLUTIONS True/False 7. According to a 2009 study in The New England Journal of Medicine, which of the following conditions involve the greatest number of hospital readmissions?

1. T / F Data on hospital readmissions rates is publicly reported.

a. Cancer c. Pressure ulcers

2. T / F Reducing avoidable hospital readmissions has been shown to improve healthcare quality and lower spending.

b. Congestive heart failure d. None of the above

8. Which of the following tools did Winchester Terrace Nursing Home use as part of their program to prevent rehospitalizations?

3. T / F Medicare requires participating hospitals to have a discharge planning process for all patients.

a. SBAR c. Clinical pathways

4. T / F Hospital-acquired conditions often result in lower readmissions rates.

b. PUSH Tool d. Both a and c

9. When will the Center for Medicare and Medicaid Services (CMS) begin penalizing hospitals for high rates of readmissions?

5. T / F There is an inverse relationship between hospital readmissions and mortality. Multiple Choice

a. 2019 b. 2015 c. 2013 d. 2012

6. Which of the following can reduce unnecessary hospital readmissions? a. Make follow-up appointments with the patientâ&#x20AC;&#x2122;s physician before the patient is discharged b. Identify patients who are at greatest risk for readmission, and expend extra resources for those patients

10. After implementing its cohort to reduce rehospitalizations, what was Burcham Hillsâ&#x20AC;&#x2122; readmissions rate? a. 12 percent b. 5 percent c. 18 percent d. 7 percent

c. Make sure patients understand all discharge instructions d. All of the above

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

References

Winchester Terrace Skilled Rehospitalizations within 30 Days of Admission per 1000 Patient Days Residents Hospitalized

2010

2011

for better patient care. American Hospital Association. Trendwatch. September 2011.

Available

at:

http://www.aha.org/research/reports/tw/11sep-tw-

readmissions.pdf. Accessed September 15, 2011.

9.8

2. Stone J & Hoffman GJ. Medicare hospital readmissions: issues, policy options and PPACA. Congressional Research Service Report for Congress. September 21,

2010. Available at: http://www.hospitalmedicine.org/AM/pdf/advocacy/CRS_Read-

6.04

1.73

1.7

missions_Report.pdf. Accessed September 19, 2011.

5.1

4.3

4 2

1. Examining the drivers of readmissions and reducing unnecessary readmissions

3. Clark C. 12 ways to reduce hospital admissions. HealthLeaders Media. Decem-

1.7

ber 27, 2010. Available at: http://www.healthleadersmedia.com/page-5/QUA260658/12-Ways-to-Reduce-Hospital-Readmissions. Accessed: September 15,

2011.

January

February

March

April

Improving Quality of Care Based on CMS Guidelines 29

Survey Readiness

Understanding the Patient-Family Experience By Lorri A. Downs BSN, MS, RN, CIC

Patients and families expect exceptional care. Today, if your organization is not looking at the patient’s experience and finding ways to hard wire service excellence into every layer of care, your organization will certainly feel the heat. The Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) has defined this experience to include care that is patient-centered, safe, effective, timely, efficient and equitable. This is a tall order to fill especially at a time when a plethora of quality measures are exploding to maintain reimbursement. This increased attention on the patient experience has stemmed from four critical changes that have occurred in healthcare: 1. Public reporting of quality indicators allowing the consumer to compare organizations. 2. Healthcare organizations continue to have difficulty improving the patients experience and sustaining any gains they achieve. 3. Partnerships between healthcare providers and patients are slow to develop. 4. Healthcare leaders struggle to integrate the patient’s experience into the strategic work of the organization” (IHI 2011), resulting in “flavor of the month” new patient satisfaction initiatives that are not sustainable.

Why has the patient’s experience become so critical? Patients want to know that the hospital is continuously working to improve the healthcare they deliver. The foundation of risk management is really about quality, safety and great communication. Health care has been promising perfect delivery of care, and as healthcare costs rise, patients expect more for their money. Healthcare providers have not been portrayed in a positive light for many years by the media and the legal community. Patients and families hear about negative outcomes and are frightened they, too, will become a statistic contracting a hospital- acquired infection or an avoidable medical complication. So how do healthcare leaders change their organization’s culture to be patient-and family-centered? The Institute for Health Care Improvement (IHI) recently published a white paper in 2011 titled Achieving an Exceptional Patient and Family Experience of Inpatient Hospital Care. This document provides a road map for healthcare organizations, identifying the target or aim and provides primary and secondary patient experience drivers.

Continued on page 33

30 Healthy Skin

Improving Quality of Care Based on CMS Guidelines 31

HOME COMFORT GLOVE PACKAGING Where the Heart Is

Medline’s designer glove boxes feature beautiful original designs with the highest-quality printing for rich, saturated colors. Speciﬁcally designed for long-term care facilities, these eye-catching boxes enhance room décor and help patients and residents feel more at home. Medline has a long-standing reputation as an industry-leading disposable glove manufacturer. These clear, exam-grade vinyl gloves are economical, durable and 100 percent latex free!

CAST YOUR VOTE

Help us choose the next designs for our glove boxes! Scan the QR code or visit www.medline.com/decorative-box-survey to vote for the designs you like best. ©2011 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.

According to the Institute of Healthcare Improvement, the target or aim of exceptional patient and family experiences is composed of the following ﬁve primary drivers.1 1. Leadership: Governance and executive leaders demonstrate that everything in the culture is focused on patient- and family-centered care, which is practiced everywhere in the organization. 2. Hearts and Minds: The hearts and minds of staff and providers are fully engaged through respectful partnerships with everyone in the organization and in a commitment to share values of patient and family-centered care. 3. Respectful Partnership: Every care interaction is anchored in a respectful partnership, anticipating and responding to patient and family needs (e.g., physical comfort, emotional, informational, cultural, spiritual, and learning). 4. Reliable Care: Hospital systems deliver reliable, quality care 24/7. 5. Evidence-Based Care: The care team instills conﬁdence by providing collaborative, evidence-based care. The secondary drivers are the steps the organization can take to change the culture to provide an exceptional patient and family experience. Some of the many action steps recommended by the IHI are listed below.1 ➢ Healthcare team members work well together and communicate ➢ Environmental cues tell the patient that the organization cares. The physical environment is clean, orderly and comfortable. Noise levels and lighting are restful. ➢ Patients and families are treated with dignity and respect. ➢ Patients and families are part of the care team and participate in decisions. ➢ Patients know that the staff is readily available to care for them. ➢ Talent is recruited and retained at all levels of the organization. ➢ Leaders are highly visible at all levels of the organization. ➢ Outcomes are what the patient and caregivers expected with transparent feedback. For further reading on this visit www.ihi.org for a white paper published by IHI called Advancing Effective Communication, Cultural Competence, and Patient and Family-Centered Care: A Roadmap for Hospitals.

In reviewing success stories and looking at award-winning organizations (e.g., winners of the Baldrige Award), a collection of tools was used to gain insight about the customer’s perception of their experience. These high-performing organizations use a multi-strategy approach. Consider the list below, “Nine Ways to Get Closer to the Customer”:2 1. Interview them. Sit down with current, former and potential customers and ask about their requirements and expectations. 2. Survey them. Ask customers what is most important to them in addition to how satisfied they are. 3. Conduct focus groups. Pull together representatives of a specific customer segment to discuss their needs. 4. Get feedback on recent transactions. This has become an effective step in health care with the use of post-discharge phone calls. 5. Collect information from your sales and service people. Be specific about seeking information that will help identify and affirm customer requirements and expectations. 6. Ask for complaints, comments and suggestions. Communicate your desire for information and make it easy for customers to respond. 7. Form customer advisory groups. Choose eight to ten key customers to meet semi-annually to discuss your strategies, potential products, or services, industry trends—and their requirements. 8. Involve customers in your processes. Have them participate in strategic planning, product/service design, and process improvement. Invite key customers to speak to senior leaders and department heads. 9. Observe customers using your products, services and programs. This seems to be the best way to discover their unarticulated needs.” The final step is to close the loop on these information-gathering approaches by designing and refining processes to collect, analyze, validate, and then use the information gathered At the end of the day, the healthcare culture must change, placing the patient and the family at the center. Every patient every time experiences a series of processes and interactions that focus on that relationship. Everyone in the organization at every level owns the patient experience! References: 1. Balik B, Conway J, Zipperer L, Watson J. Achieving an Exceptional Patient and Family Experience of Inpatient Hospital Care. IHI Innovation Series white paper. Cambridge, Massachusetts: Institute for Healthcare Improvement; 2011. Available at http://www.ihi.org. Accessed September 7, 2011. 2. Nine Ways to Get Closer to Customers. Baldrige Award website. September 16th, 2009. Available at: http://www.baldrige.com/criteria_customerfocus/9-ways-toget-closer-to-customers. Accessed September 7, 2011.

Improving Im mprovving Quality Quali of Care Based on CMS Guidelines 33

Special Feature

A Flexible Approach

to the ACO Model Accountable care organizations (ACOs) have become a hot topic in healthcare reform over the past several months as hospitals and healthcare professionals scramble to make sense of this newly proposed care model. As one of the nationâ&#x20AC;&#x2122;s foremost health industry analysts, specializing in corporate strategy, trend analysis, health policy and emerging technologies, Jeff Goldsmith, PhD, lecturer, consultant and president of Health Futures, Inc., shares his vision of the ACO as a ďŹ&#x201A;exible partnership between health plans and providers.

Goldsmith suggests breaking the costs of health services into three categories: 1. Primary care: low-intensity health maintenance delivered by primary physicians 2. Unscheduled care: episodic diagnostic services delivered by ofďŹ ce-based physicians and unscheduled emergency services at hospitals 3. Specialty care: major clinical interventions such as comprehensive cancer care

34 Healthy Skin

The physician is leader of the medical home... Medical management and support services are provided by advanced practice nurses and nurse educators.

Primary care Goldsmith proposes that the current primary care model is no longer economically viable because the fee-based payments it relies on have not grown as quickly as practice expenses. Physicians have begun seeing more patients and increasing income by more frequent use of lab testing and imaging. As a result, primary care physicians are not spending as much time with patients, and they run the risk of recommending testing more for economic reasons than for medical ones. To avoid this, Goldsmith supports the patient-centered medical home model. The physician is leader of the medical home, and much of the contact with patients is through phone calls and email. Medical management and support services are provided by advanced practice nurses and nurse educators. The goal is to follow protocols and guidelines for how speciﬁc clinical risks should be managed. Goldsmith says “there is evidence that more effective primary care focused on the patient’s speciﬁc health risks – such as diabetes, high blood pressure, and asthma – can reduce medical expenses downstream, and that this model deserves a higher level of payment than traditional fees because it offers a wider range of services.”

Surviving and Thriving Amidst Healthcare Reform Top ﬁve tips for hospitals 1. Run lean 2. Recognize risk is here 3. The place to start with population health is inside your facility 4. Invest in physician leadership and seek consensus on the new care model 5. Markedly improve the family experience, both during and after care Jeff Goldsmith

Improving Quality of Care Based on CMS Guidelines 35

Unscheduled care Goldsmith suggests that the medical home model would minimize unscheduled care with its focus on consultation on demand through email or phone calls instead of requiring that patients address all of their medical needs through an ofﬁce visit.

Specialty care Goldsmith believes the most efﬁcient and cost-effective approach to specialty care is delivered by “groups of specialists working together as a team using a well-deﬁned model of care.” Many hospitals and health systems are already using this approach with multidisciplinary centers of excellence focused on cardiac or cancer services. Using this model, Goldsmith suggests a single, severity-adjusted payment for all pre-intervention diagnostics and testing, the intervention itself (i.e., surgery or chemotherapy) and postintervention costs for follow-up surveillance, rehabilitation and testing. The overall result is better collaboration among providers and care that is in the best interest of patients.

Jeff Goldsmith, PhD, is president of Health Futures, Inc., and an associate professor of public health sciences at the University of Virginia. During the 1990s he lectured on health services management and policy at the Graduate School of Business at the University of Chicago, the Wharton School of Finance, Johns Hopkins University, Washington University and the University of California at Berkeley. Earlier in his career he served as national advisor for healthcare for Ernst and Young, providing strategy consultation to a wide variety of healthcare systems and health plans. He earned his doctorate in sociology from the University of Chicago in 1973. His areas of interest include biotechnology, health policy, international health systems, and the future of health services. To learn more, visit his website at www.healthfutures.net.

Reference Goldsmith J. Accountable care organizations: the case for ﬂexible partnerships between health plans and providers. Health Affairs. 2011; (30)1.

Goldsmith believes the most efﬁcient and cost-effective approach to specialty care is delivered by “groups of specialists working together as a team using a welldeﬁned model of care.”

36 Healthy Skin

Quality Assurance System

Placing your residents at the center of care The abaqis Quality Assurance System is the only QA tool that exactly replicates the methods and procedures of the Quality Indicator Survey (QIS). abaqis uses the same calculations, thresholds and analysis as the QIS to quickly highlight residents at risk and provides the tools to address their needs.

The three-step abaqis process improves resident satisfaction and survey results

Step 1 Communicate – Open a dialog with your residents

Step 2 Investigate – Find root causes for problems and develop solutions

Step 3 Take action – Empower your staff, enhance care and sustain excellence Using abaqis for your quality assurance will improve quality of care and life for your nursing home residents, which in turn will also improve resident satisfaction and survey results.

Treatment

Caring for Persons With Bariatric Health Care Issues: A Primer for the WOC Nurse Introduction Obesity is the most prevalent, fatal, chronic, and relapsing disease of the 21st century.2 It is a leading cause of mortality, disability, health care utilization and health care costs in the United States. More than 97 million Americans are classified as overweight, and 60 million are categorized as obese. Taken together this cohort comprises 66% of the US adult population. Unfortunately, obesity is not isolated to adults; more than 9 million US children are also classified as obese.2

The World Health Organization Obesity Task Force classifies obesity based on the body mass index (BMI), which is a well-recognized method to assess and classify obesity. The formula used to calculate BMI is calculated by dividing a person's weight (in kilograms) by their height (in meters squared). Body mass index is also recognized by an expert panel of the National Heart, Lung, and Blood Institute of the National Institutes of Health.3 Body mass index is further categorized using an ordinal scale that varies from underweight to extreme obesity (Table 1).

