Healthy Skin Volume 11 Issue 2 by Medline Industries

Improving Quality of Care Based on CMS Guidelines

Volume 11, Issue 2 June 2013

FREE CE! ARE YOU READY FOR

QAPI? SUMMER SKIN SAFETY

THE NEW MEDLINE.COM CHECKING FOR MEDICAL DEVICE-RELATED PRESSURE ULCERS

CNO CATHY BORRIS-HALE ACHIEVING ZERO PRESSURE ULCERS June 2013 I www.medline.com I Healthy Skin

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!

ON THE COVER, Chief Nursing Ofﬁcer Cathy Borris-Hale describes how Medline’s Pressure Ulcer Prevention Program helped her reduce pressure ulcers to zero at The Specialty Hospital of Washington-Hadley within a year. The hospital continues to maintain these results after three years on the program.

Healthy Skin I www.medline.com I June 2013

CO NTENTS JUN E 2013

Editor

F E AT U R E S

Sue MacInnes, RD 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 Lorri Downs, BSN, RN, MS, CIC Doreen Gendreau, MS, MSN(c), BS, RN CWCN

Getting to Zero. Cathy Borris-Hale knows the challenges of providing quality patient care with limited resources. Learn how she reduced pressure ulcers to zero at her LTCH.

The New Medline.com. Better products. Better outcomes. Better website. Visit today to test drive all the new features.

Carrie Kozak, MSN, RN Rebecca Huff, MSN, RN

CE ARTICLE

Joyce Norman, BSN, RN, CWOCN, DAPWCA Kim Kehoe, BSN, RN, CWOCN,

Medical Device-Related Pressure Ulcers: Who Thought Plastic Tubing Could Be Harmful? Discover how to monitor the placement of life-sustaining medical devices to protect the skin from damage.

DAPWCA Jackie Todd, MBA, BS, RN, CWCN, DAPWCA Patty Turner, BSN, RN, CWCN, CWS

About Medline Medline, headquartered in Mundelein, IL, manufactures and distributes more than 350,000 products to hospitals, extended care facilities, surgery centers, home care dealers and agencies and other markets. Medline has more than 1,100 dedicated sales representatives nationwide to support its broad product line and cost management services. ÂŠ2013 Medline Industries, Inc. Healthy Skin is published by Medline Industries, Inc. One Medline Place, Mundelein, IL 60060. 1-800-MEDLINE.

CE A CE ARTICLE! RT R TIC CL LE E!

Sun Safety: How to Save Your Skin! Learn new ways to protect your skin from sun damage.

June 2013 I www.medline.com I Healthy Skin

LE TTER FRO M T HE E D ITOR

I went to a meeting recently called the CMO Collective. It was a bunch of chief marketing officers from companies like Unilever, Jockey, General Mills, Valspar, Accenture and even the Cleveland Clinic. The big buzz was on “social”… how social media is our future. One break-out session I attended was on the topic of content marketing. The executive vice president of Unilever discussed a newly released YouTube video sponsored by/promoting Dove soap called “Real Beauty Sketches.” In the video, a forensic artist draws women; once as they describe themselves to him and another time as someone else describes them. Most interesting, … the women, themselves, don’t see themselves as beautiful as others do. If you haven’t seen this, you might want to search for it on YouTube. This video was released on April 14 and already had more than 48 million views in less than a month. At the meeting, Accenture told the group that 80 percent of people in the U.S. are using some type of mobile device. And, that there are four million tweets a day (Twitter has been around for only seven years), three million emails a day, and 20 hours of YouTube video produced every hour. As a matter of fact, the discussion centered on how our society is totally transparent AND all organizations have become public in the online community. We heard analogies about how Amazon has replaced Barnes and Noble, Netflix has replaced Blockbuster … I think you get it.

Our world as we know it is changing and “social” is the future of communication. Our patients and families are more active than ever and looking to communicate. I want Medline to be able to communicate with you and be your go-to resource for rich, fresh information. One of the ways we can do this is through the brand NEW Medline.com. So, what has changed on the site and how has is become a better resource for you? 1. The site is designed by Deborah Adler, who previously designed our Advanced Wound Care packaging as well as Target’s prescription drug bottles. 2. The architecture and functionality is the work of one of the most renowned web design companies in the country. 3. You can customize your experience by selecting your specific area of interest in health care. Choose from hospital, nursing home, home care/ hospice, physician office and more. 4. Explore our new videos, research, and education sections. We’ve added more content and tools you can use to learn about our products, solutions and industry issues that affect you. 5. Learn all about Medline in the new “About Us” section with great information about the company, our history, leadership and career opportunities.

Healthy Skin I www.medline.com I June 2013

6. Check out our new blog, which is being updated daily with messages from leadership, news alerts, product information and other fun stuff! The site is mobile-friendly, so you can visit Medline.com when you’re on the go. REMEMBER• All previous articles from both The OR Connection and Healthy Skin can be accessed on Medlineuniversity.com. • You can communicate to us directly though Facebook, Twitter, LinkedIn, and Pinterest. Look at Pages 5 and 34-37 to check out all the cool things that have been developed to connect us better. Medline has truly joined the digital age of communication. This is just the beginning. Best regards and follow me on Twitter,

Sue MacInnes, RD Editor

Follow on Twitter: @smacinne Connect on LinkedIn: LinkedIn.com/in/smacinnes

Join 380,000 other nurses for FREE CE courses

At the all-new Medline University ty  220 courses  20 curriculum tracks  Interactive competencies  Flexible access: PC, iPhone, iPad  Free registration

Enroll for free at medlineuniversity.com

CONT E NT S J U N E 2 0 1 3

IN THIS ISSUE 50 Wound Care Case Study: The Use of a Cyanoacrylatebased Skin Barrier in the Protection of the Skin Around a Tracheostomy

8 Infection Control Beware! Do Not Reuse Insulin Pen Injectors on Multiple Patients 16 Healthcare News 19 Patient-centered Care My Anxious Mom and a Nurse Named Wendy

52 Caring for Yourself The Science Behind a Positive Attitude

64 Recipe Lemon Bread

21 Quality Quality Assurance (QA) + Performance Improvement (PI) = QAPI 39 Hotline Hot Topic Choosing the Right Surface for the Right Reason

Forms & Tools 66 Norovirus in Healthcare Fact Sheet 68 Best Practices for Prevention of Medical Device-Related Pressure Ulcers 69 Ultrasound Bladder Scanner Guidelines

Connect with us: facebook.com/MedlineIndustriesInc

vimeo.com/medline

twitter.com/medline or @medline

mkt.medline.com/clinical-blog

pinterest.com/medline

instagram.com/medlineindustriesinc

youtube.com/medlineindustries

Healthy Skin I www.medline.com I June 2013

C O NT R IB U TING WRITERS

Beth Boynton, MS, RN

Beth Boynton is an organizational development consultant specializing in issues that affect nurses and other healthcare professionals. She is a national speaker, coach, facilitator and trainer for topics related to communication, conflict management, team building and leadership development and author of the book, Confident Voices: The Nursesâ&#x20AC;&#x2122; Guide to Improving Communication & Creating Positive Workplaces.

Joyce Norman, BSN, RN, CWOCN, DAPWCA

Joyce Norman has clinical experience in many health care arenas including acute care and home care. For several years, Joyce served as a clinical instructor and an associate faculty member at both Tucson Medical Center ETNEP and Pima Community College. She is a member of the Wound, Ostomy and Continence Nurses Society, and an active officer in the Tucson Affiliate of the WOCN. She graduated from Tucson Medical Centerâ&#x20AC;&#x2122;s ETNEP and is board-certified as a CWOCN.

Wolf Rinke, RD, CSP

Keynote speaker, seminar leader, management consultant, executive coach and editor of the free electronic newsletter Read and Grow Rich, available at www.easyCPEcredits.com. In addition he has authored numerous CDs, DVDs and books including Make It a Winning Life: Success Strategies for Life, Love and Business, Winning Management: 6 Fail-Safe Strategies for Building High-Performance Organizations. Reach him at WolfRinke@aol.com.

Jackie Todd, MBA, BS, RN, CWCN, DAPWCA

Jackie Todd is the Clinical Education Specialist for the Atlantic Division of Medline Industries, Inc. Jackie received her degree in nursing from Elizabethtown College in Elizabethtown, Kentucky and her degree in Healthcare Administration from Bryson University. Jackie has many years of experience in the acute care setting, serving as clinical coordinator of a wound care center in Kentucky. She developed protocols and procedures relating to wound care and has been extensively involved in continuous education program development.

June 2013 I www.medline.com I Healthy Skin

IN FE C T ION C ON T R O L I N S UL I N P EN INJE C TO R S

Review your practices and policy

Take this opportunity to review and monitor the injection practices of your staff in all settings where insulin is administered. Include proper glucose monitoring, insulin administration and proper pen use during orientation and annual educational programs for nursing and pharmacy staff, including agency and contract personnel.

beware!

Additional Resources

Do Not Reuse Insulin Pen Injectors on Multiple Patients Two recent incidents of reuse of insulin pen injectors on multiple patients occurred in January 2013 in two hospitals in New York State that required contacting more than 3,000 patients for HIV, HBV and HCV testing. Infection risk when pen reused on multiple patients

Insulin pen injectors were introduced in 1985 for diabetics to use in the outpatient, community and home settings to give themselves insulin more conveniently, reduce risk of medication errors and increase compliance. These insulin pen injectors are also being used in the inpatient setting with increasing frequency and with ongoing reports of misuse. In the inpatient setting, rather than labeling and using these pens for a single patient, as intended, these pens have been found to be shared among patients with staff changing the needle and reusing them. This reuse exposes subsequent patients to bloodborne pathogens through cross contamination.

Education has not been enough

How can it be that after more than two decades since insulin pens were introduced we are still seeing these pens being used on multiple patients? It only takes one individual who does not know that it is unsafe to replace the needle and then use the insulin pen on another patient to put subsequent patients at risk. We have seen that education, government alerts and staff monitoring have not eliminated this problem. Some hospitals prohibiting insulin pens in inpatient setting

Hospitals are evaluating their policies for insulin pen use with some eliminating them altogether in the inpatient setting. In January, the Veterans Health Administration, for example, issued a patient safety alert that prohibits the use of multi-dose insulin pen injectors on all patient care units with a few exceptions, e.g., patients being educated prior to discharge on their use, part of a research protocol, or when dispensed directly to the patient as an outpatient prescription.

Search for these on the Internet • FDA alert

Risk of transmission of bloodborne pathogens from shared use of insulin pens • CDC clinical reminder

Insulin pens must never be used for more than one person • Veterans Health Administration patient safety alert

Prohibiting multi-dose pen injectors • CDC website

Infection prevention during blood glucose monitoring and insulin administration • Safe injection practices coalition One and Only Campaign

created a poster and brochure for providers as reminder that insulin pens are meant for one person only and should never be shared • Institute for Safe Medication Practices ISMP Medication Safety

Alert: Ongoing concerns about insulin pen reuse in hospitals • Premier Safety Institute

Injection safety website with tools, resources, articles, links to tools from professional associations, and sample policies on injection safety.

Reprinted with permission. SafetyShare newsletter, Premier Inc.

Healthy Skin I www.medline.com I June 2013

1 , 0 2 2 You’re P l Less Li a c e kely to s Get a P res

sure Ul

Where’s your

cer

facility ?

Get results with

Medline’s Pressure Ulcer Prevention Program (PUPP) Tracking and reporting of clinical data – know what works to reduce pressure ulcers at your facility.

Proven Success

Cost-savings analysis – learn how reducing pressure ulcers strengthens your bottom line.

• Average annual savings: $215,190 1

• Average reduction in facility-acquired pressure ulcers: 72.6%1 Source: 1. Data on ﬁle

1-800-MEDLINE l www.medline.com The only way to get PUPP - and PUPP results - starts with a call to Alice Kiehl, PUPP Program Manager, 847-949-2294.

