Healthy Skin Magazine - Volume 8; Issue 1

Let Us HearFrom You!


Survey Inside

No More Skin Tears

Free CE! Skin Assessment & OASIS-C

BanishBacteria

Exclusive:Diane Krasneron Skin Care At Life’s End

Improving Quality of Care Based on CMS Guidelines

Volume 8, Issue 1

VOLUME 8, ISSUE 1

HEALTHY SKINw

ww

.medline.com

PRESSURE ULCER PREVENTION IN LONG-TERM CARE

Learn more about continuous quality improvement for the prevention of avoidable pres-sure ulcers and F-Tag 314 citations, factors leading to pressure ulcers in long-term carefacilities and comprehensive pressure ulcer prevention strategies and solutions.

Sign up at www.medline.com/PUPP-webinar

M A R C H4th 12:00 pm - 1:00 pm16th 1:00 pm - 2:00 pm24th 11:00 am - 12:00 pm

A P R I L6th 12:00 pm - 1:00 pm15th 1:00 pm - 2:00 pm21st 11:00 am - 12:00 pm

M A Y6th 12:00 pm - 1:00 pm14th 1:00 pm - 2:00 pm20th 11:00 am - 12:00 pm

J U N E3rd 12:00 pm - 1:00 pm10th 1:00 pm - 2:00 pm23rd 11:00 am - 12:00 pm

INNOVATION IN THE PREVENTION OF CAUTI

M A R C H3rd 2:00 pm - 3:00 pm10th 11:00 am - 12:00 pm12th 2:00 pm - 3:00 pm17th 12:00 pm - 1:00 pm24th 12:00 pm - 1:00 pm31th 11:00 am - 12:00 pm

A P R I L6th 2:00 pm - 3:00 pm8th 11:00 am - 12:00 pm13th 12:00 pm - 1:00 pm15th 2:00 pm - 3:00 pm26th 12:00 pm - 1:00 pm28th 11:00 am - 12:00 pm

M A Y5th 12:00 pm - 1:00 pm10th 11:00 am - 12:00 pm11th 2:00 pm - 3:00 pm18th 2:00 pm - 3:00 pm21st 12:00 pm - 1:00 pm24th 11:00 am - 12:00 pm

J U N E7th 11:00 am - 12:00 pm9th 2:00 pm - 3:00 pm11th 12:00 pm - 1:00 pm18th 12:00 pm - 1:00 pm21st 11:00 am - 12:00 pm22nd 2:00 pm - 3:00 pm

Join your colleagues from around the country to learn more about strategies to preventcatheter-acquired urinary tract infections as well as Medline’s ERASE CAUTI system.

Hosted by Connie Yuska, RN, MS, CORLNand Lorri Downs, RN, BSN, MS, CIC

Free WebinarsNew Techniques for Pressure Ulcer Prevention,

Hand Hygiene and CAUTI Prevention

MKT210055/LIT575R/25M/SEL5©2010 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.

M A R C H5th 12:00 pm - 1:00 pm19th 12:00 pm - 1:00 pm

A P R I L2nd 11:00 am - 12:00 pm23rd 11:00 am - 12:00 pm

M A Y14th 11:00 am - 12:00 pm19th 12:00 pm - 1:00 pm

J U N E14th 11:00 am - 12:00 pm17th 12:00 pm - 1:00 pm

As the number one defense against healthcare-acquired conditions, hand hygiene playsan important role in the prevention of infections. Learn how hospitals and healthcarefacilities are combining best-in-class products and education to achieve hand hygienecompliance while dramatically improving the skin condition of healthcare workers.

HAND HYGIENE COMPLIANCE IMPROVEMENT STRATEGIES

Sign up at www.medline.com/handhygiene

Sign up at www.medline.com/erase/webinar.asp

Covers_65262_MedCal:Layout 1 2/12/10 7:22 PM Page 1

creo

©2010 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.

Ultrasorbs® AP Premium DryPads

With Ultrasorbs® AP, you can count on the Power of One:

• One pad for healthy skin: The innovative backsheet allows air to flow through the pad while still acting as a barrier to moisture. The result is optimal skin dryness and comfort.

• One pad for lower cost: Ultrasorbs AP are so strong and absorbent that they eliminate the need for multiple pads.

• One pad for easy care: Can be used on both standard and air-support therapy beds!

To learn more about Ultrasorbs® AP view the online video at www.medline.com/incocare

Soft, non-woven topsheet– softer against skin for increased comfort

Advanced SuperCore® absorbent sheet– thermo-bonded to provide better pad

integrity and superior skin dryness

AquaShield film– traps moisture, providing better

leakage protection

Innovative backsheet– air permeability means better skin comfort

THE ULTIMATE ONE

Join the team!

When it comes to hot topics in long-term care,

you’re the experts!

You, our readers, are on the front lines of everything thathappens in the healthcare industry – and we want to hearfrom you! Have you ever wished you could write anarticle that would be published in a large-circulationmagazine? Nowʼs your chance. Healthy Skin is looking

for writers and contributors. Whether youʼd like to try yourhand at writing or offer suggestions for future articles, wewant to hear what you have to say! You never know – thenext time you open an issue of Healthy Skin, it might beto read your own article!

HEALTHY SKIN

Contact us at [email protected] to learn more!

Content KeyWeʼve coded the articles and information in this magazine to indicate which national quality initiativesthey pertain to. Throughout the publication, when you see these icons youʼll know immediately thatthe subject matter on that page relates to one or more of the following national initiatives:

• QIO – Utilization and Quality Control Peer Review Organization• Advancing Excellence in Americaʼs Nursing Homes

Weʼve tried to include content that clarifies the initiatives or gives you ideas and tools for implement-ing their recommendations. For a summary of each of the above initiatives, see Pages 10 and 11.


creo

Page 51

Page 44

Page 59

Page 17

Survey Readiness38 Survey Smarts: An Interview with Dr. Andy Kramer 44 Lessons Learned: One Nursing Homeʼs Winning Quality

Assurance Strategies51 Focus on Infection Control: Understanding the New

F-Tag 441 Requirements54 Ten Tips for Cleaning and Disinfecting Shared

Medical Equipment55 Product Spotlight: Dispatch Cleaning Solution for Use on

Glucose Meters

Prevention13 Do the Math: Nutrient-Based Skin Care = Fewer Skin Tears17 No More Skin Tears56 Put Bacteria in its Place59 Changing the Catheter Culture at Your Facility65 Performance Under Pressure: The Legal Side of Pressure

Ulcer Prevention

Treatment23 Skin Changes At Lifeʼs End (SCALE)

Special Features7 Medline Healthcare Survey: Letʼs Talk About You!

14 Medline Donates Critical Medical Supplies to Haiti29 Unraveling the Pressure Ulcer and Wound Care Sections

of OASIS-C64 Safe Handling of Residents: Which Technique Would You Use?76 Medlineʼs Pink Glove Dance: A YouTube Sensation

Regular Features10 Two Important Initiatives for Improving Quality of Care

Caring for Yourself70 Nine Habits of Very Happy People83 Recipe: Cheesy Potatoes

Forms & Tools86 OASIS-C: Integumentary Status89 H1N1 (Swine Flu) - Patient Handout (English)91 H1N1 (Swine Flu) - Patient Handout (Spanish)93 Clinical Fact Sheet: Quick Assessment of Leg Ulcers95 Infection Prevention and Control: Long-Term Care Audit

101 Bariatric Assessment: Home Care/Long-Term Care Facility

HEALTHY SKIN

EditorSue MacInnes, RD, LD

Clinical EditorMargaret Falconio-West, BSN, RN, APN/CNS, CWOCN, DAPWCA

Managing EditorAlecia Cooper, RN, BS, MBA, CNOR

Senior WriterCarla Esser Lake

Creative DirectorMike Gotti

Clinical TeamClay Collins, BSN, RN, CWOCN, CFCN, CWS, DAPWCA

Lorri Downs, BSN, RN, MS, CIC

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

Joyce Norman, BSN, RN, CWOCN, DAPWCA

Kim Kehoe, BSN, RN, CWOCN, DAPWCA

Elizabeth OʼConnell-Gifford, BSN, MBA, RN, CWOCN, DAPWCA

Jackie Todd, RN, CWCN, DAPWCA

Connie Yuska, RN, MS, CORLN

Wound Care Advisory BoardMary Brennan, MBA, RN, CWON

Zemira M. Cerny, BS, RN, CWS

Patricia Coutts, RN

Cindy Felty, MSN, RN, CNP, CWS

Evonne Fowler, MSN, RN, CNS, CWOCN

Lynne Grant, MS, RN, CWOCN

Diane Krasner, PhD, RN, CWCN, CWS, BCLNC, FAAN

Dea J. Kent, MSN, RN, NP-C, CWOCN

Andrea McIntosh, BSN, RN, APN, CWOCN

Linda Neiswender, BSN, RN, CPN

Laurie Sparks, BSN, RN,CWOCN

Lynne Whitney-Caglia, MSN, RN, CNS, CWOCN

Laurel Wiersema-Bryant, RN, ANP, BC

Linda Woodward, BSN, RN, OCN, CWOCN

Deborah Zaricor, RN, CWOCN


Page 70

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

Meeting the highest level of national and international quality standards, Medlineis FDA QSR compliant and ISO 13485 certified. Medline serves on major in-dustry quality committees to develop guidelines and standards for medicalproduct use including the FDA Midwest Steering Committee, AAMI Steriliza-tion and Packaging Committee and various ASTM committees. For more in-formation on Medline, visit our Web site, www.medline.com.

Improving Quality of Care Based on CMS Guidelines 3

©2010 Medline Industries, Inc. Healthy Skin is published by Medline Industries, Inc. One Medline Place, Mundelein, IL 60060. 1-800-MEDLINE.

Alts_65262_MedCal:Layout 1 2/12/10 7:31 PM Page 3

creo

Dear Reader,

Last week was one to remember! There were severalpeer-reviewed articles recently published, showingcompelling evidence on the clinical efficacy of Medline’sRemedy® skin care line. I get so excited because thereis nothing that makes a company like ours prouder thanto see our products perform with excellence. Anyway,we thought it would be really neat to have the industryexperts speak about these studies, film them doing so,and make the information available to all of you. As Iwas working out the logistics, it occurred to me that ifwe were going to film these presentations, why not doit in front of a live audience! So, instead of simple indi-vidual filming, we ended up orchestrating three confer-ences. I called it the “Trifecta.”

Three meetings, over 200 attendees in a 48-hour period– now that’s a challenge. But it worked, and I got tohear firsthand from our customers some excellent in-formation on improving outcomes as they relate to skintears, and improving the skin condition of your hands topromote better hand hygiene. Our cover shot for thisissue shows Diane Krasner sharing secrets on reducingand treating skin tears with a group of long-term careprofessionals. I had NO idea the number of skin tearsindustry wide each year is over 1.5 million. The nextmeeting was with Dr. Marty Visscher from CincinnatiChildren’s Hospital. Her study was published in the Jan-uary 2010 issue of AJIC. She presented to a group ofinfection preventionists about improving hand hygiene.The next day we had a half-day meeting with nursingleaders of hospitals and WOCNs. What a great combi-nation. There were even four area CNOs who spokeon a panel discussion on barriers they encounter in

preventing pressure ulcers in their facilities. All of thesepresentations are now available for everyone to watchon Medline University at www.medlineuniversity.com.

Now, that brings me to another fun activity that we doat many of our meetings, and that is a pre-survey. Foreach conference, we put together a series of questionsand then report the group response at the meeting. Iam always fascinated with the results. So, what do yousay we try a national survey from you, our Healthy Skinreaders? On page 7, we’ve included a list of questionsabout your workplace. You can take the survey onlineor you can mail or fax it in. For each survey we receive,we will send you a FREE Medline doll. In addition, we’veposed a question to find out more about the excep-tional work you are doing. Submit your answer to thequestion and receive the entire Medline doll series. Thefirst place answer will also receive a plaque acknowl-edging their efforts.

I can’t wait to see your responses and report back toyou in the next edition of Healthy Skin. Based upon yourresponses, we are going to focus that edition onaddressing some of your issues and finding practicalsolutions we all can share. Thank you in advance foryour participation!

Sue MacInnes, RD, LDEditor

”

“I had no idea thenumber of skintears industry wideeach year is over1.5 million

4 Healthy Skin

HEALTHY SKIN Letter from the Editor

On the coverWound care expert Diane Krasner presented

on skin tears to an audience of long-termcare professionals during Medline’s Trifectaof meetings. See also page 23 for an inter-

view with Dr. Krasner about her experiencesas co-chair of the SCALE Panel.

Body_65262_MedCal:Layout 1 2/11/10 10:21 PM Page 4

creo


TenderWet Active

TenderWet Active polyacrylate wound dressings rinseand debride necrotic wounds for up to 24 hours! Plus,they won’t stick to the wound bed, reducing patientdiscomfort at dressing removal.

TenderWet Active dressings have a “rinsing” effect aslarge-molecule proteins found in dead tissue and bacte-ria are attracted to TenderWet Active's core. Even undercompression, TenderWet Active can retain large amounts of fluid.

We’re confident you’ll find TenderWet Active more effec-tive than wet gauze therapy because TenderWet Activecan be left in place for up to 24 hours without drying outwhile simultaneously removing harmful microorganismsand stubborn necrotic tissue.

By debriding necrotic tissue, absorbing and retainingpathogens and keeping the wound moist, TenderWetActive helps create an ideal healing environment.

For a free trial of TenderWet Active and informationon Medline’s complete line of advanced woundcare products, contact your Medline representativeat 1-800-MEDLINE.

TenderWet ACTIVE GENTLY REMOVESNECROTIC TISSUE & PATHOGENS


creo

Step 1: Complete the Survey!

The first 1000 survey submissions will receive the latestand greatest addition to our Medline Doll collection.The doll is Top Secret and will debut in April.

Results of the survey will be published in the next issue of Healthy Skin!

Step 2: Answer the Bonus Question!

In 50 words or less, describe an innovative program, initiative and/or solution implemented at your facility or your organization that made a significant impact on quality and patient/resident care.

First PrizeThe entire Medline Doll collectionA plaque awarding the 2010 Contribution to Healthy Skin!

Second PrizeThere will be several second place award winners, who will all receive the entire Medline Doll collection.

?

You can submit the survey three ways:

1. Complete the survey online at www.medline.com/healthyskinsurvey

2. Manually complete the survey, tear it out and fax it to 847-949-3073.

3. Mail it back to us at Medline Industries, Inc., One Medline Place, Mundelein, IL 60060 Attn: Marketing Department – Healthy Skin

can be a winner!Everyone

All winnersand submissionswill be featured inupcoming issues ofHealthy Skin!

Let’s Talk About

You!Alts_65262_MedCal:Layout 1 2/12/10 9:22 PM Page 6


2. Where do you work?

❏ Nursing Home

❏ Hospital

❏ Long-Term Care

❏ Long-Term Acute Care

❏ Home Health Care

❏ Hospice

❏ Other (please specify)

3. Number of beds at your facility?

❏ < 100 ❏ 350-499

❏ 101-199 ❏ 500+

❏ 200-349

4. What is your job title?

❏ Director of Nursing (DON)

❏ Staff Nurse

❏ Staff LPN

❏ Nurse Manager

❏ Aide/Technician

❏ Treatment Nurse

❏ Wound Care Nurse

❏ Clinical Educator

❏ Risk/Quality Manager

❏ Restorative Nurse


5. What are your top three priorities?

1. __________________________________

2. __________________________________

3. __________________________________

6. Which of the following is most helpful in

improving patient care?

❏ Continuing Education

❏ Competency

7. How often do you believe education

is transferred by the clinician to

bedside practice?

❏ 0% – 20% ❏ 61% – 80%

❏ 21% – 40% ❏ 81% – 100%

❏ 41% – 60%

8. Which staff member are you most

concerned about when it comes to

implementing the necessary changes

at your facility to be successful?

❏ Nursing

❏ Aides/Technicians

❏ Managers

❏ Physicians


9. What medium would you like to see

education materials offered in? (Choose

all that apply)

❏ Online (e-Learning)

❏ Written

❏ Audio

❏ Video/CD/DVD

❏ Live Presentation

❏ Webinar


10. What is the CNA turnover rate at

your facility?

❏ < 5% ❏ More than 25%

❏ 6% - 10% ❏ Does not apply

❏ 11% - 25%

11. Do you see skin tears as a problem in

your facility?

❏ Yes ❏ No

12. Do you have a facility protocol for

skin tears?

❏ Yes ❏ No

13. What percentage of the time do you

feel the facility protocol is followed?

❏ 25% ❏ 75%

❏ 50% ❏ 100%

14. Average number of skin tears at

your facility

15. How much time do you spend on skin

tears during new employee orientation?

16. Do you currently use treatment

protocols or algorithms to treat wounds

after they have been diagnosed?

❏ Yes ❏ No

Continued on page 8

MEDLINE HEALTHCARE SURVEY Let’s talk about you!

1. Tell us about yourself

Name ________________________________

Credentials (i.e., RN, LPN, etc.)______________

Facility ______________________________

Street Address ________________________

City/Town ____________________________

State/Providence ______________________

Zip/Postal Code ________________________

Phone ( ) ________________________

E-mail ______________________________

Special Feature


17. What is your pressure ulcer incidence?

18. What are your biggest barriers to

pressure ulcer prevention?

19. Has your organization ever been

involved in a legal suit involving

pressure ulcers?

❏ Yes ❏ No

20. Have you personally ever been

involved in a legal suit involving

pressure ulcers?

❏ Yes ❏ No

21. Which of the following technologies

do you have? (Check all that apply)

❏ PDA (Blackberry®, Palm®, iPhone®)

❏ Cell phone

❏ iPod®/mp3

❏ DVD player

❏ CD player

❏ Electronic reading device (Kindle®,

Sony®, iPad®)

❏ Computer

22. If you checked PDA, what type do

you have?

❏ iPhone®

❏ Blackberry®

❏ Palm®

❏ Droid™

❏ Other

Fax or mail completed survey to:

Marketing Department – Healthy Skin magazineMedline Industries, Inc.

One Medline PlaceMundelein, IL 60060Fax (847) 949-3073

MEDLINE HEALTHCARE SURVEY Let’s talk about you!

8 Healthy Skin

Bonus Question: (For a chance to win the entire Medline Doll Collection)Everyone whose answer is chosen for publication in Healthy Skin will receive the collection.

In 50 words or less, describe an innovative program, initiative and/or solution implemented at your facility or your organization that made a significant impact on quality and patient/resident care.

Blackberry is a registered trademark of Research In Motion Limited

Palm is a registered trademark of Research In Motion Limited

iPhone is a registered trademark of Apple Inc.iPod is a registered trademark of Apple Inc.Kindle is a registered trademark of Amazon Technologies, Inc.

Sony is a registered trademark of Sony CorporationDroid is a trademark of Lucasfilm Ltd.


creo

Interactive courses and competenciesContinuing education courses are still available, and nowyou can earn all credits for FREE! In addition, we areadding online competencies. Courses and competenciesare more interactive with more graphics, sound and animation to make learning more fun.

Facility-specific featuresNow each facility has the option of creating a group account on Medline University. This will help you and your facility view and keep track of all completed courses.

And for facilities participating in the Pressure Ulcer Prevention and Hand Hygiene programs, all materials,pre- and post-tests are now conveniently located online at www.medlineuniversity.com.

Log on to www.medlineuniversity.com today and start earning CE credits —FREE.

ALL NEW AND UPGRADED CONTENT. WWW.MEDLINEUNIVERSITY.COM


Easier navigation to find what you need – faster.


creo

10 Healthy Skin

Two Important National Initiatives for Improving Quality of Care

Achieving better outcomes starts with an understanding of current quality of care initiatives. Hereʼs what you need to know about national projects and

policies that are driving changes in nursing home and home health care.

Origin: The QIO Statement of Work is based upon Part B of the Title XI of the Social Security Act. The Medicare-funded “NinthScope of Work” plan became effective August 1, 2008 and is a three-year work plan.