38 Healthy Skin

Anne Blackett, MS, RN, CWOCN, CPHQ

Therese Henn, BSN, APRN-BC

Susan Gallagher, PhD, CBN, MA, MSN, RN WOC

Karen Lou Kennedy-Evans, RN, CS, FNP

Susan Dugan, BS, RN

Janet H. Lutze, BSN, RN, CWOCN

Judy L. Gates, MSN, RN, BC, CWS, FACCWS

Improving Quality of Care Based on CMS Guidelines 39

Table 1. Body Mass Index Weight Classes3 Category Underweight Normal weight Overweight Class I obesity Class II obesity Class III obesity (extreme) Abbreviation: BMI, body mass index.

BMI (kg/m2) <18.5 18.5-24.9 25-29.9 30-34.9 35-39.9 ≥40

Waist circumference has also been found to be a significant indicator of abdominal fat distribution, especially in the elderly, whose risk is often underestimated due to their decreased muscle mass. Waist circumference is the distance around the natural waist, just above the navel. If the BMI is more than 25, then the ideal waist circumference is less than 40 in for men or less than 35 in for women. An additional method used is the waist-to-hip ratio but is the least accurate method. A point to consider is that for those who do weight training, a higher BMI may result as they have minimal body fat. In these circumstances, skin fold thickness may provide a more realistic assessment.5 "Bariatric" is a term that is widely used and associated with the care of the obese patient. The term, created in 1965, refers to fields of medicine that identify the causes, prevention and treatment of obesity. Comorbid issues that affect those who are obese require aggressive intervention strategies and global use of this term has become common. Generally those with a BMI 30 to 39 are obese, while those with more 40 are considered morbidly obese. Candidacy for surgical intervention to normalize weight may be considered for the morbidly obese or those with a BMI more than 35 with significant comorbidities.6 The economic impact of obesity is estimated to exceed $344 billion annually.7 These rapidly rising numbers pose serious concern for the public health. Overweight and obese individuals are at increased risk for multiple comorbid conditions including type 2 diabetes mellitus, disorders of the gall bladder, osteoarthritis, hypertension, hyperlipidemia, coronary heart disease, sleep apnea, and atypical responses to various medications. 8 Historically, many barriers have contributed to failure of patients seeking or receiving help based on limitations of equipment, environment or health care provider bias.9 An unpublished survey conducted by the WOCN Bariatric Subcommittee in 2007 demonstrated that personal care, skin care complications, and infection and safety were common issues or concerns.

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Environmental and Administrative Concerns In considering care of the bariatric patient, evaluation of every phase of care must be evaluated as to efficacy, safety, economy, patient need, and patient outcome. Planning care for the bariatric patient population is associated with multiple administrative and environmental concerns. It begins with safety, both for the patient and caregiver. Assuring patient accessibility, equipment availability and proper use of the specialized equipment and ensuring sensitivity to the physical and psychosocial needs of the bariatric patient is essential.9,10 We recommend evaluating your facility's readiness to provide care for the obese patient through a survey of the facility. This survey should pay attention to the weight limits of various equipment including chairs, beds, commodes, shower seats, exam, therapy, or radiographic tables, wheel chairs, walkers, operating suite tables, and other equipment used when caring for obese or very obese patients.11,12 All equipment should be labeled in a way that renders it simple for staff to be aware of weight restrictions, while avoiding labels that stigmatize the equipment as "bariatric equipment." Subtle methods include labeling equipment with a label "EC 500" extended capacity to 500 pounds, or "U500" for equipment capable of supporting persons less than 500 lb. The survey should determine whether toilets are floor or wall mounted. Standard wall mounted toilets can be adapted to accommodate bariatric patients by using a relatively inexpensive support that is available commercially such as the Big John Toilet Seat Support manufactured by Big John Products, Canoga Park, California. Depending on the individual, standard equipment such as beds or chairs may not permit safe patient handling or comfort. Equipment designed to handle the oversize or bariatric patient has increased dimensions in width, length, and height. As part of a facility wide evaluation structural consideration should also be given to include the width of doorways, to assure larger equipment will fit into and out of the Continued on page 42

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Sensitivity to the special needs of bariatric patients should be given priority. Obese people often face humiliation or embarrassment because of their size, often causing them to delay seeking health care, sometimes with devastating consequences.

room. Patient rooms should be adapted to enable obese patients to ambulate through doorways with a wider walker, and with a health care professional on either side for stability.13 The facility survey should determine the width, length, and weight limits of elevators used for patient transport. Larger sized personal items such as gowns, robes, slippers, identiﬁcation bands, blood pressure cuffs, antiembolus stockings, sequential compression devices, and even gait belts need to be available for patients so that they can be cared for with dignity and safety.14,15 Just as we would not put a standard sized gown on a pediatric patient, it is not acceptable to snap together 2 standard gowns to ﬁt around an obese patient.16 The evaluation should address caregiver safety, and especially prevention of back injuries.17 A shortage of nursing personnel will be paradoxically exacerbated rather than alleviated if staff is injured while caring for obese patients. Some health care workers are reluctant to care for bariatric patients in part because of concerns for their own safety.18 Equipment is available to protect caregivers and must be utilized in all areas of health care in order to provide dignity and remove this negative association with larger patients.19,20 Air transfer lifts, motorized carts and beds, and lift teams add to overhead costs of caring for patients, but in the long run are less expensive than caregiver or patient injury.

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Consistent use of lift or transfer equipment in providing care to bariatric patients can enhance the safety of patients and staff within the facility.21 The National Institute of Health has completed extensive analysis of data related to work-related injuries and found evidence that injuries result from cumulative damage from repeated patient handling situations. More than 30 years of data analysis confirm that body mechanics alone are not adequate to prevent injury. Appropriate lift equipment and protocols for use are the only confirmed method for reducing staff injuries during patient movement activities.22 Staffing is typically determined by use of acuity software or programs, but these systems do not take into consideration the care needs of the bariatric population. Inclusion of mobility and BMI are key factors in determining adequate staff ratios to provide care requiring additional staff presence and/or time. For the bariatric patient with impaired mobility, extra staff and environmental support are required to complete most tasks including dressing changes, patient transfers, daily hygiene, or procedural interventions.23 Sensitivity to the special needs of bariatric patients should be given priority.24 Obese people often face humiliation or embarrassment because of their size, often causing them to delay seeking health care, sometimes with devastating consequences.25 Many patients fear they will break equipment,

inconvenience staff, or ask embarrassing questions about their care. In extreme cases patients are taken to loading docks or laundry rooms to be weighed on commercial scales, or have not received procedures due to inadequate equipment options. Some express they are often ignored altogether, are blamed for their obesity, treated as if they do not exist, or because of other's discomfort with their size. Ongoing sensitivity training for all personnel in a health care facility should be provided. These programs not only foster a more accepting environment but can greatly improve the patient experience.9

Skin Fold Management The problem with skin folds is the "skin to skin" contact. One layer of skin resting on or against another layer of skin creates a warm, moist, and dark environment that can become a potential area for skin breakdown, skin to skin friction and shear, maceration, irritation, skin tears, rashes, candidiasis, viral or bacterial infection, and potential pressure ulcer areas. If the skin is open, delay in wound healing can be exacerbated by the negative effects of poor tissue perfusion, tension to at wound edges from weight or pressure, inadequate oxygenation, poor nutrition and other comorbidities.29,30

Obesity and the Skin The skin is a highly complex structure and functions as a barrier, as a communication modality, and as a sensory, thermoregulatory, and an elimination organ. It also produces vitamin D. Loss of skin integrity can mean the threat of infection, pain, increased odor, loss of independence or selfesteem. Experts suggest skin injuries among larger, heavier individuals typically manifest as intertrigonous dermatitis, pressure ulcers, candidiasis, incontinence-associated dermatitis, and lower leg ulcers to name a few.26

The most common or problematic area is the abdominal pannus, the excess fold or "apron" of skin that hangs dependently. A grading scale exists to describe the extent of this redundant skin fold3

Only recently has research focused on correlation of obesity and skin disorders. One study looked at 60 patients to measure transepidermal water loss. The results demonstrated that speciﬁc dermatoses such as skin tags, striae distensae, and plantar hyperkeratosis could be considered as a cutaneous stigma of severe obesity. The low permeability of the skin to evaporative water loss is observed in obese subjects compared with those of normal weight.27 This recent body of work would beneﬁt from further research. Bathing General hygiene is critical to maintaining skin integrity and minimizing skin injury and odor control with attention given to general bathing and cleansing of areas susceptible to breakdown including skin folds, genital or perinea area, and toileting. Bathing poses unique challenges such as access to bathing facilities and access to all body surfaces, including skin folds.28 No-step entry or walk-in showers are ideal for bariatric individuals in health care facilities. The shower should be equipped with a hand-held shower head and a shower chair for patients with compromised endurance. A long-handled, soft-bristle shower brush permits the bariatric patient to reach not only their back but the underside of the pannus, buttocks, lower legs and feet. Inspection of all skin folds should be done during bathing to determine skin care needs or considerations for management. Patient education should include general skin care strategies to prevent or minimize risk for injury.28

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Grading Scale for Abdominal Pannus3 Grade

1 2 3 4 5

Description

Covers the pubic hairline but not the entire mons pubis Extends to cover the entire mons pubis Extends to cover the upper thigh Extends to midthigh Extends to the knee and beyond

While this area may be a preliminary focus, attention must also be given to other areas of the body including neck, upper back, ﬂank, upper-medial thigh, and posterior legs and ankles. Patient education has become an important focus with skin fold management. Patients often use a number of effective, ineffective, or sometimes even harmful strategies at home. Management strategies in the acute care setting must focus on elimination of skin-to-skin contact without causing harm to friable tissue. Close monitoring is important to determine the outcome of intervention.30 Patients report use of cloth, tissue, pads, powders and more. A common home remedy is cornstarch-based powder, which is a carbohydrate, therefore potentially incubates yeast. This serves as one example of a commonly used product that has been determined to be harmful in the management of skin folds.28 When dealing with pendulous tissue compounded with larger areas of skin-to-skin contact, injuries in the form of skin tears, lacerations, abrasions or ulcerations can occur due to the combined forces of gravity, torsion, and a larger mass in motion. These injuries, particularly the intertrigal ﬁs-

Improving Quality of Care Based on CMS Guidelines 43

sures can be several centimeters long and sometimes only a millimeter or 2 wide but can produce a disproportionate amount of pain.31 They often are similar to long paper cuts or splits in the dermis. Nurses must remain vigilant during repositioning and shifting efforts to avoid creating or exacerbating these conditions.32 A number of strategies exist to manage skin folds.

ted textiles impregnated with antimicrobial silver complex can be placed in skin folds to manage odor, decrease bacterial load and translocate (wick) the moisture. Interdry Ag manufactured by Coloplast, Minneapolis, Minnesota, is an example of this type of intervention with clinical evidence demonstrating the reduction of moisture, odor, and an improvement of symptoms related to moisture/friction/infected skin conditions.3,29,30

Skin Fold Management • Seek patient’s input. A person of size has had a vast amount of experience in dealing with their issues. Many patients are willing to share with you tips on how to avoid unnecessary trauma during their care. • Proceed with caution, move slowly and with sufﬁcient numbers of trained staff members to avoid both/either caregiver or patient injury. • Use moisturizers to keep skin supple; if at risk for cracking/ﬁssuring due to excessive dryness. • Use absorptive fabric to manage moisture issues. • Use towels, draw sheets or manufactured sling devices, if needed, to lift or shift large areas of adipose tissue, legs, arms, etc., in order to minimize discomfort, tissue friction/drag or pain Genital Care Both men and women experience challenges in genital or perineal care. Women face challenges in general and when menstruating. Men can be at risk for Fournier's gangrene, caused by yeast as well as bacteria of the skin and intestine.33 Moisture and toileting also pose challenges. The presence of a large abdominal panniculus or skin folds can further aggravate problems. Although a number of management options exist, little research is available to drive evidence-based practice. Perhaps, the most important factor is communication, which includes setting the tone for the patient/client: nurse relationship in such a way as to promote open dialogue about one's most private issues. This may be at the center or heart for guiding patients in successful, sensitive, and meaningful care.28 Odor Control Odor can be devastating for the bariatric patient, their family members and friends, as well as nursing staff members. While other issues may be equally challenging, when odor is present it may cause embarrassment and humiliation. Odor may be caused by a number of factors, particularly by the skin-on-skin factor. The direct skin surface contact harbors moisture, increases growth of bacteria or yeast resulting in odor because of a high bacterial/fungal load. Initial changes must be to the hygiene and daily care of at risk folds, surfaces. Products to manage moisture and odor such as knit-

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Toileting Speciﬁc concerns for the bariatric person include access to adequate facilities, limited reach for post evacuation cleansing, and alterations due to weight compression of local tissues causing sphincter dysfunction resulting in various levels of urgency and incontinence. These issues are exacerbated when the person is hospitalized. In order to maintain dignity when performing toileting activities, appropriate adaptation of the care environment must incorporate a toilet riser with handrails for support or a bariatric commode. Instead of standard toilet tissue, washcloths or premoistened moisturizing wipes may better serve to clean and protect vulnerable skin. Occupational therapy consultation should be considered to help the patient locate or design a tool to reach the areas that require cleansing. An example would be the use of a female urinal to collect urine and prevent it spilling onto the skin. Home health medical supply Web sites or stores are excellent resources for equipment. Conclusion As the number of individuals who are obese increases, health care facilities, whether acute, post or subacute, and long-term care environments alike, must increase their sophistication in providing safe, effective and sensitive care for this special needs patient group. The WOC nurse has considerable expertise needed to address the environmental, administrative, skin care and continence needs of these patients. This article provides basic information intended to act as a starting point for the WOC nurse to better understand the unique challenges of caring for bariatric patients and to translate this knowledge into improvements in the patient care process. Resources American Obesity Association: http://www.obesity.org American Society of Bariatric Physicians: http://www.asbp.org/ American Society of Metabolic and Bariatric Surgeons: http://www.asmbs.org/ Association for Morbid Obesity Support: http://www.obesityhelp.com/morbidobesity/ National Heart, Lung, and Blood Institute: http://www.nhlbi.nih.gov National Institutes of Health: http://obesityresearch.nih.gov/ National Institute of Diabetes and Digestive and Kidney Diseases: http://www.niddk.nih.gov/ Shape Up America!!: http://www.shapeup.org U.S. Department of Health and Human Services: http://www.surgeongeneral.gov/topics/obesity/