ASK A C NO CAT H Y B O R R I S - H A L E

Getting to

Zero

A Chief Nursing Officer’s Success with Medline’s Pressure Ulcer Prevention Program

Cathy Borris-Hale knows the challenges of providing quality patient care with limited resources. She is Chief Nursing Officer for the Specialty Hospital of Washington – Hadley, a long-term acute care hospital in Washington, DC

10 Healthy Skin I www.medline.com I June 2013

In recent years long-term acute care hospitals have emerged as a new care model for patients recovering from severe acute illness. Long-term acute care hospitals are defined by the Centers for Medicare and Medicaid Services (CMS) as acute care hospitals with a mean length of stay equal to or greater than 25 days. In the post-intensive care unit (ICU) setting, these hospitals act as specialty hospitals for patients requiring prolonged mechanical ventilation and those with other types of chronic critical illness. The clinical and economic burden of patients with chronic critical illness is significant and likely to expand with the aging of the population and advances in critical care that increase patient survival. Long-term outcomes for the chronically critically ill are poor, with substantial need for new approaches to their care, particularly in areas such as pressure ulcer prevention. Looking for solutions to tough patient care issues, Borris-Hale accepted an

that was strategically placed next to her favorite candy – chocolate. After reading the brochure and discussing the program with her Medline rep, Borris-Hale implemented the program in 2010 at Specialty Hospital of Washington – Hadley. Shortly thereafter the hospital’s pressure ulcer rate went to zero, and they have been able to sustain it. “I actually didn’t believe it when my wound care nurses told me we got to zero, so we pulled charts and checked medical records, and found out it was really true,” Borris-Hale said. “We are extremely proud of the significant reduction in our pressure ulcer rates since the implementation of the PUP program.” She added that PUPP was easy to implement in a short amount of time. “Our Medline rep was very supportive and worked with our nursing leadership to fully implement the program. While we offered classes every week, staff also could access the training modules from their home computers, smartphones or at the nurses station. The time and resources spent implementing the program were well worth it, and our outcomes prove that,” Borris-Hale said. The National Institutes of Health (NIH) estimate that one hospital-acquired pressure ulcer costs on average $48,000, not to mention the pain and suffering it causes patients. “That’s a price we were not willing to pay,” Borris-Hale said. Hospital CEO Peter J. Miller attended the PUPP kick-off and also provided strong support throughout the implementation. Borris-Hale said she also began with an excellent wound care team, consisting of Mark Majors, MD; Anne Coles, RN, and Tammy Wade, LPN, both certified in wound care. We were already providing excellent wound care – our vision was to expand our bedside nurses’ capabilities in wound care.”

“Better outcomes occur when better clinical decisions are being made at the bedside.” - Cathy Borris-Hale invitation to Medline’s Prevention Above All conference in New York City in 2010. That’s where she first learned about Medline’s Pressure Ulcer Prevention Program (PUPP) – all because she picked up a brochure

Nurses are also happier because they began to see that their patient care efforts were making a difference and pressure ulcer rates were going down. Borris-Hale believes happier staff leads to happier patients, and the hospital’s patient satisfaction scores increased to 90 percent. Borris-Hale said, “PUPP is more than the sum of its parts – it’s not just the products or the education. Our facility experienced a culture change; a change in the way we treat patients and a change in the way we do business. That’s why we’re at zero and we continue to maintain a rate close to zero.”

June 2013 I www.medline.com I Healthy Skin

A Single Long-Term Acute Care Hospital Experience With a Pressure Ulcer Prevention Program Daniel Young, PT, DPT Assistant Professor; Department of Physical Therapy University of Nevada, Las Vegas Cathy Borris-Hale, MHA, BSN, RN Chief Nursing Ofﬁcer The Specialty Hospital of Washington-Hadley, Washington, DC

Purpose This study describes the experience of a single, long-term acute care hospital (LTAC) with the Medline Pressure Ulcer Prevention Program (mPUPP)

Total Nosocomial PrUs 10 9 8

Methods and Materials Edu ucation • An mPUPP team provided orientation • Education for caregivers who worked at the facility was provided through Medline University®, a web-based suite of interactive educational material • All Patient Care Technicians attended a 4-week 1-hour interactive educational session

7 6 5 4 3 2 1 0 Jan -10 Feb -1 Ma 0 r-1 Ap 0 r-1 0 Ma y-1 Jun 0 -10 Jul -10 Au g-1 0 Sep -10 Oc t-1 No 0 v-1 De 0 c-1 0 Jan -11 Feb -1 Ma 1 r-1 Ap 1 r-1 1 Ma y-1 Jun 1 -11 Jul -11 Au g-1 1 Sep -11 Oc t-1 No 1 v-1 1

Background/Signiﬁcance • The growing light being shed on pressure ulcer (PrU) costs for the people that get them and the health care systems that treat them, has challenged care facilities to look for programs to reduce nosocomial PrU • Each PrU can cost between $700 and $135,000 in medical care related expenses and litigation • Recent evidence suggests that successful PrU prevention programs have common characteristics

Prod ducts • Medline supplied skin care products for cleaning, moisturizing and barrier protection, as well as drypads and briefs for incontinence management Proccess • The facility also implemented: – removal of cloth chuxs from unit supplies – an algorithm for treatment of wounds discovered on admission until they could be seen by a wound nurse The mPUPP was implemented during month 10 and was fully implemented by month 11

12 Healthy Skin I www.medline.com I June 2013

Several variables were analyzed over 24-months: • wound care team assessment completed w/in 72 hrs • total number of wounds treated • total number of PrUs • total number of nosocomial PrUs • debridements performed • total wound care team assessments completed • healed / closed wounds

Continued on page 14

Gentle Enough for Skin of All Ages. Medline Remedy. The Remedies for Sensitive Skin • Hydrating Cleansers, gentle, phospholipid-based and sulfate-free; available as a spray, foam or gel • Nourishing Skin Cream, a blend of emollients including safﬂower seed oleosomes, all-natural oils, plant extracts

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

• Hydraguard, a 24% silicone cream provides a water resistant ﬁlm and smoothes gently on fragile skin • Z-Guard Protectant Paste, formulated with pure white petrolatum and zinc oxide and without potential irritants • Antifungal Clear Ointment, with 2% miconazole nitrate in a clear petrolatum base amended with soothing botanicals.*

1-800-MEDLINE l www.medline.com

Ask for a sample. Start with a trial. Change for the better.

http://goo.gl/njxPY

A Single Long-Term Acute Care Hospital Experience With a Pressure Ulcer Prevention Program

Results • A significant reduction in the mean monthly nosocomial PrU rate pre-program (mean=5.90, SD=2.56) compared to post-program (mean=0.20, SD=0.42), p=<.0001 • No significant changes in the other measured variables • Subjectively staff reported approval for the program and ease of implementation Conclusions • This LTAC experienced a significant reduction in nosocomial PrU following implementation of mPUPP • The lack of significant change in other measure variables indicates that improvements in nosocomial PrU rates were not simply the result of fewer wounds or patients • The results at this facility, from using a program with evidence based components, support previous literature • This reduction in nosocomial PrUs was sustained when rates were examined a year later

Take home points: • The mPUPP was a central piece for a single LTAC, nosocomial PrU reduction program • The implementation of mPUPP at this facility was associated with a significant reduction in the number of nosocomial PrUs • The program was sustainable

Year

Month

2010

January February March April May June July August September October November December

2.7 5.3 3.8 2.2 4.0 3.8 4.0 3.1 1.1 1.0 0.0 0.5

2011

January February March April May June July August September October November

0.5 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0

14 Healthy Skin I www.medline.com I June 2013

Rate per 1000 patient days

PILLOW-LIKE DESIGN Provides comfort and protection

UNIQUE STRAPS Multiple strapping options dependent upon the patient’s needs

COLOR-CODED TAGS For quick size identiﬁcation

OPEN HEEL DESIGN For pressure off-loading and easy clinical checks

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 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 and redistributing pressure along the calf. The open heel design allows for airflow and easy monitoring.

Foot Drop Strapping For enhanced foot drop protection. Pressure, friction and shear are reduced within the area.

Criss-Cross Strapping Firmly isolates the foot while ﬂoating the heel. Pressure, friction and shear are reduced within the area.

http://goo.gl/j94jS 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.

1-800-MEDLINE l www.medline.com Mention this ad to receive a 10% discount on your ﬁrst HEELMEDIX order

HEALTHCARE NEWS

More men entering nursing1 The percentage of male registered nurses increased from 2.7 percent in 1970 to 9.6 percent in 2011, according to data from the American Community Survey, a nationwide study conducted by the U.S. Census Bureau. Men’s representation among licensed practical and licensed vocational nurses rose from 3.9 percent in 1970 to 8.1 percent in 2011. Liana Christin Landivar, the report’s author, said the demand for long-term care and end-of-life services is growing because of the nation’s aging population. “A predicted shortage has led to recruiting and retraining efforts to increase the pool of nurses,” said Landivar, a sociologist in the Census Bureau’s Industry and Occupation Statistics Branch. “These efforts have included recruiting men into nursing.”

FDA Warns Damaged or Worn Mattress Covers Pose Risk of Contamination and Infection

Hospice reduces Medicare costs, hospital use2 Hospice enrollment within 30 days of death or 53105 days of death lowers Medicare expenditures, according to a study in a recent issue of Health Affairs. Hospice enrollment during these periods also lowers hospital and intensive care unit use, 30-day hospital readmissions and in-hospital death, the study found. “Instead of attempting to limit Medicare hospice participation, the Centers for Medicare and Medicaid Services should focus on ensuring the timely enrollment of qualified patients who desire the benefit,” the authors conclude.

References 1. Payne C. Report: more men entering nursing profession. USA Today. February 26, 2013. Available at: http://www.usatoday.com/story/news/nation/2013/02/25/mennursing-occupatins/1947243/. Accessed April 12, 2013. 2. Kelley AS, Deb P, Du Q, Carlson MAD, Morrison RS. Hospice enrollment saves money for Medicare and improves care quality across a number of different lengths-of-stay. Health Affairs. 2013;32(3): 552-561. Available at: http://content. healthaffairs.org/content/32/3/552.abstract. Accessed April 12, 2013.

From January 2011 to January 2013, the Food and Drug Administration (FDA) received 458 reports associated with medical bed mattress covers failing to prevent blood and body fluids from leaking into the mattress. This may occur if mattress covers become worn or damaged from small holes or rips in the fabric or from incorrect cleaning, disinfecting and laundering procedures. The zipper on the cover may also allow fluid to penetrate the mattress. Some reports indicate that if blood and body fluids from one patient penetrate a mattress, they can later leak out from the mattress when another patient is placed on the bed, putting these patients at risk for infection.

Recommendations • Regularly check each medical bed mattress cover for any visible signs of damage or wear such as cuts, tears, cracks, pinholes, snags or stains.

• Routinely remove the medical bed mattress cover and check its inside surface. Once the mattress cover is removed, inspect the mattress for wet spots, staining, or signs of damage or wear. Check all sides and the bottom of the mattress.

• Immediately replace any medical bed mattress cover with visible signs of damage or wear to reduce the risk of infection to patients.

• Do not stick needles into a medical bed mattress through the mattress cover. 16 Healthy Skin I www.medline.com I June 2013

The RESULTS are in THERAHONEY ®

STERILE WOUND DRESSING 100% medical-grade Manuka honey

95% LESS COSTLY THAN OTHER MODALITIES1

% 100 NATURAL

SIMPLE INGREDIENT

Available exclusively from Medline. Call your rep about a trial program today.

PROMOTES AUTOLYTIC DEBRIDEMENT

LOW PLAYS pH NICE

COMPATIBLE WITH SILVERS & SURFACTANTS3 medline.com/pages/therahoney

CAN “JUMP START” STALLED WOUNDS2

PRESCRIPTION OR CO-PAYS

References: 1. Vincencio, G. Honey use in an LTAC, Clinical Beneﬁts and Economics II April 2013. 2. Gethin GT, Cowman S, Conroy RM. The impact of Manuka honey dressings on the surface pH of chronic wounds. Int Wound J 2008;5:185-194 3. Gibson, D., Schultz, G., Silver Containing Dressings, and Certain Wound Cleansers, Do Not Decrease Measurable Sugars in 100% Manuka Honey Gel Dressings. University of Florida, Gainesville. 21 March 2013.