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

Goal: In the 9th SOW, the QIO Program has been redesigned with a framework for accountability and also in content. The content now consists of four themes with the goal to help providers, both in long-term care and acute-care facilities, prevent illness, decrease harm to patients and reduce waste in health care. Of note: QIOs will be required to help Medicare promote three overarching themes: adopt value-driven healthcare, support the adoption and use of health information technology and reduce health disparities in their communities. Under the direction of the Centers for Medicare & Medicaid Services (CMS), the QIO Program consists of a national network of 53 QIOs located in each of the 50 U.S. states, the District of Columbia, Puerto Rico and the Virgin Islands.

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

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

Purpose: A coalition consisting of the Centers for Medicare & Medicaid Services (CMS), organizations representing providers, consumers and government that developed a grassroots campaign to build on and complement the work of existing quality initiatives including Nursing Home Quality Initiative (NHQI), Quality First and the culture change movement.

Goal: To ensure that continuous quality improvement is comprehensive, sustainable and consumer-focused, the coalitionhas adopted goals that seek to improve clinical care, incorporate nursing home resident and family satisfaction surveys into continuing quality improvements and increase staff retention to allow for better, more consistent care for nursing home residents.

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

Advancing Excellence The coalition is meeting to consider the following additions for the next two-year campaign:

1. Improving immunizations as a clinical goal2. Including target setting in all goals3. Changes to the order in which the goals are presented

QIO Utilization and Quality Control Peer Review Organization 9th Round Statement of Work1

Advancing Excellence in America’s Nursing Homes2


creo

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

Goal 1: 70.9% Goal 5: 32.1%

Goal 2: 45.3% Goal 6: 62.8%

Goal 3: 54.2% Goal 7: 41.2%

Goal 4: 39.6% Goal 8: 31.3%

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

*Based on the latest available count of Medicare/Medicaid nursing homes


Theme #1: Beneficiary Protection Activities will focus on nine Tasks:1. Case reviews2. Quality improvement activities (QIAs)3. Alternative dispute resolution (ADR)4. Sanction activities5. Physician acknowledgement monitoring6. Collaboration with other CMS contractors7. Promoting transparency through reporting8. Quality data reporting9. Communication (education and information)

Theme #2: Patient Pathways/Care Transitions Activities will focus on three Tasks:1. Community and provider selection and recruitment2. Interventions 3. Monitoring

Theme #3: Patient Safety Activities will focus on six primary Topics:1. Reducing rates of health care-associated methicillin-resistant

Staphylococcus aureus (MRSA) infections2. Reducing rates of pressure ulcers in nursing homes and hospitals3. Reducing rates of physical restraints in nursing homes4. Improving inpatient surgical safety and heart failure treatment

in hospitals5. Improving drug safety6. Providing quality improvement technical assistance to nursing

homes in need

Theme #4: Prevention Activities will focus on nine Tasks:1. Recruiting participating practices2. Identifying the pool of non-participating practices3. Promoting care management processes for preventive services

using EHRs4. Completing assessments of care processes5. Assisting with data submissions6. Monitoring statewide rates (mammograms, CRC screens, influenza

and pneumococcal immunizations)7. Administering an assessment of care practices8. Producing an Annual Report of statewide trends, showing baseline

and rates9. Submitting plans to optimize performance at 18 months

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

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

in facility quality improvement programs

The 9th Scope of Work Content Themes

Clinical Goals: Goal ActualGoal 1: Reducing high-risk pressure ulcers < 10% 11%Goal 2: Reducing the use of daily < 5% 3%

physical restraintsGoal 3: Improving pain management for < 4% 3%

longer-term nursing home residentsGoal 4: Improving pain management for < 15% 19%

short-stay, post-acute nursing home residents

Operational/Process Goals: Goal ActualGoal 5: Establishing individual targets for > 90% 36.5%

improving qualityGoal 6: Assessing resident and family 22.5%

satisfaction with quality of careGoal 7: Increasing staff retention 13.9%Goal 8: Improving consistent assignment 26.6%

of nursing home staff so that residents receive care from the same caregivers

Clinical and Operational/Process Goals

Participating nursing homes: 7,481 Percentage of participating nursing homes:* 47.6% Participating consumers: 2,233

Average number of goals per nursing home: 3.8

Regular Feature


creo

12 Healthy Skin

Nursing home and medical facilities inspections$347 million ($54 million above 2009)This funding has been allocated within the Centers forMedicare and Medicaid Services (CMS) for enhancedstate inspections in nursing homes and other medicalfacilities where healthcare-associated infections are ris-ing. The funds will give inspectors greater opportunitiesto identify infection control problems. CMS is also urgedto include additional infection control measures in itshospital performance reporting system, Hospital Com-pare, and its “pay for performance” and “pay for re-porting” systems.

Healthcare-associated infections (HAIs) $190 million ($28 million above 2009)This funding will help continue an aggressive campaignto dramatically reduce life-threatening infections patientsacquire while receiving treatment for medical or surgicalconditions. HAIs are among the top 10 leading causesof death in the United States, accounting for nearly100,000 deaths, 1.7 million infections and $30 billion inexcess healthcare costs every year.

Nurse training$244 million ($73 million above 2009)The substantial increase in funding for nurse training isessential because the United Sates is in the midst of anursing shortage that is expected to intensify as babyboomers age and the need for health care grows. TheHealth Resources and Services Administration (HRSA)estimates that the nation’s nursing shortage will grow tomore than one million nurses by the year 2020.

Source: Memo – United States Congress Committees on Appropriations, December 8, 2009. Available at: http://appropri-ations.house.gov/pdf/FY10_LHHS_Conference_Summary.pdf. Accessed January 25, 2010.

FY 2010Labor HHS-Education Appropriations Bill AllocatesFunds for Health Care

Happenings on the Hill


creo


A skin care regimen using a phospholipid-based cleanser and adimethicone/nutrient-based moisturizing cream resulted in skintear likelihood that was 30 times less than in a similar group usinga surfactant-based cleanser and dimethicone/aloe moisturiz-ing cream.

Just released in the January/February 2010 issue of the Journalof Wound Ostomy and Continence Nursing, researchersrecommend nutrient-based skin care (NBSC) as one part of acomprehensive skin tear prevention program, along with otherpreventive interventions such as staff education, properpositioning, protective clothing, turning, lifting and transfer-ring techniques.

The six-month study at a 108-bed convalescent center in south-ern Illinois compared outcomes after randomly assigning one halfof a resident population (n = 100) to a group using Remedy®

cleanser, moisturizer and skin protectant products (all NBSCproducts). The second group (n = 100) was cared for with a sur-factant-based cleanser and dimethicone/aloe moisturizer anda zinc oxide barrier product when indicated.

Incidence of Skin TearsA group of 100 residents experienced a total of 180 skin tearsduring the initial six-month period when non-NBSC productswere used compared to 1.6 skin tears per resident over sixmonths when a NBSC was used. The number of expected skin-tear-free days when skin care was completed using NBSC was179.7 days as compared to 154.8 days when non-NBSC prod-ucts were used, yielding an incremental effect of 24.9 days.

Cost ImplicationsIn addition to a 250 percent greater likelihood of maintainingintact skin when the NBSC products were used, the researchersconsidered cost of treatment.

The expected cost to treat a skin tear in the NBSC groupwas $287.70 per resident versus $331.80 per resident inthe non-NBSC group. The cost per skin-tear-free day was$1.60 per resident for treatment with NBSC and $2.14 per resi-dent for treatment with non-NBSC products. NBSC was foundto be significantly less costly and more effective than a reginmenusing non-NBSC products.

A limited number of reprints of the full study are availablefrom your Medline representative or by calling 1-800-Medline.The Remedy® Advanced Skin Care Line is available throughMedline Industries, Inc.

For additional information, visit www.medline.com/skincare.

Remedy is a registered trademark of Medline Industries, Inc.

Source: Groom M, Shannon RJ, Chakravarthy D, Fleck CA. An evaluation of costs andeffects of a nutrient-based skin care program as a component of prevention of skin tearsin an extended convalescent center. Journal of Wound, Ostomy and Continence Nurs-ing. 2010; 37(1):46–51.

Do the MathNutrient-Based Skin Care = Fewer Skin Tears

Prevention


creo

“Medline Industries, Inc. has donated more than $250,000 ininitial humanitarian aid to the people of Haiti in response tothe devastating earthquake that struck the country recently.The aid includes medical and surgical supplies, as well as logistics resources and support to both U.S.-based hospital systems and international aid organizations that are providing medical supplies, doctors and other resources tothe people in Haiti.

We are deeply saddened by the devastation from the earthquake and the millions of victims left in its wake,” said BillAbington, President of Operations for Medline. “As we havedone in past disasters when people are in need, we immediately initiated our Disaster Response Plan that mobilized our distribution and logistics network around thecountry to prepare and stage medical and surgical suppliesthat are needed in this type of disaster to assist with theheroic efforts taking place in Haiti.

Abington said the supplies were immediately delivered to aircraft and ships being utilized by Medline’s key healthcarepartners and global relief organizations. Throughout the coming months Medline will continue providing support toorganizations aiding Haiti.

Medline Donates Critical Medical Supplies to

How you can helpIn order to ensure that relief efforts are conducted in themost effective and efficient manner, individuals interestedin volunteering or donating to help the people of Haiti are advised to get in touch with a relief organization. The following is a list of resources.

American Medical Associationhttp://www.ama-assn.org/ama/pub/news/news/haiti-earthquake-response/help.shtml

American Red Crosswww.redcross.org

Center for International Disaster Information (CIDI)www.cidi.org/incident/haiti-10a/

Department of Health and Human Serviceshttp://www.hhs.gov/haiti/

Medscape Nurseshttp://www.medscape.com/viewarticle/579888

Major Infectious Complications of Haitian Earthquake

� Wound infections� Diarrheal illness - Cholera, shigella, Salmonella� Mosquito borne infections - Malaria, dengue fever� Preventable illness eradication disruption

- Lymphatic filariasis, parasites, tuberculosis� Interruption in chronic medication treatments

- HIV/AIDS

”Source: Medscape. Earthquake in Haiti and the Medical Aftermath of Natural Disasters. Available at:www.medscape.com/features/slideshow/haiti-earthquake. Accessed February 4, 2010.

14 Healthy Skin

Special Feature


Knowing that clinicians in the field have some of the best ideasfor improving health care, Medline is now accepting applica-tions for research funding through their Prevention Above AllDiscoveries Grant program. Through the grant program,Medline intends to award up to $1 million in grants forresearch on innovative ideas and evidence-based practicesthat will improve patient safety and quality of care.

Healthcare providers interested in submitting letters of intentcan apply for one of two funding categories: pilot grants of upto $25,000 for projects that can be completed within sixmonths or empirical study grants of up to $100,000 for projectscompleted within 12 months. Pilot study grantees, ifsuccessful, may qualify for future funding through an empiricalstudy grant.

Expert Review BoardRecognizing that the grant target groups haven't had muchexperience in developing research studies, the review boardhas come up with a creative way to ensure that a rigorousresearch process is followed. An Expert Review Board (ERB)composed of members who represent a breadth of researchand practice knowledge will independently review eachrequest. Applicants whose proposals are selected for fundingwill then be assigned an ERB member as a mentor to helpdevelop a final proposal that will then receive funding.

Deadline for grant applications is March 31, 2010. For more information on the grant program visit www.med-line.com/prevention-above-all/grants.asp and for a sampleletter of intent visit www.medline.com/prevention-above-all/pdf/LofI_Example.pdf. To submit a grant contact ToniMarchinski, grant coordinator, at [email protected] call 866-941-1998.

Prevention Above All Discoveries Grants:

Supporting the adoption of solutions into everyday

clinical practice

2010

PERIOPERATIVE PRESSURE ULCER EDUCATION.MORE IMPORTANT THAN EVER BEFORE

I have seen an increase in

the number of legal issues

linking facility-acquired pressure

ulcers to post-surgical patients.

A pressure ulcer program for the

OR is more critical than ever.”

Diane Krasner, PhD, RN, CWCN, CWS, BCLNC, FAAN

Medline’s Pressure Ulcer Prevention Program now has a component designed specifically for the perioperative services. The easy-to-use interactive CD addresses the following:

• Hospital-acquired conditions• CMS reimbursement changes• Best practices for pressure ulcer prevention• Perioperative assessment tools• Critical patient and equipment risk factors

“


To learn more about Medline’s Pressure Ulcer Prevention Programsfor long-term care, acute care andperioperative services, call your Medline representative or visitwww.medline.com/pupp-webinar.


creo

Each package is a 2-Minute Coursein Advanced Wound Care™


Medline’s Educational Packaging offers all the information you need, step by step,short and sweet, to help the Medline dressing do its job of healing.

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

MEDLINE’S REVOLUTIONARY SHOW-AND-TELL PACKAGING


Techniques

for Prevention

and Treatment

Aging skin, coupled with reliance on others for assistance withactivities of daily living, puts the elderly at high risk for skin tears.Firmly gripping delicate elderly skin while offering assistance canlead to tissue trauma and tearing. In fact, an estimated 1.5 millionskin tears occur in institutionalized adults each year,1 with nearly 80percent appearing on the arms and hands.2

Minimizing the occurrence of skin tears begins with an under-standing of the skin’s structure and common risk factors, followedby developing a plan of care using the most effective products forprevention and treatment.


Prevention


Between the epidermis and dermis is the basement mem-brane, a moving junction that both separates and attachesthe epidermis and the dermis (also known as the dermal-epidermal junction). This junction provides structural sup-port and allows for the exchange of fluid and cells betweenthe skin layers.

The epidermis has an irregular shape resembling down-ward, finger-like projections called rete ridges or pegs, andthe dermis has upward projections. These upward anddownward projections fit together like puzzle pieces an-choring the epidermis to the dermis. This connection helpsto prevent the epidermis from sliding back and forth acrossthe dermis with normal movement and skin manipulation.The two move together as one unit in people with healthy,young skin. As the skin ages – typically by the sixth decadeof one’s life – these rete ridges or pegs begin to flattenbetween that dermal-epidermal junction.3 This diminishedanchoring between the two layers increases the potentialfor the epidermis to detach from the dermis, leading to tear-ing of the skin, especially in older adults.4

AssessmentIn the late 1980s Payne and Martin developed the Payne-Martin Classif ication System for Skin Tears, whichaddresses assessment, prevention and treatment of skintears. The system, which was revised in 1993, defines askin tear as “a traumatic wound occurring principally on theextremities of older adults as a result of friction alone orshearing and friction forces that separate the epidermis fromthe dermis or separate both the epidermis and the dermisfrom underlying structures.” The Payne-Martin ClassificationSystem places skin tears into three categories:5

Category I: Skin tears without tissue lossCategory II: Skin tears with partial tissue lossCategory III: Skin tears with complete tissue loss

Risk factorsPatients and residents who are completely dependent onothers for activities of daily living, such as dressing, bathingand positioning, are at the highest risk for sustaining skintears.2 Often, these individuals are elderly and may have ahistory of previous skin tears, compromised nutrition, fluidvolume deficit, confusion, limitations in mobility, lack of inde-pendence and bruised skin. Certain medications, includingsteroids, also make skin more prone to injury by causing fur-ther thinning as well as suppression of the immune system.

In addition, wound healing progresses more slowly in the eld-erly due to several factors, including decreased inflammatoryresponse, delayed angiogenesis (i.e., formation of new bloodvessels), slower epithelialization, decreased function ofsebaceous glands, decreased collagen synthesis, alternationin melanocytes (resulting in skin discoloration) and thinningof all the skin layers. Less adipose tissue means decreasedinsulation and protection. The subcutaneous tissue alsoatrophies in very specific areas: the face, hands and feet.6

Research has shown that 25 percent of skin tears are causedby wheelchair/geri-chair injuries. Another 25 percent occurfrom accidents involving bumping into objects, 18 percentinvolve patient or resident transfers and 12.4 percent are theresult of falls.1 These situations increase contact with the skin,thus increasing the potential for the skin to tear.

Structure of the skinThe basic structure of the skin has a great deal to do with howand why skin tears occur. First, it’s important to know that theskin consists of three layers:

1. The epidermis — outermost layer

2. The dermis — the thicker second layer thatcontains hair follicles, sweat glands and nerves

3. The subcutaneous tissue — the fatty layer that provides cushioning and protection

Subcutaneous tissue

Epidermis

Dermis

18 Healthy Skin


creo

“

Prevention of skin tearsThe basics. Common sense strate-gies, such as clothing residents in longsleeves and long pants, the use of gen-tle adhesives and staff education ongentle handling of the skin, are all good

first steps toward preventing skin tears.7 Use great care whileproviding full or partial assistance with activities of daily living.These tasks increase contact with the skin, thus increasing thepotential for the skin to tear.8 Use of appropriate equipment(i.e., lifts, walkers, transfer and turn aids, etc.) to assist with toi-leting and transferring also can be helpful in decreasing thechance of developing skin tears.

Skin care. Advanced skin care products that deliver ender-mic nutrition as well as antioxidants can provide for nourishedskin topically – even if the patient or resident is not receiving ad-equate nutrition from oral, enteral or parenteral nutrition.9

One study looked at skin tear incidence in a 100-bed long-term care facility and showed a reduction from 180 skin tearsin a six-month period to two skin tears in a six-month time pe-riod.10 This particular facility used a gentle, advanced skin careline with pH-balanced soap and surfactant-free cleansers;moisturizers containing amino acids and free radical scav-engers like grape seed extract, vitamin C (ascorbic acid), andhydroxytyrosol (from olives); essential fatty acids like omega-3,-6 and -9; and tenacious skin protectants containing sophisti-cated combinations of silicones.

Similarly, in a four-month prospective crossover study com-paring the use of emollient soap (containing moisturizers) withnon-emollient soap, Mason found that residents of a 173-bed,

long-term care facility developed fewer skin tears when anemollient soap was used during bathing. When comparing thetotal rate of skin tears per resident, the rate of skin tears whenemollient soap was used was 34.8 percent lower than whennon-emollient soap was used.8

Plante and Regan conducted a controlled study among 64residents of a long-term care facility to compare the effects ofusing a non-detergent, no-rinse cleanser to bathing with soapand water. After 12 weeks, the total number of skin tears de-creased by 90 percent, with an 82 percent reduction in skintears in the treatment group. Annual cost savings for patientsin the treatment group was $2,446.11

Skin Tear Prevention Strategies12

• Perform risk assessments to identify at-risk individuals• Use moisturizers/emollients daily• Make sure vulnerable individuals wear long-sleeved

shirts, pants and stockings• Use skin sleeves and leg protectors• Maintain individuals’ hydration and nutrition

Treatment of skin tearsDespite your best efforts to prevent skin tears, they can stillhappen. The primary goals for treating skin tears are to stopbleeding, recover skin integrity, prevent infection of the wound,minimize pain and promote comfort.12 There are several goodtopical products that can help alleviate the discomfort of skintears while protecting the area to allow healing. It is also im-portant to look at your dressing choices and choose productsthat allow you to avoid adhesives, decrease dressing changesand maintain an optimally moist wound healing environment.

“Residents of a 173-bed, long-term care facility developed fewer skin tears when anemollient soap was used during bathing.



Three Steps for Treating Skin Tears12

Hydrogel sheets. Hydrogel sheets are clear or translucentwater- or glycerin-based products that can be used to main-tain a moist wound environment.13 They look like a thin sliceof sticky gelatin and can handle the initial fluid from a woundfor the first 24-48 hours. They vary in thickness and are non-adherent to the wound base. The hydrogel sheet may be heldin place with elastic net dressing or a tubular-type dressing.

Protective sleeves. The use of protective sleeves or elastictubular support bandages that come on a roll is a good wayto hold dressings in place without irritating sensitive skin withadhesive tape. They also protect the patient or resident whois prone to picking at the dressing.

Use caution with adhesive closure strips. Adhesive clo-sure strips are common for keeping skin tears closed whilethey heal, however, caution is advised. Traction on the frag-ile epidermis combined with inflammatory action can causeskin damage. When it’s time to remove the closure strips, useextra care, as blood crusts can tear off the epidermis. 14

Outdated Treatments for Skin Tears12

• Transparent films (as primary dressing) • Telfa-type non-adherent dressings• Sutures• Removal of a viable skin flap immediately post-injury

ConclusionOverall, when it comes to skin tears, keep it simple. Basicstrategies, such as a comprehensive skincare program thatavoids soap and includes nutrient-based moisturizers, con-suming plenty of fluids and a nutritious diet, combined withusing extra care to protect patients’ or residents’ skin from in-jury, will go a long way toward preventing skin tears.