References 1. Hedley AA, Ogden CL, Johnson CL, Carroll MD, Curtin LR, Flegal KM. Prevalence of overweight and obesity among US children, adolescents, and adults, 1999-2002. JAMA. 2004;291: 2847-2850. 2. Ogden CL, Carroll MD, Curtin LR, McDowell MA, Tabak CJ, Flegal KM. Prevalence of overweight and obesity in the United States, 1999-2004. JAMA. 2006;295:1549-1555. 3. National Heart, Lung, and Blood Institute. Clinical guidelines on the identiﬁcation, evaluation, and treatment of overweight and obesity in adults. http://www.nhlbi.nih.gov/guidelines/obesity/ob_home.htm. Accessed June 2008. 4. Research Chair in Obesity. Body mass index. Merck Frosst/CIHR. Research Chair in Obesity. http://obesity.ulaval.ca/obesity/generalities/evaluation.php. Accessed February 16, 2010. 5. American Heart Association. Body composition tests, 2010. http://www.americanheart.org/presenter.jhtml?identiﬁer/4489. Accessed July 2010. 6. American Heritage Dictionaries. The American Heritage Dictionary of the English Language. 4th ed. Houghton “Bariatrics”; 2000. http://dictionary.reference.com/browse/bariatric. Accessed 14 February 2006. 7. Hellmich N. U.S. Obesity Rate Leveling Off at About One-Third of Adults, January 13, 2010. USA TODAY http://www.usatoday.com/news/health/weightloss/2010-01-13-obesityrates_N.htm. Accessed July 9, 2010. 8. Sugerman HJ. The epidemic of severe obesity: the value of surgical treatment. Mayo Clin Proc. 2000;75:669-672. 9. National Association to Advance Fat Acceptance. http://www.naafaonline.com/dev2/about/index.html . Accessed July 13, 2010. 10. Gourash W, Rogula T, Schauer PR. Schauer PR, Schirmer BD, Breithauer SA. Essential bariatric equipment: making your facility more accommodating to bariatric surgical patients. In: Minimally Invasive Bariatric Surgery. New York, NY: Springer Science + Business Media, LLC; 2007:37-50. 11. Herron DM. Inabnet WB, DeMaria EJ, Ikramuddin S. Establishing and organizing a bariatric surgery program. In: Laparoscopic Bariatric Surgery. Philadelphia, PA: Lippincott Williams & Wilkins; 2004:23-31. 12. Gallagher S. The Challenges of Caring for the Obese Patient. Edgemont, PA: Matrix Medical Communications; 2005. 13. Cheung DS, Maygers J, Khouri-Stevens Z, De Grouchy L, Magnuson T. Failure modes and effects analysis: minimizing harm to our bariatric patients. Bariatr Nurs Surg Patient Care. 2006;1:(2):107-114. 14. Baptiste A, Evitt C, Kelleher V, et al.. Safe bariatric patient handling toolkit. Bariatr Nurs Surg Patient Care. 2007;2:(1):17-45. 15. Mathison C. Skin and wound care challenges in the hospitalized morbidly obese patient. J Wound, Ostomy Continence Nurs. 2003;30:(2):78-83 16. Randall S, Drake D. Handle with Care: Bariatric Mobility. Equipment and Facility Considerations. 2007. http://www.dicardiology.net/node/28302/. Accessed July 15, 2010. 17. Gallagher S. Charney W, Hudson A. Bariatrics: Considering mobility, patient safety, and caregiver injury. In: Back Injury Among Healthcare Workers. Baton Rouge, LA: Lewis Publishers; 2004:141-161. 18. Camden SG. Nursing care of the bariatric patient. Bariatr Nurs Surg Patient Care. 2006;1:(1):21-30. 19. Baptiste A, Leffard B, Vieira ER, Rowen L, Tyler RD. Roundtable discussion: caregiver injury and safe patient handling. Bariatr Nurs Surg Patient Care. 2007;2:(1):7-16. 20. Vieira ER. Why do nurses have a high incidence of low back disorders, and what can be done to reduce their risk? Bariatr Nurs Surg Patient Care. 2007;2:(2):141-147. 21. Gallagher SM, Arzouman J, Lacovara J, et al.Criteria-based protocols and the obese patient: planning care for a high-risk population. Ostomy Wound Manage. 2004;50(5):32-44. 22. Waters T, Nelson A, Hughes N, Mensel N. Safe Patient Handling Training for Schools of Nursing, 2009. http://www.cdc.gov/niosh/docs/2009127/pdfs/2009-127.pdf . Accessed July 15, 2010.

23. Rose MA, Baker G, Drake DJ, et al.. Nurse stafﬁng requirements for care of morbidly obese patients in the acute care setting. Bariatr Nurs Surg Patient Care. 2006;1:(2):115-121. 24. Puhl RM, Schwartz MB, Brownell KD. Impact of perceived consensus on stereotypes about obese people: a new approach for reducing bias. Health Psychol. 2005;24(5):517-525. 25. Bachman K, Friedman KE, Kunz RL, Latner J, Rowen L, Tyler R. Weight stigmatization and bias. Bariatr Nurs Surg Patient Care. 2008;3(1):7-15. 26. Knudsen AM, Gallagher SM. Care of the obese patient with a pressure ulcers. J Wound, Ostomy Continence Nurs. 2003;30(2):41-50. 27. Guida B, Nino M, Perrino N, et al.. The impact of obesity on skin disease and epidermal permeability barrier status. J Eur Acad Dermatol Venereol. 2010;24:191-195. http://www.ncbi.nlm.nih.gov/pubmed/19929936. Accessed July 13, 2010. 28. Pokorny ME, Scott E, Rose ME, et al.. Challenges in Caring for the Morbidly Obese Patient. Home Healthcare Nurs. 2009;27(1): 43-52. http://www.nursingcenter.com/prodev/ce_article.asp?tid/837896. Accessed July 12, 2010. 29. Mulvihill E. Guidelines for Care of the Bariatric Patient, 2006. http://www.safeliftingportal.com/hottopics/bariatrics.html. Accessed February, 2011. 30. Gallagher S, Arzouman J, Lacovara J, et al. Criteria-based protocols and the obese patient: pre-planning care for a high-risk population. Ostomy Wound Manage. 2004;50(5):32-34. http://www.o-wm.com/article/2627. Accessed July 15, 2010. 31. Kennedy-Evans K, Henn T, Levine N. Skin and Wound Care for the Bariatric Patient. Chronic Wound Care. 4th ed. Malvern, PA: HMP Communications LLC; 695-699. 32. Krasner D, Kennedy-Evans K, Henn T. Bariatric wound care: common problems and management strategies. Bariatr Times. 2006;3(5):26-28. 33. Sorenson M, Krieger J, Rivara F, et al. Fournier's Gangrene: population based epidemiology and outcomes. J Urol. 2009;181(5): 2120-2126. http://www.jurology.com/article/S0022-5347(09)00056-1/abstract. Accessed July 11, 2010. Published with permission from the Journal of Wound, Ostomy and Continence Nursing, March/April2011; 38(2):133-138.

Improving Quality of Care Based on CMS Guidelines 45

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Special Feature

Unusual Alliance Slashes Expenses By Duke Helfand August 2, 2011

By working together, Blue Shield of California, Catholic Healthcare West and Hill Physicians Medical Group saved more than $20 million in costs last year in serving 41,500 HMO members in Northern California. A rare alliance of healthcare rivals â&#x20AC;&#x201D; a giant insurance company, a major hospital chain and a large doctors group â&#x20AC;&#x201D; has managed to reduce healthcare costs through a radical new strategy: working together. The collaboration among Blue Shield of California, Catholic Healthcare West and Hill Physicians Medical Group shaved more than $20 million in costs last year and prevented an insurance rate hike for public sector workers in Northern California. Continued on next page...

Improving Quality of Care Based on CMS Guidelines 47

Unusual Alliance Slashes Expenses Continued...

The three partners cite evidence that the quality of care also improved: Hospital stays were shorter, readmissions dropped and doctors and nurses kept closer tabs on patients. Relationships between these kinds of companies are typically adversarial, with doctors and hospitals trying to negotiate higher prices for their services as insurers strive to limit what they pay out. But driven by a mutual interest to cut costs and to be more competitive, the three devised a strategy they believed would deliver medical care more efﬁciently. Skeptics worry that the partnership and others like it will put cost-cutting ahead of patient care. Healthcare experts believe, however, that such experiments — including one being planned in Orange County — hold important lessons for an expected wave of similar "accountable care organizations" as part of the nation's healthcare overhaul. "The fact that they achieved substantial savings in the first year highlights the potential for the model," said Dr. Elliott Fisher of the Dartmouth Institute for Health Policy and Clinical Practice in New Hampshire. "There are a lot of opportunities to achieve savings, even in the short term." The three partners began planning their experiment in early 2008 — well before President Obama and Congress opened a heated national debate over how best to control healthcare spending. Their talks centered on 41,500 members of a Blue Shield HMO who were served by Hill Physicians, whose doctors are afﬁliated with Catholic Healthcare West, the state's largest hospital chain. All of the participants got their Blue Shield insurance through the California

Public Employees' Retirement System and lived in Sacramento, El Dorado and Placer counties. Senior executives from the three healthcare companies said they had to overcome past quarrels to collaborate.

"Our staffs had a history of combating with each other through negotiations," said John Wray, a senior vice president with Catholic Healthcare West. "We had to trust one another to make it happen. This was a very signiﬁcant culture change between the organizations." The partners overhauled procedures for medical treatment and hospital care. They started by taking the extraordinary step of sharing closely guarded ﬁnancial and medical information. They discovered, for example, that a handful of elective procedures — including weight-control measures — were among the biggest cost drivers. They took action to cut these costs. Overweight patients, for instance, were given an opportunity to enroll in a Hill Physicians weight-loss program in which a psychotherapist and dietitian teach how to manage food cravings and make healthier eating choices. The efforts helped reduce the surgeries by 13% last year, the hospital system reported. Emergencies were another target. When patients were taken to hospitals outside of Catholic Healthcare West, they were stabilized and then directed back to the hospital system for lower-cost "in-network" treatment. In all, 113 patients in the experiment went to emergency rooms outside the network last year. Of them, 85 were transferred back to Catholic Healthcare West hospitals once stabilized.

Medical centers and doctors also took aim at expensive repeat visits for hospital patients by paying greater attention to follow-up care. As part of the hospitals' checkout procedures, nurses reviewed patients' post-hospital instructions and then asked them to repeat it all back. The providers also made sure patients had made appointments with doctors before going home. As a result, hospital stays overall were shortened and the numbers of patients who had to be readmitted dropped by 15% in 2010, the providers said. Both results, they said, were signs of improved care: Spending less time in the hospital meant less chance of getting infections, while fewer readmissions meant patients remained healthier after surgery. Of the $20 million in savings, Blue Shield recouped $15.5 million for a pledge it had made to CalPERS not to increase insurance rates for the 41,500 people in the experiment. The remaining $5 million was divvied up among the three partners. They also had agreed to share the risk if the experiment didn't pay off. Blue Shield executives believe the rate cut helped attract about 1,000 new policyholders last year and gave the company a competitive edge as it vied for a new CalPERS contract. Blue Shield covers more than 400,000 CalPERS members, about one-third of those who get health insurance through the giant state pension fund. "Clearly it was worth our while," said Juan Davila, Blue Shield's top executive who oversees provider contracting. "Our biggest client is happy with us." Some healthcare advocates question whether patient health will suffer as Blue Shield and its partners look for additional cost savings. Could procedures or tests be denied because they are too expensive, they ask. Continued on page 50

48 Healthy Skin

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Improving Quality of Care Based on CMS Guidelines 49

Special Feature "You want to make sure that people have access to the care they need," said Anthony Wright, executive director of the consumer group Health Access California. "That's part of the balancing act." The experiment's three partners insist that healthcare quality is as important as saving money. CalPERS, meanwhile, said it is pleased to see improvements on both fronts, even though most of the savings in Northern California went unnoticed by individuals because the money was shared among the agency's entire statewide membership. Blue Shield is joining with hospitals and medical groups for similar alliances in San Francisco, Modesto and Orange County. The insurer and St. Joseph Health System in Orange are gearing up to launch a collaboration in January for 30,000 Blue Shield HMO members. About one-quarter of them belong to CalPERS. "We ﬁrmly think this is the right way to go," said Ann Boynton, a CalPERS beneﬁts executive. The cost-cutting strategy, she said, "will boost care for our members and moderate the longterm increases in cost."