MEDLINE’S REVOLUTIONARY SHOW-AND-TELL PACKAGING

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

Medline’s Educational Packaging offers all the information you need, step by step, short and sweet, to help the Medline dressing do its job of healing. In a study involving 139 nurses at eight different facilities, 88% who used a wound care product with an education guide attached were able to apply the dressing to a wound correctly. None of the nurses who received traditional dressing packaging were able to apply the dressing correctly.1

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

A NU R SE NA ME D W E NDY PATI ENT-CENT ERED CARE

MOM

and a Nurse Named Wendy

Beth Boynton, MS, RN

There is no way I can paint a rosy picture of my mom’s recent hospitalization and subsequent rehab stay for a fractured left upper arm following a fall. She is 91, stubborn, hard of hearing, and has both reasonable and picky expectations. She is smart and pretty astute despite some forgetfulness. Her anxiety has been off the charts and she wants, among other things, to be HOME!

Her panic, hearing deficit, pain and dependence on many new and unfamiliar people all contributed to her confusion and despair. It is very painful for me to see her suffer. But, one story in particular made me cry with gratitude. I had taken her out for a drive and lunch by the river, which is something we always do when I visit her in Florida. We sat feeling the breeze as she shared:

It was late. I couldn’t sleep. I don’t know what time it was. A woman came in and asked me, “Would you like me to sit with you?” I couldn’t see her face, but she sat down and reached for my hand. Something in the way she held and gently squeezed my hand comforted me. We just sat for a bit. I think she told me her name was Wendy. After a while she said she had to go. She came back later. I was able to fall asleep.

I welled up with tears when she told me this story, and do so now as I write about it. This profound example of human caring is as therapeutic as medication, rehab or brain surgery. And we need all of these. Wendy helped my mother feel safe and cared for! Days later, when I tracked her down and thanked her, Wendy smiled and said, “It was nothing!” Nothing? NOTHING?

June 2013 I www.medline.com I Healthy Skin

PAT IE NT- C E NT E R E D C AR E A N UR S E NA ME D W E NDY

This profound example of human caring is as therapeutic as medication, rehab or brain surgery.

It was a huge gift to my mother and her circle of family and friends. And if I can step back from my emotional involvement for a minute, I believe Wendy is an example of what health care should include at every step in every intervention. Or at least more of a priority than it is. Our patients are human beings, and caring for them during times of vulnerability, a privilege. Sometimes we lose sight of this. Maybe some of us lose our way. But not Wendy.

• Valerie, the COTA, was so gentle and such a great listener as she moved my mom’s healing arm through painful exercises and helped her discover hopeful goals for gaining independence. She spoke softly near my mother’s ears, and my mom could hear her.

The emotional intelligence that she used to assess my mother’s fear that night and understand what she needed and then to take the time to be with her is a reflection of her own compassion and brilliance. It also is indicative of an organization that allows her the time and perhaps promotes this kind of intervention. And there were other examples where I could feel kindness and respect extended towards my mom:

• Emily, one of the nurses. When I asked if someone could help me get my mom in the car, she simply took the wheelchair and got my mom into the car.

• Tyrone, the P.T.. engaged her in conversation while working with her. They rode to St. Augustine on an exercise bike, and he encouraged her to walk while holding her hand because that seemed easier for her than using a hemi-walker.

• Cait, the LPN/MDS Coordinator/ Clinical Liaison, listened to my concerns and my mom’s and facilitated a medication change and an informal team meeting. She also handed me the company “Core Values” card so I could formalize my gratitude for Wendy’s efforts that night. (Which I did with my mother!)

• Kayla, one of the CNAs, always smiled and gently listened to what my mother needed and worked to help her.

• Pat, one of the CNAs (I think), was coming in the facility when I was returning. I didn’t even have to ask, and she said, “Need some help?” And then helped get my mom out of the car.

20 Healthy Skin I www.medline.com I June 2013

• Emanual, another CNA NA (I tthink), nudged my mom to join the table for dinner despite my mom’s reluctance, helping her become part of the community. I appreciate every one of you, and I suspect there are others who offered similar support that I didn’t personally observe. These are not small gestures. Please know, I hold you all in deep gratitude and heartfelt respect. We may never eliminate suffering from health care. Perhaps it goes hand in hand with our work. But when we honor patients in authentic caring connections, (like you did, Wendy), it makes a huge difference.

Q A PI Q UALITY

Quality Assurance (QA) + Performance Improvement (PI) = QAPI Transforming the lives of nursing home residents through continuous attention to quality of care and quality of life

What is QAPI? QAPI is the merger of two complementary approaches to quality management, Quality Assurance (QA) and Performance Improvement (PI). Both involve seeking and using information, but they differ in key ways: QA is a process of meeting quality standards and assuring that care reaches an acceptable level. Nursing homes typically set QA thresholds to comply with regulations. They may also create standards that go beyond regulations. QA is a reactive, retrospective effort to examine why a facility failed to meet certain standards. QA activities do improve quality, but efforts frequently end once the standard is met.

PI (also called Quality Improvement - QI) is a pro-active and continuous study of processes with the intent to prevent or decrease the likelihood of problems by identifying areas of opportunity and testing new approaches to fix underlying causes of persistent/ systemic problems. PI in nursing homes aims to improve processes involved in health care delivery and resident quality of life. PI can make good quality even better. QAPI is a data-driven, proactive approach to improving the quality of life, care, and services in nursing homes. The activities of QAPI involve members at all levels of the organization to: identify opportunities for improvement; address gaps in systems or processes; develop and implement an improvement or

corrective plan; and continuously monitor effectiveness of interventions. QAPI builds on QA&A QAPI is not entirely new. It uses the existing QA&A, or Quality Assessment and Assurance regulation and guidance as a foundation. Maybe you recognize some of the statements below as things you are already doing: • You create systems to provide care and achieve compliance with nursing home regulations. • You investigate problems and try to prevent their recurrence. • You track and report adverse events. • You compare the quality of your home to that of other homes in your state or company. • You receive and investigate complaints. • You seek feedback from residents and front-line caregivers.

June 2013 I www.medline.com I Healthy Skin

Q UALIT Y QAPI

• You set targets for quality. • You strive to achieve improvement in specific goals related to pressure ulcers, falls, restraints, or permanent caregiver assignment; or other areas; (for example by joining the Advancing Excellence Campaign). • You are committed to balancing a safe environment with resident choice. • You strive for deficiency-free surveys. Five Elements of QAPI CMS has identified five strategic elements that are basic building blocks to effective QAPI. The five elements are your strategic framework for developing, implementing, and sustaining QAPI. In doing so, keep the following in mind: • Your QAPI plan should address all five elements. • The elements are all closely related. You are likely to be working on them all at once—they may all need attention at the same time because they will all apply to the improvement initiatives you choose. • Your plan is based on your own center’s programs and services, the needs of your particular residents, and your assessment of your current quality challenges and opportunities.

Element 1: Design and Scope A QAPI program must be ongoing and comprehensive, dealing with the full range of services offered by the facility, including the full range of departments. When fully implemented, the program should address all systems of care and management practices, and should always include clinical care, quality of life, and resident choice.

Element 4: Performance Improvement Projects (PIPs) The facility conducts Performance Improvement Projects (PIPs) to examine and improve care or services in areas that are identified as needing attention. A PIP project typically is a concentrated effort on a particular problem in one area of the facility or facility wide.

Element 2: Governance and Leadership The governing body and/or administration of the nursing home develops and leads a QAPI program that involves leadership working with input from facility staff, as well as from residents and their families and/ or representatives.

Element 5: Systematic Analysis and Systemic Action The facility uses a systematic approach to determine when in-depth analysis is needed to fully understand the problem, its causes, and implications of a change. The facility uses a thorough and highly organized/ structured approach to determine whether and how identified problems may be caused or exacerbated by the way care and services are organized or delivered.

Element 3: Feedback, Data Systems and Monitoring The facility puts in place systems to monitor care and services, drawing data from multiple sources. Feedback systems actively incorporate input from staff, residents, families, and others as appropriate.

22 Healthy Skin I www.medline.com I June 2013

The CMS QAPI website can be found at http://go.cms. gov/Nhqapi. Visitors to the site may also email any questions to: Nhqapi@cms.hhs.gov. Source -- QAPI at a Glance: A Step by Step Guide to Implementing Quality Assurance and Performance Improvement (QAPI) in Your Nursing Home

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CE ART IC L E PR ES S UR E UL C ER S

MDR Pressure Ulcers: Who Thought Plastic Tubing Could Be Harmful?

Bony prominences, including the sacrum, coccyx, trochanter, ischial tuberosities, elbows and shoulder blades, are common sites for pressure ulcers to develop. These are areas of risk for all patients, however, those who are inactive or immobile are at even greater risk because they cannot reposition themselves regularly to relieve pressure on these bony prominences.

by Joyce Norman, BSN, RN, CWOCN, DAPWCA

Evelyn is a 71-year-old patient in the intensive care unit with respiratory failure and a past medical history of poorly controlled diabetes. She is ventilated, has multiple lines for fluids and medication, and has a urinary catheter. She is sedated and unable to alert caregivers if something is bothering her. Upon admission, she received a focused skin inspection and risk assessment. Although Evelyn did not have any pressure ulcers, the nurse noted in her chart Evelynâ&#x20AC;&#x2122;s risk factors for developing a pressure ulcer: Decreased circulation due to diabetes Incontinence which can cause a buildup of moisture against the skin Poor nutrition Advanced age Poor sensory perception due to neuropathy Inability to communicate discomfort or pain Immobility

The skin is the largest organ of the body, and most healthcare facilities require a focused skin assessment upon admission and regular skin inspection throughout the patientâ&#x20AC;&#x2122;s stay. Skin breakdown in the form of a pressure ulcer is defined as localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear.

24 Healthy Skin I www.medline.com I June 2013

Not only is Evelyn at risk for pressure ulcers in these common locations, she is also at high risk for developing a medical device-related pressure ulcer (MDRPU) due to her use of a ventilator, tubes for fluids and medications, and a urinary catheter. Often medical devices must be secured tightly to ensure a proper seal, which, in turn creates pressure in unusual areas other than bony prominences. The devices themselves can constantly rub on the skin or remain in the same place too long without being repositioned. Edema may increase, causing a tube that was fitted appropriately at first become too tight over time, leading to undue pressure. Also, humidity and heat can develop between the device and the skin leading to skin breakdown. The presence of moisture enhances the ill effects of friction fivefold.1 The materials used to secure the device (i.e., tape or straps) may also make it difficult to inspect the skin underneath. All of these factors increase the risk of MDRPUs.

THE LOWDOWN ON MEDICAL DEVICE-RELATED PRESSURE ULCERS MDRPUs were described in the literature as far back as 40 years ago, however, they seem to be receiving greater attention today as traditional pressure ulcer rates begin to decline. Despite the recent heightened

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

June 2013 I www.medline.com I Healthy Skin

CE ART IC L E P R ES S UR E UL C ER S awareness of MDRPUs, they are not typically tracked, trended or reported and little research about them exists. 2 MDRPUs occur directly under diagnostic or therapeutic devices or at insertion sites for devices. They tend to progress rapidly, as they often occur Device

over areas with minimal fatty tissue, and the tissue injury typically mimics the device shape. 2 For example, pressure ulcers underneath plastic tubing present as a discolored line on the skin the same height and width as the tubing. Area(s) Affected

Face Masks

Nose, forehead, eyebrows

Nasal Cannula

Ears

Cervical Collar

Chin, jaw, ears

Tracheostomy

Area under trach plate, around ostomy, under straps/ties, under chin.

Pulse Oximetry

Fingers and toes, ears

Endotracheal Tubes

Lips, oral mucosa, mouth, tongue, neck

Nasogastric Tubes

Cheeks, ears, nostrils

Urinary Catheters and Tubing

Thighs, abdomen, lower legs, penis, labia

26 Healthy Skin I www.medline.com I June 2013

Adhesive therapeutic devices such as those affixed to intravenous catheters, nasogastric tubes and urinary catheters, tapes that affix tracheostomy tubes, and adhesive dressings can also irritate susceptible skin.3

Ways to Avoid MDPRUs 1. Assess skin before applying mask. 2. Pad skin.