When a skin tear does occur, be sure to keep it protectedfrom infection and further injury. Avoid outdated treatments,such as telfa-type non-adherent dressings or removal of a vi-able skin flap. One very effective treatment is use of a hydro-gel sheet kept in place with an elastic net dressing.

With these tips and techniques, your facility will be well on itsway toward eliminating skin tears all together.

References1. Brillhart B. Preventive skin care for older adults. Geriatrics & Aging. 2006;9(5):334-

339.2. Baranoski S. How to prevent and manage skin tears. Advances in Skin & Wound

Care. 2003;16(5):268-70.3. Humbert P, Sainthillier JM, Mac-Mary S. Capillaroscopy and videocapillarsocopy and

assessment of skin microcirculation: dermatologic and cosmetic approaches. J Cos-met Dermatol. 2005;4(3):153-162.

4. Baranoski S, Ayello E. Skin: an essential organ. In: Baraoski S, Ayello E, eds. WoundCare Essentials: Practice Principles. Springhouse, Penn.:Lippincott Williams &Wilkins; 2004.

5. Baronoski S. Skin tears: the enemy of frail skin. Advances in Skin & Wound Care.2000; 13(3 Pt 1):123-126.

6. Thomas-Hess C. Fundamental strategies for skin care. In: Krasner D, Rodheaver G,Sibbald G., eds. Chronic Wound Care: A Clinical Source Book for Healthcare Pro-fessionals. 2nd ed. Wayne, Pa: HMP Communications; 1997.

7. Fleck CA. Ethical wound management for the palliative patient. ECPN. 2005;100:38-46.

8. Mason SR. Type of soap and the incidence of skin tears among residents of a long-term care facility. Ostomy Wound Management. 1997;43(8):26-30.

9. Groom M. Decreasing the incidence of skin tears in the extended care setting withthe use of a new line of advanced skin care products containing Olivamine. Pre-sented at the 18th Annual Symposium on Advanced Wound Care and the 15th An-nual Medical Research Forum on Wound Repair in San Diego, Calif. April 21-24,2005.

10. Frantz RA, Gardner S. Clinical concerns: management of dry skin. J Gerontol Nurs.1994;20(9):15-18, 45.

11. Birch S & Coggins C. No-rinse, one-step bed bath: the effects on the occurrenceof skin tears in a long-term care setting. Ostomy Wound Management.2003;49(1):64-67.

12. Krasner D. Prevention and Treatment of Skin Tears in Older Adults. Presented atMedline’s Prevention Above All Symposium in Oakbrook, Ill. January 26, 2010.

13. Hess CT. When to use hydrogel dressings. Advances in Skin & Wound Care.2000;13(1):42.

14. Meuleneire F. Using a soft silicone-coated net dressing to manage skin tears. J Wound Care. 2002;11(10):365-369.

1 Cleanse using normal saline, tap water or wound cleanser

2 Assess according to the Payne-Martinscale or by classifying wounds as partialthickness or full thickness

3 Dress the wound using recommended products

20 Healthy Skin


creo

Problem: Periwound Maceration

Solution: Marathon® Liquid Skin Protectant

1-800-MEDLINE | www.medline.com

© 2010 Medline Industries, Inc. Medline® and Marathon are registered trademarks of Medline Industries, Inc.

Periwound maceration hampers wound healing. So it only makes sense to

do everything you can to protect the periwound area. Marathon Liquid Skin

Protectant helps protect against friction and maceration by creating a

barrier against physical and chemical assault.

Marathon bonds to the skin surface, integrating with the epidermis

on a molecular level. While other skin protectants may flake off,

Marathon stays put, offering robust protection.

For a free trial, visit www.medline.com

More solutions than any other skin and wound care company.

“A recent survey graded physicians’ abil-ities to recognize, assess and document

Stage III and IV pressure ulcers at a “D”level. Medline’s new Pressure Ulcer Prevention

Program MD Education CD contains everything physiciansneed to brush up on their skills and comply with the newCMS Inpatient Prospective Payment System (IPPS).

The new MD Education component of Medline’s Pressure

Ulcer Prevention Program is critical for acute-care facilities

to ensure that physicians understand their role in recognizing

and accurately documenting POA pressure ulcers.”

Michael Raymond, MD, Associate Chief Medical Quality Officer, NorthShore University HealthSystem, Skokie Hospital, Skokie, IL

To learn more about Medline’s Pressure Ulcer Prevention Programs and FREE webinars for acute care and perioperativeservices, call your Medline representative, or visitwww.medline.com/pupp-webinar.

Are Your Physicians Making the Grade?


creo

It’s another level of

comfortand

protection

Restore®/Remedy® briefs provide maximum dryness with skin nourishment built right in.

Restore®/Remedy® briefs not only keep wetness away from your residents’ skin, they also help provide protection from skin irritation with a coating of Medline’s Remedy®

Skin Repair Cream on the inner liner. Using a combination of the Remedy skincare line and the Restore/Remedy brief was shown to keep the pressure ulcer incidence rate and incontinence-associated dermatitis prevalence rate down according to a retrospective,cohort study conducted at Meridian Nursing and Rehabilitation in Brick, NJ.1

The brief’s absorbent UltraCare core helps provide maximum dryness for improved comfort and protection. And the cloth-like outer cover is comfortable against the skin, helping to minimize rash or irritation.

1 Shannon R., Fisher K. A Nursing and Rehabilitation Center Project in New Jersey: Expected Value of Remedy Skin Care and Restore Briefs in an At-Risk Resident Population for Pressure Ulcer and Incontinence-Associated Dermatitis Prevention. ©2010 Medline Industries, Inc.

Medline is a registered trademark of Medline Industries, Inc.

Purchase a 12 month supply of Restore/Remedy briefs and receive one month free. For details contact your Medline representative or call 1-800-MEDLINE.


creo


Sue MacInnes:What is the SCALE Panel and why was it formed?Diane Krasner:The SCALE Panel was convened to explore the issues surrounding skin conditions associated with dying patients.The panel reviewed existing literature, best practices and research on the issue. Eighteen participants met for the firstpanel meeting April 4-6, 2008 in Chicago, which was fundedby an unrestricted educational grant from Gaymar Industries,Inc. Participants included nurses, physicians, legal experts and a medical writer. All had an interest in or clinical experience with skin conditions in dying patients. Includedin the panel were Karen Lou Kennedy, a nurse practitionerwho has published on the Kennedy Terminal Ulcer(www.kennedyterminalulcer.com) and Dr. Diane Langemo,who proposed the concept of skin failure. SCALE Panel mem-bers represented the continuum of care from acute care tohospice. Dr. Gary Sibbald and I served as panel co-chairs.Cindy Sylvia was the panel facilitator. Jim Lutz served as themedical writer. Dr. Thomas Stewart conceived the acronymSCALE: Skin Changes At Life’s End.

Sue MacInnes: What process did the SCALE Panel use to reach consensus?Diane Krasner:After reviewing the existing literature on the topic and hearing presentations by selected panel members, theSCALE panel worked in three teams, drafting preliminary consensus statements. Jim Lutz used audiotapes and notesfrom the April 2008 meeting to craft a Preliminary ConsensusStatement. This document was reviewed and edited by the entire panel. From September 2008 to June 2009 the Preliminary Consensus Statement was presentedinternationally at wound conferences, published and posted on the SCALE website. Stakeholders were encouraged to circulate the document for comments. All thecomments were used to generate a Final Consensus Statement, which was then returned to the original18-member expert panel and a 52-member reviewer panel.The two groups of panel members then voted on each of the10 statements for consensus using a modified Delphi Methodapproach. A quorum of 80 percent that strongly agreed or

Healthy Skin Editor Sue MacInnes interviewsSCALE Panel Co-Chair Diane Krasner

Skin Changes At Life’s End

Wound care expert Dr. Diane Krasner shares her experiences as co-chair of the SCALE Panel and corresponding author of the SCALE Final Consensus Statement.

Sue MacInnes,RD, LD

Diane Krasner, PhD,RN, CWCN, CWS,

BCLNC, FAAN

Treatment


creo

10 statements proposed by the SCALE Expert Panel:Statement 1 ........................................................................Physiologic changes that occur as a result of the dying process may affect

the skin and soft tissues and may manifest as observable (objective) changes

in skin color, turgor, or integrity, or as subjective symptoms such as localized

pain. These changes can be unavoidable and may occur with the application

of appropr iate interventions that meet or exceed the standard of care.

Statement 2 ........................................................................The plan of care and patient response should be clearly documented

and reflected in the entire medical record. Charting by exception is an

appropriate method of documentation.

Statement 3 ........................................................................Patient centered concerns should be addressed including pain and activities

of daily living.

Statement 4 ........................................................................Skin changes at life’s end are a reflection of compromised skin (reduced

soft tissue perfusion, decreased tolerance to external insults, and impaired

removal of metabolic wastes).

Statement 5 ........................................................................Expectations around the patient’s end of life goals and concerns should be

communicated among the members of the interprofessional team and the

patient’s circle of care. The discussion should include the potential for

SCALE including other skin changes, skin breakdown and pressure ulcers.

Statement 6 ........................................................................Risk factors, symptoms and signs associated with SCALE have not been fully

elucidated, but may include:

■ Weakness and progressive limitation of mobility.

■ Suboptimal nutrition including loss of appetite, weight loss, cachexia and

wasting, low serum albumin/pre-albumin, and low hemoglobin as well

as dehydration.

■ Diminished tissue perfusion, impaired skin oxygenation, decreased local

skin temperature, mottled discoloration, and skin necrosis.

■ Loss of skin integrity from any of a number of factors including

equipment or devices, incontinence, chemical irritants, chronic exposure

to body fluids, skin tears, pressure, shear, friction, and infections.

■ Impaired immune function.

Statement 7 ........................................................................A total skin assessment should be performed regularly and document all

areas of concern consistent with the wishes and condition of the patient.

Pay special attention to bony prominences and skin areas with underlying

cartilage. Areas of special concern include the sacrum, coccyx, ischial

tuberosities, trochanters, scapulae, occiput, heels, digits, nose and ears.

Describe the skin or wound abnormality exactly as assessed.

somewhat agreed with each statement was used as apre-determined threshold for having achieved consensuson each of the statements. A consensus based on 52votes was reached after the first round of the Delphi.Numerous comments were made, and a final draft waswritten to incorporate the comments. The SCALE FinalConsensus Statement was released on October 1, 2009.

Sue MacInnes:How would you describe the SCALE Final Consensus Statement?Diane Krasner:The SCALE Final Consensus Statement reflects the current evidence and best practices surrounding SkinChanges At Life’s End. The ten statements represent theexpert opinions of thought leaders from around the world.There is clear agreement that more research needs to beundertaken to enhance our understanding of the multipleand complex skin change phenomena that occur duringthe dying process. In the meantime, the 10 consensusstatements give practical and focused suggestions forclinical management. In addition to the 10 consensusstatements, which are reprinted in this issue of HealthySkin, the SCALE Final Consensus Statement includes aglossary, a reference list and several charts/enablers forclinical practice.

Sue MacInnes:How can the SCALE documents be accessed and utilized?Diane Krasner:Free downloads of the SCALE documents are availableat the website of the panel sponsor, Gaymar Industries:www.gaymar.com. Look under “Clinical Support and Education” and “SCALE Consensus Documents.” Inaddition to the 19-page final consensus statement, thereis a three-page guide and the SCALE annotated bibliog-raphy. All of these documents can be utilized for educa-tion and training. The SCALE documents have relevance across the continuum of care for all members ofthe interprofessional wound care team. For further information, contact corresponding author Dr. Diane Krasner at [email protected].

Dr. Krasner is a Wound & Skin Care Consultant in York, PA. She

works part-time at Rest-Haven York, is the lead co-editor of Chronic

Wound Care (www.chronicwoundcarebook.com) and clinical editor

of Wound Source (www.woundsource.com).

24 Healthy Skin


A = Assess and document etiology: An assessment should then be made

of the general condition of the patient and a care plan.

P = Plan of care: A care plan should be developed that includes a decision

on skin care considering the 5P’s as outlined in Figure 1. This plan of care

should also consider input and wishes from the patient and the patient’s

circle of care.

I = Implement appropriate plan of care: For successful implementation, the

plan of care must be matched with the healthcare system resources (avail-

ability of equipment and personnel) along with appropriate education and

feedback from the patient’s circle of care and as consistent with the

patient’s goals and wishes.

E = Evaluate and educate all stakeholders: The interprofessional team also

needs to facilitate appropriate education, management, and periodic reeval-

uation of the care plan as the patient’s health status changes.

Statement 10 ......................................................................Patients and concerned individuals should be educated regarding SCALE

and the plan of care.

Statement 8 ........................................................................Consultation with a qualified health care professional is recommended for

any skin changes associated with increased pain, signs of infection, skin

breakdown (when the goal may be healing), and whenever the patient’s

circle of care expresses a significant concern.

Statement 9 ........................................................................The probable skin change etiology and goals of care should be determined.

Consider the 5 Ps for determining appropriate intervention strategies:

■ Prevention

■ Prescription (may heal with appropriate treatment)

■ Preservation (maintenance without deterioration)

■ Palliation (provide comfort and care)

■ Preference (patient desires)

S = Subjective skin & wound assessment: The person at the end of life

needs to be assessed by history, including an assessment of the risk for

developing a skin change or pressure ulcer (Braden Scale or other valid and

reliable risk assessment scale).

O = Objective observation of skin & wound: A physical exam should iden-

tify and document skin changes that may be associated with the end of life

or other etiologies including any existing pressure ulcers.

SCALE Final Consensus StatementDetermined as a result of a two-day panel discussion and subsequent panel revisions with input from noted wound care experts using a modified Delphi Method approach.

Evaluate & revise care plan as needed

Evaluate & revise care plan as needed

Figure 1: The SOAPIEmnemonic with the 5P enabler.



creo

1. Why was the SCALE Panel convened? A. To discuss weight loss issues B. To explore the issues surrounding skin conditions

associated with dying patients C. To develop new treatments for dry, scaly skin D. None of the above

2. When was the SCALE Final Consensus Statement released? A. February 1, 1972B. September 30, 2008C. May 15, 1997 D. October 1, 2009

3. In addition to the 10 consensus statements, the SCALE Final Consensus Statement includes a glossary, a reference list and _________________.A. A dictionary B. A thesaurus C. Several charts/guides for clinical practice D. Free samples of skin care lotion

4. Which approach was used by the SCALE Panel to reach consensus? A. Modified Delphi MethodB. Accelerated Apolo Ohno C. Prediction Partnership D. Phase I Delphi Method

5. The SCALE Final Consensus Statement reflects the current evidence and best practices surrounding _______________________.A. Choosing the best bathroom scale B. Sunny Climates And Lifelong Eczema C. Skin Changes At Life’s EndD. Treatment of dry skin in long-term care residents

6. The letter “A” in the SOAPIE mnemonic stands for ___________________.A. Answer all questions B. Assess and document etiology C. Accentuate the positiveD. All of the above

7. The 5P enabler for determining appropriate intervention strategies consists of: A. Prevention, Prescription, Preservation, Palliative,

Proactive B. Potential, Prescription, Pattern, Palliative, PreferenceC. Prevention, Perseverance, Panic, Persuade,

PreferenceD. Prevention, Prescription, Preservation, Palliative,

Preference

8. Which of the following might cause loss of skin integrity at the end of life?A. InfectionsB. Binge eatingC. Incontinence D. Both A and C

9. Choose the false statement below. A. Expectations around the patient’s end of life goals

and concerns should be kept secret.B. Skin changes at life’s end are a reflection of

compromised skin (reduced soft tissue perfusion, decreased tolerance to external insults, and impaired removal of metabolic wastes).

C. The plan of care and patient response should be clearly documented and reflected in the entire medical record.

D. A total skin assessment should be performed regularly and document all areas of concern consistent with the wishes and condition of the patient.

10. Physiologic changes that occur as a result of the dying process may affect the skin and soft tissues and may manifest as observable (objective) changes in skin color, turgor, or __________________, or as subjective symptoms such as localized pain. A. Sensitivity B. DensityC.TextureD. Integrity

CE Questions

Skin Changes At Life’s End Continuing Education QuestionsSCALE:

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

26 Healthy Skin


1-800-MEDLINE I www.medline.com




More than 1 million Americans receive home health care services every year.1 Just as every patient is unique, so is every home health care agency.

That’s why Medline HomeCare is proud to offer innovative solutions for every segment of your business, designed to fit your specific needs. We provide: • Supply management• Clinical support• Increased productivity• Back office connectivity• Documented cost savings

To learn more about Medline HomeCare, call us at 1-800-678-7852.

Reference1 The Centers for Disease Control and Prevention. Home Health Care Patients:Data from the 2000 National Home and Hospice Care Survey. Available at:www.cdc.gov/nchs/pressroom/04facts/patients.htm. Accessed April 12, 2008.

For your free cost-savings analysis, contact yoursales representative or call 1-800-678-7852.

BRINGING IT HOME TO YOU


creo


Unraveling thePressure Ulcer

and Wound CareSections ofOASIS-C

by Clay E. Collins, RN, BSN, CWOCN, CFCN, CWS

It’s finally here! The long-awaited OASIS-C data collectiontool for home care agencies was implemented January 1,2010, leaving many home care nurses and agenciesscrambling to understand the multitude of additions andrevisions. These changes could significantly affect agencyreimbursement and publicly reported quality measureswhile also providing essential guidance for surveyors.

With this in mind, home care agencies arefaced with the daunting task of re-learningand understanding the new OASIS-Cdocument. This article will help you makesense of the changes in the documenta-tion of pressure ulcers and wound carethat appear under the section ofOASIS-C called “IntegumentaryStatus.”

History and backgroundIn 1999 the Centers for Medicare andMedicaid Services (CMS) began requiringall Medicare-certified home care agenciesto begin collecting and submitting datarelated to all adult, non-maternity patientsreceiving skilled nursing services underMedicare and Medicaid. These require-ments were documented in the Outcomeand Assessment Information Set (OASIS).Over the years, OASIS has undergonechanges to improve data collection require-ments, refine items for payment algorithms andenhance outcome reporting.

Special Feature


creo

30 Healthy Skin

Over the past decade CMS has focused on quality improve-ment and evidence-based practice recommendations fromthe Institutes of Medicine (IOM), the National Quality Forum(NQF) and the Medicare Payment Advisory Commission(MedPAC). Beginning in 2004, with the revision of long-termcare’s F-Tag 314 regarding pressure ulcers and the release ofnew guidelines to direct surveyors of long-term care facilities,CMS embarked on a journey to bring the providers of long-term care, acute care and home care into a synergistic rela-tionship focused on improving outcomes and the quality ofpatient care.

Next, as a result of the federal Value Based Purchasing (VBP)Initiative, came the implementation of the present-on-admission (POA) indicators for acute care facilities onOctober 1, 2008. It includes a list of hospital-acquiredconditions, including full thickness pressure ulcers (StageIII and IV), which are no longer reimbursable when they occurduring a hospital stay.1 In home care, the focus on quality andevidence-based practice has never been more evident thanin the new OASIS-C data collection tool.

Development of OASIS-COASIS-C was developed for three reasons:

1. To address issues raised by home care providers2. To expand home care quality measurement to

include care processes

3. To align and “harmonize” OASIS measures with othercare measurement instruments currently being developed across post-acute care settings (i.e., the nursing home Minimum Data Set [MDS] and the Continuity Assessment Record Evaluation [CARE]).

Regarding reason #3, pressure ulcer items on OASIS wererevised to reflect current pressure ulcer assessment guide-lines from the National Pressure Ulcer Advisory Panel(NPUAP) and the Wound, Ostomy and Continence NursesSociety (WOCN) and to collect additional information consid-ered to be essential to care planning (i.e., wound length, widthand depth).