50 Healthy Skin

Hospital-related infections drop under California initiative THE GOAL: Cut costs and save lives by preventing hospitalrelated infections from taking root. 'We're deﬁnitely making progress,' says a doctor in Newport Beach. By Duke Helfand August 23, 2011

Scores of California hospitals, under pressure to reduce infections that kill an estimated 12,000 patients every year, say they have managed to cut costs and save lives through an initiative that has nurses and doctors redoubling efforts to prevent deadly germs from taking root. The three-year campaign is bringing together 160 hospitals across the state with the aim of reducing an estimated 200,000 hospital-related infections in California that add $600 million to healthcare costs every year. Since its launch 19 months ago, the initiative is credited with cutting ventilatorassociated pneumonia 41%. Urinary tract infections related to catheters fell 24% last year, and cases of blood poisoning dropped 11%. The lower rates have saved an estimated $11 million in healthcare costs. "We're deﬁnitely making progress," said Dr. Philip Robinson, who oversees infection prevention at Hoag Memorial Hospital Presbyterian in Newport Beach. "Each one of these infections is a burden

to patients, hospitals and the whole healthcare system." Hospital infections have long been a problem, but the health threat has become more urgent with medical care increasingly delivered in outpatient clinics, leaving hospitals to treat the sickest patients, who are most susceptible to infectionrelated illnesses. The situation contributes to an estimated 99,000 deaths nationally every year and adds as much as $33 billion annually to healthcare spending, according to university and government researchers. Separately, the California Department of Public Health estimates that 12,000 people in the state die each year of healthcare-related infections in hospitals. Alarmed by these statistics, both the federal government and insurers are stepping up pressure on hospitals to act. Washington no longer pays the extra fees when Medicare patients get infections from catheters and intravenous lines, and the new federal healthcare law will soon withhold money from hospitals that fail to reduce infection rates. Major national and state insurers also are targeting what they see as

unacceptably high infection rates. California insurance giant Anthem Blue Cross is putting up $6 million to pay for the statewide Patient Safety First program but already has recouped nearly double that amount through lower healthcare spending in the program's ﬁrst year. Anthem's corporate parent, WellPoint Inc., announced this year that it is cutting payment increases to hospitals in 14 states that fail to meet its deﬁnition of quality care related to infections, readmission rates and other factors.

quently, sterilizing equipment, eliminating unnecessary procedures, closely following safety checklists and documenting every step along the way. "We know we can prevent many of these infections by doing some very simple things," said Dr. Arjun Srinivasan, who oversees efforts to combat the problem for the federal Centers for Disease Control and Prevention. Doctors and nurses at Hoag Memorial in Newport Beach, for example, say they had been closely following procedures to

Urinary tract infections related to catheters fell 24% last year "If we can improve the quality of care, that will translate into lower cost," Anthem President Pam Kehaly said. "These are real dollars." The California initiative is credited with saving an estimated 800 lives, based on lower mortality rates than had been projected, but leaders say the hospitals can still do better. "Patient safety is something you never ﬁnish," said Jim Barber, president of the Hospital Assn. of Southern California, one of three regional hospital groups that recruited hospitals for the state program. "You just continually work at it." Nationally, 1 in 20 patients admitted to a U.S. hospital develops an infection. An estimated 1.7 million are infected each year, according to the most recent federal estimates, making hospital-borne infections one of the nation's top 10 causes of death. Leaders of the statewide initiative say they have brought hospitals together to exchange ideas and strategies for ﬁghting the infections. The solutions, they say, are relatively easy, if often overlooked: washing hands, brushing patients' teeth more fre-

curb infections among patients on ventilators, doing such things as setting hospital beds at 30-degree angles to help keep patients' airways clear. Then doctors picked up a valuable tip from other hospitals to improve oral care: Enlist respiratory therapists to help keep deadly bacteria from building up in patients' mouths, potentially leading to pneumonia. The therapists began swabbing patients' mouths with hydrogen peroxide four times a day, supplementing the work of nurses who already were brushing patients' teeth with an antibacterial solution twice a day. The hospital said the extra effort has paid off: It has not recorded a single case of ventilator-associated pneumonia since December, down from 18 in the one-year period before that. "It's become second nature," respiratory therapist Rico Thomas said of the cleanings. "You know you have to do oral care. It's of the utmost importance. You keep down the bacteria." Fifty miles north, at Hollywood Presbyterian Medical Center, doctors have likewise focused on better oral care but also

on reducing the number of infections from central intravenous lines, keeping close watch over patients to remove the tubes as quickly as possible to avoid bacteria buildup. In response, the hospital has seen its rate of central-line bloodstream infections decline 38% since the end of 2008, when it was part of a similar, smaller hospital initiative. "We need to be vigilant with this," said Marie Falcis, the hospital's director of performance improvement and quality. "Our goal, of course, is to get to zero. It's a high priority." Federal ofﬁcials are watching California's experiment to see whether it produces the sort of long-term results seen in other states that have invested in anti-infection efforts. They say the cost of inaction is too high to ignore. "Nobody should go into a hospital and wind up sicker than when they went in," said Dr. James Cleeman, a federal expert on healthcare quality. "It is a challenge that the entire healthcare system needs to address to make care safer."

Improving Quality of Care Based on CMS Guidelines 51

Caring for Yourself

Professional

S NET by Anita Prinz, MSN, RN, CWOCN, CFNC, COS-C

When my grandparents were children, they communicated in person or by letter. In my parents’ generation, the telephone became popular. Today, much of our communication takes place through social media—namely, social networking websites and services. Websites such as Facebook® and LinkedIn® and social media services such as Twitter® let us connect with a network of friends and colleagues to share ideas, updates, and events in a virtual community. Many nursing organizations are accessible on these sites. For instance, if you use the microblogging service Twitter, you can get up-to-the minute mini-messages (“tweets”) on your cell phone from colleagues, or you can follow organizations such as the American Nurses Association (ANA) and Sigma Theta Tau International (STTI).

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CIAL

WORKING FOR

NURSES Improving Quality of Care Based on CMS Guidelines 53

Facebook, LinkedIn, Twitter, and other social media can expand your professional knowledge. Using social media for professional networking with colleagues worldwide is proving to be an effective way to advance your career. It’s easy and free, too. Social networking helps nurses think more globally and understand nursing perspectives in other parts of the country and world. Online nursing groups give you unlimited opportunities to network with like-minded nurses in your profession or specialty. To network with peers in your specialty, you can join a nursing group or form your own specialty nursing group. You can stay in touch with group members by registering with the social media websites they use and creating a profile. Use of these websites is fairly intuitive for the average computer user. Facebook, the largest social networking site, claims to have more than 500 million active users around the world connecting to an average of 80 community pages, groups, and events. Professional nursing associations such as the ANA and journals such as American Nurse Today have Facebook pages that allow users to connect with an online community of nurses. LinkedIn claims it has 100 million members worldwide and is gaining about 1 million new members every week. It maintains it gives users the keys to controlling their online identities because its subscriber profiles rise to the top of Google and other search engine results. With its job search tools and company pages, LinkedIn is a great site if you’re looking for work or exploring career options. You can search for employers you want to research and find out which companies’ profiles are the most viewed, fastest growing, and most connected. Posting your profile (which should include a photo of yourself, your current position, where you work, past work experience, and education) helps the right people and opportunities find you. Twitter users can send and receive tweets (up to 140 characters) via the Twitter website, compatible external applications

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such as smart phones, or the Short Message Service (SMS). While Twitter use is free, accessing it through SMS may incur phone-service provider fees. Tweets communicate up-to-themoment updates of any person or organization you’re following. ANA and STTI are a few of the nursing organizations that can tell you “what’s happening” on Twitter. Some organizations are trying out their own social networking sites, such as STTI’s The Circle (www.nursingsociety.org/Pages/TheCircle.aspx). These sites require you to be a member of the organization.

Social media and nursing education Social media can enhance nursing education. Some nursing schools have started to use social media to enhance their classrooms. For instance, Mesa Community College in Arizona has a manikin named Stella Bellman who has her own Facebook page. Stella provides welcome messages and notices about exams; more importantly, she provides simulation scenarios for students. Harriet L. Schwartz, PhD, assistant professor of professional leadership at Carlow University in Pittsburgh, calls Facebook her “cyber hallway” where she provides relational mentoring to her students.

Hospital networking sites Many hospitals and other healthcare organizations are creating their own social networking sites and blogs as a marketing and outreach tool. As of May 2011, 965 U.S. hospitals were using social networking. One example is the Mayo Clinic (http://sharing.mayoclinic.org), which has blogs where patients and others can share their stories of strength and hope. Make sure to ﬁnd out your employer’s policies on using social media. Many healthcare organizations prohibit employees from using social media at work or using an organizational handle on a social networking site (such as Mary.nurse@hospitalxyz.org).

remarks. Your friends ﬁnd your comments amusing and repost it on their Facebook “walls,” where friends of their friends see it and repost it on their own sites. Now your friends-only message has gone viral and is circulating around the social-media universe—and potentially can get back to the patient or your supervisor. Nurses have been terminated for posting even seemingly harmless statements, such as “My job is boring.” Five California nurses lost their jobs and are facing disciplinary action for discussing a patient on Facebook even though their posts included no names, photos, or identifying information.

Privacy concerns Sharing information on social networking sites is easy—too easy, some might say. Health care is one of the most regulated professions in the United States, and nurses are held to the highest standard of confidentiality. When using social media, always adhere to the Health Insurance Portability and Accountability Act (HIPAA) regulations and maintain professional boundaries of the nurse-patient relationship. Revealing private patient information is a leading type of social-networking misuse. The National Council of State Boards of Nursing (NCSBN) has published “Professional boundaries: A nurse’s guide to the importance of appropriate professional boundaries,” which addresses some of the issues involved. Currently, the ANA is revising its Code of Ethics for Nurses to include principles of social networking. The distinction between the privacy of one’s personal life versus one’s work life is a gray area poorly deﬁned by current laws. Consider this: Should your patient be your Facebook friend? Patricia Sullivan, APN, FNP-BC, states, “accepting a patient’s ‘friend’ request can damage the nurse-patient therapeutic relationship.” When a patient becomes privy to a nurse’s personal information, erosion of trust may occur.

Control how much you share Social networking sites offer tools that let you control how you share your information and communications; options include sharing with everyone and sharing with friends only. Sharing with friends only is recommended as the default—yet making it your default doesn’t guarantee your posts will stay between friends. For example, suppose you post something witty about a challenging patient, while withholding names and identifying

Tom Breslin, Associate Director of Labor Education for the Massachusetts Nurses Association, suggests following these rules when using social networking sites: • Assume anything you post will be read by everyone, especially those you don’t want reading it. • If there’s something you don’t want your employer to read or to know about you, don’t post it. • Don’t post anything you wouldn’t want your spouse, child, parent, or employer to read. (See Social networking: Some do’s and don’ts.)

Realize the risks Most employers can terminate employees for making disparaging comments about their employer, coworkers, or patients. Posting defamatory remarks on the Internet can lead to civil lawsuits alleging defamation or slander. What’s more, postings to social media sites generally are considered permanent, even if you delete them. Electronic information is easily distributed, archived, and downloaded, and copies of your deleted posts may still exist on search engines or in friends’ electronic ﬁles.

Improving Quality of Care Based on CMS Guidelines 55

You might ask, “What about my freedom of speech?” Privacy in the United States is a given natural right guaranteed by several constitutional amendments. But U.S. laws regarding digital rights vary by jurisdiction. The National Labor Relations Board (NLRB) has been working actively with employees who believe they’ve been terminated unjustly for social networking activity. A Connecticut ambulance driver was ﬁred for posting negative comments about her supervisor on Facebook; the case was settled by the NLRB more than 6 months later, but the employee’s reputation has been damaged.

Social networking: Some do’s and don’ts Make sure you use social media wisely. Here are some tips.

Do’s: • Do use social networking sites as tools to broaden your educational and professional horizons. • Do stay abreast of your employer’s policy on social networking and Internet use. • Do educate yourself about the privacy settings on websites you use. • Do be aware that current and future employers may see what you post. • Do know that your employer has the right to monitor your online activity on work computers.

Dont’s: • Don’t use social networking sites at work. • Don’t reveal personal details, such as your employer, your address, or your date of birth. • Don’t use your employer’s e-mail address or “handle.” • Don’t upload images or videos of yourself in a clinical environment or uniform. • Don’t discuss patients, visitors, vendors, or organizational partners. • Don’t talk about coworkers, physicians, your supervisor, or your employer. • Don’t discuss clinical events or news stories about your employer. • Don’t “friend”patients, even after they’re no longer patients. • Don’t give medical advice online.

Is your boss watching? Nursing recruiters pore over social networking sites for new nursing hires. Many nursing employers use these sites to do background and character checks, scanning them for questionable posts or photographs of employees or applicants. In multiple cases, nurses have been terminated for violating employers’ Internet communication policies, and some employers have rejected applicants based on Facebook or other postings that cast the applicants in a bad light. Social networking is a great tool you can use to expand your professional network, connect with colleagues, and increase

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your nursing knowledge. But using it carelessly can imperil your job and livelihood. Let common sense and discretion guide you online. Maintain appropriate boundaries and privacy and adhere to your employer’s code of professional conduct and social networking policies. Remember—you’re a professional nurse 24/7. Note: This article is not meant to constitute legal advice. About the author

Anita Prinz is a certiﬁed wound ostomy continence nurse educator at Memorial Hermann Home Health in Houston, Texas.

Selected references American Nurses Association. Principles: social networking and the nurse. (Draft for public comment). April 25, 2011. www.nursingworld.org/MainMenuCategories/ThePracticeofProfessionalNursing/NewCNPE/CNPEMembersOnly/Principles-Social- Networking-and-Nurse.aspx. Accessed May 25, 2011. Breslin T. When social networking enters the workplace. Massachusetts Nurses Association. September 15, 2009. www.massnurses.org/news-andevents/p/openItem/3013. Accessed May 25, 2011. McBride D. Misuses of social networking may have ethical implications for nurses. ONS Connect. 2009; 24(7):17. Saver C. Social responsibility: social media opportunities and pitfalls. iNurse.com. August 9, 2010. http://news.nurse.com/apps/pbcs.dll/ article?AID=2010108090045. Accessed May 25, 2011. Tariman JD. Where to draw the line: professional boundaries in social networking. ONS Connect. 2010;25(2):10-13. Visit www.AmericanNurseToday.com/Archives.aspx for a complete list of selected references. Reprinted with permission. American Nurse Today. Volume 6, Number 7 www.AmericanNurseToday.com

Improving Quality of Care Based on CMS Guidelines 57

Special Feature

Promote your facility using Facebook An easy and low cost way to promote your facility is by setting up a Facebook page. Here are some tips for creating your social media presence: The Facebook for Business page has simple instructions for publishing your own Facebook page. You’ll want to include a link to your website, a company overview, your mission statement, and services that you offer. The fastest-growing user group on Facebook is women 55 and over. Baby boomers on Facebook are 1.2 million strong.1 And they just happen to be the same population taking care of their elderly parents. This is your audience! Don’t miss out on the opportunity to connect with them through Facebook.

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Ask family members of prospective and current residents for their email addresses, including written permission to send them emails. You can then begin asking them to “like” your facility’s Facebook page. Once you have 25 fans, you can register a customized web address that includes your facility’s name. Update your Facebook page often, including information on new programs, healthcare-related articles and news about your staff. Reference 1. Gates A. For baby boomers, the joys of Facebook. The New York Times. March 19, 2009. Available at: http://www.nytimes.com/2009/03/22/nyregion/new-jersey/22Rgen.html. Accessed September 9, 2011.

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www.medline.com/incontinence/drypads/ultrasorbs.asp

Treatment

By Nancy Muller, PhD, MBA Executive Director, National Association For Continence (NAFC)

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Getting Started So much of what matters in the quality of outcomes in healthcare delivery depends on how well expectations are framed. In the framing of expectations, a reference point is established for what is important and what is expected to occur. But accompanied with that process should be a discussion of what is uncertain, what adverse events are likely to arise, the risks associated with complications or uncertainties, and the consequences of such events. Without this framework, shared decision-making cannot take place. Dialogue is lacking because information is missing. Ultimately, both the resident and the family are set up for disappointment and may be underserved by a facility because of poor communication. The other thing that happens with such dialogue is that agreement is reached on responsibilities, both on the part of providers but equally on the shoulders of the individual and involved family members. Without such discussion, a care plan cannot be individualized as it needs to be. It will likely be lop-sided and incomplete. It also may be more aggressive or more invasive than it needs to be or it may be too passive for the circumstances. As expectations are framed and shared decision-making unfolds, goals for managing incontinence can be established and understood by all parties.

very relevant. To begin the process, let’s start with the quality indicators for urinary incontinence in long-term care, as provided by the Centers for Medicare & Medicaid (CMS).1 The following is shared to help begin the process of framing your expectations.