Commentary (if any) A mask that is too loose will cause air leaks. A mask that is too tight can lead to pressure ulcers. Watch for edema.

1. Use ear protectors on tubing. 2. Check strap tension.

1. Obtain order to remove extrication collar and replace with acute care rigid collar. 2. Change pads in collar every 24 hours.

One study showed that 33 percent of patients who wore a cervical collar less than 5 days developed a pressure ulcer and 55 percent who wore a cervical collar 5 days or more developed a pressure ulcer.2

1. Use thicker, wider non-adherent foam collar strips. 2. Pad under plate and around stoma.

One study showed that 66.7 percent of MDRPUs were secondary to trach ties.2,3

1. Accurately place probe. 2. Rotate sites regularly. 3. Avoid securing too tightly.

In a study of 125 surgical ICU patients, the frequency of injury caused by clip-on pulse oximeters was 5 percent.1

1. Regularly assess skin and mucosa. 2. Regularly rotate position (right, middle, left). 1. Secure tubes so they are free-ďŹ&#x201A;oating in the nares. 2. When patient is on his side, make sure tubing is not against cheek or ear. 1. Avoid use if indwelling catheters as appropriate. 2. Allow tubing slack when securing.

Continued on page 28

Camera not included.

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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. ©2013 Medline Industries, Inc. NE1 is a trademark of Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc. Patent pending.

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CE ART IC L E P R ES S UR E UL C ER S Findings indicate that patients with a medical device are up to four times more likely to develop a pressure ulcer of any kind.1 MDRPUs represent more than one-third of pressure ulcers in acute care.

neuropathy) and/or impaired ability to communicate discomfort, (i.e., oral intubation, presence of language barriers, unconscious, nonverbal) are at highest risk for MDRPUs.

and heels (8 percent).1

Age, gender, admitting diagnosis, body mass index, surgery during hospitalization, edema, diabetes and serum albumin level have been analyzed to determine their association with the development of MDRPUs, however, no unique risk factors of this kind were noted that would allow for identification of patients at risk for MDRPUs. The key risk factor for those who will develop an MDRPU is placement of the medical device itself. 1

WHO IS AT HIGHEST RISK FOR MDRPUs?2

WHY DO MDRPUs DEVELOP?2

Individuals with impaired sensory perception, (i.e., paralysis or

MDRPUs can develop for a number of reasons, including:

A study of acute care patients by The Nebraska Medical Center showed a 5.4 percent overall rate of hospitalacquired pressure ulcers. More than one third were MDRPUs. Most (35 Percent) of the MDRPUs were Stage I, 24 percent were unstageable and three percent were Stage III (full thickness). The most common locations were the ears (35 percent), lower leg (11 percent)

• Rigidity of devices • Difficult to secure or adjust the device to the body • Difficult to safely remove or lift the device to inspect the skin underneath • Increased moisture and heat surrounding the device • Tight securement of the device • Poor positioning or fixation of the device • Inappropriate size of the device • Lack of awareness of the impact of edema • Failure to check tubing • Lack of awareness of the need to remove, reposition and provide basic skin care underneath devices • Lack of best practice guidelines • Lack of standardized practice A study published by Apold and Rydruch in 20122 showed that nearly one-third of reported serious pressure Continued on page 30

Medical devices associated with pressure ulcers - Cervical collars - Bedpans - Endotracheal tubes/tube holders - Face masks for non-invasive positive pressure ventilation - Fecal containment devices - Nasal cannula - Pulse oximetry probes - Radial artery catheters - Compression devices - Splints and braces - Urinary catheters - Wristbands

28 Healthy Skin I www.medline.com I June 2013

Gentle on patients. Tough on exudate. Optiva™ Gentle’s Silitac™ adhesive takes the dread out of dressing changes. Dressing changes can be painful for the patient and traumatic to the skin. But not with Optiva Gentle. This new, super absorbent foam dressing features our unique Silitac™ adhesive on the border of the dressing. This specially formulated silicone adhesive keeps the dressing in place, while allowing you to reposition and remove the dressing without harming the periwound skin. But it’s not only the adhesive the makes Optiva Gentle so gentle... Gently protects – two layers of soft foam plus an absorbant core Gently absorbs – with the superabsorbant Liquitrap™ polymer core Gently retains – moisture is trapped as a gel within the dressing Gently adjusts – keeping the wound environment optimally moist

For samples of the Optiva family of dressings, visit medline.com, contact your Medline representative, or call 1-800-MEDLINE. © 2013 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc., Liquitrap, Optiva and Silitac are trademarks of Medline Industries, inc.

CE ART IC L E P R ES S UR E UL C ER S ulcers were device related; 70 percent of them appeared on the head, face and neck and 20 percent occurred on the heel/ankle/foot.

with team participation is important for training, as well as for the detection, reporting and treatment of related pressure ulcers.3

A 2011 study by Long, Ayer & Borchert of patients in three longterm acute care hospitals showed MDRPUs in similar location.2 Here is a breakdown of the locations of MDRPUs that formed: • 28.1 percent - head and neck • 21 percent - lower leg • 15.5 percent - pelvis • 14.1 percent - foot

Communication and collaboration with other healthcare providers are essential to prevent MDRPUs. For example, nurses can work with occupational therapists to develop a splint that may include padding over bony prominences or restructuring the brace to avoid an already injured area. 1

The MDRPUs were related to the following medical devices: 18.9 percent – Splints, braces, boots 14.7 percent – Tubing, (urine, fecal) 14.7 percent – Respiratory devices Another study by Jaul, also published in 2011, looked at 32 patients in a skilled geriatric long-term care nursing department. Their average age was 71.5 years. All 32 patients were immobile; 91 percent had feeding problems; 80 percent with neurological problems. During the six-month study, 26 new pressure ulcers developed. Six were associated with medical devices. Four of the MDRPUs developed on the back of the neck underneath the strap holding a trach tube in place. Staff treated the ulcers and stabilized the trach tubes. All ulcers healed within about one month. One of the pressure ulcers was located in the urethral meatus next to an indwelling urinary catheter, and the other MDRPU was found in the abdominal wall next to the insertion

Any tube can create pressure no matter where it is. Finding the tube and checking the skin around it is essential to quality nursing care.

site of a percutaneous gastrostomy tube (PEG).

INCREASING STAFF AWARENESS Clinicians are finding the need for more frequent and thorough skin and neurovascular assessments on patients with medical devices. These assessments should include loosening and removing the devices on each shift (if the patient’s medical condition allows) for a thorough inspection. Patients of particular concern are those with a significant amount of edema a already, those at risk for developing edema and immobilized patients with sensory deficits who are unable to feel the increasing pressure or alert the nurse that the device is painful and tight. 1 A multidisciplinary staff and team approach in which each discipline has its own task in the prevention and treatment of pressure ulcers and as a team provides comprehensive assessment of the whole patient appears to be medically advantageous. A weekly multidisciplinary conference

30 Healthy Skin I www.medline.com I June 2013

Respiratory therapists can help nurses make sure the endotracheal tube is moved from one side of the mouth to the other every shift to assess lips, skin on the cheeks, teeth and tongue. Face masks and oxygen tubing should also be removed every 8 to 12 hours to inspect the skin.1 Any tube can create pressure no matter where it is. Finding the tube and checking the skin around it is essential to quality nursing care. While positioning a patient, the key is to know where each tube or monitoring device is and to be certain that the patient is not lying on it. Every tube and/or medical device is the nurse’s responsibility to make sure it does not harm the patient. 1 A 2011 study by Jaul revealed the importance of increasing the level of awareness of MDRPUs among the treating staff and to emphasize caution with the use and placement of medical devices. Tubing should be situated so it is completely visible and cannot pass under the patient’s body. Continued on page 32

Clean Hands

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Proven. Exceeds some of the world’s strictest hand hygiene guidelines.1 Pr Effective. A quick pump kills 99.999% of most germs in 15 seconds.2 Ef Gentle. Skin emollients soften without stickiness. G 1-800-MEDLINE l www.medline.com Contact your Medline representative for a FREE sample or visit our web site for more information

Reference: 1. World Alliance for Patient Safety. WHO Guidelines in Hand Hygiene in Health Care, Global Patient Safety Challenge, Clean Care is Safer Care. 2009. 2. Time Kill Test. Data on file. © 2013. Sterillium is a registered trademark of Bodie Chemie GmbH and distributed by Medline Industries, Inc.

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CE A RT IC L E P R E S S UR E UL C ER S

IMPLICATIONS FOR PRACTICE 2 • Staff education regarding MDRPU risk • Be certain staff know the definition of a “device” • Incorporate prevention measures into policy • Pad under devices as feasible (e.g., silicone, hydrocolloid, foam or liquid filled dressings) • Perform random audits • Examine and report trends • Perform a thorough skin assessment under devices on each shift if not medically contraindicated • Communication and collaboration with other health providers is critical. • Avoid replacing devices on injured skin as appropriate • Follow manufacturer’s guidelines for proper use of medical devices • Report adverse events to the manufacturer • Collaborate with manufacturers to develop more skin sensitive products • Ensure proper sizing (resize with edema) • Use commercially available drain and tube securement devices that can be opened and closed • Be cognizant of areas with minimal or no adipose tissue

BEST PRACTICES 2

LOOKING TO THE FUTURE

• Choose the correct size of medical device(s) to fit the individual • Cushion and protect the skin with dressings in high-risk areas • Remove or move the device daily to assess skin • Avoid placement of device(s) over sites of prior, or existing pressure ulcers • Educate staff on correct device use • Be aware of edema under device(s) • Confirm that the individual is not lying on top of the device(s)

As the U.S. population ages, more and more patients will be admitted to the hospital needing to rely on medical devices to assist with their treatment. The goal is to decrease the risk for MDRPUs by spreading awareness among all staff of their likelihood to develop, providing regular skin assessments, particularly in the areas of the medical devices and working with manufacturers to modify devices so they are less likely to cause pressure ulcers. Additional research into the frequency and types of MDRPUs would also be beneficial, along with the development of universal clinical practice guidelines.

32 Healthy Skin I www.medline.com I June 2013

References 1. Black JM, Cuddigan JE, Walko MA, Diddier LA, Lander MJ, Kelpe MR. Medical device related to pressure ulcers in hospitalized patients. International Wound Journal. 2010; 7(5): 358-365. 2. Baharestani M, Quillen JH. Medical device related pressure ulcers: the hidden epidemic across the lifespan. Presentation on behalf of the National Pressure Ulcer Advisory Panel; February 28, 2013. 3. Jaul E. A prospective pilot study of atypical pressure ulcer presentation in a skilled geriatric nursing unit. Ostomy Wound Management. 2011; 57(2):49-54.

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medline.com The new Medline.com offers you the opportunity customize your experience by selecting your speciﬁc area of interest in healthcare. Choices include: • Hospital • Nursing Home • Home Care/Hospice • Physician Ofﬁce • Surgery Center • HME Provider • Laundry • Lab

All banners, clinical solutions, products and videos are customized to your chosen healthcare setting. The system remembers the setting you choose each time you come back to the site. This saves you from sifting through information that doesn’t apply to you. The new site is also optimized to work well on your mobile Internet device.

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June 2013 I www.medline.com I Healthy Skin

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Updated information about our company, history, leadership and career opportunities.

Direct access to Medline University (MU)

Just click on the link and youâ&#x20AC;&#x2122;ll be connected to MU, Medlineâ&#x20AC;&#x2122;s education site for free continuing education (CE) courses and online access to Medline magazines, Healthy Skin and The OR Connection.

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Opportunities to email us or share content with friends and colleagues through social media. Emails go to Medline employees who are experts in the topic area of your correspondence, and we are committed to getting back to you in a timely fashion.

36 Healthy Skin I www.medline.com I June 2013

New daily blog Visit often for up-to-the-minute acute and post acute care news, tips and perspectives from Medline clinical professionals and guest authors. We welcome your questions and comments to our posts.

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Medline University

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Site design by award-winning designer Deborah Adler who also designed Medline’s advanced wound care packaging that provides product education on every package.