Home care agencies also are being encouraged to useevidence-based practices, although the care processesincluded in OASIS-C are not currently mandated in the HomeHealth Agency (HHA) Conditions of Participation. Home careagencies may choose not to incorporate the care processesincluded in OASIS-C, but should be aware that since some ofthe process items will be utilized to support publicly reportedmeasures, failure to incorporate the care processes may bereflected in their Home Health Compare scores. For example,one measure that will be publicly reported on Home HealthCompare is: “Percentage of home health episodes of care inwhich the patient was assessed for risk of developing pres-sure ulcers at start of care/resumption of care.” The data forthis care process will be obtained from a new question added



to the OASIS-C, “M1300 - Pressure Ulcer Assessment: Wasthe patient assessed for risk of developing pressure ulcers?”

The goal is clear; CMS expects home care agencies to takean active role in the prevention and treatment of pressureulcers and expects patients’ wounds to improve. This willchallenge agencies to take a closer look at their policies andprocedures guiding delivery of care to ensure that they are inline with OASIS-C and the patient care practices beingimplemented. Staff training and education on wound healingand assessment will be essential in achieving the expertisenecessary to accurately complete the questions included inthe Integumentary Status section of OASIS-C. The inability tocorrectly assess, describe and measure wounds could notonly result in serious financial implications for a home careagency, but also in poor outcome quality measures.

OASIS-C items related to pressure ulcers and other wounds2,3,4,5

With that in mind, let’s take a look at OASIS-C. The first thingyou will notice is that the items have been renumbered. Theitems for Integumentary Status are now numbered M1300through M1350. For a copy of the Integumentary Status sec-tion of OASIS-C, turn to page 86. It will be helpful to followalong with that document as you read this article.

Here is a detailed explanation of each item in the Integumen-tary Status section of OASIS-C:

(M1300) Pressure Ulcer Assessment: Was this patientassessed for Risk of Developing Pressure Ulcers? (M1302) Does this patient have a Risk of DevelopingPressure Ulcers? These are two new questions added to OASIS-C to capturehome care agencies’ use of best practices in the assessmentof pressure ulcer risk. Agencies are now required to screenpatients for risk of developing pressure ulcers. They are not,however, required to use a standardized, validated riskassessment tool. CMS defines a standardized, validated toolas one that “1) has been scientifically tested and evaluated

with a population with characteristics similar to the patientwho is being evaluated and shown to be effective in identify-ing people at risk for developing pressure ulcers; and 2)includes a standard response scale.” Examples of thesetypes of tools include the Braden Scale and the Norton Scale.In place of the Braden or Norton Scale, agencies may chooseto develop their own risk assessment tool or assess patients’risk based on an evaluation of clinical factors. If an agencychooses this method, then they must also define what con-stitutes risk. These two questions are to be answered at Startof Care and Resumption of Care.

(M1306) Does this patient have at least one UnhealedPressure Ulcer at Stage II or Higher or designated as“not stageable”? The National Pressure Ulcer Advisory Panel (NPUAP) definesa pressure ulcer as: “Localized injury to the skin and/orunderlying tissue usually over a bony prominence, as a resultof pressure, or pressure in combination with shear and/or fric-tion.”6 It is important for the assessing clinician to make anaccurate determination of the true causative factors/etiologyof a wound to be sure that it truly is a pressure ulcer. If apatient’s wound is not a pressure-related injury, then the cor-rect answer would be “0-No.”

If it is determined that the wound is a pressure-related injury,the clinician must have a thorough understanding of theNPUAP staging system, updated February 2007, as well asprinciples of wound healing. Stage I pressure ulcers involveintact skin, and thus no open wound, so they are not included

The goal is clear; CMS expects home care agencies to take an active

role in the prevention and treatment of pressure ulcersand expects patients’ wounds to improve.

“”

Agencies are now required to screen patients for risk of developing pressure ulcers.


creo

32 Healthy Skin

in this question. Research regarding wound healing hasrevealed that partial thickness wounds such as Stage II pres-sure ulcers heal through regeneration of the dermis and epi-dermis. Once complete epithelialization occurs, the wound isconsidered healed and no longer counted as a pressure ulcer.

Under M1306, if the patient has a healed Stage II pressureulcer and no other pressure ulcers, the correct answer wouldbe “0-No.” On the other hand, full thickness wounds such asStage III and Stage IV pressure ulcers heal differently than par-tial thickness wounds. Full thickness wounds heal through aprocess of granulation, contraction and epithelialization, whichresults in the formation of scar tissue. As a result, full thicknesswounds never can be considered “healed.” However, theymay be considered “closed” when they have fully granulated,and the wound has been resurfaced with new epithelium.

So, if a patient presents with a “closed” (or open) Stage III orIV pressure ulcer or if the patient has an Unstageable pressureulcer or suspected deep tissue injury, the correct answer tothis question would be “1-Yes.” The OASIS-C guidance alsodirects clinicians to select “1-Yes” if pressure ulcers are known

to exist or suspected to exist, but may not be observable dueto the presence of dressings or devices (e.g., casts) that can-not be removed to assess the underlying skin. This questionis to be answered at the following points in time: Start of care,Resumption of care, Follow-up and Discharge from agency –not to inpatient facility.

(M1307) Date of Onset of Oldest Unhealed Stage IIPressure Ulcer identified since most recent Start ofCare (SOC)/Resumption of Care (ROC) assessmentThis item is designed to identify the oldest Stage II pressureulcer only and is collected upon discharge from the agency.An ulcer that is suspected of being a Stage II, but isUnstageable, should NOT be identified as the “oldest” StageII pressure ulcer. With this question, CMS will be able to tellhow long this ulcer remained unhealed while receiving serv-ices from the home care agency and identify patients whodeveloped a pressure ulcer while under the care of the homecare agency. Once again, as previously mentioned, CMSexpects to see healing and not deterioration of patients ortheir wounds while receiving home care services.

Continued on page 34


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

Medline Remedy®

Serious care. Serious results.

Nosocomial pressure ulcers reduced by

50% after 3 months1

Nosocomial pressure ulcers reduced to zero

after 8 months1

Estimated cost savings of $6,677.11

per patient

* A silicone-based dermal nourishing emollient (SBDNE)

1. Shannon RJ, Coombs M, et al. Reducing hospital-acquired pressure ulcers with a silicone-based dermal nourishing emollient-associatedskincare regimen. Adv Skin Wound Care, 2009;22:461-7.

©2010 Medline Industries, Inc. Medline and Medline Remedy are registered trademarks of Medline Industries, Inc.

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


creo

(M1308) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at Each StageThis chart of items requires the clinician to count the numberof current open pressure ulcers and their stage. Completionof this item requires a sound understanding of theNPUAP Pressure Ulcer Classification System, available atwww.npuap.org/resources.htm.

The clinician must be sure that each pressure ulcer meets therequirements of the definition of each stage. Stage I pressureulcers and any healed (epithelialized) Stage II pressure ulcersare not counted. Likewise, pressure ulcers that arerepaired surgically through procedures such as a muscle flap,skin advancement flap or rotational flap, are no longer con-sidered to be pressure ulcers. Instead, the patient now hasa surgical wound. Surgical debridement of a pressure ulcer,on the other hand, only removes necrotic tissue, so a surgicallydebrided wound would still be counted as a pressure ulcer.

When counting Stage III and IV pressure ulcers remember,“once a Stage III always a Stage III; once a Stage IV alwaysa Stage IV.” Reverse staging of pressure ulcers is clinicallyincorrect and inappropriate because the stage only refers tothe level of tissue damage. Stage III and IV pressure ulcers,as mentioned previously, heal through granulation,contraction and epithelialization and do not restore thepreviously damaged underlying layers.

So, if a Stage III pressure ulcer means a full thickness tissueloss down to the subcutaneous layer, then this amount ofdamage will always be present even when the wound hasgranulated to surface level and has been resurfaced withnew epithelium. As a result, if a patient has a previouslyclosed Stage III or IV that reopens, it is still a Stage III or IV(even if it only looks like a Stage II). When attempting to stagea granulating pressure ulcer, challenges arise if the cliniciandid not see the ulcer at its worst. In this case, the assessingclinician should make every reasonable attempt to determinethe original stage of the ulcer at its worst by contactingprevious providers (i.e., physician, hospital, nursing home).

(M1310) Pressure Ulcer Length, (M1312) Pressure Ulcer Width, (M1314) Pressure Ulcer Depth These three questions are new to OASIS data collection andrequire the measurement of the largest unhealed Stage III orIV or Unstageable pressure ulcer only. To determine thelargest ulcer, measure the length and width of each openStage III, IV or Unstageable pressure ulcer to determine whichhas the largest surface area. The instructions direct the clini-cian how to obtain the measurements: length is measured asthe longest length from “head to toe,” width is measured asthe greatest width measured perpendicular to the length, anddepth is measured from the visible surface to the deepestarea of the wound. All measurements are to be recorded incentimeters.

M1310, M1312 and M1314 require all home care agenciesto measure wounds in the same manner to allow CMS to col-lect data that directly reflects a home care agency’s woundhealing efforts as evidenced by either increasing or decreas-ing wound sizes. These items are completed at Start of Care,Resumption of Care and upon Discharge from agency – notto inpatient facility.

Measurements may be made using a variety of tools, includ-ing a cotton-tipped applicator, disposable measuring device,a camera or other device that calculates measurements.Measurements should always be taken following removal ofthe dressing and thorough wound cleansing.

CMS expects to see healing and not deterioration of patients or their wounds while receiving home care services.

W

L

L

34 Healthy Skin


(M1320) Status of Most Problematic (Observable)Pressure Ulcer For this question, the “most problematic pressure ulcer” doesnot necessarily mean the largest. The most problematic pres-sure ulcer could be the largest or the most advanced stageor the ulcer the clinician is having the most problem access-ing because of location, difficulty with pressure relief or avariety of other factors.

Once the most problematic pressure ulcer is determined,the clinician must then make a determination of the healingstatus. The Wound, Ostomy and Continence Nurses Society(WOCN) recently issued a new guidance document to assistclinicians in making this determination. It’s available atwww.wocn.org/pdfs/GuidanceOASIS-C.pdf. Here are a fewitems of note:

1. Since Stage II pressure ulcers do not granulate, as previously explained, the only appropriate answer for a Stage II pressure ulcer would be “3-Not healing.”

2. The response “NA-No observable pressure ulcer” onlyrefers to pressure ulcers that cannot be observed due to the presence of a dressing or device that cannot be removed.

3. Unstageable pressure ulcers or ulcers with necrotic tissue (eschar/slough) would either be scored as “2-Early/partial granulation” or “3-Not healing,” depending on the amount of necrotic tissue present.

4. If a patient has only one pressure ulcer, then that ulcer is the most problematic. Stage I pressure ulcers are not considered for this item.

(M1322) Current Number of Stage I Pressure UlcersA Stage I pressure ulcer is characterized by intact skin withnon-blanchable redness of a localized area usually over abony prominence. The area may be painful, firm, soft, warmeror cooler as compared to adjacent tissue. This question iden-tifies the presence of Stage I pressure ulcers at Start of Care,Resumption of Care, Follow-up and Discharge.

(M1324) Stage of Most Problematic Unhealed (Observable) Pressure Ulcer This item identifies the stage of the most problematic pressureulcer that was previously determined in item M1320. Again,a thorough understanding of the NPUAP Pressure Ulcer Clas-sification System is required to correctly answer this item.If the patient has no pressure ulcers or if the most problem-atic is Unstageable due to the presence of necrotic tissue orunobservable due to a non-removable dressing or device,then the correct answer would be “NA-No observable pres-sure ulcer.”

(M1330) Does this patient have a Stasis Ulcer? (M1332) Current Number of (Observable) Stasis Ulcer(s) These items pertain to stasis ulcers, which are caused byvenous insufficiency in the lower leg. It is important for clini-cians to differentiate stasis ulcers from other lower leg ulcers,such as arterial ulcers and other types of skin ulcers. Thisrequires the clinician to utilize clinical assessment skills andknowledge of various etiologies of lower leg ulcers. Theseitems are to be completed at Start of Care, Resumption ofCare, Follow-up and Discharge from agency – not to inpa-tient facility. Hint: The WOCN produced a “Clinical Fact Sheetfor Assessment of Leg Ulcers” that may be of value in helpingwith this process. For a copy, turn to page 93 or go towww.wocn.org/pdfs/WOCN_Library/Fact_Sheets/C_QUICK1.pdf.

(M1334) Status of Most Problematic (Observable) Stasis Ulcer This item utilizes the same thought process as item M1320 todetermine the most problematic stasis ulcer and describesthe healing status of the ulcer dependent on the amount ofnecrotic tissue and granulation tissue based on the WOCNguidance.

The “most problematic pressure ulcer” does not necessarily mean the largest.



36 Healthy Skin

(M1340) Does this patient have a Surgical Wound? (M1342) Status of Most Problematic (Observable) Surgical Wound This item identifies the presence of any wound caused by asurgical procedure. Scars and keloids are NOT consideredsurgical wounds. Bowel ostomies and all other ostomies arenot considered surgical wounds, either; however, the woundthat results after an ostomy reversal procedure is consideredto be a surgical wound. As mentioned previously, surgicalrepair of a pressure ulcer with flap surgery is NOT considereda pressure ulcer and would instead be included under thisitem. Debridement or skin grafting does NOT create a surgi-cal wound, and these wounds would continue to be consid-ered the same type of wound as previously identified prior tothe procedure.

The CMS guidance states “For the purpose of this OASISitem, a surgical site closed primarily (with sutures, staples ora chemical bonding agent) is generally described in docu-mentation as a surgical wound until epithelialization has beenpresent for approximately 30 days, unless it dehisces or pres-ents signs of infection.” Surgical sites that have been epithe-lialized for 30 days should be described as a scar, and shouldnot be included in this item.

Surgical wounds also include: Orthopedic pin sites, centralline sites, wounds with drains, medi-port sites and other typesof implanted infusion devices or venous access devices.A PICC line is NOT considered a surgical wound since it isperipherally inserted. Also EXCLUDED are procedures suchas cataract surgery, surgery to mucosal membranes orvaginal gynecological procedures.

Item M1342 identifies the most problematic surgical woundand the status of the healing surgical wound based on theWOCN Guidance Document. CMS encourages clinicians tofollow the guidance suggested in the WOCN Guidance Doc-ument on "OASIS Skin and Wound Status M0 Items" (revisedJuly 2006) in the assessment of surgical wounds. The docu-ment is available at www.wocn.org/pdfs/WOCN_Library/OASIS_Guidance_rev_07_24_2006.pdf.


creo


Item M2250 (plan of care synopsis) asks whether the physi-cian-ordered plan of care includes interventions to addressseven process measures: vital signs and other clinical find-ings, diabetic foot care, falls prevention, depression, pain andpressure ulcer prevention and treatment.

ConclusionAs you can see, the new OASIS-C incorporates many newideas and concepts intended to improve patient care. Asoverwhelming as it may seem, this should be viewed as agreat opportunity to improve not only your clinical assessmentskills with wounds, but also to improve the care you provideto your patients. With a little time, education and experience,you will feel more confident in assessing your patients, andyour patients will feel more confident with you. I encourageyou to seek out opportunities to further your knowledge baseand never stop learning.

References 1. Lyder C & Ayello E. Annual checkup: the CMS pressure ulcer present-on-admission

indicator. Advances in Skin and Wound Care. 2009; 22(10):476-484.2. Highlights of OASIS-C Changes by Section: Train the Trainer Part 2 of 3. Available at:

http://www.cms.hhs.gov/HomeHealthQualityInits/02_CMSSponsoredCalls.asp. Accessed January 11, 2010.

3. OASIS-C Development and Impact on Agency Operations. Available at:http://www.cms.hhs.gov/HomeHealthQualityInits/02_CMSSponsoredCalls.asp. Accessed January 11, 2010.

4. OASIS-C Guidance Manual September 2009 for 2010 Implementation. Centers forMedicare & Medicaid Services. Available at: http://www.cms.hhs.gov/homehealth-qualityinits/14_hhqioasisusermanual.asp. Accessed January 11, 2010.

5. Wound Ostomy Continence Nurses Society Guidance on OASIS-C Integumentary Items.Available at: http://www.wocn.org/pdfs/GuidanceOASIS-C.pdf. Accessed January 11, 2010.

6. Pressure Ulcers Prevention & Treatment: Clinical Practice Guideline. National Pressure Ulcer Advisory Panel & European Pressure Ulcer Advisory Panel. 2009.

7. AHCPR Treatment of Pressure Ulcers: Clinical Guideline Number 15. December 1994. Available at http://www.ncbi.nlm.nih.gov/bookshelf/br.fcgi?book=hsahcpr&part=A5124.Accessed January 11, 2010.

Clay E. Collins BSN, RN, CWOCN, CFCN, CWS,

DAPWCA is a certified wound, ostomy, conti-nence and foot care nurse through the WOCNCertification Board and a certified wound spe-cialist through the American Academy ofWound Management. He currently serves onthe Foot Care Exam Committee for the WOCNCertification Board and is a member of theWound, Ostomy, Continence Nurses Society,

Sigma Theta Tau International Nursing Honor Society and a Diplo-mat of the American Professional Wound Care Association. He hasextensive experience in the home care setting serving as adminis-trator, clinical director and wound program director. He has devel-oped and implemented advanced wound care programs and servedas expert reviewer for best practice documents for the WOCN. Heis currently a clinical education specialist for Medline Industries, Inc.

(M1350) Does this patient have a Skin Lesion or OpenWound, excluding bowel ostomy, other than those described above that is receiving intervention by the home care agency?This final item identifies all other types of wounds or skinlesions other than pressure ulcers, stasis ulcers and surgicalwounds that are CURRENTLY receiving intervention. On pre-vious versions of OASIS, clinicians identified the presence ofall skin lesions, including moles, scars, etc. With OASIS-C,however, this item now pertains only to lesions that arereceiving intervention by the home care agency. PICC linesand IV sites qualify as skin lesions/open wounds under thisitem. Tracheotomies, urostomies and nephrostomies are alsoincluded here if interventions such as cleansing and dressingchanges are being provided by the home care agency.

Two new care process items, M2250 and M2400, alsoinclude items that directly pertain to the use of best practicesin the prevention and treatment of diabetic foot ulcers andpressure ulcers. As mentioned earlier, CMS is encouraginghome care agencies to use best practice patient careprocesses, and OASIS-C includes data items to measure theuse of these best practices. Clinicians are asked if the plan ofcare ordered by the physician includes the following:

• Diabetic foot care, including monitoring for the presenceof skin lesions on the lower extremities

• Patient/caregiver education on proper foot care• Intervention(s) to prevent pressure ulcers• Pressure ulcer treatment based on principles of moist

wound healing: When determining if the wound care isbased on the principles of moist wound healing, the clinician might consider the definition of a moist wounddressing as published in the “AHCPR Treatment of Pressure Ulcers: Clinical Guideline Number 15,” December 1994.7 According to this guideline:

– A moist dressing keeps the ulcer bed continuouslymoist. Wet-to-dry dressings should be used only for debridement and are not consideredcontinuously moist saline dressings.

– The dressing needs to keep the surrounding intact(periulcer) skin dry while keeping the ulcer bed moist.

– Pressure ulcers require dressings to maintain theirphysiologic integrity. An ideal dressing should protectthe wound, be biocompatible, and provide ideal hydration. The condition of the ulcer bed and the desired dressing function determine the type ofdressing needed.


SURVEYSMARTS

An Interview with Dr. Andy Kramer on QIS

Facts & Myths

The transformation of the long-term care (LTC) survey processis under way, with more than 3,100 nursing facilities in 14 states

having experienced at least one Quality Indicator Survey (QIS) review. As expected, QIS is bringing much change to the long-termcare survey process and a new paradigm in the assessment of careand quality-of-life indicators in LTC facilities.

The QIS is designed to improve consistency in what surveyors pinpoint – and possibly cite – and to facilitate surveyor review of thefull range of regulations. The QIS methodology utilizes 162 qualityof care indicators—far more than those comprising the QIs/QMs.The QIS calculates rates for each facility for particular care areasand compares them to specified national thresholds, allowing that a certain number of those occurrences could be normal. Whena facility’s QIS indicator exceeds the threshold for a particular area,it will likely prompt surveyors to pay close attention to that area during the survey process.

Quality Care magazine recently spoke with Dr. Andrew Kramer tolearn more about how the QIS is affecting the long-term surveyprocess. Dr. Kramer led the development of the QIS and is currently principal investigator in support of CMS to refine the QISprocess and to conduct the training of state survey agencies in the national rollout of QIS.