Assessment of Continence Status Within the ﬁrst 48 hours of admission to a long-term care facility, a continence nurse or other advanced practice nurse should assess the following in a new resident: • Signs and symptoms of urinary and fecal incontinence, identifying the type of urinary incontinence present • History of incontinence, identifying any modiﬁable causes of incontinence and/or voiding dysfunction including causal factors increasing the resident’s risk of a problem • Toileting habits • Appropriateness and continuing need for an indwelling catheter if one is present • Need for follow-up or tests after performing a limited physical examination • Cognitive and mental status, including the presence of depression, dementia, or any behavioral or communication disturbances that could present obstacles to toileting or contraindicate intervention • Functionality and the relevance of environmental factors

While all of this may sound rather theoretical and irrelevant to long-term care residents and their families, I assure you it is

• A full review of all medications, both prescription and non-prescription Continued on page 65

A reference point is established for what is important and what is expected to occur [and] what is uncertain... Without this framework, decision-making cannot take place.

Improving Quality of Care Based on CMS Guidelines 63

Introducing Medline’s New

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

Replaces Compass Box F315

The program includes: • RN/LPN workbook with 4 CE credits

LEARN MORE ABOUT CONTINENCE MANAGEMENT PROGRAMS AND PRODUCTS

• CNA workbook

1 Download a QR Code Reader app

• Reproducible care plans, assessment guidelines and other quality assurance tools

2 Launch the QR app 3 Scan this QR Code or visit http://www.medline.com/ programs/continencemanagement-program/

All of this should be documented and discussed with the resident and involved family members. If a resident is hospitalized and then returned to the same nursing facility, a full reassessment must be undertaken. As part of revisions by CMS to F-Tag 315, great lengths have been taken to eliminate the overreliance on indwelling catheters in long-term care settings because catheter usage is associated with risks of symptomatic urinary tract infection, urosepsis, and even death, and should only be used for specific indications.2, 3 Because many nursing home residents are discharged from a short stay in an acute care hospital with an indwelling bladder catheter, an attempt should be made at this assessment to determine the indication for the catheter and remove it as soon as medically appropriate. While there may be specific justification for a catheter, such as in the case of hospice or end-of-life care, this needs to be thoroughly assessed, explained to family members, and understood by all. Family members should also expect a physician serving as medical director to provide oversight for this assessment and concur with any conclusions reached, especially as a care plan is discussed and agreed to with the resident and family members. The family should also have access to this physician for a private consult, if there are issues or concerns that the family believes remain unresolved.

The bladder gradually loses its elasticity, just like a rubber band that has been repeatedly stretched.

Regardless, aging is accompanied by risk factors for bladder and bowel control problems. The bladder gradually loses its elasticity, just like a rubber band that has been repeatedly stretched. It doesn’t stretch as well to hold urine over the course of the day, and it cannot contract fully to empty. The residual urine left in the bladder after urinating may be as much as 200 ml, meaning that the bladder is always at least one third full. This contributes to frequency because the brain receives frequent signals that the bladder needs emptying. This also explains nocturia, or the need to get up more than once nightly to urinate.

Understanding the Role of the Aging Process Although the majority of residents in long-term care have urinary or fecal incontinence or both, incontinence is not a guaranteed clinical destination for everyone as they grow old. Nevertheless, we do see prevalence increase as age brackets rise. Women are four to ﬁve times more likely than men to experience stress urinary incontinence (SUI), which is urine leakage that occurs when coughing, laughing, lifting, or placing any “stress” downward on the bladder. This is due largely because of pelvic ﬂoor dysfunction, nerve damage and weakness of muscles precipitated by pregnancy and the physical trauma of childbirth. Men are more likely to begin experiencing urgency and frequency as their prostate gland increases in size with the aging process, but by the age of 80 they are equally as likely as women to experience urge urinary incontinence (UUI) due to an overactive bladder. Women are more likely to experience mixed incontinence, or symptoms of both SUI and UUI. The most important thing is for the type of problem to be accurately diagnosed so that its symptoms can be appropriately managed. Family members should not simply accept a diagnosis of “incontinence.”

The older bladder also may suffer the effects of nerve damage (common in stroke survivors), sending errant signals to the brain to empty. This contributes to overactive bladder, yet another possible urinary diagnosis. In some older persons, there may also be decreased awareness of the bladder ﬁlling. The older person may have a neurological disorder such as Parkinson’s disease, which can impair safe ambulation to and from the toilet. Because of childbirth, younger women are more likely to experience fecal incontinence than men the same age, but by the time men and women become elderly, they are equally likely to experience fecal incontinence. Because older people typically do not hydrate as they should and are less physically active, they suffer from constipation more often than other bowel control problems. An impacted colon can even be confused with diarrhea because there may be seepage around the hard stool. Understanding the aging process alerts involved family members to a bladder or bowel control problem that may need to be addressed and more closely supervised by the nursing staff. All of this factors into framing expectations and improves the assessment process.

Improving Quality of Care Based on CMS Guidelines 65

considered and implemented without undue delay or excessive paperwork. Most importantly, the plan and all approaches must be individually appropriate. Such thinking lies at the heart of patient-centered care and contemporary approaches to healthcare quality.

Optimizing Quality When Choosing a Facility As the resident’s continence status, including skin health and integrity, is being constantly monitored, speciﬁc goals for intervention and management should be revisited to determine if they are being met or deserve further reﬁnement. The best care plan is a dynamic one, as no one’s health status is static. It should be reviewed and updated at least every 90 days or in the case of any “event” such as a fall, illness, or medical intervention. This includes dialogue with the resident and involved family members to avoid unhappy surprises or avoidable misunderstandings.

The Care Plan Following the initial assessment, an agreed upon care plan is put into place. This should be discussed openly with the resident and caregivers so everyone understands the plan and agrees to it. If the resident has a recent history of chronic constipation, part of the shared decision-making may include the resident’s agreement to eat at least three servings of fresh fruit and vegetables every day and take supplemental ﬁber, for example. The care plan should address simple ways to reverse factors that cause bladder control or bowel health problems, including dietary and ﬂuid management and scheduled toileting. Fall prevention may need to be separately addressed, with special precautions added. Selection of a properly sized absorbent product may be part of the care plan, including different product choices for nighttime to safeguard quality of sleep. The resident and family members can reasonably expect that the chosen residential facility for long-term care has a formal process for assessing the effectiveness of care plan interventions that are put in place. The process should be sufficiently robust so that additional or alternative interventions can be readily

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To give the individual the best chance of receiving the highest level of care, start with facilities already earning the 5-star Nursing Home Compare quality rating assessed by CMS. It can be accessed online at: www.medicare.gov/nursing/overview.asp About NAFC National Association For Continence is a national, private, nonproﬁt organization dedicated to improving the quality of life of people with incontinence, voiding dysfunction and related pelvic ﬂoor disorders. To learn more, visit www.nafc.org.

References 1 Johnson TM & Ouslander JG. The newly revised F-Tag 315 and surveyor guidance for urinary incontinence in long-term care. Journal of the American Medical Directors Association. 2006; 7(9): 594-600. 2 Fantl JA, Newman DK, Colling J, et al. Urinary incontinence in adults: acute and chronic management. Clinical Practice Guideline No. 2. 1996. Rockville, MD: U.S. Department of Health and Human Services, Public Health Service, Agency for Health Care Policy and Research, AHCPR Publication No. 96-0682. Available at: http://www.ncbi.nlm.nih.gov/books/NBK16544. Accessed August 30, 2011. 3 Gould CV, Umscheid CA, Agarwal RK, Kuntz G, & Pegues DA and the Healthcare Infection Control Practices Advisory Committee (HICPAC) of the Agency for Healthcare Research and Quality. (2009). Guideline for prevention of catheterassociated urinary tract infections. Available at: http://www.cdc.gov/hicpac/ cauti/001_cauti.html. Accessed on August 10, 2011.

NO O CATHETER CA C ATHETER R IS THE T E BE BEST EST T CATHETER CATH AT ETE ER

ERASE ERAS SE CAUTI CAU UTI

速

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Improving Quality of Care Based on CMS Guidelines 67

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Treatment

Part 1

Peristomal Skin Problems Are More Common Than You Think by Cynthia Ann Fleck, RN, BSN, MBA, CWS, DNC, CFCN, DAPWCA, FACCWS

When we think about skin and wounds, sometimes we forget some of the most vulnerable skin of all – the epidermis surrounding an ostomy. Skin complications ranging from denudation (commonly misdescribed as “excoriation”), or partial thickness skin loss due to mechanical or chemical damage, leakage, skin burning, irritation, yeast, itching and the like occur frequently. Peristomal skin disorders are a common problem for patients with stomas, and can have a negative impact on quality of life.1 The range of peristomal skin complications reported in the literature varies from 10% to 70%,2,3,4 and rarely patients seek the help of a professional or even realize that what they are experiencing is abnormal. In fact, Tavernelli and Reif found in their research that only 38% of patients identiﬁed with a peristomal skin disorder recognized it, and <20% sought medical care.5

Peristomal skin challenges are most often caused by: Moisture-associated skin damage (MASD) and denudation

Infection (bacteria)

Mechanical injury

Folliculitis

Chemical or enzyme damage

Allergic response

Irritant dermatitis

Yeast or Candida

Disease processes such as Pyoderma gangrenosum

Improving Quality of Care Based on CMS Guidelines 69

Photos of various peristomal skin complications are depicted here:

Peristomal Pyoderma

Acute Dermatitis

Denuded Peristomal Skin

Mechanical Irritation

Sometimes the situation is due to creases in the abdominal skin, bony structures, irregular anatomy or an inappropriately placed stoma. Patients’ bodies change with the aging process. Gaining or losing weight and changes in muscle to adipose ratio are just a few issues. It is always recommended that a WOC nurse see the preoperative patient and mark the site for the surgeon prior to creating the stoma. This will help reduce problems in the future. Since there is no standard way of assessing or describing peristomal skin disorders, some tools have been developed and proposed,3,5 but none have been universally adopted. Until now, there has been no usual accepted way of assessing or describing peristomal skin disorders. Recently, the Ostomy Skin Tool was developed by a global group of experts in collaboration with an ostomy product company. It is a novel standardized tool for assessing peristomal skin through objective observations. It consists of two components: ﬁrst to score the condition of the peristomal skin and second a diagnostic guide to help determine the cause of the problem. The Ostomy Skin Tool allows the user to score the peristomal skin in the following three areas according to severity to produce a single composite value (the DET score):5 1. Discoloration 2. Erosion 3. Tissue Overgrowth

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Allergic Dermatitis

Complications commonly attributed to a variety of things including: Flush or retracted stoma

A pouch that is heavy and needs to be emptied

Peristomal hernia Barrier or ﬂange that is cut too large

Sensitivity and/or a true allergy to the appliance

Ostomy Skin Tool Scoring Unaffected < 25% 25-50% > 50%

= = = =

0 1 2 3

Within each area assessed, the tool takes into account the size of the affected area and severity of the problem. The diagnostic guide helps identify the possible cause of any peristomal skin disorder. Observations are matched with standard descriptions, which are categorized according to likely cause. A ﬁnal conclusion can then be made and appropriate treatment initiated. The use of a standardized tool to evaluate peristomal skin has the

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

potential to improve everyday care. The Ostomy Skin Tool provides a common language to describe both the severity and cause of peristomal skin conditions. This enables evaluation and monitoring over time of a patient’s peristomal skin by different healthcare professionals in different clinical settings and locations.5 When in doubt, consult a WOC nurse. WOC nurses are often afﬁliated with large metropolitan hospitals but can also be found in smaller towns in clinical environments and even in some durable medical equipment (DME) suppliers businesses as value-added services. Stay tuned for Part 2 coming in the next issue of Healthy Skin! References 1. Herlufsen P, Olsen AG, Carlsen B et al. Ostomy Skin Study: a study of peristomal skin disorders in patients with permanent stomas. B J Nursing 2006;15:854-62.) 2. Salvadalena G. Incidence of Complications of the Stoma and Peristomal Skin Among Individuals with Colostomy, Ileostomy and Urostomy: A Systematic Review. J Wound Ostomy Continence Nurs. 2008;35(6):596-607. 3. Ratliff CR. Early Peristomal Skin Complications Reported by WOC Nurse Journal of Wound, Ostomy & Continence Nursing. 2010; 37(5):505–510. 4. Colwell JC, Beitz J. Survey of wound ostomy and continence (WOC) nurse clinicians on stomal and peristomal complications: a content validation study. J Wound Ostomy Continence Nurs. 2007; 34(1):57–69.) 5. Tavernelli K, Reif S. An Ostomy Skin Evaluation Tool: How A Tool Can Help Patients With Peristomal Skin Problems Journal of Wound, Ostomy & Continence Nursing. 2008; 35(3).

About the Author

Cynthia Ann Fleck is a certified wound specialist, dermatology advanced practice nurse, certiﬁed foot and nail care nurse, writer, speaker, past president and chairman of the board, The American Academy of Wound Management (AAWM), Past Director, the Association for the Advancement of Wound Care (AAWC), and Vice President, Clinical Marketing for Medline Industries, Inc. Advanced Skin and Wound Care. Cynthia can be reached at cﬂeck@medline.com.