Welcome to the new Medline University, featuring a brandnew look and improved functionality. Based on user feedback, we continue to implement changes to create a better learning environment. Take advantage of new fully customized home pages More customized than ever before, your home page will feature a custom course curriculum, participating program links, and specific courses tailored to your profile type. Streamlined and efficient, the new layout will increase staff participation and promote better outcomes.

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Underbody Warming for All Patients and Procedures For protection from unintentional hypothermia in patients undergoing surgery, PerfecTemp is an excellent alternative to forced-air warming systems. While other systems use disposable blanketss to force nique warm air on top of patients, PerfecTemp’s unique surgical table pads offer: Flexible and durable carbon heating element for uniform heating.

• Efﬁcient underbody warming as effective ass onal forced-air systems for preventing unintentional hypothermia1 (SCIP Measure #10) • Pressure redistribution to aid in pressure ulcer prevention (CMS Hospital-Acquired Condition) • Complete patient access • Silent operation • Reduced staff time • No blowing air

1-800-MEDLINE I www.medline.com PerfecTemp is custom-ﬁt to your table conﬁguration. Ask Medline for a free quote.

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References 1. Egan C, Bernstein E, Reddy D, et al. A Randomized Comparison of Intraoperative Warming With the LMA PerfecTemp and Forced Air During Open Abdominal Surgery. ©2013 Medline Industries, Inc. Medline and PerfecTemp are registered trademarks of Medline Industries, Inc.

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SU PPO RT SU R FA C E S HO TLI NE H OT TOPIC

Support Surface Terminology Overview

Choosing the Right Surface for the Right Reason Jackie Todd MBA, BS, RN, CWCN, DAPWCA

Support surfaces are an integral intervention for both the prevention and treatment of pressure ulcers; however, the terms and definitions associated with support surfaces have been extremely inconsistent for many years. Many groups have attempted compiling a comprehensive set of definitions to help clinicians determine the appropriate support surface based on patient need. The Centers for Medicare and Medicaid Services (CMS) has divided support surfaces into three groups. Support surfaces are generally

designed to either replace a standard hospital or home mattress or as an overlay placed on top of a standard hospital or home mattress. Group 1: Products in this category include mattresses, pressure pads and mattress overlays (foam, air, water, or gel). Group 2: Products in this category include powered air flotation beds, powered pressure-reducing air mattresses, and non-powered advanced pressure-reducing mattresses.

Group 3: Support surfaces are complete bed systems, known as air-fluidized beds, which use the circulation of filtered air through silicone beads. The National Pressure Ulcer Advisory Panel (NPUAP) also has attempted to compile a set of definitions. In 2001 the NPUAP research subcommittee established the Support Surface Standards Initiative or S3I. This group was formed to help fill the need for performance and reporting standards for support surfaces. With the recent affiliation with ANSI/RESNA, S3I

June 2013 I www.medline.com I Healthy Skin

HOTL I NE HO T TO P IC SU PPORT SU RFACE S

becomes the official standards body for the United States. As a result of this expanded role, NPUAP has made S3I a continuing subcommittee under the Research Committee with the charge to implement appropriate standards. Historically we have had many terms and not a lot of clarity, for example, static and dynamic, which refer to conditions or states of activity and ultimately have come to mean powered and non-powered. Also we’ve had the terms pressure reduction and pressure relief. Pressure defines the amount of force over an area and relief indicates weightlessness. Because a person cannot be weightless, they cannot be free of pressure. Therefore, pressure reduction is the preferred terminology. During the review of terminology used across the continuum, it became clear that many other terms were either misused or confusing. A subgroup of S3I was formed to compile a set of terms that provides a common understanding of basic physical concepts, design considerations and product characteristics.

Terms associated with support surfaces The following is a snapshot of the terms associated with support surfaces that will assist clinicians in making informed decisions when choosing support surfaces for their patients.

• Active Support Surface – A powered support surface with the capability to change its load distribution properties, with or without applied load. – The surfaces constantly evaluate the patients weight and position and adjust automatically to maximize weight redistribution. • Air Fluidized Therapy – A feature of a support surface that provides pressure redistribution via fluidlike medium created by forcing air though silicone beads as characterized by immersion and envelopment. • Alternating Pressure – A feature of a support surface that provides pressure redistribution via cyclic changes in loading and unloading as characterized by frequency, duration, amplitude, and rate of change parameters. • Closed Cell Foam – A non-permeable structure with a barrier between cells that prevents gases or liquids form passing through the foam. • Elastic Foam – A type of porous polymer material that conforms in proportion to the applied weight. Air enters and exits the foam cells more rapidly, due to greater density (non-memory). • Fatigue – The reduced capacity for a surface or its components to perform as specified. This change

40 Healthy Skin I www.medline.com I June 2013

may be the result of intended or unintended use and/or prolonged exposure to chemical, thermal, or physical forces. – Support surfaces should be inspected daily with hand checks to help evaluate for bottoming out. Surfaces also should be checked regularly for compromise of cover integrity to prevent internal contamination. • Friction (Frictional Force) – the resistance to motion in a parallel direction relative to the common boundary of two surfaces. – The greater the perpendicular force or pressure at the same time as the parallel force, the greater the risk for skin damage. • Gel – A semisolid system consisting of a network of solid aggregates, colloidal dispersions or polymers which may exhibit elastic properties (can range from hard gel to soft gel). • Integrated Bed System – A bed frame and support surface that are combined into a single unit whereby the surface is unable to function independently. • Lateral Rotation – A feature of a support surface that provides rotation along a longitudinal axis as characterized by degree of patient turn, duration, and frequency.

Continued on page 42

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Contact your Medline Sales Representative today or call 1-800-Medline.

HOTLINE HO T TO PIC SU PPORT SU RFA C E S

• Low Air Loss – A feature of a support surface that provides a flow of air to assist in managing the heat and humidity (microclimate) of the skin. – Most low air loss surfaces are designed to also detect patient weight and position change in order maximize weight redistribution while maintaining an optimum microclimate. • Mattress – A support surface designed to be placed directly on the existing bed frame. – Mechanical Load – External force applied to the skin as a result of contact with another surface. Examples: • Pressure – Perpendicular to the skin surface. • Friction – Mechanical surface damage caused by skin rubbing against another surface. • Shear – Mechanical force parallel to another area. – Magnitude and time are indirectly proportional

• Non-Powered – Any support surface not requiring or using external sources of energy for operation. • Open Cell Foam – A permeable structure in which there is no barrier between cells, and gases or liquids can pass through the foam. • Overlay – An additional support surface designed to be placed on top of an existing surface. • Powered – Any support surface requiring or using external sources of energy for operation. • Pressure – The force per unit area exerted perpendicular to the surface. – Measured in pounds per square inch (psi). – Affected by immersion and envelopment, weight distribution and tissue composition.

42 Healthy Skin I www.medline.com I June 2013

• Pressure Redistribution – The ability of a support surface to distribute load over the contact areas of the human body. (This term replaces prior terms pressure reduction and pressure relief.) – The amount of skin to surface contact, along with immersion and envelopment, determines the degree of redistribution. • Self-Adjusting or Reactive Support Surface – A powered or nonpowered support surface with the capability to change its load distribution properties only in response to applied load. • Viscoelastic Foam – A type of porous polymer material that conforms in proportion to the applied weight. The air exits and enters the foam cells slowly, which allows the material to respond slower than a standard elastic foam (memory foam).

Continued on page 46

Don’t let your CNAs hang up their Scrubs! Reduce turnover

NAHCA

has the answer Together, the National Association of Health Care Assistants (NAHCA) and Medline are changing the employment landscape for nursing assistants through innovative programs that support leadership development. Care centers that join NAHCA have reported a 25 percent annual increase in retention translating to an estimated cost savings of $42,000.1 Medline is the proud sponsor of the NAHCA Annual Conference in Oklahoma City, June 19-20. For more information go to NAHCAcareforce.org.

To ﬁnd out more about membership, contact your Medline Sales Representative or visit us at Medline.com/NAHCA

www.medline.com/nahca

Documentation on ﬁle with NAHCA

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

Make the change to

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

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

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

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

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

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

HOTL INE HO T TO P IC SU PPORT SU RFAC E S

Are you facing a skin or wound care challenge with a patient or resident and need more clinical information? Call Medline’s Educare Hotline at 1-888-701-SKIN (7546) to speak with one of our clinical nurses Monday through Friday, 8 am to 5 pm CST.

Choosing a support surface Decisions about which support surface to use should be based on cost considerations and an overall assessment of the individual, including: • Identified level of risk • Skin assessment • Comfort • General health/comorbid conditions • Mobility As with any clinical decision, many other components must be taken into consideration when making support surface recommendations and some may not be appropriate for use in all circumstances. Decisions must take into account: • Available resources • Local services, policies and protocols • The patient’s circumstances and wishes • Available personnel and devices • Experience and knowledge of the end user

Sources Centers for Medicare and Medicaid Services, Available at: www.cms.gov/supportsurfaces. Accessed April 29, 2013. National Pressure Ulcer Advisory Panel (NPUAP) (2007). “Support Surface Standards Initiative: Terms and Definitions Related to Support Surfaces.” Available at www.npuap.org. Accessed April 29, 2013. Jordan RS. Pressure Redistribution: multiple methods are under development to test: the efficacy of therapeutic support surfaces. Advance for Long Term Care Management. 12/2012 Bergstrom N, Allman RM, Carlson CE, et al. (1992). Pressure Ulcer in Adults: Prediction and Prevention.Clinical Practice Guideline. No.3. Rockville, MD: U.S. Department of Health and Human Service. Public Health Service Agency, Agency for Health Care Policy and Research. AHCPR Publication No. 92- 0050. Bergstrom N, Bennett MA, Carlson CE, et al. (1994). Treatment of Pressure Ulcers. Clinical Practice Guideline, No. 15. Rockville, MD: U.S. Department of Health and Human Services. Public Health Service Agency, Agency for Health Care Policy and Research. AHCPR Publication No. 95-0652.

46 Healthy Skin I www.medline.com I June 2013

Wound, Ostomy and Continence Nurses Society (WOCN). Guidelines for Prevention and Management of Pressure Ulcers: WOCN Clinical Practice Guideline Series. 2010. Glenview, IL: Wound, Ostomy and Continence Nursing Society. Langemo D, Cuddigan J, Baharestani M, Ratliff CR, Posthauer ME, Black J, Garber S. Pressure ulcer guidelines: “minding the gaps” when developing new guidelines. Advances in Skin and Wound Care. 2008; 21 (5): 213-217. Posthauer ME, Jordan RS, Sylvia C. Support surface initiative: terms, definitions, and patient care. Advances in Skin and Wound Care. 2006;19 (9): 487- 489.

Quality Assurance System

Admit it. A reputation of high rehospitalizations is hard to shake. To reduce their avoidable hospitalization rates and the accompanying ďŹ nancial penalties, hospitals will be looking at where those readmissions are coming from. Is it you? Can you show your facility is doing the right things?

abaqis is the answer. The abaqis quality management system helps you track readmission trends to determine and correct root causes. Because if you worry about your reputation, it means you have a reputation to worry about.

To connect with an abaqis specialist in your area, call Gloria at 847-643-3537. http://goo.gl/aKhrk

1-800-MEDLINE

| medline.com

ÂŠ2013 Medline Industries, Inc. abaqis is a registered trademark of Providigm, LLC. Medline is a registered trademark of Medline Industries, Inc.

Readmissions can hurt.

INTERACT can help. ®

WHAT IS INTERACT? INTERACT, which stands for “Interventions to Reduce Acute Care Transfers,” is a quality improvement program designed to improve the identification, evaluation and communication about changes in resident status in an effort to reduce potentially avoidable hospitalizations of nursing home residents.