QIS SURVEYSCONDUCTED

As of 12/14/2009

California.....................36Connecticut ..............584Delaware.......................9Florida.......................911Kansas......................328Louisiana ..................268Maine..........................29Maryland.....................56Minnesota .................333North Carolina...........186New Mexico................44Ohio..........................278Vermont ........................9Washington.................51West Virginia ...............17Total ......................3,139

38 Healthy Skin


Dr. Kramer, a noticeable difference in QIS is that it has two stages. Can you briefly describe them?Dr. Kramer: Stage 1 is conducted during the first dayand a half of a Quality Indicator Survey. The surveyteam conducts resident interviews, family interviews,staff interviews, resident observations and chartreviews. At the end of Stage 1, the team of surveyorswill compile all of the data they have collected fromthese assessments. The data will be used to calculaterates that are compared to national thresholds todetermine whether Stage 2 investigations for potentialcompliance concerns are warranted. No compliancedecisions are made in Stage 1.

Stage 2 is the portion of the survey process in whichan in-depth investigation is conducted on behalf ofresidents within care areas that exceeded thresholdson indicators identified during the Stage 1 process.Compliance decisions are made at the completion ofStage 2.

Does that make QIS surveys longer than traditional surveys?Dr. Kramer: On average, even though QIS includeslarger samples of resident and very comprehensiveassessments, they generally require about the sameamount of time and resources as the traditional surveyprocess. In a specific sense, however, the length of aQIS survey is variable depending on how many careareas are “triggered” in the Stage 1 investigation. Ifonly a few care areas are triggered, the survey couldbe relatively short. If many care areas are triggered,the survey could be considerably longer.

The other factor to consider is that when each newstate begins implementing the QIS process, it maytake longer than the traditional survey because thereis a learning curve for surveyors. As you would expect,efficiency increases substantially once they gainexperience with the process.

Surveyors use both a resident’s CPS score and a series of screening questions to determinewhether a resident is interviewable.


Survey Readiness


creo

40 Healthy Skin

You mentioned the surveyor’s learning curve— What do you think is the hardest thing for them to adapt to?Dr. Kramer: Surveyors face two primary adaptationswhen learning the QIS process. First and most obvi-ous is the intensive use of computer software andtechnology in the QIS. This isn’t a trivial thing for a lotof them—the adjustment really does take some timeto get used to. The other challenge is getting to usethe highly structured protocols and larger samplesizes, and the fact that they have tasks that need to be completed within a defined timeframe.

So, with all the structured protocols and larger samplesizes, do “zero deficiencies” surveys still occur?Dr. Kramer: Yes. Zero deficiency surveys still occur.

Are there certain types of deficiencies that are cited at a higher rate in QIS?Dr. Kramer: A major change resulting from QIS is thatStage 2 in-depth investigations of residents are trig-gered mostly from resident interviews and observa-tions and family interviews. In contrast, in thetraditional survey, most of the investigation is triggeredby the QIs/QMs.

The QIS results in resident-centered assessmentswhere far more information is derived from residents and families. As a result, F-tags cited at substantially higher rates include quality of life deficiencies such as choices, dignity and activities, which are directly assessed in the resident interview and the resident observation; resi-dent behavior and facility practices relating to abuse, restraints and staff treatment of residents; and quality of care deficiencies relating to providing necessary care for highest prac-ticable well being, weight loss and hydration, and adrug regimen that is free from unnecessary drugs.

What criteria are used to determine a resident interview candidate? Dr. Kramer: Surveyors use both a resident’s Cognitive Performance Scale (CPS) score and a series of screening questions to determine whethera resident is interviewable. To determine whether aresident can be interviewed, surveyors ask the follow-ing questions:

1. Are you from around here, the area, etc?2. Tell me a little about yourself.3. How long have you been here?4. What is the food like here?

If the resident provides reasonable answers to thesequestions, the surveyor marks the resident as inter-viewable. If the resident provides unreasonableanswers, the surveyor marks the resident as non-interviewable. If a surveyor is uncertain, they mark theresident as interviewable and conduct the interview. Ifthey find the responses unreasonable or inconsistent,they are able to change the resident’s status tonon-interviewable.

Where Stage 2 “trigger” information comes from:

13% QIs/QMs

11% New MDS Indicators

16% Resident

Observation

21% Resident Interview

12% Family Interviews

8% StaffInterviews

8%CensusChart

11% Admission

Chart



Can a surveyor add a specific resident that wasn’t chosen randomly by the computer?Dr. Kramer: Yes. After the initial random sample isdrawn by the surveyor software tool, the surveyor willreconcile that sample with the facility census. They willask for a list of residents admitted within the last 30days and who are still in the facility. If any residents from the initial draw of 40 are no longer in the facility,they will be replaced with one of the newly admittedresidents.

Surveyors can also “surveyor initiate” a resident intothe sample based on resident- or facility-specificinformation obtained from ombudsman information,off-site complaints, surveyor observation or interviews.

How do surveyors go about finding family members to interview? What are they looking for?Dr. Kramer: Surveyors screen all 40 census sampleresidents and conduct a resident interview with thosewho are interviewable. Then they select three non-interviewable residents who have a family member or personal representative who is likely to be able to complete a family interview either in person or over the phone before the end of the Stage 1 investigation. They screen the family mem-ber or personal representative, asking about theirknowledge of and the extent of their relationship withthe resident. It is desirable that the family member befamiliar with the resident’s care planning, preferencesand daily routines when the resident was more inde-

pendent and more able to make choices andexpress preferences.

How will a surveyor handle concerns, not related to a direct question, which are brought up during the resident or family interview?Dr. Kramer: The surveyor will note the concerns in thecomments section of the interview and then bring theconcerns to the team. If the concerns indicate poten-tial for non-compliance, the surveyor will initiate thatresident and applicable care area into the Stage2 sample.

How do you think the QIS will affect residents overall?Dr. Kramer: The Quality Indicator Survey is a moreresident-centered survey process designed toimprove consistency and accuracy, enhance docu-mentation and focus survey resources where they’reneeded most. The QIS can also be used by providersas part of a continuous quality improvement processto review and improve quality-of-life and quality-of-care for residents.

QIS will eventually contribute to the objective of aligning the definition of quality among regulatory,provider and consumer constituents. Its resident- andfamily-centered perspective will have the greatestimpact on quality-of-life and quality-of-care for residents.

The Quality Indicator Survey is a more resident-centered survey process designed to improve consistency

and accuracy, enhance documentation and focus survey resources where they’re needed most.

”“


creo

42 Healthy Skin

EDUCATIONAL OPPORTUNITIESFOR LONG-TERM CARE PROFESSIONALS

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

Designed for: Nurses and CNAs

You’ll earn: One Continuing Education Credit

This course covers:

• How the state survey process has evolved into the new Quality Indicator Survey (QIS)

• The importance of the CNA in QIS and resident-centered care

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

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

Understanding the Quality Indicator Survey

Designed for: Long-Term Care Administrators

You’ll earn: One Administrator Credit

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

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

• The top six objectives of the QIS

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

• How the QIS differs from traditional state surveys

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


creo


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

This webinar gives a QIS overview and demonstration on how the abaqis® system canhelp prepare for both the traditional and QIS survey processes. This demonstration alsohighlights how abaqis® provides:

• Rich reporting capabilities to identify which care areas to target for

quality improvement

• Root cause analysis on a facility-wide or individual-resident basis, enabling

prioritization and focusing of interventions for maximum impact

• Emphasis on information reported by residents and families to help identify

the needs of residents, aiding your efforts to improve consumer satisfaction

Now with the new Stage 2 module featuring:• A dashboard view of triggered care areas based on data collected

using abaqis® Stage 1 Suite• Investigative tools to determine deficiencies in triggered care areas

Free Webinar at www.medline.com/abaqisdemo

Quality Assurance System Webinar


creo

44 Healthy Skin

One Nursing Home’s Winning Quality Assurance Strategies By Betty Lou Barron, MSN, MBADirector of Nursing, Bear Creek Nursing Center



Our Nursing HomeBear Creek Nursing Center is located in Hudson,Florida in the Central West region of the state alongthe Gulf of Mexico. Our mission is to ensure the high-est quality of care to the residents entrusted in ourcare. Residents and their families are our first priority.Our focus is to help all residents achieve their highestlevel of function.

Bear Creek has 120 licensed beds and offers an array of services including traditional nursing care, which can range from several months to a long-term stay; rehabilitation care and respite care – a short-term program designed to give familymembers a much needed b reak f rom thedemands of caring for the chronically ill at home.Whether it’s for a weekend or a few weeks,we provide a comfortable, secure medical and socialenvironment.

Our ChallengeFlorida was one of the first states to pilot the new QualityIndicator Survey (QIS) for nursing homes. With QIS, wehad to change the culture of our nursing home staff.Compared to the traditional survey, QIS is designed tobe more consistent and less subjective, with a resi-dent-centered focus.

Because QIS is a new and very different process thanthe traditional survey, our staff was naturally unsurewhat to expect and how to prepare for the newinspection. The idea of having to change the focus ofour quality assurance efforts after having the traditionalsurvey for so many years was unsettling for all of us.

Along those same lines, we also realized that our nursinghome was managed with an “institutional” mentality,meaning all of our residents were on the same sched-ule, participated in the same activities, went to bed atthe same time, and so on. While we did not know it atthe time, this type of system was not the optimal envi-ronment for our residents to thrive.

Bear Creek Nursing Center is an 120 bed short-term stay and long-term care health carefacility located in Hudson, Florida.

With the change in the survey process, we knew we not only had to alter the

way we prepared for the new QIS, we had to reassess our entire quality assurance approach to focus more on the resident.

“

”

Survey Readiness


creo

46 Healthy Skin

The Solution With the change in the survey process, we knew we notonly had to alter the way we prepared for the new QIS, wehad to reassess our entire quality assurance approach tofocus more on the resident.

Back in June 2008, I was introduced to a new quality assurance system for nursing homes calledabaqis®. What got me initially interested in abaqis® wasthat it used the same calculations, thresholds and analysisas the QIS to quickly highlight residents at risk. I wantedsomething to help take the guess work out of preparingfor the survey and make our nursing staff feel confidentthat what they were doing was helping the resident and enhancing their chances of getting a good survey.

The abaqis® Stage 1 Suite examines 125 resident-cen-tered indicators of quality-of-care and quality- of-life that are used to identify care areas for a Stage 2 in-depth investigation and possible citations during a QIS. These indicators are contained insix modules that exactly replicate the QIS assessmentsconducted on-site during the survey, plus one modulethat uploads and reviews MDS data. The modules are:

• Resident Interview• Family Interview• Staff Interview• Resident Observation• Census Sample Record Review• Admission Sample Record Review• MDS Data

One of the biggest benefits of abaqis®

is that it helps us ask our residents insightful questions about

their likes and dislikes, and then it statistically analyzes the data to focus

us on our residents’ key issues.

Facility: Bear Creek Nursing Center

Location: Hudson, FL

Size: 120 licensed beds with an array of services including traditional nursing care, rehabilitation care and respite care

Challenge: Prepare for the new Quality Indicator Survey and change the culture of the nursing home staff to be more resident centered.

Some of the Bear Creek clinical staff who have helped transform the facility into a resident-centered nursing center.

“

”


creo


After I was trained on abaqis®, I identified 13 key personnel at the facility – our department heads – to trainand inservice them on abaqis®. At first, they were reluc-tant because this new system was a significant departurefrom what they had been doing in their current QAprocess and they were uncertain if this was really going tohelp them prepare for the new inspection.

In early February 2009, we started implementing the abaqis® system in our facility. Although abaqis® isa Web-based system that can be accessed from anycomputer, we have an older facility without wirelesscapabilities or laptop computers. So, we used a manualprocess to collect data and then we gave the informationto our administrative staff to input into the computer.

I divided the data collection responsibilities accordingto each staff member’s strengths and concentration. Forinstance, it made sense that our social workers focusedon the resident interviews, while the administrative staffconcentrated on record reviews.

By the end of February, we had completed all the mod-ules, interviews and data analysis for our 112 residents.What we found was that we had 28 areas of concern –areas that abaqis® flagged as red and a possible Stage 2investigation if we did not correct these deficiencies.

Specifically, but not surprisingly, many of the areas of con-cern came from the resident interviews and their specific

needs and suggestions. One of the biggest benefits ofabaqis® is that it helps us ask our residents insightfulquestions about their likes and dislikes and then it statis-tically analyzes the data to focus us on our residents’ key issues. It allows us to uncover trends among our res-idents and see areas where we can change and improve.For instance, we learned that our planned activities werenot meeting our residents’ needs. The abaqis® systemasks residents for their own suggestions and they cameup with movie nights and more activities on weekendsand during afternoon shift changes. In fact, we ended upoverhauling the entire activities schedule as a result of thefeedback we received from the abaqis® interviews. Wealso discovered the temperature of the food was not tothe liking of many of our residents and some of themwanted to eat at different times than when we had themscheduled.

Over the next several weeks, we whittled down the numberof focus areas to six and then we did a mock QIS surveyof the facility at the end of March. Of the six identifiedareas, four did not get flagged. The two remaining areasof concern we fixed during the next three weeks.

With this new QA tool, we felt positive about the progresswe were making on improving the quality of our residents’experiences. Moreover, we became increasingly moreconfident about the impending Quality Indicator Survey.

Since abaqis® has become an integral part of our QA system, the patients are noticeably happier now that we are changing things based

on their specific feedback. They appreciate that we have become more resident-centered and customer friendly — meaning we are asking what they

think about their care and listening to their suggestions and issues.

“

”


The ResultsOn August 30, the official reporting agency, theAgency for Healthcare Administration (AHCA), visitedour facility and began our first inspection using thenew QIS – and we were ready. The inspectionresulted in only four citations. (We had 16 during ourmock survey.) According to the team leader of thesurvey at our facility, we had the fewest areas citedfor a Stage 2 investigations he had seen so far.

Of the four citations, two were for nurse observations,which are easier issues to resolve than citationsresulting from residents complaints about a specificaspect of their care. I truly believe we had such positivefeedback because we had abaqis® to prepare us.

At the conclusion of the survey, several of our staffmade the following comments:

“You were right, the surveyors asked me the same questions that abaqis® asked.”

“It really works.”

“I see what you mean when you said it was resident-centered.”

From the feedback of the surveyors, clearly our staff was less nervous and more preparedfor this survey than any other we had had previously, despite the new inspection process.

Similarly, since abaqis® has become an integral partof our QA system, the patients are noticeably happiernow that we are changing things based on their spe-cific feedback. They appreciate that we have becomemore resident-centered and customer friendly –meaning we are asking what they think about theircare and listening to their suggestions and issues.

Future OpportunitiesGoing forward, abaqis® has become an integralcomponent of our ongoing QA system. We areimplementing two of the modules each month, whichmeans we will complete one full survey of all of ourresidents every quarter.

This type of comprehensive quality assurance systemimpacts our facility in many important and significantways. It not only decreases our chances for a StageII investigation, but more profoundly, our residentsappear happier and more satisfied with their lives.And, as a result, our CNAs and other staff haveincreased job satisfaction with the knowledge thatthey are making a real and valuable contribution in the lives of each resident.

About the Author

Betty Lou Barron is Director of Nursingat Bear Creek Nursing Center inHudson, Florida, a 120 bed skillednursing facility with emphasis on long-term and short-term rehabilitationresidents. Betty has been working inthe long-term-care industry for almost

10 years in various capacities. She is a Certified Director ofNursing and has earned her certification as an Alzheimer’strainer for the Department of Elder Affairs. She also hasearned a masters degree in nursing and health careadministration. Betty is certified with the QIS system.This certification enables her to train and educate otherdirectors of nursing and administrative staff on theQIS process.

48 Healthy Skin


creo


The new Quality Indicator Survey (QIS) for nursing homesis more resident-centered, with more information obtainedfrom direct questioning of residents and families. In fact,60 percent of facilities have had more deficiencies in QISthan in the prior traditional survey, often in regulatory areassuch as quality of life that were not as fully investigatedin the traditional process.

abaqis® is the only quality assessment and reportingsystem for nursing homes that is tied directly to the QIS,and its quality assessment modules reproduce the sameforms, analysis and thresholds used by State Agencysurveyors. Rich reporting capabilities on 30 care areasguide you to what surveyors will be targeting in your facility.

That gives you a unique advantage in preparing for yoursurvey – and in meeting your resident’s needs.

abaqis® is sold exclusively through Medline. Learn more by signing up for a free webinar demo at www.medline.com/abaqisdemo.

“ How do we improveour resident and family-centered quality of care and prepare for QIS?

We use abaqis.” Sherri Dahle, RN, DNSDirector of Nursing Central HealthcareLeCenter, MN


creo

Medline’s OptiumEZ monitor, manufactured by Abbott Diabetes Care, minimizes the variables that can affect glucose readings with its patented TrueMeasure® Technol-ogy. TrueMeasure Technology screens out common med-ications that may interfere with the accuracy of bloodglucose results. Individual foil wrapping ensures that thetest strips are not compromised by humidity, dust or dirt.

Advanced Technology Made Simple™ for the Post Acute Care Professional.

• No coding required• Simple two-step testing• Results in five seconds• Small blood sample size – 0.6 µl• Easy-to-read display with backlight• Simple 3-button navigation• Test starts only when enough blood is applied–

designed to minimize errors, repeat tests and wasted test strips

To learn more about Medline’s Compass DiabetesResource for Long-Term Care, which includes patient, family and nurse education—including the opportunity to earn 4 CE credits, send an e-mail to [email protected].


OptiumEZ BLOOD GLUCOSE MONITORING PROVIDES

EASY, ACCURATE & RELIABLE RESULTS


creo


Focus on

Why are the regulatory eyes of CMS looking so closely at cleaning and disinfection? Healthcare-associated infections are a major concern, andgerms are commonly transmitted from person to person viamedical devices. The new F-Tag 441 states:1

“Infections are a significant source of morbidity and mortality for nursing home residents and account for up tohalf of all nursing home resident transfers to hospitals. Infections result in an estimated 150,000 to 200,000 hospital admissions per year at an estimated cost of $673million to $2 billion annually. When a nursing home residentis hospitalized with a primary diagnosis of infection, the deathrate can reach as high as 40 percent. It is estimated that anaverage of 1.6 to 3.8 infections per resident occur annuallyin nursing homes.”

Reducing and/or preventing infections acquired through indirect contact with surfaces or medical equipment requiresdecontamination (cleaning, sanitizing or disinfection) prior toexposing a different resident to the particular piece of medical equipment.

When devices are shared, staff training and education iscrucial to ensure proper infection control. One common barrier is lack of clear delegation of equipment cleaning tasks.If the responsibility is left to everyone, often no one ends upperforming the cleaning task. Healthcare workers are busyand simply assume another staff member completed thissimple but critical task.

How has F-Tag 441 changed?As mentioned earlier, CMS is especially concerned about infection control due to the rising rates of healthcare-acquiredconditions. They have combined all F-Tags related to infection control (i.e., F-Tag 441, 442, 443, 444 and 445) intoone location under F-Tag 441 to make these guidelines moreaccessible. F-Tag 441 is now the “one-stop-shop” for infection control requirements.

The revisions to F-Tag 441 are based in part on a Centers forDisease Control and Prevention (CDC) report describing separate outbreaks of hepatitis B virus (HBV) linked to thesharing of blood glucose monitoring equipment at long-termcare facilities in Mississippi, North Carolina and California.2

If you’re confused about the Centers for Medicare & Medicaid Services(CMS) revised F-Tag 441 requirements regarding shared medical devices –particularly glucose meters – you’re not alone.

Although every infection preventionist, healthcare worker, administrator andregulatory surveyor certainly would prefer long-term care facilities to providededicated medical equipment for each resident, they also realize this can becost prohibitive. Therefore, CMS and the CDC guidelines allow for the sharing of durable medical equipment – such as glucose meters – as longas it is properly cleaned and disinfected between every patient use.