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

Stoma site before treatment with Marathon.1

Same stoma site after treatment with Marathon.1

www.medline.com/wound-skin-care/marathon/application.asp

CASE STUDY

Cyanoacrylates* in Neonatal and Infants Peristomal Skin Damage ABSTRACT Introduction: Peristomal skin damage in neonates and infants is an all too common occurrence, and such damage to skin can lead to further complications and morbidity. Given the fragility of the infant or neonatal skin, which is still not fully developed at birth, the clinician’s options in terms of choosing a skin protectant are very limited. Denuded skin prevents containment devices from adhering. Skin preps that contain solvents carry associated inhalation and fire hazard risks in a neonatal environment. A relatively new class of materials, cyanoacrylates, is applied solvent-free to the skin, and forms a non-adhesive polymer barrier very quickly. The formation of such film allows relief to the peristomal skin, protects underlying ,skin from further damage caused by leaking gastric mcontents or stoma effluent, and allows the skin to, recover its natural health. It also provides a robust platform for the attachment of a collection device. Intervention: A cyanoacrylate barrier was applied to infants and neonates with peristomal skin damage in gastrostomy and ostomy patients in an effort to recover denuded skin and, in the case of ostomy patients, increase wear-time of the appliance. Results: Appliance wear-time was increased for neonatal and infant patients with ostomies. Skin condition improved, and none of the patients developed an adverse reaction to the cyanoacrylate during their stay in the hospital. In previous experience this type of skin breakdown has been difficult to manage. COMMON MANAGEMENT OF NEONATAL SKIN DAMAGE Infants and children have very sensitive skin. In our practice we frequently encounter severe cases of skin breakdown due to a number of issues. Contributing factors include 1) frequent loose stools, 2) leakage of acidic gastric contents from gastrostomy tubes, and 3) harsh enzymatic effluent from an ileostomy. Additionally, denuded skin prevents proper adherence of ostomy pouches requiring frequent pouch changes and additional breakdown of skin. Alternatively a barrier creammay be used over the damaged skin, and the child double-diapered with consequent frequent diaper changes. We have used numerous products in the past to help protect and heal denuded skin with varying degrees of success and have felt that a more robust skin protectant could have a special role in the management of particularly challenging neonatal skin issues.

Case 1 7 week old born at 25 weeks gestation Stoma opening at skin level 3:00

4-9-2010

4-15-2010 The erythema and skin breakdown were totally resolved. The cyanoacrylate barrier was applied to the patient on an as needed basis for the following month long stay of the child in the unit. 5-10-2010

Case 2 22 month old, 31 week gestation

11-25-2009

11-27-2009

Case 3 17 month old – Necretizing enterocolitis

12-9-2010

72 Healthy Skin

4-13-2010 Skin appears purple and wrinkled from the cyanoacryate application but the disappearance of erythema is clearly visible.

The mother of the patient stated that she was unable to keep a pouch on the patient. Cyanoacrylate protectant was applied and the pouch placed around the stoma. The pouch stayed in place 10 hours, and then developed some leaking. At this point the pouch was removed, the skin cleansed with water and dried. Cyanoacrylate protectant was reapplied and patient was double-diapered. Frequent diaper changes were required throughout the night. The skin was seen to be much improved and pink in color in the morning. The cyanoacrylate barrier was intact on the skin and patient was discharged home.

Treatment

Linda O. Neiswender, RN, BSN, CWOCN, CPN Primary Children's Medical Center Salt Lake City, UT

TECHNOLOGICALLY ADVANCED MANAGEMENT OF NEONATAL SKIN DAMAGE Recently we have begun applying a cyanoacrylate skin protectant to cover and protect the skin from further damage from external elements as it heals naturally. We chose for this case series a set of patients whose skin required urgent management due to the severity of the underlying cause and/or the failures of standard methods we had at our disposal for skin protection. The type of cyanoacrylate we used is a non-cytotoxic liquid skin barrier.

Case 4 14 month old prior gastroschesis patient

1-20-2010

1-21-2010

OBSERVATIONAL RESULTS We found that the cyanoacrylate protectant dried within about one minute of application and formed a flexible “crust” over the denuded skin. As the skin regenerated naturally underneath the crust, the product sloughed off in course of time without further intervention. Newer layers of the barrier could be applied to the older partially adherent layers with no ill effects. Once in place and dry, the product allowed for wafers to be placed, in order to allow uninterrupted containment of the sometimes corrosive effluent. We found that use of the cyanoacrylate skin protectant provided the needed protection which allowed our patients’ highly denuded skin to resolve in a shorter period of time. We saw no adverse effects from the use of the product in infants or children. During application, we noticed no distress on the patients and the parents reported no concerns about the product use. Based on this, it appears to us that the product likely does not sting on skin that is damaged. The application method via the cracking of unit dose vials was easy and the quantity of product quite sufficient for use on our little patients. The absence of solvents was appreciated by us.

Case 5 Very visible denudement of skin on the buttocks of a child was managed with the application of a cyanoacrylate barrier. The condition of the reddened skin improved and normalcy was restored within a week.

12-6-2010

12-13-2010

Case 6 10 month old baby with inﬂuenza

2-14-2011

12-15-2011 “Crusted on” cyanoacrylate barrier, with clearly improved underlying skin with the redness not apparent, within a day of skin management with the cyanoacrylate

Conclusion: It is remarkable the speed at which the skin issues were resolved after providing robust external protection. It is apparent in these case reports that neonatal skin may regenerate rapidly as long as there is no continuing insult to the already damaged skin from external elements such as corrosive bodily ﬂuids. * Marathon®, Medline Industries Inc., Mundelein, IL.

REFERENCES Milne CT, Saucier D, Trevellini C, Smith J. Evaluation of a Cyanoacrylate Protectant to Manage Peristomal Skin Irritation Under Ostomy Skin Barrier Wafers. Presented at: Clinical Symposium on Advanced Skin and Wound Care, Orlando, FL, 2010.

Improving Quality of Care Based on CMS Guidelines 73

Special Feature

An Interview with

Nancy Estocado, BS PT CWS Developer of the NE1 Wound Assessment Tool HS: What is the purpose of the NE1 Tool? NANCY: The NE1 Tool helps clinicians assess wound healing through the use of what I call the HATT Methodology. The NE1 Tool prompts the user to collect all of the important information needed to properly assess a wound: History/cause of the wound Anatomy/location of the wound on the body Tissue type/worst (WTT) Touch details/palpation to determine the texture and temperature of the wound

HS: What are the advantages of using the NE1 Tool? NANCY: I can name four main advantages: 1. It signiﬁcantly improves assessment accuracy 2. It standardizes assessment and documentation 3. It trains nurses to properly evaluate wounds using a simple method 4. It spreads the responsibility for wound evaluation past the expert HS: How did the NE1 Tool get its name?

I really want to emphasize the importance of touching the wound when appropriate. Touching lets you know the temperature of the wound, and whether it feels boggy, soft, ﬁrm, blanches or does not blanch. These are all clues as to the type of wound. Touch details differentiate between Pre-Stage I (blanchable erythema), Stage I and sDTI, which are the most common areas of inaccuracy. HS: What inspired you to create the NE1 Tool? NANCY: In 2008, when CMS released the new regulations for healthcareacquired conditions, including present-on-admission (POA) pressure ulcers, it occurred to me that most of the physicians and bedside nurses who were expected to assess patients’ skin upon admission were not properly trained to do so. Wound care nurses – for those hospitals fortunate to have one on staff – do not begin caring for patients until after the 24-hour threshold for assessing and documenting POA pressure ulcers. So there was deﬁnitely a need for a simple, accurate tool to help non-experts achieve accuracy. There was also the incentive of increased financial reimbursement for discovering and correctly assessing Stage III and IV pressure ulcers upon admission.

74 Healthy Skin

NANCY: Well, the letters N and E are my initials, and when you say “NE1,” it sounds like “anyone.” Bottom line – the tool makes it easy for anyone to assess a wound. Anyone can do it! Nancy Estocado, a physical therapist and certiﬁed wound specialist at Sunrise Hospital in Las Vegas, NV, won an HCA Innovators Award for the NE1 Tool. For more information about the NE1 Tool, including a step-by-step demonstration of how to use it, go to www.medlineNE1.com.

Camera not included.

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

Winner of National HCA Innovators Award

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

LEARN MORE ABOUT THE NE1 WOUND ASSESSMENT 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.

Download a QR Code Reader app

2 Launch the QR app 3 Scan this QR Code or visit http://www.medlineNE1.com

S ome bowel control problems improve simply by changing what â&#x20AC;&#x201D;and how much â&#x20AC;&#x201D; the patient or resident eats and drinks.

76 Healthy Skin

Prevention

Eating & Bowel Control Common foods and drinks linked to diarrhea and bowel control problems include: • • • • • • • •

Dairy products such as milk, cheese, or ice cream Foods and drinks containing caffeine such as coffee, tea, or chocolate Cured or smoked meats such as sausage, ham, or turkey Spicy foods Alcoholic beverages Fruits such as apples, peaches, or pears Fatty and greasy foods Sweeteners in diet drinks and sugarless gum and candy, including sorbitol, xylitol, mannitol, and fructose

Dietary changes that may improve bowel control problems include the following:

Getting plenty to drink. Drinking eight, 8-ounce glasses of liquid a day may help prevent constipation. Water is a good choice. Drinks with caffeine, alcohol, milk, or carbonation should be avoided if they trigger diarrhea.

Source: National Institutes of Health

Eating the right amount of fiber. For many people, fiber adds bulk to their stool and makes it softer and easier to control. Fiber can help with diarrhea and constipation. Fiber is found in fruits, vegetables, whole grains, and beans. Fiber supplements sold in a pharmacy or health food store are another common source of fiber to treat bowel control problems. A normal diet should include 20 to 30 grams of fiber a day. Fiber should be added to the diet slowly to avoid bloating.

ga Keepin ry ia food d foods lp identify e h n a c iary trol prob A food d wel con o b e s d u t foo s that ca should lis ry ia d d o en lems. A fo and wh n size, io rt o p c oc ur. eaten, roblems p l o tr n o may bowel c e diary days, th w fe a ain foods After een cert tw e b k ms. show a lin l proble o tr n o c l wel to bowe and bo ds linked o fo r e e w v Eating fe ay impro blems m ro p ls l a o can o contr od diary fo A . s vider symptom h care pro lt a e h a l to nbe helpfu bowel co on with rs e p a treating lems. trol prob

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

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.

www.medline.com/programs/vap 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.

80 Healthy Skin

Prevention

Joint Commission PDF book now available! Preventing Catheter-Associated Urinary Tract Infections 171 pages. PDF book plus additional tools. ISBN: 978-1-59940-605-3 Item Number: EBPCAU11 Price: $35.00 USD To order, go to http://jcrinc.com/e-books/EBPCAU11/3929

CAUTI Facts • Urinary tract infections are the most common type of healthcare-associated infection in health care settings around the world, and the vast majority of these are catheter-associated urinary tract infections (CAUTIs). • As many as half of urinary catheters are placed inappropriately, and one third remain in place longer than medically necessary. • Physicians often forget that their patients are catheterized or do not remember why they have urinary catheters. • The Centers for Medicare & Medicaid Services does not reimburse for CAUTIs that are not present on admission. Urinary catheters are inserted for a variety of medically necessary reasons, but as these statements indicate, they can also cause medical harm. Fortunately, the majority of CAUTIs can be prevented by strict adherence to evidence-based guidelines. In Spring 2011, The Joint Commission introduced a new National Patient Safety Goal to prevent CAUTIs. Clinical Care Improvement Strategies: Preventing Catheter-Associated Urinary Tract Infections is your authoritative guide to ensure the safety of patients who have urinary catheters. Features include: • A description of The Joint Commission’s new National Patient Safety Goal to prevent CAUTIs • A thorough explanation of best practices to insert urinary catheters, including following appropriate indications, using aseptic technique, and removing these as soon as medically possible • Detailed descriptions of best practices to care for urinary catheters, including properly securing and positioning the collection system, maintaining a closed system, and checking the collection system • A discussion of how health care organizations should perform surveillance for CAUTIs, including equations for outcome and process measures • Tips, tools, and case examples to help improve staff compliance with CAUTI preventive strategies (many of the tools are customizable). Includes information and tools from Medline’s ERASE CAUTI program. • Available in PDF format so you can easily access it anywhere in your organization Stop CAUTIs from causing harm to your patients!

Patient and family education is a vital component of any CAUTI prevention program. The book features Medline’s patient care card, a creative way to deliver valuable patient education.

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

We found THREE more ways to make it even better. We’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.

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.

Special Feature

PRECIOUS

The same Kuddle Up blanket sold today was featured in an original Medline textiles brochure (~1978).

84 Healthy Skin

MOMENTS More than four million babies are born in the United States every year and a quarter of them are wrapped in Medline’s Kuddle Up baby blanket.

hile there are tons of throws and snugglies on the market today, Medline’s flannelized white cotton blanket with pink and blue striped border is one of the most popular receiving blankets used in labor and delivery units across the nation. In fact, Google® “hospital baby blanket” and it’s the number one image to pop up in the search. Medline, one of three major distributors of the 30 x 40 blanket in the United States, sold about 1 million Kuddle Up blankets in 2010 — that’s nearly 100,000 more sales than any other pediatric blanket in the company’s textile line, according to Dan Sanchez, VP of Medline’s Medcrest Division. He said the majority of buyers are laundry and linen service companies who sell or rent supplies to healthcare facilities.

How did Medline come to sell this iconic blanket? Records show that Medline has been selling this particular blanket for more than 50 years. According to Roger Berndt, who began working in the linen division in 1973 and served in the role of division president from 1983-1996, Medline was purchasing the blanket from Dundee Mills, a textile manufacturer in South Carolina, in the 1970s. Toward the end of the decade, Medline found a manufacturer overseas to supply the blanket, which allowed the company to privately label the item for sale in the United States and pass on competitive pricing to customers.

Since this sourcing move nearly 30 years ago, the division has seen continued sales growth in the product line and they expect that trend to continue despite the rising cost of cotton. “The Kuddle Up is a quality blanket that is soft and warm and available at a good price,” said Dan. “Whether you ask a parent or a labor and delivery nurse, they both want the same thing – the best comfort for their babies.”

Dan points to four key features that keep this blanket in hot demand: it’s soft, it’s simple, it’s economical and it’s generic for baby boy or girl.

Scan this QR code to see thousands of photos featuring precious babies in Medline’s Kuddle Up blanket.

Improving Quality of Care Based on CMS Guidelines 85

Special Feature

Deb

Ace

To order Medline dolls, visit www.scrubs123.com or call 1-800-MEDLINE.

Deb and her Medline Friends Enter the Pink Glove Dance Competition! 86 Healthy Skin

Ace, Deb, Anastasia and SCIP began choreographing their moves as soon as Deb heard about the Pink Glove Dance Competition. SCIP, the photographer in the group, ﬁlmed their dance in a patient room at Medline General Hospital. “We’re deﬁnitely in it to win it, but even if our dance doesn’t win, we had a great time performing it and promoting breast cancer awareness,” Deb said.