48 Healthy Skin I www.medline.com I June 2013

http://goo.gl/0gZ8w

GOALS OF INTERACT improve care and reduce  Topreventable hospital transfers improve the management of  Toresidents with a change in condition

THE IMPACT OF INTERACT 1

Hospital transfers are common and often result in complications in older nursing home residents

Some hospital transfers are preventable

Care can be improved, resulting in fewer complications and reduced cost

Financial and regulatory incentives are changing

Using INTERACT can lower the rate of unnecessary 1 hospitalization by

24%

Cost savings to Medicare can be shared with nursing homes to further improve care

Available Now! Comprehensive training courses to implement INTERACT at your facility INTERACT Basic Training Build skills and competencies on these evidencebased and expert-recommended interventions designed for everyday practice in long-term care. • Overview of INTERACT • Introduction to all INTERACT quality improvement tools • Tracks for nurses, CNAs, administrators

INTERACT Implementation Training Curriculum • Learn key strategies for implementing and sustaining INTERACT • Find out how to partner and interact with local hospitals • Master the tools that support INTERACT • Call 1-800-MEDLINE for fee structure

• FREE!

1. Ouslander JG, Lamb G, Tappen R, Herndon L, Diaz S, et al. Interventions to reduce hospitalizations from nursing homes: evaluation of the INTERACT II collaborative quality improvement project. J Am Geriatr Soc. 2011;59(4):745-53



CASE STUDY C YAN OAC RY LATE - BAS E D S K I N B A R R I E R

The Use of a Cyanoacrylate-based Skin Barrier* in the Protection of the Skin Around a Tracheostomy Martha Ondrejko, BSN, RN, CWOCN Kindred Hospital, Denver, CO

Introduction The creation of a tracheostomy to ease breathing is associated frequently with leakage of fluids onto intact skin around the insertion point. Such constant exposure to fluids tends to corrode skin putting patient welfare at risk. In patients with more challenging peristomal tracheostomy issues, we have found that traditional interventions are unable to manage this usually intractable problem. We have had remarkable results with a new skin barrier based on medical superglue (cyanoacrylates) in other skin protection applications and this knowledge led us to consider a trial on a convenience sample of eleven patients with skin damage around the tracheotomy insertion site. Such patients are frequently admitted in our Long Term Acute Care (LTAC) facility. Methods Upon admission, with any evidence of skin damage around the puncture wound, we assessed the extent of the skin damage, and then applied the Cyanoacrylate* per the instruction for use on the “at risk” or damaged skin, taking care not to get the material into the airway. The skin protectant was re-applied as needed. Skin health was noted on patient charts and photographic images were captured.

Discussion Of the eleven patients treated with the cyanoacrylate skin barrier to the peri-tracheostomy sites, five were male and six female. The average age of these long-term acute care patients was 65 with a range of 36-79 years of age. Initially, the cyanoacrylate was applied three times per week, but with staff comfort and familiarity, we felt that two times per week was adequate frequency of application. The days to discontinuing the cyanoacrylate averaged 12.5, with one outlier of 53 days. Considering the other 10 patients, the average to discontinuing the cyanoacrylate was only 8.5 days. The average Braden score for this study group was 14.2, which is considered “Moderate Risk” for pressure ulcer development. Among the comorbidities are diabetes, COPD, nutritional support, CVA, developmental issues, s/p liver transplant, vasopressors and kidney disease and GERD.

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Results and Conclusion Skin improvement was observed for all 11 patients enrolled in this study. The details on the medical conditions of the patients are shown in Table 1. We found that the skin protectant did not cause pain or stinging, and dried in usually less than a minute. Application of the barrier still allowed easy routine care using normal saline and gauze in every shift. We found that the polymeric fi lm does disappear over time, primarily during the process of wiping down body fluids leaking around the breathing device. We did not notice any problems around the ingress of the barrier, either during application, or between applications, into the airways. This product is one we may consider as an alternative skin protectant in management of tracheostomy peristomal skin challenges. Cyanoacrylates are a new class of skin protectant and our primary concern is patient safety. In this multipatient study we did not find any adverse events. Nursing care time was significantly reduced in our opinion during the use of the cyanoacrylates, and we would like to propose a health economic study to determine the nature of savings that this type of advanced product can bring into the care of nosocomial conditions.

End size

Days

Start size (length x width) 1.9 x 0.5

0.6 x 0.3

PreAlbumin 15

1.1 x 2

1 x 1.5

1x4

0.4 x 0.1

0.5 x 2.2

Initials

Age

Gender

Albumin

Braden

Co-morbidities

2.1

MVA, respiratory failure, multiple cardiac arrests, CVA

2.2

CVA, aspiration pneumonia, Chronic Kidney dx, DM2

1.8

0.3 x 0.8

2.3

2x2

0.8 x 0.8

1.9

2.5 x 0.9

0.5 x 0.3

2.5

CP, mental retardation, dysphagia, Failure to thrive, peritonitis, vasopressors, TPN Hepatitis, cirrhosis, s/p liver transplant, sepsis, ARDS, GERD, breast cancer Upper GI bleed, hemorrhagic shock, perforated hernia, vasopressors, TPN Necrotizing MRSA pneumonia, seizure disorder, DM, Hyperlipidemia

1x1

0.5 x 0.6

2.9

1.3 x 0.6

0.9 x 0.1

3.2

1.4 x 0.4

0.8 x 0.2

2.7

2x4

0.9 x 0.1

2.9

2.5 x 0.6

0.8 x 0.3

1.9

5M 6F

12.5

16.4

2.4

14.2

CHF, sepsis, vasopressors, pneumonia, COPD, tobacco abuse, PEG/TF Seizure, aspiration pneumonia, pulmonary edema, developmentally delayed, PEG/TF MVA, multiple orthopedic injuries, VAP, A. Fib, tardive dyskinesia, heavy tobacco use, NGT/TF COPD, pneumothorax, HTN, tobacco use, NGT/TF Thrombolytic occlusion, alvelor hemorrhage (Aspergillus), CVA, CHF, splenectomy, PEG/TF

References

D.B. 3/11/13

E.M. 2/21/13

Milne CT, Valk D, Mamrosh M. Evaluation of a cyanoacrylate protectant to manage skin tears in the acute care population. Symp. Adv. Wound Care. April 2010; Orlando, FL.

Milne CT: The role of cyanoacrylates in the prevention of superficial tissue injury. Symp.Adv. Wound Care. April 2008; San Diego, CA.

Milne CT, Saucier D, Trevellini C, Smith J: Evaluation of a cyanoacrylate dressing to manage peristomal skin alterations under ostomy skin barrier wafers. J Wound Ostomy Continence Nurs 2011; 38(6) 676-679.

Ratliff CR, Dixon M. What to do if an ostomy pouch wonâ&#x20AC;&#x2122;t stick. Presentation at the Wound Ostomy Continence Nurses Annual Meeting, June 2011, New Orleans, LA.

Neiswender L, Cyanoacrylates in neonatal and infant peristomal skin damage. SAWC. April 2011, Dallas, TX.

Van Gils CC, Anderson N. The use of cyanoacrylate skin protectant to treat periwound maceration in combination with negative pressure wound therapy in the treatment of neuropathic foot ulcers. SAWC.April 2011, Dallas, TX.

Vlahovic TC, Hinton EA, Chakravarthy D, Fleck CA. A review of cyanoacrylate liquid skin protectant and its efficacy on pedal fissures. J. Am. Coll. Cert. Wound Spec. 2010 (2) :79-85.

D.B. 3/21/13

E.M. 3/7/13

June 2013 I www.medline.com I Healthy Skin

CARI NG FO R YO U R S ELF POSITIVE ATT I T UD E

the science behind a

positive attitude

52 Healthy Skin I www.medline.com I June 2013

Wolf J. Rinke, PhD, RD, CSP

You may consider much of the positive attitude literature a bunch of hype or even psychobabble. With this article my goal is to have you consider the science, and perhaps change your perceptions about this topic, which has the potential to help you, your patients and loved ones live a healthier, more productive and longer life.

Positive Attitude and the Mind-Body Connection Scientists and physicians have explored the mind-body connection since the days of Hippocrates, the father of medicine. However, Western medicine got off to a wrong start when, in the seventeenth century, René Descartes, philosopher and founding father of modern medicine, made a deal with the Pope. You see, Descartes had a dilemma. He needed human bodies for dissection to be able to study and teach medicine. However, the Pope was not interested in giving up those bodies because the church was in charge of the soul, the mind and the emotions. So Descartes agreed that he would not in any way trespass on the church’s exclusive jurisdiction as long

as he could have the physical parts of the human body for his study. This resulted in Western medicine splitting the human body into two separate dimensions—psyche, the mind, and soma, the body—which has pervaded every scientific inquiry for the past two centuries. And it influences much of our thinking to this date. However, change—may it ever be so gradual—is taking place.

What Are Psychosomatic Illnesses? The term psychosomatic is from the Greek words psyche, which means mind, and soma, which means body. According to Mosby’s Medical Dictionary, psychosomatic illnesses, also known as psycho physiologic

disorders, refer to any of a large group of mental disorders that is characterized by the dysfunction of an organ or organ system controlled by the autonomic nervous system and that may be caused or aggravated by emotional factors. Included in this category are such common ailments as tension headaches, body pains, upset stomachs, and more serious conditions such as depression, asthma, peptic ulcers, rheumatoid arthritis, hypertension and neurodermatitis. Some physicians even include cancers. These ailments and diseases are so common that Dr. Herbert Benson, founder of the Mind Body Medical Institute at the Beth Israel Deaconess Medical Center in Boston, and author of “Timeless Healing and the Relaxation Response,” stated in a Good Morning America interview that “...60 to 90 percent of visits to healthcare professionals are in the stress-related mind-body realm where surgery doesn’t work, where medications don’t work.” Since then, numerous studies have demonstrated the importance of a positive attitude on one’s perception of well-being, wellness and health.

Positive Attitude and Health One example of the impact of a positive attitude on healing is a double-blind, randomized study of surgical patients undergoing hysterectomies. This study, which was reported in the prestigious British medical journal Lancet, found that patients who received positive messages during general anesthesia

June 2013 I www.medline.com I Healthy Skin

CARING FO R YOU R S ELF POSITIVE AT T I T UD E

“spent significantly less time in [the] hospital after surgery, suffered from significantly shorter period of pyrexia [fever], and made a better than expected recovery” in comparison with the group that received no such messages.

“

Research shows that when people work with

And optimism even appears to offer some level of protection from cancer. According to Sharot, “a study of cancer patients revealed that pessimistic patients younger than age 60 were more likely to die within eight months than non-pessimistic patients of the same initial health, status, and age.” Similarly, a study of almost 100,000 woman found that optimists had a 16 percent lower risk of having heart attacks, leading the researchers to conclude that “Optimism and cynical hostility are independently associated with important health outcomes in black and white women.”

a positive mindset, performance on nearly every level—productivity, creativity, engagement— improves.

”

A positive attitude can even reduce the incidence of strokes. Researchers at the University of Texas Medical Branch at Galveston reported that individuals who had a positive outlook in their later years had far fewer strokes than their negative counterparts. This major study of 2,478 men and women older than age 65 who were followed for seven years concluded “elderly folks who often feel blue tend to have more strokes than those who are not depressed.”

Positive Attitude and Longevity How you express yourself may even predict how long you will live. An analysis of brief autobiographies written more than 60 years ago by a group of then-young Catholic nuns—who were participating in a study on aging and Alzheimer’s disease—revealed that those nuns who chronicled positive emotions in their 20s have lived markedly longer than those who recounted emotionally neutral personal histories. Deborah D. Danner of the University of Kentucky in Lexington and her colleagues analyzed positive emotional content in life stories written by 180 nuns when they were, on average, 22 years old. The scientists then noted which nuns had died and when. Nuns whose stories contained the most sentences expressing any of 10 positive emotions lived an average

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of 7 years longer than those whose accounts included the fewest such sentences. The researchers also found that longevity increased by 9.5 years for nuns whose life stories contained the most words referring to positive emotions and by 10.5 years for nuns who used the greatest number of different positive emotion words. Optimistic people live 19 percent longer than pessimists, according to a 30-year study conducted at the Mayo Clinic. The study, which evaluated 839 people living in Minnesota, found that people classified as optimists had a significantly better survival rate, while pessimists had a 19 percent increase in the risk of death. These findings, according to Maruta, the lead researcher in the study, “Tell us that mind and body are linked and that attitude has an impact on the final outcome, death.” Similarly, a 25-year longitudinal study of 660 people conducted at Yale University found that a positive attitude about old age was more important than wealth, gender and even cholesterol levels in determining how long people lived. In fact, people who had positive self-perceptions about aging lived 7.5 years longer than those who dreaded the thought.