Understanding the New F-Tag 441 Requirements

By Lorri A. Downs, RN, BSN, MS, CIC

Survey Readiness


creo

Investigators suggest that recommendations concerningstandard precautions and the reuse of fingerstick deviceshave not been adhered to or enforced consistently in long-term care settings. The potential for devices to carrybloodborne pathogens and multidrug resistant bacteria andviruses (if the device is not cleaned between every use) iswell-documented in the CDC report. For a copy of the report, go to www.cdc.gov/mmwr/preview/mmwrhtml/mm5409a2.htm. Ultimately the safety of your residents andemployees is at the core of most of the rules and regulationssurrounding infection control. Yet it can be challenging tokeep up with all the regulatory changes. Implementing routine processes will increase your staff’s knowledge andawareness, along with the assurance that clean care really issafer care.

How will this regulatory change affect long-term care facilities? Regulatory inspections will be more frequent, and facilitiesthat are 1.) cited with severe non-compliance with the new F-Tag 441 requirements and 2.) fail to implement preventativeor corrective measures will no longer be able to participate inMedicare – a financially devastating prospect.

Non-compliance is categorized into the following levels according to severity. Note that not cleaning glucose meters between residents falls under the most severe level of non-compliance.

52 Healthy Skin



Severity Level 4 – Immediate jeopardy to resident healthor safety: Non-compliance with one or more requirementshas caused or is likely to cause serious harm, impairment ordeath to a resident.

Example:“The facility failed to follow standard precautions during theperformance of routine testing of blood sugars. The facilitydid not clean and disinfect the glucometers before or afteruse and did not use new glucometer lancets on residentswho required blood sugar monitoring. This practice of notcleaning and disinfecting glucometers between every useand re-using glucometer lancets created an Immediate Jeopardy to resident health by potentially exposing residentsto the spread of blood borne infections for multiple residentsin the facility who required blood sugar testing.” 1

Severity Level 3 – Actual harm that is not immediate jeopardy: The negative outcome can include, but may not be limited to clinical compromise, decline or the residentsinability to maintain and/or reach his or her highest practicable well-being.

Example:“The facility routinely sent urine cultures of asymptomatic residents with indwelling catheters, putting residents withpositive cultures on antibiotics, resulting in two residents acquiring antibiotic-related colitis and significant weight loss.” 1

Severity Level 2 – No actual harm with potential for morethan minimal harm that is not immediate jeopardy:Non-compliance that results in a resident outcome of no morethan minimal discomfort and/or has the potential to compro-mise the resident’s ability to maintain or reach his or her high-est practicable level of well being. The potential exists forgreater harm to occur if interventions are not provided.

Example:“The facility failed to ensure that their staff demonstratesproper hand hygiene between residents to prevent thespread of infections. The staff administered medications to aresident via a gastric tube and while wearing the same glovesproceeded to administer oral medications to another resident. The staff did not remove the used gloves and washor sanitize their hands between residents.” 1

References1. CMS Manual. Interpretive Guidelines for Long-Term Care Facilities TagF441. Available at: http://www.cms.hhs.gov/transmittals/downloads/R55SOMA.pdf. Accessed January 21, 2010.

2. Centers for Disease Control and Prevention. Transmission of hepatitis Bvirus among persons undergoing blood glucose monitoring in long-termcare facilities: Mississippi, North Carolina and Los Angeles County, California, 2003-2004. MMWR 2005;54(09): 220-223. Available at:http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5409a2.htm. Accessed January 21, 2010.

Listed below are the infection control requirementsunder F-Tag 441 that long-term care facilities mustfollow in order to be Medicare providers and receivereimbursement from CMS. 1

“The intent of this regulation is to assure that the facility develops, implements, and maintains an Infection Prevention and Control Program in order toprevent, recognize, and control, to the extent possible, the onset and spread of infection within thefacility. The program will:

Perform surveillance and investigation to prevent,to the extent possible, the onset and the spreadof infection.

Prevent and control outbreaks and cross-contamination using isolation precautions in addition to standard precautions.

Use records of infection incidents to improve itsinfection control processes and outcomes by taking corrective actions, as indicated.

Implement hand hygiene practices consistentwith accepted standards of practice, to reducethe spread of infections and prevent cross-contamination.

Properly store, handle, process, and transportlinens to minimize contamination.”

New CMS Infection Control Requirements for Long-TermCare Facilities


creo

1 Make a list of every piece of shared medical equipment. (Assign clinical staff to help identify and generate the equipment list.)

2 Assign the cleaning and disinfection responsibility to the type of healthcare worker who will be performing the task within your policy.

3 Communicate this administrative decision to all members of your staff, both written and verbally, and document.

4 Educate and train staff on proper care, maintenance, cleaningand storage of each piece of equipment. At a minimum, provide this education upon initial employment, when the equipment is replaced with a newer model and annually. Document that this training has occurred.

5 Select easy-to-use, EPA-registered hospital grade disinfectants and cleaning products. Make sure the productslist which microorganisms and viruses it kills. Common cleaners are sodium hypochlorite (bleach solution) or quaternary ammonium products. However, to help avoid warranty issues or equipment damage, be sure to follow manufacturers’ recommendations regarding which cleaning products to use.

6 Clean medical device surfaces when visible blood or bloodyfluids are present by wiping with a cloth dampened with soap and water to remove any visible organic material, and then disinfect.

7 If no visible organic material is present, disinfect the exterior surfaces after each use using a cloth or wipe with either an EPA-registered detergent/germicide with a turberculocidal or HBV/HIV label claim, or a dilute bleach solution of 1:10 to 1:100 concentration.

8 Note that alcohol also is not an EPA-registered detergent/disinfectant.

9 Disposable professional grade wipes with a short “kill time” (60 seconds after application) can make the time spent cleaning equipment quick and easy.

10 All cleaning should be done in well-ventilated areas with gloves to protect healthcare workers’ hands.

10Ten Tips for Cleaning and Disinfecting

Shared Medical Equipment

54 Healthy Skin

Survey Readiness



Dispatch® Cleaning Solution for Use on Glucose Meters

Product Spotlight

Dispatch is a liquid cleaner that contains a unique deter-gent and bleach dilution strength (5500 ppm sodiumhypochlorite [NaOCl]) equivalent to the 1:10 bleach solu-tions recommended by the Centers for Disease Control andPrevention (CDC) for disinfecting. It can be used on hard,non-porous external surfaces such as glucose meters;however, care must be taken to protect the electrical com-ponents of the equipment from any contact with liquid.Always remember to turn off electrical equipment prior tocleaning it with a liquid product.

Glucose meters should be stored in their carrying casewhen not in use. After use on a patient, the monitor shouldbe wiped down with Dispatch, left on for one minute, andthen wiped off with a fabric cloth or paper towel.

More stable than bleach solutionsDispatch is more stable than bleach solutions and morepleasant to use. It remains stable through the expirationdate (two years from manufacture), unlike bleach solutions,which begin to deteriorate immediately. It is an excellentcleaner because it contains detergent along with an anti-corrosive ingredient that minimizes damage to surfaces andequipment.

Dispatch is available as a liquid or as pre-moistened wipesin a canister. It meets both Universal and StandardPrecautions set forth by OSHA and CDC. It is also regis-tered with the EPA.

Germicidal efficacyDispatch kills Mycobacterium bovis (TB) within 30 secondsand the following within 60 seconds: Acinetobacter bau-mannii, Avian Influenza A, Canine Parvovirus, Enterobacteraerogenes, Enterococcus faecium, Vancomycin resistant(VRE), Escherichia coli, ESBL, Feline Panleukopenia Virus,Hepatitis A Virus (HAV), Hepatitis B Virus (HBV), Hepatitis CVirus (HCV), Herpes Simplex Virus (HSV-2), HumanImmunodeficiency Virus Type 1 (HIV-1), Influenza A Virus,Klebsiella pneumoniae, Norovirus, Poliovirus Type 1(Mahoney), Pseudomonas aeruginosa, Rhinovirus,Rotavirus, Salmonella enterica (formerly choleraesuis),Staphylococcus aureus, Methicillin resistant Staphylococ-cus aureus (MRSA), Streptococcus pyogenes and Athlete’sFoot Fungus.

Dispatch is a registered trademark of Caltech Industries, Inc.


56 Healthy Skin

Put Bacteria

in its PlaceMicrofiber mops minimize infection.According to the CDC, there are an es-timated two million incidents related tohealthcare-associated infections eachyear, making infection control one of thehighest priorities for healthcare facilities.Thorough cleaning and disinfection of allsurfaces, including floors, is one way toreduce infection. Microfiber mops areparticularly useful for infection controlbecause they reduce floor surface bac-teria by 99 percent.1

Why is Microfiber NICE?

New Product to the long-term care market

Infection Control

• One wet mop per room reduces cross-contamination, helping

with infection control

• Due to their size, microfiber mops get into the small pores of the floor, enhancing your cleaning

• A positive charge is created on the mop as it is pulled acrossthe floor to attract negatively charged dust and dirt particles

• There is a 99 percent reduction in floor surface bacteria afterusing a micofiber mop1

Cost Savings

• Using microfiber mops reduces water and chemical usage 95 percent1

• Microfiber mops weigh less than a traditional loop mop, saving money in processing costs

• Because microfiber mops will last about 10 times longer than a loop mop,2 there is a lower cost per use

Ergonomics

• The lighter weight of a microfiber mopping system compared to a traditional mopping system can significantly reduce the risk of back injuries

• The telescoping handle allows the mop to be placed in anideal ergonomic position for each individual employee

References1. Environmental Best Practices for Health Care Facil-

ities. Using microfiber mops in hospitals. November2002. Available at: http://www.epa.gov/region09/waste/p2/projects/hospital/mops.pdf. Accessed onFebruary 4, 2010.

2. Sustainable Hospitals Project. 10 Reasons for Mi-crofiber Mops. 2003.

Survey Readiness


creo


SAY GOODBYE TO THE 80-POUND MOP!

“One Keeper, One Kit” start up pack

Trial the microfiber concept with just one housekeeper.Each “One Keeper, One Kit” start up pack contains:• MDT217610Z1 — Locking mop head (1 ea.)• MDT217605Z1 — Ergonomic telescoping handle

(1 ea.)• MDT217600 — Specially designed bucket (1 ea.)• MDT217630 — MicroMax dust mops (5 ea.)• MDT217520 — PolyPro long-lasting wet mops

(5 ea.)• MDT217750 — High duster (1 ea.)• MDT217649 — Light weight cleaning cloths,

light blue (5 ea.)• MDT217663 — Glass towels (5 ea.)

Order “One Keeper, One Kit” trial pack today andreceive 10 FREE MDT217888Z Purple Grabber Mitts as a Gift! Call your Medline representative or 1-800-MEDLINE. Offer ends May 31, 2010. Limit 2 per facility.

MDT217605Z1

MDT217600

MDT217610Z1

MDT217663

MDT217649

MDT217520

MDT217630

MDT217750

MDT217888Z


creo

Wipe out Multidrug-Resistant Organisms in just

one minute with DISPATCH® MDRO Solutions.

A unique, stabilized bleach and detergent solution, DISPATCH® cleans

and disinfects in one step in just one minute for today’s infectious

multidrug-resistant organisms including:

� Acinetobacter baumannii� Enterobacter aerogenes� Enterococcus faecium� Klebsiella pneumoniae� Methicillin resistant Staphylococcus aureus (MRSA)

� Pseudomonas aeruginosa

DISPATCH is approved for most medical use surfaces and as a pre-soak

for medical instruments.

DISPATCH is available in convenient packaging options, including

sprays and pre-moistened towels.

To learn more about DISPATCH® Hospital Cleaner Disinfectant with

Bleach and DISPATCH® Hospital Cleaner Disinfectant Towels with

Bleach, visit dispatchmdro.com.

DISPATCH®


creo

Changing theCatheter Culture

at Your Facility


Recently my husband was hospitalized following a10-foot fall at work. We were thankful his injuries werenot life-threatening, but he did have bilateral ankle and heelfractures. Given the immobility we knew was ahead, I wasdiscussing the treatment plan with a good friend who is anurse. One of her first questions was, “They are going toput in a catheter aren’t they?” My reply was, “I certainlyhope not. I don’t want him to get a catheter-associatedinfection. That is the last thing we need with everything elsethat’s going on!”

This conversation verified what I have experienced for themajority of my career both as a staff nurse and as a chiefnursing officer. More likely than not if a patient was inconti-nent or having difficulty getting to the bathroom, one of thefirst requests would be an order for a urinary catheter. Thenurses believed that their primary intervention of catheterinsertion would maximize the patient’s comfort and avoidskin breakdown. Today we know that urinary tract infectionis the most common healthcare-associated infection (HAI);80 percent of these infections are attributable to anindwelling urethral catheter.1 One in four patients receivesan indwelling urinary catheter at some point during theirhospital stay and up to 50 percent of these catheters areplaced unnecessarily.2,3

So, how do you change the culture at your facility if nursesstill want to place a catheter? We all know that changingan organization’s culture can feel like turning a cruise shiparound in a wild and stormy sea. The perception of nursestraditionally has been that putting a catheter in an inconti-nent patient is the best standard of care. We have tochange that perception. As we begin to collect data, theevidence is showing that avoiding catheterization protectsthe patient from acquiring a catheter-associated urinary

Connie M. Yuska, MS, RN, CORLN

Prevention


creo

tract infection. And we know that too many indwellingurinary catheters are inserted. We also know that indwellingurinary catheters stay in too long.4

Components of Successful Culture ChangeSuccessful culture change consists of many components.The following are some key strategies you can try at yourfacility, including use of the new Guideline for Preventionof Catheter-Associated Urinary Tract Infections 2009,education and training, engaging front-line staff, a rewardprogram, and finally, being creative, having fun and trackingprogress.

The Centers for Disease Control and Prevention (CDC) GuidelineThe Healthcare Infection Control Practices AdvisoryCommittee (HICPAC) of the CDC recently published theGuideline for Prevention of Catheter-Associated UrinaryTract Infections 2009. This is an excellent reference toreview prior to initiating a catheter reduction program atyour facility. The document contains recommendations onappropriate urinary catheter use and proper techniques forurinary catheter insertion and maintenance. In addition, theguideline outlines strategies for quality improvement andsurveillance programs and summarizes recommendationsfor an administrative infrastructure to support a CAUTIprevention program.5

60 Healthy Skin

Education and trainingA logical place to start is by designing a comprehensiveeducation and training program. Having a program thatprovides the supporting framework for education also helpsto organize and publicize the initiative. Medline’s ERASECAUTI program will give you all the tools you will need.

The ERASE CAUTI Program for nurses (RNs and LPNs) isa two-part educational program. Part One is a step-by-stepproduct training program on the ERASE CAUTI cathetertray and insertion methodology. Part Two includes thefollowing four modules:

Module 1: Indications and Alternatives to CatheterizationModule 2: Aseptic Technique and Proper Insertion of

a Foley CatheterModule 3: Care and Maintenance, Signs and Symptoms

of CAUTIModule 4: Competency Validation

In addition, current practice guidelines, sample policies andprocedures and competency validation tools are included.You have the opportunity to initiate the training at orientationwhen a new employee joins your organization. This “setsthe stage” for the catheter culture in your facility. You aresetting the expectation that your staff will keep an inconti-nent patient clean and dry without exposure to the unnec-essary risk of acquiring a catheter-related urinary tractinfection. Then during your annual competency reviews foryour staff, you can reinforce the training and the new“catheter culture.” This gives you a greater chance of hard-wiring the change into your culture and ensuring that yourstaff’s new viewpoint on catheterization is sustained.

Engaging front-line staffIt is also important to identify staff nurse champions atthe beginning of the program. Enlisting their help through aformalized assignment is one good way to generate enthu-siasm and support for the new program. Staff nurses havevery good ideas and often know the best answer if weremember to include them! Getting them involved in theliterature review and in planning the staff education roll-outwill solidify their role as “champions” in the Race to ERASECAUTI!

Reward programIn sustaining any long-term change, it is extremely impor-tant to recognize achievement. Staff work very hard, and


creo


their efforts need to be recognized. Another part of theERASE CAUTI Program is a reward component. Everyonewho successfully completes the course and achieves atleast an 80% on the post test receives one CE credit, a cer-tificate of completion and a pin to display on their IDbadge or uniform. The pin recognizes individual achieve-ment and provides an opportunity for the staff to talkabout the program with patients, families and otherhealthcare professionals, keeping the program top-of-mind.

Being creative, having fun and tracking progressSince this is a Race to ERASE CAUTI, encourage your staffto post statistics regarding the decline in catheter- associatedinfections. Nursing units in hospitals or hospitals in systemscan make this a fun, competitive event that results inbetter patient care. Finally, celebrate when an individual orthe entire facility crosses the finish line of achieving zerocatheter-associated urinary tract infections.

A Happy Ending Although my husband did not have any incontinence,he was non-weight bearing and thankfully, none of thenurses actually asked that a catheter be placed prior to sur-gery. He did have a catheter placed during surgery, but itwas taken out within 24 hours! The hospital staff did followthe Guideline for Prevention of Catheter-Associated UrinaryTract Infections 2009, which states “for operative patientswho have an indication for an indwelling catheter, removethe catheter as soon as possible postoperatively, preferablywithin 24 hours, unless there are appropriate indications forcontinued use.”5

I am happy to report that my husband was discharged fromthe hospital to a rehabilitation facility, and he was able tocome home for Thanksgiving. This year I was very thankfulthat he was in a hospital with an up-to-date catheterculture, and he is on the road to recovery!

References1. Lo E, Nicolle L, Classen D, Arias A, Podgorny K, Anderson DJ, et al. SHEA/IDSA

practice recommendations: strategies to prevent catheter-associated urinary tract infections in acute care hospitals. Infect Control Hosp Epidemiol. 2008;29:S41-S50.

2. Saint S, Kaufman SR, Thompson M, Rogers MA, Chenoweth CE. A reminder reducesurinary catheterization in hospitalized patients. Jt Comm J Qual Patient Saf.2005;31(8):455-462.

3. Stokowski, LA. Preventing catheter-associated urinary tract infections. Medscape Nursing Perspectives. February 3, 2009. Available at:http://www.medscape.com/viewarticle/587464-4. Accessed July 6, 2009.

4. Sulzback-Hoke, Linda M. “Ask the Experts.” Critical Care Nurse. 2002,22:84-87. Available at: http.//ccn.accnjournals.org/cgi/content/full/22/3/84. Accessed July 24, 2009.

5. Guideline for Prevention of Catheter-Associated Urinary Tract Infections 2009, HealthcareInfection Control Practices Advisory Committee, Centers for Disease Control. Availableat: http://www.cdc.gov/ncidod/dhqp/pdf/guidelines/CAUTI_Guideline2009final.pdf.

About the author

Connie Yuska RN, MS, CORLN began hercareer as a nurse in the specialty of otorhi-nolaryngology. Her clinical experienceincludes both inpatient and outpatient careof head and neck oncology patients, and sheis certified in otorhinolaryngology and head-necknursing. She has held clinical manager anddirector of nursing positions in a large

academic medical center and also has experience in the homecare setting as the vice president of operations for a largeacademically affiliated home care agency in the Chicago area.Connie later joined the executive suite as the chief nursing officerof a large community hospital in Chicago, and she is currently avice president of clinical services for Medline. In all of her leader-ship roles, she has been responsible for ensuring the delivery ofhigh quality, safe and cost-effective nursing care.

Connie is a 2003 graduate of the J&J/ Wharton Nurse ExecutiveProgram. She is member of the Board of the Illinois Organizationof Nurse Leaders and a member of the American Organization ofNurse Executives. In 2005, she was inducted into the 100 WiseWomen Program sponsored by Deloitte & Touche. In addition, shehas published several articles and chapters in oncology journalsand textbooks.


creo

We didn’t just design anew tray, we designed away to make it hard forhealthcare workers to dothe wrong thing.The new ERASE CAUTI program combines design, education and awareness to tackle catheter-associated urinary tract infection – the number one hospital-acquired infection.1

DesignThe innovative one-layer tray design guides the clinician throughthe process of placing a catheter to ensure aseptic technique.

EducationThe acronym ERASE is easy to remember, reminding the clinician to:

Evaluate indications – Does the patient really require a catheter?