SCIP

Anastasia

â&#x20AC;˘

Medline pink bouffant cap with breast cancer ribbon embroidery (405BCA22) Nitrile exam glove (PINK6802)

T AL U O K C

EO D I V E TH

os e vide h t h c t e! wa om to Glove Danc c . e c n k a gloved bout the Pin k n i p ! o Go t ore a states m 0 ! 4 n r a m ro , 2011 f 8 s 2 o and le r e e ob vid on Oct an 135 d h e t c e n r ou Mo be ann l l i w rs Winne

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Winners will receive a donation to their favorite breast cancer charity. First Place: $10,000 Second Place: $5,000 Third Place: $2,000

Improving Quality of Care Based on CMS Guidelines 87

ends i r f r e h nd a b e D p Hel r the o f p u s dres Dance!

e v o l G k Pin

•

American ﬂag bouffant cap (NON28226) Medline single head black stethoscope (MDS926101)

Deb

Ace

•

Comfortease pink bouffant cap (405BCA1) PerforMAX scrub top (810NNT) PerforMAX scrub pant (800NNT) Oxy-Pas shoes (MEGANBLK)

•

Visit www.medline.com, www.scrubs123.com, call 1-800-MEDLINE, or contact your Medline rep to order the items shown.

88 Healthy Skin

Nitrile exam glove (PINK6802)

Anastasia

•

Breast cancer awareness bouffant cap (NON28230R) I’m a Pink Glove Dancer T-shirt (PGDSHIRT)

Brea st ca fashi ncer aw www ons availa areness .scru bs12 ble at 3.com

•

Medline Comfortease scrub top with pink ribbon embroidery (8800SPR) Medline Comfortease scrub pants (8865)

3M Littman® pink stethoscope (MMM2815H) Medline Comfortease scrub top (8800) Medline Comfortease scrub pants (8850)

Improving Quality of Care Based on CMS Guidelines 89

In Celebration of

Breast Cancer Awareness Touring Art Exhibit Spotlights Survivors and Family Members

Most people can say they know someone who has been diagnosed with breast or ovarian cancer. Women everywhere face the fear of diagnosis every year as they have their annual mammograms and physician examinations. A new national traveling art exhibit, titled “Voices and Visions, Standing on the Bridge between Health and Disease” gives voice to those who have been touched by women’s health, who may live in fear, or who are survivors of women’s cancers. Sponsored by Medline Industries, Inc., the company that produced the Pink Glove Dance video, the exhibit made its ﬁrst stop earlier this spring at the Lakewood Center for the Arts in Lake Oswego, Ore., located just outside of Portland. Fittingly, this inaugural exhibit was held in partnership with Portland-based Providence St. Vincent Medical

90 Healthy Skin

Center, the hospital that was featured in the original Pink Glove Dance video. The exhibit features more than 27 artists and 45 pieces of art. All the pieces have been produced by artists who have been dramatically affected by women’s cancers. “The art exhibit is an extension of our breast cancer awareness campaign with the goal of empowering those who live on that bridge between health and disease,” said Sue MacInnes, Medline’s chief marketing ofﬁcer. “Similar to our message with the Pink Glove Dance, our hope with the art exhibit is to reach people in a creative and interesting way to get them engaged and talking about breast cancer.” The exhibit also features statements of women who have undergone breast or ovarian surgeries. Whether elective

Special Feature

“...as I stood before the blank canvas, I asked myself how I can begin the process of “detaching” as I face another “elective” life saving surgery.” - Caren Helene Rudman

Paintings by Caren Helene Rudman

for prophylactic reasons, or recommended because of a positive diagnosis, women who undergo surgeries endure life changes, both physical and emotional. About the Artists In one way or another, all of the artists have been dramatically affected by women’s cancers. Some are survivors; some have had family members with the disease and some are carriers of the BRCA1 gene linked to the development of hereditary breast and ovarian cancer. One photographer, for example, had an 18-year-old cancer patient ask him to photograph her. Another male artist took care of his mother through multiple cancers, including ovarian. Several artists have sisters who had cancer, and others had mothers with the disease.

The Curator Caren Helene Rudman is an artist who works with mixed media, photography and writing. After learning she carried the BRCA1 gene, a hereditary increased risk for breast and ovarian cancers, she began to delve into genetics. She has become part of a coalition of woman who are passionate about educating people on the risk of hereditary cancers and the power of taking control of our own bodies. Recently, she was invited to participate in a project, Heroes in the Fight Against Breast Cancer, where she and 14 other devoted women were honored by the governor of Illinois. The exhibit is currently on display at The Breast Cancer Center at Floyd Medical Center in Rome, GA through November 1, 2011.

For more information, email slentz@theartcenterhp.org or call 847-432-1888.

Improving Quality of Care Based on CMS Guidelines 91

Time Management: How to

STRETCH Your Time “Rubber Band”

Wolf J. Rinke, PhD, RD, CSP

Time is your second most precious resource. It’s the only resource you can’t buy, borrow, rent or produce. Its preciousness exists because time is the only commodity that is required for everything we do. Unlike most things we deal with, time is totally perishable and absolutely irreplaceable. In fact the only thing that is more precious than time is our health. Unfortunately, most of us are equally careless with both.

92 Healthy Skin

Caring for Yourself

This article will help you manage your time more effectively. Come to think of it, time management is a misnomer. Each of us is provided with 24 hours every day. No matter how well you manage it, it still only adds up to 24 hours. Instead of managing time, we manage and prioritize the activities in those 24 hours. And we get everything done that we perceive to be important. (Read that again, it is a critical concept.) Before you nix this idea, please pause a moment, reflect and recall the one activity that is the most important to you. On the personal side it may be being with your family, football or gardening. On the professional side it may be making more money, being recognized by your peers or getting promoted. Now think back: how often have you been unable to devote enough time to whatever it is that is the most important to you? I bet it doesn’t happen very often, does it? In other words, most people make time for all the things they consider important. In other words, time is like a rubber band.

completed a particular task. An easy way to do this is to record your activities on your calendar—electronic or paper, in halfhour increments. (My Time Management CPE program has an easy-to-use form you can use for this purpose http://www.wolfrinke.com/CEFILES/cenutr.html#C196.)

Analyze Your Time Expenditures

Here’s how to stretch your time rubber band and help you get the most out of every 24 hours:

Now ask several questions of the data you have collected. The first and most important: What would happen if I did not do this task or activity at all? If the answer is nothing, stop doing it! (Just this one step will save you lots of time!) If not sure, figure out how what you are currently doing originated. Then go back and find out whether the originator wants you to continue, or if it is still required in a current regulation. Note the words are required and current, not nice to have or because we always have done it that way, or even it is in one of our standard operating procedures. If you can’t figure out how the practice originated, and you don’t see any positive impact on the bottom line, quit doing it. If it is really important, someone will ask about it.

Record Your Time

Look for Time Patterns

Before you can make more time, you must first figure out how you are currently spending it by keeping a time log for at least three to five days. Do this as soon as possible after you have

Next look for patterns in your use of time so that you can “chunk” your time. Let’s assume that your 3- to 5-day time record reveals that you are faced with constant interruptions Continued on page 95

Improving Quality of Care Based on CMS Guidelines 93

“

“Excellent. 50 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

Access courses on your computer, iPhone or iPad.

Download a QR Code Reader app

2 Launch the QR app 3 Scan this QR Code or visit http://www.medlineuniversity.com

from email, telephone, and a wide variety of administrative functions. Combine these. For example, only answer emails and other routine calls during speciﬁed times of the day. Similarly, routine administrative functions should be handled only during a certain period of the day – ideally when you tend to be least productive. Obviously, you must still take care of the true emergencies, which should be analyzed, especially the recurrent ones. The reason is that frequent crises are an indication of sloppy management. Processes must be put into place to routinize them so that someone other than you can handle them.

Take Advantage of the 80-20 Rule Your next step is to categorize your time to ﬁgure out whether you spend most of your time on trivial tasks—the “irrelevant many”—or on the important biggies—the “critical few.” The Pareto principle, better known as the 80-20 rule, maintains that 80 percent of the important results are accomplished in 20 percent of the time. This phenomenon exists because work falls into two major categories, the critical few and the irrelevant many. The irrelevant many include all the mundane things such as ﬁlling out forms, attending meetings, answering emails and so on, which will devour about 80 percent of your time. The time that you have left, about 20 percent, can be devoted to the critical few. These will determine whether your hospital will be a leader in the industry and whether you will be promoted or get a bonus. They include such things as taking care of patients, interviewing new employees, cost-cutting, system development, etc. I call these winning results areas (WRAs). When you allocate more time to the critical few, you will realize massive productivity increases. For example, by allocating just one percent more of your time to the critical few, you will realize an increase of four percent in the WRAs. That represents a 400 percent return on your time investment. Bingo!

Set Goals and Priorities Goals can serve as a driving force in your life, continually pulling you in the right direction. Basically, a person without a goal is like a ship without a rudder. Likewise, an organization without clearly defined goals, stated in a prioritized fashion, is an organization that will not be successful. The irony is that many of us work in organizations that have very elaborate goals and objectives—in many cases, we are the ones who developed

them—yet most of us do not have similar goals for our personal lives and careers. (For specifics read my popular How to Maximize Professional Potential CPE program-www.wolfrinke.com/CEFILES/cepd.html#C187.) Because effective goal-setting is critical, I would like to briefly share a bit of management folklore with you that has come to be called the $25,000 idea. A simple tool to prioritize your life. Folklore has it that an efficiency consultant by the name of Ivy Lee was meeting with the president of a steel mill. The president, Charles Schwab, wanted to find out how to get more done within available time, and he was willing to pay anything within reason for such advice. Lee said that he could help him increase his efficiency by at least 50% provided he could have about 20 minutes of his time. After Schwab consented, Lee gave him a blank piece of paper and told him to write down the six most important things he wanted to accomplish tomorrow. Schwab thought about it and completed the task in about three minutes. Then Lee instructed him to order these things from most important to least important. Now Schwab was instructed to keep the list until the following morning, at which time he was asked to look at the first item and to start working on it until it was completed. After that he was told to work on task number two and so on until the end of the day. Lee further advised Schwab not to worry about the tasks that he could not get done, since they didn’t matter, because they would not have gotten done anyway. Then Schwab was asked to repeat this process every working day. Lee also asked Schwab to have his employees try this system and, if it worked, to send him a check for whatever the idea was worth to him.

Improving Quality of Care Based on CMS Guidelines 95

After several months Lee received a check for $25,000 and a letter in which Schwab said that it was one of the most profitable ideas he had ever been taught. It is further reputed that the consistent application of this strategy helped turn this small steel mill into Bethlehem Steel. The moral of this story relates to what it takes to “eat an elephant.”

How to eat an elephant. I’m sure you’ve heard that “if you want to eat an elephant, you have to take one bite at a time.” Your job is probably just like that proverbial elephant, so if you want to master it—instead of it mastering you—you have to have goals, prioritize them and take each one in turn, just like Lee said. These two strategies are effective because they not only provide you with a sense of direction, but also provide you with a focus and a sense of accomplishment. Many healthcare professionals tend to diminish their effectiveness because they come to work without a vision. They are there to work on the irrelevant many, never asking themselves, “What is the one thing I can accomplish today that will make a big difference to this hospital or in my life?”

One More Time with Feeling Which strategy you use to stretch your time rubber band is not important, provided it “forces” you to work on the critical few and it disciplines you to ﬁnish one task before starting another. You see, how many projects you start doesn’t count; the number you ﬁnish, even if it is only one important one, does! In fact, being busy or working long hours doesn’t count either; results, especially the WRAs, do! So visualize your prioritized goals, and work them tenaciously until they are done. Never worry about all the things you are not doing, or all the things you were unable to accomplish yesterday, because yesterday is gone and all the fretting in the world won’t make it come back.

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Take Advantage of the Three-Minute Rule I suggest you use these strategies as guidelines and set up a system that works for you. Note I said “guidelines” because of a recent experience with one of my coachees. She had just finished reading my time management CPE program (http://www.wolfrinke.com/CEFILES/cepd.html#C198).and was trying to abide by the rules I had prescribed. Proud of her success, she was telling me how she had told someone that she would call him back with an answer, so that she could continue working on a major task. I asked her what the interruption was about and found out that she could have quickly resolved it. When asked why she had not taken care of it right away, or at least had offered to reply with an email later, she said she wanted to “chunk” her time so that she could concentrate on the major task at hand and be more productive. In this case the “operation” was a success, but the “patient died.” By the time she would finally be able to reconnect with the caller (you know how long it can take to play telephone tag) my coachee would have used up far more time than she saved by chunking her time. In other words, the literal application of any theory seldom works unless you tailor it to yourself and to the situation, and then superimpose some common sense. To help my coachee I shared the three-minute rule with her: Once interrupted, do anything on the spot, provided it can be accomplished in less than three minutes. Let’s face it, you’ve been interrupted. So get it over with. You will find that even though it may violate one of the other rules, it will save you lots of time in the long run. The moral of this story is that you must always look at the bottom line and ask: “Which is the most costeffective strategy over the long run?” © 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 FailSafe 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. Reach him at WolfRinke@aol.com.

50% LESS FRICTION than the leading competitor3

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

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

Download a QR Code Reader app

2 Launch the QR app 3 Scan this QR Code or visit http://www.medline.com/ heel-and-elbow/ 1 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.

Featured Recipe

Nutrition Information Servings: 12 Calories: 288 Fat: 8.4 g Sodium: 98 mg Fiber: 3.1 g

Apple Crisp Apple mixture: 6-9 baking apples 1 cup sugar 1 tablespoon flour

Pinch salt 1 teaspoon cinnamon

Crunchy topping: 1 cup oatmeal 1 cup flour 1 cup brown sugar

Directions: Mix ingredients for the apple mixture and set aside. Butter a 9'' x 13'' in. pan. Peel and slice apples and place them in the pan. Spoon the apple mixture over the top, covering all of the apples. In a bowl, add the dry ingredients for the crunchy topping to the melted butter and mix well. Using your hands works best! Cover the apples with the topping. Baking 35-40 at 350 degrees. Can be served warm or cold. Top with whipped topping or vanilla ice cream, if desired.

Kurt Behning, Inside Sales Representative – Dubuque, IA Kurt Behning has more than 20 years of experience in sales, and joined Medline’s sales team in February 2010. His apple crisp recipe actually belongs to his wife, Patti. It was passed down from her 103-year-old grandmother, who is still living.