Continued on page 56

Program for Healthcare One-on-one sustainability guidance and services The greensmart approach for reaching your unique goals:

Measure Your Baseline

1 2

From calculations to benchmarking, your greensmart RoadMAP provides all the tools you need to green your OR, Housekeeping, Laundry, Food Services and Patient Rooms.

Receive One-on-one Consultation You will receive personal assistance from your dedicated greensmart Program Manager.

Identify Green Products and Strategies

With the help of your Program Manager, you will identify products, services and education that are right for your facility.

Monitor and Promote You are given the tools to not only monitor your progress, but to promote your success.

ONE CALL STARTS YOU ON YOUR WAY TO BECOMING GREENSMART Francesca Olivier, Medlineâ&#x20AC;&#x2122;s corporate sustainability manager, is ready to work with you no matter where your facility is on your sustainability journey. Call her at (847) 643-3821 or email folivier@medline.com

medline.com/pages/green/greensmart ÂŠ2013 Medline Industries, Inc. greensmart is a trademark and Medline is a registered trademark of Medline Industries, Inc.

CARING FO R YOU R S ELF POSITIVE AT T I T UD E

Positive Attitude and Performance It seems that positivism even impacts individual and organizational performance. For example, an article in the Harvard Business Review concluded, “Research shows that when people work with a positive mindset, performance on nearly every level— productivity, creativity, engagement —improves.” In another study, researchers recorded how people express themselves in company meetings, and then take a ratio of positive to negative statements. (That is referred to as the Losado Ratio.) They found that “Companies with better than a 2.9:1 ratio for positive to negative statements are flourishing. Below that ratio, companies are not doing well economically.” On a more personal level, another researcher used the same statistic by listening to couple’s conversations and found that a Losado Ratio of 2.9:1 means that couples are headed for a divorce, while a 5:1 ratio is predictive of a strong and loving relationship.

Positive Attitude and Diseases and Illnesses These studies represent only the tip of the iceberg. Studies increasingly link attitude to the body’s propensity to ward off disease and illness. An entire new branch of medicine—referred to as psychoneuroimmunology—has been established. One of these scientists,

Dr. Candace Pert, research professor in the Department of Physiology and Biophysics at Georgetown University Medical Center and pioneer in the mind-body connection, has concluded that, “Virtually all illness … has a definite psychosomatic component … [and that] the molecules of emotion run every system in our body … this communication system is in effect a demonstration of the bodymind’s intelligence, an intelligence wise enough to seek wellness, and one that can potentially keep us healthy and disease-free … .”

It Can’t Cure Disease Before I conclude I would like to express a word of caution. What I have said in this article is that your attitudes, your thoughts, your feelings and your emotions influence your well-being, your health and probably even your longevity. I am convinced that what goes on inside of your head will control your future. It is, however, much less likely to affect what has happened in the past or what is happening in the present. In other words, if you have cancer or some other serious disease you cannot just think positive thoughts and make the disease go away! In fact, one author who suffered from cancer makes a compelling point that when tragedy strikes, anger, fear and depression are reasonable responses. And telling someone to just “think positive thoughts” may indeed be

56 Healthy Skin I www.medline.com I June 2013

counterproductive. What you need to do is get expert medical treatment. Once you have received such treatment, you can use your incredible positive attitude as adjunct therapy to help you get better faster. You can also continue that type of positive programming after you have conquered the illness or disease and very likely decrease the probability of recurrence.

A Continence Management Program That’s as Unique as Your Residents 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. The program includes: • RN/LPN workbook (with 4 CE credits available through www.medlineuniversity.com) • CNA workbook • Reproducible care plans, assessment guidelines and other quality assurance tools

Learn more about the Medline Continence Management Program. Scan the QR code or call 1-800-MEDLINE. http://goo.gl/92D9j

F EATURE SUN SAFE TY

Sun safety is never out of season season. Summer’s arrival means it’s time for picnics, trips to the pool and beach … and a spike in sunburns. But winter skiers and fall hikers need to be as wary of the sun’s rays as swimmers do. People who work outdoors need to take precautions as well.

: y t e f a S n u S

58 Healthy Skin I www.medline.com I June 2013

w o H

! n i k S r u o Y e v a S to

he need for sun safety has become clear over the past 20 years, with studies showing that excessive exposure to the sun can cause skin cancer. Harmful rays from the sun—and from sunlamps and tanning beds — may also cause eye problems, weaken your immune system, and give you unsightly skin spots and wrinkles, or “leathery” skin. Sun damage to the body is caused by invisible ultraviolet (UV) radiation, which reaches us as long wavelengths known as UVA and short wavelengths known as UVB. UVB radiation can cause sunburn. But the longer wavelength UVA is dangerous too, as it can penetrate the skin and damage tissue at deeper levels.

Tanning is a sign of the skin reacting to potentially damaging UV radiation by producing additional pigmentation that provides it with some—but not nearly enough—protection against sunburn. No matter what our skin color, we’re all potential victims of sunburn and the other detrimental effects of excessive exposure to UV radiation. Although we all need to take precautions to protect our skin, people who need to be especially careful in the sun are those who have: • pale skin • blonde, red or light brown hair • been treated for skin cancer • a family member who’s had skin cancer

June 2 2013 013 01 3 I ww www.medline.com ww. w me m dline.com I Healthy Skin

F EATURE SUN SAFE TY

If you have an illness and take medicines, ask your doctor about extra sun-care precautions, because some medications may increase sensitivity to the sun. Cosmetics that contain alpha hydroxy acids (AHAs) also may increase sun sensitivity and susceptibility to sunburn. Look for FDA’s recommended sunburn alert statement on products that contain AHAs. Reduce time in the sun This is especially recommended from 10 a.m. to 4 p.m., when the sun’s rays are strongest. Even on an overcast day, up to 80% of the sun’s UV rays can get through the clouds. Stay in the shade as much as possible throughout the day. Dress with care Wear clothes that protect your body. Cover as much of your body as possible if you plan to be outside on a sunny day. Wear a wide-brimmed hat, long sleeves and long pants. Sun-protective clothing is now available in stores. However, FDA does not regulate such products unless the manufacturer intends to make a medical claim. Consider using an umbrella for shade. Be serious about sunscreen Check product labels to make sure you get: • a “sun protection factor” (SPF) of 15 or more—SPF represents the degree to which a sunscreen can protect the skin from sunburn. The higher the number, the better the protection. • “broad spectrum” protection—sunscreen that protects against UVA and UVB. • water resistance—sunscreen that stays on your skin longer, even if it gets wet. “Water-resistant” does not mean “waterproof.” Water-resistant sunscreens need to be reapplied as instructed on the label. Tips for applying sunscreen • Apply the recommended amount evenly to all uncovered skin, especially your lips, nose, ears, neck, hands, and feet. • Check the label for the correct amount of time to apply it before you go out. • If the label doesn’t give a time, allow about 15 to 30 minutes. • If you don’t have much hair, apply sunscreen to the top of your head, or wear a hat. • Reapply at least every two hours. Read the label to see how often. • Give babies and children extra care in the sun. Ask a doctor before applying sunscreen to children under 6 months old. • Apply sunscreen to children older than 6 months every time they go out. Continued on page 62

60 Healthy Skin I www.medline.com I June 2013

OPTILOCK

™

The key to locking away exudate • Wound ﬂuids—even heavy exudate—are locked away to prevent maceration • Non-adherent contact layer doesn’t stick—for greater patient comfort • Fewer dressing changes required—better for patients and staff

Need a better dressing to manage drainage? Consider Optilock for heavily draining wounds in your care. Arrange for a sample and trial with your Medline representative.

http://goo.gl/fmftS

FE ATURE SUN SA FE TY

Don’t forget the eyes Sunlight reflecting off snow, sand or water further increases exposure to UV radiation, increasing your risk of developing eye problems such as cataracts. Long hours on the beach or in the snow without adequate eye protection also can result in a short-term condition known as photokeratitis, or reversible sunburn of the cornea. This painful condition--also known as “snow blindness”—can cause temporary loss of vision. • When buying sunglasses, look for a label that specifically offers 99100% UV protection. This assures that the glasses block both forms of UV radiation. • Eyewear should be labeled “sunglasses.” Be wary of dark or tinted eyewear sold as fashion accessories that may provide little or no protection from UV or visible light. • Don’t assume that you get more UV protection with pricier sunglasses or glasses with a darker tint. • Be sure that your sunglasses don’t distort colors and affect the recognition of traffic signals. • Ask an eye care professional to test your sunglasses if you’re not sure of their level of UV protection. • People who wear contact lenses that offer UV protection should still wear sunglasses. • Consider that light can still enter from the sides of sunglasses. Those that wrap all the way around the temples can help. • Children should wear real sunglasses—not toy sunglasses—that indicate the UV protection level. Polycarbonate lenses are the most shatter-resistant.

So-called “tanning pills” No tanning pills of any kind have been approved by FDA. However, there are companies that market products they call “tanning pills.” Some of these pills contain a color additive known as canthaxanthin, which, when ingested, can turn the skin a range of colors from orange to brown. Canthaxanthin is only approved for use as a color additive in foods and oral medications, and only in small amounts. Dihydroxyacetone (DHA) Some tanning sprays contain DHA, a color additive that interacts with the dead surface cells in the outermost layer of the skin, to darken skin color. It is commonly used in “sunless tanning” lotions, creams, and spray-on products. DHA is approved by FDA for use in coloring the skin, but it is limited to external application. The industry has not provided safety data to FDA to consider approving it for other uses, such as applying it to your lips or the area of your eyes, or inhaling it. Therefore, the risks, if any, are unknown. FDA recommends that if you visit a spray tanning salon, take precautions to protect your eyes and lips and avoid inhaling the spray.

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Some tanning products on the market do not contain sunscreen. FDA requires these products to carry a warning statement. Check for skin cancer Check your skin regularly for signs of skin cancer. Look for changes in the size, shape, color or feel of birthmarks, moles and spots. If you find any changes or find sores that are not healing, see your doctor. Source: U.S. Food and Drug Administration

B E G I N S J U LY 1 What you can do to get ready! 1 Get consent from your facility 2 Gather your friends and coworkers to participate 3 Start practicing

Watch for further details and song choices at

pinkglovedance.com

Follow us on Facebook and Twitter ÂŠ2013. Medline Industries, Inc. Medline and Pink Glove Dance are registered trademarks of Medline Industries, Inc.

RE CIPE LEMO N BRE AD

Nutrition Information Servings: 12 Fat: 9.6 g Fiber: 9.1 g Calories: 229 per slice Sodium 27 mg

Lemon bread Rachel Druschel has worked for Medline for seven years. She was a sales representative in Indianapolis for five years, and for the past two years she has been serving as director of sales training at Medline’s corporate headquarters in Mundelein, IL. Her lemon bread comes from a family recipe that her grandma “Bubba” makes for all of their family functions. “I hope it wasn’t a secret recipe!” Rachel joked.

For topping: Mix sugar and lemon juice together before starting bread. Set aside. You will pour this mixture over the bread as it is cooling.

“Cooking is a great thing to do to take a break from the stress of life. Many people work out to relieve stress, but for me, working out is when I work through my problems; however, when I cook nothing else seems to matter. I enjoy cooking for friends and family—and even strangers,” she said. 2

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Ingredients for bread: ½ cup butter, margarine or other shortening 1 cup sugar 2 eggs 1½ cups ﬂour 1½ teaspoons baking powder Pinch of salt 1 lemon rind, grated ½ cup milk Directions

Rachel said she loves cooking and especially enjoys using a recipe as a guide – not following it exactly, and making the meal her own.

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

Ingredients for topping: ¼ cup sugar Juice of 1 lemon

For bread: Stir together flour and baking powder. Cream shortening and sugar. Add eggs one at a time and beat well. Add pinch of salt and lemon rind. Alternate adding flour mixture and milk into the cream mixture. Pour batter into a greased and floured loaf pan. Bake at 350 degrees F for 40-45 minutes. Place bread on cooling rack, and then pour the topping over the bread as it cools. Do not put the bread back in the oven after you have poured on the topping.