Read directions and tips – Follow evidence-based insertion techniques

Aseptic techniques – Key design solutions support aseptic technique

Secure catheter – A properly secured catheter will reduce movement and urethral traction

Educate the patient – Printed materials tell the patient how to reduce the likelihood of infection

AwarenessJoin the Race to ERASE CAUTI! The current state of health care demands that nurses play a leading role in identifying andimplementing CAUTI risk reduction strategies. Help us reach ourgoal to introduce 100,000 nurses to the ERASE CAUTI system.

To sign up for a FREE webinar, “Innovation in the Preven-

tion of CAUTI,” go to www.medline.com/erase/webinar.asp.

DesignOpen up the

innovative one-layercatheter tray and see the intuitive

design for yourself.



creo

EducationClick here for

details on nursing education materials

that promote evidence-based

practice. AwarenessVisit this section to join 100,000nurses in the

Race to ERASE CAUTI.

Reference1. Catheter-related UTIs: a disconnect in preventive strategies.

Physicians Weekly. 25(6), February 11, 2008.


creo

64 Healthy Skin

Safe Handling of ResidentsWhich Technique Would You Use?

1. ____ Mrs. Brown is non-weight-bearing, weighs 475 pounds, and is transferred between bed and recliner.

2. ____ Judy, 205 pounds, has limited upper body strength, is partial weight-bearing, and needs help transferring from bed to chair and from chair to commode.

3. ____ Always active, Chuck recently had a stroke and has trouble standing on his own. He is partial weight-bearing and has some upper body strength.

4. ____ Mr. Anderson is non-weight-bearing, weighs 162 pounds, and is transferred between bed, commode and wheelchair.

5. ____ Mrs. Horton is bedbound, 185 pounds, and is completely non-weight bearing. She is transferred laterally from bed to shower gurney.

6. ____ 90-pound Ella is fully weight-bearing, uses a walker for part of the day, but in the afternoon uses a wheelchair. She is unsteady transferring between the two.

7. ____ Mrs. Grant, 180 pounds, is on a unit that has no lift. She is partially weight-bearing and needs assistance between bed, toilet and chair.

8. ____ Mr. Kent, 185 pounds, remains in bed much of the day. He is often is found on the lower half of the bed and needs repositioning regularly.

A. Manual stand-assist lift

B. Low friction lateral transfer device with 2-person assist

C. 600-pound patient lift

D. 1 person and gait belt

E. 400-pound power stand-assist lift

F. 2-person assist with gait belt

G. 2-person assist with drawsheet

H. 400-pound patient lift

Safe handling of residents affects both the caregiver and the resident. Poor technique can result in resident injury ordispleasure in addition to caregiver injury. Nursing is consistently listed as one of the top ten occupations for work-related musculoskeletal disorders, with incidence rates of 13.5 per 100 nurses in nursing home settings.1 Manualhandling also can be a causal factor in resident falls.

Imagine you are asked to assess the following residents and help develop a care plan for safe patient handling andtransfer, while also considering the caregivers’ risk of injury. Find the best matches below.

Answers: 1C, 2E, 3A, 4H, 5B, 6D,

7F, 8G

Please note that the answers provided here are not hard-and-fastrules. We realize there are many differ-ent ways to safely and effectively liftand handle residents, depending onindividual circumstances.

Reference: 1. U.S. Department of Labor. Bureau of LaborStatistics. Survey of Occupational Injuries and Illnesses, 2001.

Special Feature


creo


The Legal Side of Pressure Ulcer Prevention

Among the tools of the healthcare trade are medicines, dressings, instruments, nutritives and durableequipment. The tools of the legal trade are words. When these two professions meet, it’s words that

become the focus of attention. The outcome of a medical litigation is highly dependent on the words usedin a care setting, arguably as important as the care delivered itself.

The concept of the importance of words in a clinical setting was discussed at the Medline “Prevention Above All” conference in Washington, D.C. by Kevin W. Yankowsky, JD, a partner in the Health Law–Health Litigation department of Fulbright & Jaworski LLP and Caroline Fife, MD, CWS,Director of Clinical Research at the Memorial Hermann Center for Wound Healing and Associate Professor–Division of Cardiology at the University of Texas Health Science Center. They explained the potential fortrouble when words are turned against their original user.

Perhaps nowhere is a facility’s choice of words more important than in the policies and procedures it creates and expects its employees to follow. “The road to litigation is paved with well-inten-tioned policies,” explained Mr. Yankowsky. “Policies and procedures are kept in libraries by plaintiff’s attorneys.They’re shared electronically online.” The implication is that a facility’s own policies may be used to supporta judgment against itself and its workers. Though policies and procedures are not law, a skillful lawyer canhold them up as standards. Because they’re the facility’s own words, they can be very powerful.

PERFORMANCE UNDER PRESSURE

Prevention


creo

66 Healthy Skin

In their single-minded pursuit of improved clinicalcare, policy drafters often fail to consider the legalimplications of words they choose to insert in policies. Even more dangerously, they often failto appreciate the plain, common sense meaningslay people give to those words when they are jurors in a professional liability trial.

For example, never, always, equal, complete andimmediately are absolute words. Absolutes shouldbe used cautiously, as they imply a binary,black or white, yes or no state. Suppose one particular two-hour turn of a bariatric resident overa four-day period was not done until three hourshad passed. If your policy stated that residentswith certain risk factors for pressure ulcers mustbe turned every two hours, have you delivered sub-standard care because of that one incident?

Actually, this scenario captures two potentialproblems – the imperative must and the implied linkage between a policy and standard of care. In nearly all jurisdictions, jurors in a healthcare liability lawsuit will be asked to decide whether

the “standard of care” was violated. Typically, “stan-dard of care” in a medical legal context is unique toeach resident, very factually specific and generallyno more than what would be reasonable careunder the same or similar circumstances.

However, a policy incorrectly identified as the definition of the standard of care can fundamen-tally change this important question. When a policy is labeled the “standard of care” a jury canbe asked to simply consider whether or not everyexact detail of the policy, as written, was followed.Put another way, the focus shifts to whether thepolicy was strictly adhered to instead of whetherclinically appropriate care was delivered.

A policy should be a guideline that recognizes the uniqueness of each resident, which allows the sound judgment of the healthcare team to be exercised and provides flexibility in implementation.When “standard of care” is too closely bound to apolicy, the answer to policy adherence is too closelybound to the assessment of appropriate care.

“Never”


creo

One of the most dangerouswords in precipitating litigation may well beno words at all.

“We really need to think about … whatdrives residents to attorneys,” explained Mr. Yankowsky. “Some-times it’s greed. Certainly sometimes it’s grief. Sometimes it’sanger. Most of the time … it’s a search for answers.”

Two typical scenarios lead to litigation. The first is a resident or family who had questions thatwere simply not answered. The second is a question that was answered incompletely,inappropriately, unhelpfully or dismissively.

“If you don’t provide the answers, your adversarywill,” Yankowsky cautioned, “and once they go tothe plaintiff’s attorney, the game’s up. You’re pastthe point of being able to prevent the legal risk.”

The role of the apology is a topic of debate. Apol-ogizing is not new; it has been almost universally taught in homes and classrooms and liberally applied on sporting fields and in department stores. In a clinical setting, though, it is a relatively new phenomenon.

Current thinking is that this practice may be effica-cious, but words can be tricky when attached to an apology. Unintended and unexpected messages may be communicated. A nurse wishing to communicate sympathy by saying, “I’msorry,” may mean, “I’m sorry this has happened to you,” but the resident may hear an admissionof guilt for substandard care. Like many good treatments, apologies must not be dispensed with-out cautious, conscious consideration.


The word stage means a point in a progressionor series of events. When we think of stages, weusually consider them moving through a usual set order, such as stages of development or grief.Staging a pressure ulcer, however, does not fit withthat widespread understanding of the term.

“There is the misconception that if you have a StageIII or IV, it must have begun as a Stage I,” Dr. Fife explained. “Therefore it follows that had it beenidentified at Stage I, the Stage IV would never havehappened. If that’s true, the fact the Stage IV is theremust mean that there was negligent care.”

All of these assumptions are false. The currentNPUAP (National Pressure Ulcer Advisory Panel)pressure ulcer staging system indicates only thedepth of tissue damage at the time the ulcer is assessed – it implies nothing about progression.Furthermore, our current understanding of howstage 3 and 4 ulcers develop is that they form fromthe inside out, the way an apple rots. As a result,tissue damage has already occurred at the level ofthe muscle by the time skin changes are apparent.

When communicating with residents and their families about pressure ulcers, using the stagingsystem, while clinically correct, may be more confusing than helpful. Spending time to educate them – about the development of wounds from theinside out, about the skin as an organ that can failand about the healing process may save you from trying to educate a jury later on those same points.

Of course, you should only answer questions appropriate to your clinical expertise and specificknowledge of the resident’s case. Otherwise, athree-part response is called for: Acknowledge the question and its importance, name the person who can address their question, and promptly notify that person by calling them or leaving them a detailed message—and note the action in the chart.

“Stage” “[silence]”


creo

68 Healthy Skin

Join us for this webcast presentation as two industry experts bring you critical informa-tion on how the utilization of the nursing process and proper documentation are vital components in maintaining the standard of care and avoiding litigation.

Dr. Caroline Fife is the Chief Medical Officer of Intellicure, Inc. and isan Associate Professor within the Department of Medicine, Divisionof Cardiology at the University of Texas Medical School at Houstonand Director of Clinical Research at the Memorial Hermann Center forWound Healing and Hyperbaric Medicine. She has served on theBoards of the American Academy of Wound Management and the Association for the Advancement of Wound Care. She is the co-editor of the textbook, "Wound Care Practice" and is the authorof many scientific papers.

Kevin Yankowsky is a partner in the health law litigation group of Fulbright & Jaworski L.L.P.’s Houston office. A true trial lawyer,Kevin’s trial practice encompasses virtually all types of civil litigationfacing the healthcare industry. In addition to his extensive courtroom experience, he advises on Joint Commission investigations, hospitalcommittee and medical peer review matters.

To pre-register for this special webcast visitwww.medlineuniversity.com

LEGAL IMPLICATIONS OF PRESSURE ULCERS

Preventative medical care and preventative dentistryare concepts we understand conceptually and whoseeffectiveness we can prove empirically. The conceptof preventative legal care for healthcare facilities andpractitioners is not as widely adopted. Understandingthe potential pitfalls of simple words and respondingappropriately is one facet of a comprehensive preven-

tative legal care approach. Far from being an underhanded way of deflecting blame for poor healthcare, it is an open and honest way to improve healthcare while preventing litigation that is preventable andprotecting oneself against litigation that may be un-preventable.

Prevention Above All

Available beginning March 22, 2010 1 Contact Hour


creo


“Systematic efforts at education, heightened awarenessand specific interventions by interdisciplinary healthcareteams have demonstrated that a high incidence of pressure ulcers can be reduced.1 The main challenges to having an effective pressure ulcer prevention programare: lack of resources; lack of staff education; behavioralchallenges; and lack of patient and family education.2

Medline’s comprehensive Pressure Ulcer Prevention Program offers solutions to these challenges.

The Pressure Ulcer Prevention Program from Medline will help you in your efforts to reduce pressure ulcers in your facility. The program includes:

• Education for RNs, LPNs, CNAs and MDs• Teaching materials for you to help train your staff• Practical tools to help reduce the incidence of

pressure ulcers• Innovative products supported by evidence-based

information that results in better patient care

This has been a great learning experience for

our staff and for our facility as a whole. I am

thankful Medline had this program and that we

were able to access it. I can’t imagine recreating

this wheel!”

Katrina “Kitty” Strowbridge, RNQuality Improvement CoordinatorSt. Luke Community Healthcare NetworkRonan, Montana

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

References1 Holmes A, Edelstein T. Envisioning a world without pressure ulcers. ECPN. 2007;122(8):24-29.2 CMS Roundtable, Omni Hotel, Chicago, Ill. March 10, 2008.

JOIN THE PROGRAM TO REDUCE PRESSURE ULCERS

We’ve made pressure ulcer prevention easy.


creo

70 Healthy Skin


creo


9 Habits of Very Happy People

Economy sputtering; swine flu getting everyone upset;lots of changes at my facility, and you want me to behappy? You’re kidding, right?

Actually not! Because no matter how bad things seem to be,it’s important to remind ourselves that Abraham Lincoln wasabsolutely right when he said, “Most people are about ashappy as they make their minds up to be.” Happy people arenot happy because they are endowed with the happinessgene—although researchers tell us that accounts for abouthalf of one’s potential for happiness—happy people are happybecause they realize that happiness is something they controlby doing certain things every day. So here are nine things youcan do that will make you happier:

1. Love what you doI find it ironic that many people deny themselves the joy of theirwork. Somehow they assume that work is a dirty four letterword and that they must escape it as soon and as fast as pos-sible so that they can get home and plop down in front of theTV. (This by the way, is a great way to become more unhappyand depressed.) I suspect it is because they have not foundwhat they love to do. The key word here is love—not like—because once you find what you love to do you will not everhave to “work” another day in your life. (By the way, it took me36 years to find what I love to do, so don’t give up your search,because when you find your passion, the quality of your lifewill improve dramatically.) If you would like help with this, readmy book Make It a Winning Life: Success Strategies for Life,Love and Business.

By Wolf J. Rinke, PhD, RD, CSP

Caring for Yourself


creo

72 Healthy Skin

2. Chase your dreamsHappiness is often a byproduct of something that we aregoing after—something that juices us. Think of children. Whenare they the happiest? About two weeks before the Christmasor Hanukkah holidays, or when they have ripped all the pres-ents open? Once we have clearly-defined, specific, fire-in-the-belly goals, we get turned on, and we become happy.In other words, if your goal is to be happy—that’s what manypeople in my seminars tell me—you won’t necessarily behappy. You get happy from traveling the journey or remindingyourself that you are doing something that improves the qualityof someone else’s life. Chasing your dreams cranks up yourinternal body chemistry to such an extent that it energizes youto achieve extraordinary results and may keep or may evenmake you healthy.

Want proof? A good example is Lance Armstrong, who afterbeing diagnosed in 1996 with an advanced form of testicularcancer that had metastasized to his brains and lungs, wasgiven only about a 50 percent chance of survival. Afterreceiving aggressive cancer therapy, including brain andtesticular surgery and extensive chemotherapy, he went on towin the Tour de France—cycling’s most prestigious andgrueling race—seven times in a row from 1999-2005. (Theprevious record was winning it five times.) And just wheneveryone thought he was down and out, he returned tocompetitive racing after four years of “retirement” to finish thirdin the 2009 Tour de France. Not bad for someone who atage 38 is considered old in the punishing sport of competi-tive cycling. 3. Nourish an attitude of gratitude

A difficulty for many successful people is that they perpetuallylook up the mountain, never down. To feel a sense of grati-tude you must have goals—look up the mountain—but alsotake the time to reflect on all that you have already achievedand accumulated—look down the mountain.

If you need a bit of help with this, take advantage of the nextholiday season. Instead of buying gifts for people who alreadyhave more than they will ever need, rally the whole family andserve a meal at a homeless shelter. Or visit a third world coun-try. For example, when I used to speak in the Pacific Rim, mysense of gratitude was always renewed. Typically the clientbooked me in a five-star hotel, which makes any of our fivestar hotels pale in comparison. One of the hotels in Jakartaeven had a marble driveway. Not concrete, not flagstones—marble. When I looked out of my 29th story window I sawmany other super-modern high-rise buildings. I also saw agarbage dump several blocks away swarming with people –people who were living on the dump in cardboard “houses”and foraging for scraps. Stop right now, and be grateful for allthe love and abundance that surrounds you.


creo


4. Love someone deeplyBarbra Streisand was absolutelyright, “people who love peopleare the luckiest people in theworld.” Start by developing astrong bond and lifetime relation-ship with a significant other. Hav-ing been happily married to my“Superwoman” for 41 years, Ican attest that she by far ismy biggest source of joy andhappiness. (She got that name

because she is a one-in-a-million mate, mother, businesspartner and confidant.) If you don’t have such a relationship,make it one of your top three fire-in-the belly goals, becausesuch a partner becomes increasingly more important as youenter the later passages of your life. Extend that same love toyour family and your close friends. The greater your circle ofloving relationships, the greater your happiness.

5. Treat your “body-mind” like a templeNeuroscientist and pharmacolo-gist Dr. Candance Pert, who dis-covered the opiate receptor – thecellular binding site for endor-phins in the brain – calls our bodyand mind the “body-mind” be-cause her work has unequivo-cally demonstrated that the mindand the body are one. Her workalso shows that thoughts are

things – things that manifest themselves in the body and inyour life. So if you think “bad” or negative thoughts, then thatwill have a negative impact on your body. And of course thereverse is true. Since the mind can have only one thought ata time, get in the habit of monitoring your thoughts and self-talk by asking, “Is what I’m thinking about right now nega-tive?” (The worst is hate.) If it is, it will move you away fromhappiness and optimum health. On the other hand, positivethoughts, such as love, kindness and appreciation will moveyou in a positive direction. This is so powerful that we nowhave a whole science concerned with this phenomenon—

psychoneuroimmunology, or PNI for short. (Want to knowmore? Read Dr. Pert’s books: Molecules of Emotions: TheScience Behind Mind-Body Medicine and Everything YouNeed to Know to Feel Go(o)d.)

6. Laugh moreThat’s right – go ahead andlaugh right now. Can’t seem toget it going? Go to the bath-room, stick your tongue out,wiggle your nose and make thesilliest face you can possiblycome up with and get yourself tolaugh. If you need more help, joina laughter yoga club, popular-ized in India, and now availableall over the world including the

United States (http://www.laughteryoga.org). Or consult witha “certified laughter leader.” (Hey, I’m not making this stuff up!)A good way to nurture this is to laugh more at yourself. It willcause you to take yourself less serious—which is a great startbecause you are not nearly as important as you think you are.(I’m including myself in that statement; so don’t get bent outof shape). Laughter has innumerable benefits. It turns on yourendorphins and other internal “drugs” that are far more pow-erful than anything you can ingest—legal or illegal. In fact, it isso powerful that the late Norman Cousins used it as an “anes-thetic” to combat pain associated with his incurable disease.

7. Give more of whatyou wantA shortcut to happiness is mak-ing other people feel happy.Why? Because life is like a mir-ror—whatever you give—is whatyou get. Make people happy andyou will be happier. Hate peopleand you will live in a hateful world.Love people the way they are,and you will experience morelove. You catch my drift. Actually

you already knew that. And that’s why you are much moreanxious to give a gift than get one. Happiness certainly doesnot come from things. Otherwise the happiest people on


earth would be lottery winners. They are not. In fact lotterywinners often become discouraged and depressed becausethey become so obsessed with “stuff” that most are brokethree years after they have won the jackpot. “Superwoman”and I have come to the realization that less is more. That is tosay, the more stuff we have, the more problems and stress wehave. That’s why we evaluate every new opportunity by ask-ing ourselves whether taking advantage of the new opportu-nity will add to the quality of our lives. If the answer is yes, wego for it. If the answer is no, we don’t.

8. Develop a Positive Explanatory StyleProfessor Marty Seligman, of theUniversity of Pennsylvania, whohas had a tremendous influenceon getting psychologists to focuson the good—what he hasdubbed “positive psychology”—wrote a number of powerfulbooks addressing this topic(http://www.authentichappi-

ness.sas.upenn.edu/seligman.aspx). His research hasdemonstrated that we can learn to be more optimistic by de-veloping a “positive explanatory style” (PES). The way you dothat is by focusing on the good stuff, especially when badthings happen to you. In other words you learn to fake it untilyou make it. Research has shown that people who have de-veloped PES, as opposed to a Negative Explanatory Style(NES) are able to evaluate “reality” more clearly—just theopposite of what most people assume. Process “bad” newsmore effectively, and you are more likely to accept what can’tbe changed and move on. In short, PES enables you toinoculate yourself against the negative attitude “virus” and hisbig cousin—depression.