98 Healthy Skin

¼ cup baking soda ¼ teaspoon baking powder

½ cup melted butter

Patti grew up with the recipe, which she would make with her grandmother as a child. In turn, Patti and Kurt have passed it on to their children. “It’s a really fun and easy recipe to make with kids, and it’s the world’s best apple crisp!” Kurt said. “My coworkers here in Dubuque love it – I bring it in a few times a year.” It’s also a big hit with friends and family, who always request it for parties and other social gatherings. Try it for yourself. It’s the perfect comfort food for “crisp” fall days. The Medline employee cookbook is $10. To purchase your own copy, please e-mail Judy at jdesalvo@medline.com.

FORMS & TOOLS

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

Heart Failure My Heart Failure Knowledge Passport…………………….101 Heart Failure Care Path.......................………………….106 Communication SBAR Communication Tool.....…………………………..104 Wound Care PUSH Tool……....…………………………………………..107 Continence What Should Nursing Home Residents Expect from a Continence Care Program?....................................110

Improving Quality of Care Based on CMS Guidelines 99

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

pinkglovedance.com

Heart Failure Knowledge Passport

Forms & Tools

My Heart He ea ar rt Failure rt Fa lure Fail re Knowledge K Knowled n dge Passport Pa Passpor rt rt

name: This passport was developed by the Greater Lansing (MI) Area Heart Failure Collaboritive, which was organized as part of the Michigan Quality Improvement Organization by CMS.

Forms & Tools

Heart Failure Knowledge Passport

My Heart Failure Knowledge Passport Summary This Passport is issued on (date): Name: I have SYSTOLIC / DIASTOLIC heart failure (circle one) The doctor treating my heart failure is:

Phone Number: My primary care doctor (if different) is:

Phone Number: Other doctors I see: Name:

Phone:

Name:

Phone:

My support person or the person who helps me manage my medical condition is: Name:

Relation:

Phone Number:

My last EF was: (measurement)

My last BNP was:

(date)

on (measurement)

(date)

I HAVE/DO NOT HAVE (circle one) a device. My device is a:

K Pacemaker K AICD (deďŹ brillator) K BiVICD (biventricular deďŹ brillator) Date of Implant: The company that makes my device is:

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Forms & Tools

Heart Failure Knowledge Passport

My Medications: My allergies are: My last vaccine for ďŹ&#x201A;u:

For pneumonia: (date)

(date)

I HAVE/DO NOT HAVE (circle one) an advance directive. name

dose/time

reason

t, cumen tm o d s i h of t rt.h asspo he rest t P e F e H s / . g To Attach your most recent medication list here. panish pro.or S m . d n w a w h go to w ble in Englis a 2 l i Ava

Improving Quality of Care Based on CMS Guidelines 103

Forms & Tools

Purpose:

SBAR Communication Tool

The purpose of the SBAR Communication Tool is to improve communication between nurses and physicians by encouraging standardized criteria and clear guidelines for communication of resident changes in condition in an efficient and effective manner. The SBAR form can also be used in place of the nursing narrative progress note.

When to use: Use prior to contacting the physician when a resident has a change in condition. Before completing the SBAR form, the nurse should check with other staff members who have regular contact with the resident to obtain an accurate history. Staff members who can provide useful information about the condition change include, STNA, therapy staff, social worker and activity staff. • Before completing the tool, review the resident’s chart • Refer to Care Paths or Change of Condition Cards if indicated • Complete every section of the SBAR form prior to calling the physician • Have chart available when making the call to the physician • Use SBAR form to guide your change of shift report Used with permission from Winchester Terrace Nursing Home.

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SBAR Communication Tool

Forms & Tools

Before Calling Physician: Evaluate the resident and complete the SBAR form o o o o

Check vital signs: BP, pulse, respiratory rate, temperature, pulse ox, blood sugar (if indicated) Review chart: nursesâ&#x20AC;&#x2122; notes from previous shifts, recent labs, progress notes Review an appropriate care path Have relevant information available when reporting: resident chart, vital signs, advance directives, allergies, medication list

Situation- State what is happening at the present time that has prompted the communication. This is_______________________ (nurse) I am calling about__________________________(resident). The problem I am calling about is________________________________________________________ The problem started_________________and has __gotten worse ___gotten better ___stayed the same. ________________________________________________________________makes the problem worse. ________________________________________________________________makes the problem better. ________________________________________________________has also occurred with this problem. Recent medication changes______________________________________________________________

Background- Explain the circumstances leading up to this situation. Primary diagnosis/reason for admission to the nursing home____________________________________ Mental Status/Neurological: ___Alert ___Change in level of consciousness ___Confusion ___ Change in speech pattern ___Depression Lungs/Respiratory: o Lung sounds ___Wheezes ___Rales ___Rhonci o Cough ___dry ___productive (describe) _____________________________________ o Breathing ___SOB ___difficulty breathing ___must sit up to breathe o Respiratory rate ___________________ o Pulse ox _________________________ o 02 @ __________liters per minute via ___nasal cannula ___mask ___trach Cardiac:

GI:

____Heart rate ____regular ___irregular ____edema (location/amount)____________________________________________________

___Nausea ___Vomiting (color/amount/consistency) ____________________________________ ___Constipation ___ Diarrhea ___Abdominal tenderness Last Bowel Movement ___________ Bowel sounds ___present x 4 ___Hypoactive ___Hyperactive ___Absent __________________

GU: ___Frequency ___Urgency ___Dysuria ___Urine color/odor ___Catheter ___Urine dipstick (results) ___positive nitrites ___positive leukocytes Date of last UTI________ Pain: location/character____________________________ ___New onset ___Worsening chronic

Severity: ___Mild ___Moderate ___Severe Affects ___appetite ___activity ___sleep

Assessment (RN) or Appearance (LPN)

(For RNs): What do you think is going on with the resident (e.g. cardiac, infection, respiratory, mental status change, urinary, etc.) I think the problem may be ______________________________________________________________________ OR I am not sure what the problem is, but there has been an acute change in condition. (For LPNs): The resident appears ________________________________________________ (e.g. SOB, in pain, more confused)

o o o o

Request- I request/may I have an order for: Lab work, xray, EKG, other tests_______________________________________________________________________ Medication changes__________________________________________________________________________________ New orders ________________________________________________________________________________________ IV meds/fluids______________________________________________________________________________________

Resident Name____________________________________________________________________________ Staff Name___________________________RN/LPN

Reported via

phone

Fax

In person

Reported to _____________________________MD/NP/PA DATE_________

Time ______________am/pm

Used with permission from Winchester Terrace Nursing Home.

Improving Quality of Care Based on CMS Guidelines 105

Forms & Tools

Care Path: Congestive Heart Failure

RECOGNITION (PROBLEM) S/S of CHF in resident with known CHF Unrelieved shortness of breath or new shortness of breath at rest Wheezing or chest tightness at rest Inability to sleep without sitting up or stand without dizziness Weight gain > 5 pounds in 3 days Worsening edema with other symptoms

ASSESSMENT Take vital signs + apical heart rate Finger stick glucose (diabetics) Oxygen Saturation level (pulse ox) Auscultate Lung Sounds- note areas and severity of adventious lung sounds Complete respiratory assessment- rate/rhythm, use of accessory muscles, cough SOB, etc Edema-amount/location

ANY VITAL SIGN CRITERIA MET?

Portable Chest X Ray Blood work: Complete Blood Count Basic Metabolic Panel EKG

Yes

Temp>102 째 Apical HR > 100 Resp rate > 30/min BP < 90 systolic Unable to eat or drink Oxygen Saturation < 90% Finger stick glucose <70 or > 400

Notify MD Immediately

YES Evaluate and Re-assess Chest Xray suggestive of CHF or pneumonia? Critical values in blood work? EKG shows new changes suggestive of: * acute MI or arrhythmia Worsening clinical condition?

Notify MD and request Treatment to Manage in Facility *Monitor Vital Signs every 4-8 hours *Daily weight if >5# in 3 days notify MD *Monitor urine output every 24 hours *Oxygen supplementation to maintain oxygen saturations >90% *Request MD: Initiate or increase diuretic Monitor electrolytes and kidney function Initiate or modify other cardio medications *Document every shift vital signs and head to toe assessment include sign and symptoms exhibited and interventions used and effectiveness of interventions.

GOAL(s): Resident will verbalize less dyspnea And be more comfortable in 48 hrs. ____________________________ ____________________________ ____________________________

Resident Name________________________ Nurse Signature________________________ Date initiated_____________ 106

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Used with permission from Winchester Terrace Nursing Home.

Forms & Tools

PUSH Tool Pressure Ulcer Scale for Healing (PUSH)

PUSH Tool 3.0 Patient Name________________________________________________ Patient ID# _____________________ Ulcer Location ____________________________________________________ Date _____________________

Directions: Observe and measure the pressure ulcer. Categorize the ulcer with respect to surface area, exudate, and type of wound tissue. Record a sub-score for each of these ulcer characteristics. Add the sub-scores to obtain the total score. A comparison of total scores measured over time provides an indication of the improvement or deterioration in pressure ulcer healing.

LENGTH X WIDTH (in

< 0.3

0.3 – 0.6

0.7 – 1.0

1.1 – 2.0

2.1 – 3.0

3.1 – 4.0

4.1 – 8.0

8.1 – 12.0

12.1 – 24.0

> 24.0

None

Light

Moderate

Heavy

Slough

Necrotic Tissue

Sub-score

cm2)

EXUDATE AMOUNT TISSUE TYPE

Closed

Epithelial Tissue

Granulation Tissue

Sub-score

TOTAL SCORE

Length x Width: Measure the greatest length (head to toe) and the greatest width (side to side) using a centimeter ruler. Multiply these two measurements (length x width) to obtain an estimate of surface area in square centimeters (cm2). Caveat: Do not guess! Always use a centimeter ruler and always use the same method each time the ulcer is measured. Exudate Amount: Estimate the amount of exudate (drainage) present after removal of the dressing and before applying any topical agent to the ulcer. Estimate the exudate (drainage) as none, light, moderate, or heavy. Tissue Type: This refers to the types of tissue that are present in the wound (ulcer) bed. Score as a “4” if there is any necrotic tissue present. Score as a “3” if there is any amount of slough present and necrotic tissue is absent. Score as a “2” if the wound is clean and contains granulation tissue. A superficial wound that is reepithelializing is scored as a “1”. When the wound is closed, score as a “0”. 4 – Necrotic Tissue (Eschar): black, brown, or tan tissue that adheres firmly to the wound bed or ulcer edges and may be either firmer or softer than surrounding skin. 3 – Slough: yellow or white tissue that adheres to the ulcer bed in strings or thick clumps, or is mucinous. 2 – Granulation Tissue: pink or beefy red tissue with a shiny, moist, granular appearance. 1 – Epithelial Tissue: for superficial ulcers, new pink or shiny tissue (skin) that grows in from the edges or as islands on the ulcer surface. 0 – Closed/Resurfaced: the wound is completely covered with epithelium (new skin).

www.npuap.org 11F

Improving Quality of Care Based on CMS Guidelines 107

Forms & Tools

PUSH Tool

Pressure Ulcer Healing Chart To monitor trends in PUSH Scores over time (Use a separate page for each pressure ulcer) Patient Name________________________________________________ Patient ID# _____________________ Ulcer Location ____________________________________________________ Date _____________________

Directions: Observe and measure pressure ulcers at regular intervals using the PUSH Tool. Date and record PUSH Sub-scores and Total Scores on the Pressure Ulcer Healing Record below.

Pressure Ulcer Healing Record Date Length x Width Exudate Amount Tissue Type PUSH Total Score Graph the PUSH Total Scores on the Pressure Ulcer Healing Graph below. PUSH Total Score

Pressure Ulcer Healing Graph

17 16 15 14 13 12 11 10 9 8 7 6 5 4 3 2 1 Healed = 0 Date www.npuap.org 11F

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PUSH Tool Version 3.0: 9/15/98 ÂŠNational Pressure Ulcer Advisory Panel

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. ™

www.medline.com/wound-skin-care/puracol-plus/ 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.

Forms & Tools

Continence

What Should Residents Expect From a Continence Program? Facilitate conversation about the continence program at your facility with your new/prospective resident and family members. Here are some points to discuss: 1. Soon after admission you will receive a comprehensive assessment of your continence status. This includes your medical history, toileting habits, medications and a complete physical evaluation including a full body skin assessment, rectal exam (and vaginal exam). Discussion should include reasons that it might be difficult for you to use the washroom independently. (For example: difficulty with zipper, poor eyesight, unable to move quickly enough.) 2. If you had an indwelling catheter inserted prior to your admission, its medical necessity will be re-assessed. The catheter may need to be removed to prevent urinary tract infections. 3. The staff will work with you and/or your family for appropriate treatment, recognizing that even though incontinence is more common as we age, it is not a fact of life. 4. The staff will thoroughly review your diet, removing troubling foods and adding beneficial ones. 5. You will be involved in the process of developing an individualized care plan that helps you maintain as much bladder and bowel function as possible. 6. A pharmacist will review your medications, looking for those that may cause trouble with respect to bladder and bowel control. 7. The staff will most likely complete a voiding diary of your bathroom habits to help establish your voiding pattern. The staff will then help you toilet according to a schedule that best maintains your continence (dryness). 8. Incontinent products will be selected according to the amount and frequency of bowel and/or bladder incontinence you have with consideration of your comfort and preference. 9. You will be encouraged to stay well hydrated for your overall good health and to help reduce urinary tract infections and constipation. 10. The staff will treat you with dignity and respect while working with you to manage your continence status. 11. The goal of your continence program is to help you maintain and/or restore as much normal bowel and bladder function as possible and to prevent any related skin issues and/or urinary tract infections.

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BioConâ&#x201E;˘- 500 Bladder Scanner Safely Measures Bladder Volume Minimize unnecessary catheterization Research has shown that 80 percent of urinary tract infections acquired at healthcare facilities are associated with an indwelling urethral catheter.1 This type of infection is known as CAUTI, or catheter-associated urinary tract infection. Avoiding unnecessary catheter use is a primary strategy for preventing CAUTI, and clinical guidelines recommend the consideration of alternatives to catheterization.2 Bladder scanners accurately assess bladder volumes, and many urinary catheterizations can be avoided.3

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

www.erasecauti.com/bladder-scanner

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

Keep Your Skin Healthy with Remedy Skin Care. Now available to be shipped directly to you at

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SAVE 10% ON YOUR FIRST ORDER BY USING PROMO CODE: ISAVED10 1

Download a QR Code Reader app

2 Launch the QR app 3 Scan this QR Code or visit http://www.remedyadvancedskincare.com/

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

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MKT211359/LIT939/35M/RIP5