F O R M S & TOOLS

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

Infection Prevention Norovirus in Healthcare Fact Sheet………………………………………...…66 Professional Guidelines Best Practices for Prevention of Medical Device-Related Pressure Ulcers ……………………… ……………………………………...…68 Ultrasound Bladder Scanner Guidelines……………………………….…...…69

June 2013 I www.medline.com I Healthy Skin

FORMS & TO O LS N OROVIR U S

Norovirus in Healthcare Facilities Fact Sheet hand transfer of the virus to the oral mucosa via contact with materials, fomites, and environmental surfaces that have been contaminated with either feces or vomitus.

General Information Virology Noroviruses (genus Norovirus, family Caliciviridae) are a group of related, single-stranded RNA, non-enveloped viruses that cause acute gastroenteritis in humans. Norovirus is the oﬃcial genus name for the group of viruses provisionally described as “Norwalk-like viruses”. Currently, human noroviruses belong to one of three norovirus genogroups (GI, GII, or GIV), which are further divided into >25 genetic clusters. Over 75% of conﬁrmed human norovirus infections are associated with genotype GII.

Clinical manifestations The average incubation period for norovirus-associated gastroenteritis is 12 to 48 hours, with a median period of approximately 33 hours. Illness is characterized by nausea, acute-onset vomiting, and watery, non-bloody diarrhea with abdominal cramps. In addition, myalgia, malaise, and headache are commonly reported. Lowgrade fever is present in about half of cases. Dehydration is the most common complication and may require intravenous replacement ﬂuids. Symptoms usually last 24 to 60 hours. Up to 30% of infections may be asymptomatic.

Epidemiology of transmission Noroviruses are highly contagious, with as few as 18 virus particles thought to be suﬃcient to cause infection. This pathogen is estimated to be the causative agent in over 21 million gastroenteritis cases every year in the United States, representing approximately 60% of all acute gastroenteritis cases from known pathogens. Noroviruses are transmitted primarily through the fecaloral route, either by direct person-to-person spread or fecally contaminated food or water. Noroviruses can also spread via a droplet route from vomitus. These viruses are relatively stable in the environment and can survive freezing and heating to 60°C (140°F). In healthcare facilities, transmission can also occur through

Norovirus infections are seen in all age groups, although severe outcomes and longer durations of illness are most likely to be reported among the elderly. Among hospitalized persons who are immunocompromised or have significant medical comorbidities, norovirus infection can directly result in prolonged hospital stays, additional medical complications, and, rarely, death. There is currently no vaccine available for norovirus and, generally, no specific medical treatment is offered for norovirus infection apart from oral or intravenous repletion of volume. The ease of its transmission, a very low infectious dose, a short incubation period, environmental persistence, and lack of durable immunity following infection enables norovirus to spread rapidly through confined populations. Healthcare facilities and other institutional settings (e.g., daycare centers, schools, etc.) are particularly at-risk for outbreaks because of increased personto-person contact. Healthcare facilities managing outbreaks of norovirus gastroenteritis may experience significant costs relating to isolation precautions and personal protective equipment, ward closures, supplemental environmental cleaning, staff cohorting or replacement, and sick time.

Diagnosis of norovirus infection Diagnosis of norovirus infection relies on the detection of viral RNA in the stools of affected persons, by use of reverse transcription-polymerase chain reaction (RT-PCR) assays. This technology is available at CDC and most state public health laboratories and should be considered in the event of outbreaks of gastroenteritis in healthcare facilities. Enzyme immune-assays may also be used for identification of norovirus outbreak but are not recommended for diagnosis of individuals. Identification of the virus can be best made from stool specimens taken within 48 to 72 hours after onset of symptoms, although positive results can be obtained by using RT-PCR on samples taken as long as 7 days after symptom onset. Because of the limited availability of timely and routine laboratory diagnostic methods, a clinical diagnosis of norovirus infection is often used, especially when other agents of gastroentertis have been ruled out.

U.S. Department of Health and Human Services Centers for Disease Control and Prevention CS216887-ANorovirusFactSheet

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N O R O V I R US F O R MS & TOOLS

Measures to Limit Transmission* Patient Cohorting and Isolation Precautions Avoid exposure to vomitus or diarrhea. Place patients on Contact Precautions in a single occupancy room if they present with symptoms consistent with norovirus gastroenteritis

Hand Hygiene

Staﬀ Leave and Policy

During outbreaks, use soap and water for hand hygiene after providing care or having contact with patients suspected or conﬁrmed with norovirus gastroenteritis.

Develop and adhere to sick leave policies for healthcare personnel who have symptoms consistent with norovirus infection.

Patient Transfer and Ward Closure Consider limiting transfers to those for which the receiving facility is able to maintain Contact Precautions; otherwise, it may be prudent to postpone transfers until patients no longer require Contact Precautions. During outbreaks, medically suitable individuals recovering from norovirus gastroenteritis can be discharged to their place of residence.

Exclude ill personnel from work for a minimum of 48 hours after the resolution of symptoms. Once personnel return to work, the importance of performing frequent hand hygiene should be reinforced, especially before and after each patient contact. Establish protocols for staﬀ cohorting in the event of an outbreak of norovirus gastroenteritis. Ensure staﬀ care for one patient cohort on their ward and do not move between patient cohorts (e.g., patient cohorts may include symptomatic, asymptomatic exposed, or asymptomatic unexposed patient groups).

Diagnostics

Communication and Notiﬁcation

In the absence of clinical laboratory diagnostics or in the case of delay in obtaining laboratory results, use Kaplan’s clinical and epidemiologic criteria to identify a norovirus gastroenteritis outbreak.

As with all outbreaks, notify appropriate local and state health departments, as required by state and local public health regulations, if an outbreak of norovirus gastroenteritis is suspected.

Kaplan’s Criteria

*Prevention and control recommendations taken from priority recommendations in the CDC HICPAC Guideline for the Prevention and Control of Norovirus Gastroenteritis Outbreaks in Healthcare Settings (http://www.cdc.gov/hicpac/pdf/norovirus/NorovirusGuideline-2011.pdf )

1. Vomiting in more than half of symptomatic cases and, 2. Mean (or median) incubation period of 24 to 48 hours and, 3. Mean (or median) duration of illness of 12 to 60 hours and, 4. No bacterial pathogen isolated in stool culture

Date last modiﬁed: September 6, 2011

Environmental Cleaning

Content source: Division of Healthcare Quality Promotion (DHQP), National Center for Preparedness, Detection, and Control of Infectious Diseases (NCEZID)

Increase the frequency of cleaning and disinfection of patient care areas and frequently touched surfaces during outbreaks of norovirus gastroenteritis (e.g., increase ward/ unit level cleaning to twice daily to maintain cleanliness, with frequently touched surfaces cleaned and disinfected three times daily using the US Environmental Protection Agency’s list of approved products for healthcare settings (http://www.epa.gov/oppad001/chemregindex.htm).

Contact Us: Centers for Disease Control and Prevention 1600 Clifton Road, Atlanta, GA 30333, USA 1-800-CDC-INFO (1-800-232-4636) TTY:888-232-6348, 24 hours/everyday at cdcinfo@cdc.gov (TTY)

U.S. Department of Health and Human Services Centers for Disease Control and Prevention CS216887-ANorovirusFactSheet

June 2013 I www.medline.com I Healthy Skin

68 Healthy Skin I www.medline.com I June 2013 CPAP Mask

Oxygen Tubing

Trach Ties

ET Tube

Bedpan

Retention Sutures

Arterial Line

NG Tube

Wrist Splint

O2 Saturation Probe

Confirm that devices are not placed directly under an individual who is bedridden or immobile

Be aware of edema under device(s) and potential for skin breakdown

Choose the correct size of medical device(s) to fit the individual Cushion and protect the skin with dressings in high risk areas (e.g., nasal bridge) Remove or move the device daily to assess skin Avoid placement of device(s) over sites of prior, or existing pressure ulceration Educate staff on correct use of devices and prevention of skin breakdown

F ORMS & TO O LS ME D ICAL D E VIC E -R E L AT E D P R E S S UR E UL C E R S

B L A D D E R S CA N N E R G UI D E L I N E S F O R MS & TOOLS

Ultrasound Bladder Scanner Guidelines Who may perform procedure RN, LPN, LVN or CNA who has successfully completed training in the use of their facility’s bladder scanner and has, verified)that this activity is within their scope of practice in accordance with their state licensure (RN, LPN, LVN) and/or certification boards (CNA). Objective Non invasive bladder volume measurement Indications 1. To obtain post void residual for assessment & diagnosis of urinary retention and incomplete bladder emptying • To obtain post void residual – perform scan within 10 minutes of voiding completely 2. To determine need for post-void intermittent catheterization of resident at risk of urinary retention 3. To determine need for intermittent catheterization of resident with physicians order of scheduled intermittent catheterization 4. To determine bladder volume if resident has symptoms of urinary retention or cannot void 5. To monitor bladder function following foley catheter removal 6. To assist in toileting treatment programs VOIDING DIARY Perform hourly scans as a means to document bladder volumes when completing urinary component of 3 day Bowel and Bladder diary. i. If scanned volume greater than 250 mls ask resident to try to void. ii. Scan bladder after void to document post void residuals, if any and document results. HABIT TRAINING/SCHEDULED VOIDING PROGRAMS Once any voiding patterns determined (through use of 3 day Bowel and Bladder Diary) scan bladder at pre-determined toileting intervals to determine bladder volumes and need for resident to empty bladder (voiding will be based on volumes as opposed to specific time frames. Bladder emptying should be encouraged before the resident reaches a leakage point of a full bladder as may have been denoted in diary as the volume documented closest to the time of any non-stress induced leakage or incontinent episode noted). Continued on page 71

June 2013 I www.medline.com I Healthy Skin

Don’t Catheterize. Visualize. ™

BioCon - 700 Ultrasound helps minimize unnecessary catheterization Bladder scanners accurately assess bladder volumes, and many urinary catheterizations can be avoided.3 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

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.

Learn more here, call your Medline representative or 1-800-MEDLINE. http://goo.gl/8Zxvw

B L A D D E R S CA N N E R G UI D E L I N E S F O R MS & TOOLS

PROMPTED VOIDING Scan bladder to determine amount of urine in bladder to determine whether toileting at that time should be encouraged. (Amount should be greater than 200-250 mls.) If scanned volume below that encourage resident to wait to feel urge to void. BLADDER RETRAINING Perform scan prior to voiding when resident has urge or pre-determined time frame (based on bladder diary). Discuss urine volume with resident compared to previous scans. Use encouragement to gradually increase intervals between voids and improve control over bladder urgency. Contraindications 1. Pregnant individuals 2. Residents with ascites (abnormal fluid in abdominal cavity) 3. Residents with open or damaged skin or wounds in suprapubic region Procedure 1. Greet resident 2. Provide privacy, explain procedure 3. Wash hands, apply non-sterile gloves if needed. 4. Resident should be in a supine position with the suprapubic area exposed 5. Apply generous amount of ultrasound gel to the head of the scanner probe 6. Place the scan head against the abdomen according to manufacturer’s instructions (Place your manufacturer’s instructions here) 7. Follow manufacturer’s instructions to obtain the urine volume (Place your manufacturer’s instructions here) 8. Wipe excess gel off the abdomen with paper towel or washcloth 9. Reposition the patient 10. Clean the scan head according to manufacturer’s instructions (Place your manufacturer’s instructions here) 11. Dispose of waste 12. Remove gloves and wash hands 13. Document the urine volume and resident’s tolerance of procedure Factors affecting accuracy of bladder scan measurement 1. Resident with abdominal scars, sutures or incisions 2. Morbidly obese resident 3. Resident with a catheter in the bladder 4. Lack of sufficient ultrasound gel 5. Air gap between probe head and patient’s skin 6. Use of an unclean probe head

June 2013 I www.medline.com I Healthy Skin

TheraHoney™ Sterile Wound Dressings

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

TheraHoney™ Gel

For more details on the uses for TheraHoney or to arrange a trial, call your Medline representative or 1-800-MEDLINE (633-5463).

http://goo.gl/HgjRJ