9. Keep Hope AliveHope is an incredibly powerfulemotion. Without it not only doyou become unhappy—you die.No one has told that story morepowerfully than Dr. Victor Franklin his book Man’s Search forMeaning, in which he details therole of hope in surviving the Ger-man concentration camps. Sobe sure to never give up hope, nomatter how bleak it gets. And

even more important, be sure not to confuse inconvenienceswith problems. Because many of the “problems” that we getourselves all worked up about are inconveniences, nottragedies. When you are in the middle of one of these, a greatdiagnostic is to ask yourself: “How will I feel about this fiveyears from now?” And then act accordingly. To deal more ef-fectively with the real tragedies—which will come—turn to thesource of hope and inspiration that works for you. It may bereligion, spirituality, meditation or listening to a great motiva-tional speech. (Just had to sneak that in there.) It will help youkeep hope alive and make you more optimistic and happier.

© 2009 Wolf J. Rinke

Dr. Wolf J. Rinke, PhD, RD, CSP is a keynotespeaker, seminar leader, management con-sultant, executive coach and editor of the freeelectronic newsletters Make It a Winning Lifeand The Winning Manager. To subscribe goto www.WolfRinke.com. He is the authorof numerous books, CDs and DVDs includingMake it a Winning Life: Success Strategies forLife, Love and Business; Winning Manage-

ment: 6 Fail-Safe Strategies for Building High-Performance Organi-zations and Don’t Oil the Squeaky Wheel and 19 Other ContrarianWays to Improve Your Leadership Effectiveness. All are available atwww.WolfRinke.com. His company also produces a wide variety ofquality, pre-approved continuing professional education (CPE) self-study courses including Beat the Blues: How to Manage Stress andBalance Your Life, on which this article is based, available atwww.easyCPEcredits.com. Reach him at [email protected].

Be sure to never give up hope, no matter how bleakit gets. And even more important, be sure not to confuse inconveniences with problems.

74 Healthy Skin


creo


Snug-fitting sheets for healthier skin.

A patented blend of cotton, polyester and spandex provides softness and a non-abrasive surface, alongwith better air circulation for skin health.

Independent laboratory studies1 showed that SoftSpanfitted sheets had 260% stretch in the width and 98%stretch in the length, compared to a regular knit sheet,which has 104% stretch in the width and 45% in thelength. Regular woven sheets have no stretch at all.

More stretch means a tighter, smoother fit, and no wrinkles. Mayo Clinic and other healthcare experts recommend keeping the bottom sheet pulled tight to prevent wrinkles and bunching, which can causepressure that contributes to skin breakdown.2,3

References1. Diversified Testing Laboratories, Inc. ASTM D 6614-07, “Standard TestMethod for Stretch Properties of Textile Fabrics – CRE Method.” July 29,2009. Data on file.2. Mayo Clinic. Bed sores (pressure sores). Available at http://www.may-oclinic.com/health/bedsores/DS00570. Accessed on February 5, 2010.3. Oregon Department of Human Services. Pressure Sores: A Self-StudyCourse. 2008. Available at: http://www.oregon.gov/DHS/spd/provtools/nurs-ing/study-guides/pressure_sores.pdf3.

SoftSpan sheets with spandex fit snugly on the bed to comfort and protect the skin.

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


creo

PINK GLOVEMEDLINE’S

Thank You!Providence St. Vincent

Medical Center

From the h ighest leve ls of yourorganization down through your entirestaff, we could not have picked a betterpartner for the “Pink Glove Dance,”video project.

Thank you for taking part in acause that touches us all.

76 Healthy Skin


creo

DANCEA YouTube™ Sensation One early November morning, when the OR

staff of Providence St. Vincent Medical Centerwas approached by Medline to take part in a littlebreast cancer awareness video they were doing, littledid they know what an impact their participationwould soon make.

A little more than a month later, over six million peopleacross the globe have seen the “Pink Glove Dance” video.

The YouTube video phenomenon has been featured onCNN, ABC World News with Charles Gibson, Fox &Friends - Fox News Network’s national morning show,and literally more than 100 local TV newscasts acrossthe country.

News stories about the video also span the Internet, fromthe Huffington Post to the AOL home page. People can’tstop talking about this video, which showcases morethan 200 hospital workers from the medical center inPortland, OR. dancing in Medline’s pink gloves. Phonecalls, cards and e-mails are flooding both the hospitaland Medline. And more than 10,000 people have postedcomments about the video on YouTube. It has enter-tained and inspired laughter and, for many, it has evokedmemories of their own battle with breast cancer or bat-tles faced by loved ones.

One viewer wrote: “Wonderful! This brought tears tomy eyes as I am a survivor 13 years out and it remindedme of the wonderful staff at Yale Oncology unit. Thankyou to all in the medical field. Please be sure to sharethis with those who are going through treatments. I amsure this will be helpful.” – mamakawecki55

Another said: “Given the type of work that they do,it is good to see them having fun for a good cause.Remember they are the ones who care for those withcancer.” – seaglassfriends

Boosting Hearts, Minds and Support for Breast

Cancer Awareness

Special Feature



creo

Birth of an IdeaWhy would perfectly sane and incredibly busy hospitalworkers agree to dance in a YouTube video? The shortanswer is to get people talking about breast cancer. Butthere’s more to the story. It all began at Medline’s Corporateoffice when employees were brainstorming ideas to pro-mote their new Generation Pink™ glove (launched inOctober). To further support Medline’s ongoing breast cancerawareness campaign (visit www.medline.com/breast-can-cer-awareness for details), they had already implemented apromotion to donate $1 of every case purchased to theNational Breast Cancer Foundation to fund mammogramsfor individuals who cannot afford them.

But they needed a big idea to help spread the word. So,they asked, “What if we were to video healthcare workersdancing in pink gloves? Could we produce a viral video?”Little did they know. . .

The first step was finding the right hospital to partner withMedline to create the video. The Providence Health Sys-tem, a 26-hospital system in the northwest area of thecountry, proved to be the perfect choice. The health systemsuggested Medline work with Providence St. Vincent Med-ical Center in Portland, which not only was willing to give fullaccess to each area of the facility for the video shoot, butalso shared Medline’s passion for breast cancer awareness.

The next few days were a blur of action. The hospital sentout a call for employee volunteers to dance in the video.Back at Medline, the wheels were in motion. Jay Sean’s hitsong “Down” was selected for the video and discussionstook place to coordinate which areas of the hospital wouldbe filmed, the number of staff participating in each shot andthe overall plan of events.

The Making of the VideoA week later, Medline product manager Emily Somers wasat the hospital with a few boxes of pink gloves and the filmcrew. More than 200 employees of all ages, departmentsand skill levels answered the call to participate.

“We had so many people who said, ‘You know, thisdisease has touched my life. I want to be a part of it,’” said

78 Healthy Skin


creo

“”

I am very honored that Medline and Providence St. Vincent Medical Centerused my song “Down” to promote and support Breast Cancer Awareness. I like that such a fun and light heartedapproach was taken to create aware-ness for a serious disease that can be cured if caught early.

– Jay Sean



creo

Martie Moore, the chief nursing officer at ProvidenceSt. Vincent Medical Center.

The filming took two days and Emily taught the volunteersbasic dance moves to showcase the pink gloves. “In anenvironment filled with sickness and gloom, the caregiversbrought incredible energy to the making of the video,expressing their great heart and spirit,” Emily said. Fromlab technicians and the kitchen help to surgical teams, theyall let loose, dancing throughout the hospital.

Touching People Around the WorldThousands of people across the globe have posted inspiringcomments about the video — even singer Jay Seanresponded by posting a link to the video on his website.On his Facebook page he wrote, "The vid is awesome …medicine will always be close to my heart and this is sucha worthy and important cause. So maybe I could havebeen a doctor and a singer at the same time after all then?Just brilliant."

17,000 Screaming Pink-Gloved FansTo further spread the “Pink Glove Dance” message, morethan 17,000 passionate fans recently wore Medline’s pinkgloves at a live concert held in Chicago. With 34,000 pinkgloved hands swaying back and forth to a live performanceby Jay Sean singing his hit song “Down,” the arena took ona surreal appearance of a dense forest of pink trees wavingin the wind. It was an unbelievable sight that brought tearsto the eyes of many in the audience.

Emily Somers, Medline product manager – and the choreographerof the “Pink Glove Dance” – teaches the lab staff of ProvidenceSt. Vincent some dance moves during the shooting of the video.

Monte Crawford, “themop man,” has becomeone of the more popularfigures in the “Pink GloveDance” video.

80 Healthy Skin


A world without breast cancer is in our hands.

Medline’s Generation Pink latex-free, third-generation vinyl exam gloves have the comfort, barrier protection and price you love.

Even better, when you choose Generation Pink gloves, you’re helping Medline support the National Breast Cancer Foundation.

For more information on Medline’s exam gloves, please contact your

Medline representative, call 1-800-MEDLINE or visit www.medline.com.

©2010 Medline Industries, Inc. The cross-fingered pink glove hand image is a trademark of Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.

Watch the “Pink Glove Dance” video at:YouTube.com/watch?v=OEdvfyt-mLw

Other ways to show your support:

Become a Facebook fan at: facebook.com/medlinebreastcancerawareness


creo

Support The Cause. Help fund free mammograms!When you choose Generation Pink Gloves, a portion of the proceeds will be donated to theNational Breast Cancer Foundation to fund free mammograms for women who cannot afford them.

Depending on who you are (an individual or a facility), there are two sites to choose fromwhen ordering gloves. • Individuals visit www.scrubs123.com• Healthcare facilities visit www.medline.com/breast-cancer-awareness• If you wish to donate directly to the National Breast Cancer Foundation,

visit the NBCF website www.nationalbreastcancer.org.

• Over 6 million views on YouTube• Over 10,000 comments on YouTube• More than 120 TV news stories

across the country

• National news – ABC, CNN, FOX, MSNBC• 17,000 fans donning pink gloves during

a live performance of Jay Sean’s hit song, “Down”

Pink Glove DanceVideoGoes Viral!

“”

82 Healthy Skin


creo

Featured Recipe

• 16 oz. bag frozen hash brown potatoes (cubed or shredded)

• 16 oz. container sour cream• 1 can cream of chicken soup• ½ c. chopped onion• 8 oz. bag shredded cheddar cheese

Topping:• 2 c. corn flakes• ¾ stick melted butter or margarine

Directions:Mix together all ingredients and place in a baking dish. Top withcrushed corn flakes mixed with the melted butter. Cover withfoil and bake at 350 degrees F for 30 minutes. Remove the foiland bake an additional 20-30 minutes.

Hint: To cut down on salt and fat, use low-sodium soup and reducedfat cheese and sour cream.

Shipping employee Dennis Shannon has worked at Medline’sAllentown, Penn. warehouse for 10 years. In his spare time, heenjoys cooking and entertaining. He said at his house, “I do thecooking and my wife does the baking, so it works out well.”

The Shannons regularly host parties at their home, where theyhave a fully outfitted game and entertainment room. Dennissaid his cheesy potatoes dish is a big favorite with guests. “It’seasy and inexpensive to make, and people really like it.”

Dennis offers another quick, easy andinexpensive recipe that’s also a big hit atparties: Spread a thin layer of chive-flavored cream cheese onto a flourtortilla and then layer it with a slice ofturkey breast lunch meat, a piece of redleaf lettuce and pimentos. Roll it up andcut into slices for an attractive and deli-cious snack.

Cheesy Potatoes (12 servings) Nutrition Information

Servings: 12Calories: 296Fat: 12.7 gSodium: 407.7 mgFiber: 1.2 g



creo



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

FORMS & TOOLS

OASIS-C Integumentary Status ........................................86

H1N1 (Swine Flu) Patient Handout (English) ..................................89Patient Handout (Spanish) ................................91

Leg Ulcers Clinical Fact Sheet: Quick Assessment of Leg Ulcers ......................................................93

Infection Prevention and Control Long-Term Care Audit ........................................95

Bariatrics Bariatric Assessment: Home Care/Long-TermCare Facility ....................................................101



creo

OASIS-C INTEGUMENTARY STATUS

(M1300) Pressure Ulcer Assessment: Was this patient assessed for Risk of Developing Pressure

Ulcers?

� 0 - No assessment conducted [ Go to M1306 ]

� 1 - Yes, based on an evaluation of clinical factors, e.g., mobility, incontinence, nutrition, etc.,

without use of standardized tool

� 2 - Yes, using a standardized tool, e.g., Braden, Norton, other

(M1302) Does this patient have a Risk of Developing Pressure Ulcers?

� 0 - No

� 1 – Yes

(M1306) Does this patient have at least one Unhealed (non-epithelialized) Pressure Ulcer at Stage

II or Higher or designated as "not stageable"?

� 0 - No [ Go to M1322 ]

� 1 – Yes

(M1307) Date of Onset of Oldest Unhealed Stage II Pressure Ulcer identified since most

recent SOC/ROC assessment:

__ __ /__ __ /__ __ __ __ month / day / year

� UK - Present at most recent SOC/ROC assessment

� NA - No new Stage II pressure ulcer identified since most recent SOC/ROC assessment

86 Healthy Skin

This checklist is part of the new OASIS-C guidance from the Centers for Medicare & Medicaid Services. OASIS-C went into effect at the end of 2009. For a step-by-step explanation of this portion of OASIS-C, turn to the article on page 29.

Forms & Tools OASIS-C Integumentary Status


creo

OASIS-C INTEGUMENTARY STATUS (cont’d.)

(M1308) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at Each Stage: (Enter

“0” if none; enter “4” if “4 or more”; enter “UK” for rows d.1 – d.3 if “Unknown”)

Stage description – unhealed pressure ulcers

Number Present Number of these that were present on admission

(most recent SOC / ROC)

a. Stage II: Partial thickness loss of dermis

presenting as a shallow open ulcer with red pink wound bed, without slough. May also

present as an intact or open/ruptured serum-

filled blister.

� �

b. Stage III: Full thickness tissue loss. Subcutaneous fat may be visible but bone,

tendon, or muscles are not exposed. Slough

may be present but does not obscure the depth of tissue loss. May include

undermining and tunneling.

� �

c. Stage IV: Full thickness tissue loss with

visible bone, tendon, or muscle. Slough or eschar may be present on some parts of the

wound bed. Often includes undermining and

tunneling.

� �

d.1 Unstageable: Known or likely but not stageable due to non-removable dressing or

device

� �

d.2 Unstageable: Known or likely but not

stageable due to coverage of wound bed by slough and/or eschar.

� �

d.3 Unstageable: Suspected deep tissue

injury in evolution. � �

Directions for M1310 and M1312: If the patient has one or more unhealed (non-epithelialized) Stage III or IV pressure ulcers, identify the pressure ulcer with the largest surface dimension

(length x width) and record in centimeters:

(M1310) Pressure Ulcer Length: Longest length “head-to-toe” | ___ | ___ | . | ___ | (cm)

(M1312) Pressure Ulcer Width: Width of the same pressure ulcer; greatest width perpendicular to

the length | ___ | ___ | . | ___ | (cm)

(M1314) Pressure Ulcer Depth: Depth of the same pressure ulcer; from visible surface to the

deepest area | ___ | ___ | . | ___ | (cm)

(M1320) Status of Most Problematic (Observable) Pressure Ulcer:

� 0 - Re-epithelialized

� 1 - Fully granulating

� 2 - Early/partial granulation

� 3 - Not healing

� NA - No observable pressure ulcer


OASIS-C Integumentary Status Forms & Tools



88 Healthy Skin

OASIS-C INTEGUMENTARY STATUS (cont’d.)

(M1322) Current Number of Stage I Pressure Ulcers: Intact skin with non-blanchable redness of a

localized area usually over a bony prominence. The area may be painful, firm, soft, warmer or cooler

as compared to adjacent tissue.

� 0 � 1 � 2 � 3 � 4 or more

(M1324) Stage of Most Problematic (Observable) Pressure Ulcer:

� 1 - Stage I [Go to M1330 at SOC/ROC/FU ] � 2 - Stage II � 3 - Stage III � 4 - Stage IV

� NA - No observable pressure ulcer

(M1330) Does this patient have a Stasis Ulcer?

� 0 - No [ Go to M1340 ]

� 1 - Yes, patient has one or more (observable) stasis ulcers

� 2 - Stasis ulcer known but not observable due to non-removable dressing [ Go to M1340 ]

(M1332) Current Number of (Observable) Stasis Ulcer(s):

� 1 - One

� 2 - Two

� 3 - Three

� 4 - Four or more

(M1334) Status of Most Problematic (Observable) Stasis Ulcer:



� 3 - Not healing

(M1340) Does this patient have a Surgical Wound?

� 0 - No [ Go to M1350 ]

� 1 - Yes, patient has at least one (observable) surgical wound

� 2 - Surgical wound known but not observable due to non-removable dressing [ Go to M1350 ]

(M1342) Status of Most Problematic (Observable) Surgical Wound:

� 0 - Re-epithelialized



� 3 - Not healing

(M1350) Does this patient have a Skin Lesion or Open Wound, excluding bowel ostomy, other than those described above that is receiving intervention by the home health agency?

� 0 - No

� 1 - Yes

Forms & Tools OASIS-C Integumentary Status


H1N1 (Swine Flu)What is H1N1 flu?H1N1 influenza, or swine flu, is a respiratoryillness caused by type A influenza viruses. This virus was originally referred to as “swine flu”because it was thought to be very similar to fluviruses that normally occur in pigs (swine) in North America. H1N1 flu was first detected in people in the United States in April 2009.

How does H1N1 flu spread?H1N1 flu is contagious and is spreading between people. This virus may be transmitted in similar ways that other flu virusesspread, through coughing or sneezing. A person may be able to infect another person one day before symptoms develop andfor seven or more days (longer for children) after becoming sick. It is possible that someone may become infected by touchingsomething with the virus on it and then touching his mouth or nose. Eating pork does not cause swine influenza.

What are the symptoms of H1N1 flu?The symptoms of H1N1 flu include fever, cough, sore throat, runny or stuffy nose, bodyaches, headache, chills and fatigue. Diarrhea and vomiting may also be associated withH1N1 flu. Most people with the virus have recovered without needing treatment, but hospitalizations and deaths have occurred.

What should I do if I think I have H1N1 flu?If you have flu symptoms, stay home and avoid contact with other people to avoid spreading your illness. It is recommended that you stay home for at least 24 hours afteryour fever is gone, or if possible, until your cough is gone. If you have severe illness or you are at high risk for flu complications, contact your health care provider. He or she will determine whether testing or treatment is needed.

Seek emergency medical care for any of the following warning signs:

In children:• Fast breathing or trouble breathing • Bluish skin color • Not drinking enough fluids • Not waking up or not interacting • Being so irritable that the child does not want to be held • Flu-like symptoms improve but then return with

fever and worse cough • Severe or persistent vomiting

In adults: • Difficulty breathing

or shortness of breath • Pain or pressure in the chest or abdomen • Sudden dizziness • Confusion • Severe or persistent vomiting • Flu-like symptoms improve but then return with

fever and worse cough

• Headache

• Fever

• Fatigue

• Chills

• Runny or

stuffy nose

• Sore throat

• Cough

• Body aches

H1N1 Symptoms

Page1 5mcc.comnursingcenter.com anatomical.comText courtesy of NursingCenter.com. Images courtesy of Anatomical Chart Company. Lippincott Williams & Wilkins | Wolters Kluwer Health Businesses.


Forms & Tools H1N1 Patient Handout


creo

Page2

How is H1N1 flu treated?The CDC recommends the use of oseltamivir (brandname Tamiflu) or zanamivir (brand name Relenza) totreat and/or prevent swine influenza. These antiviralmedications may also prevent serious complications. For treatment, antiviral drugs work best if started within 2 days of symptoms.

• Coughing or sneezing into your arm; avoiding close contact with people who haverespiratory symptoms such ascoughing or sneezing

• Staying home when you're sick and getting as much rest as possible

• Washing your hands often with soap and water for 15-20 seconds; using alcohol-based hand cleansersis also acceptable

• Not touching your eyes, nose, ormouth because this is how germsget into your body

• Keeping surfaces and objects(especially tables, counters, door-knobs, toys) that can be exposedto the virus clean

• Practicing other good health habits,including getting plenty of sleep,staying active, drinking plenty offluids, and eating healthy foods

What can I do to prevent H1N1 flu?You can reduce your risk of contracting and spreading swine influenza and other influenza viruses by:

Lisa Morris Bonsall, MSN, RN, CRNP

Check with your healthcareprovider to see if the H1N1 vaccine is right for you.

Text courtesy of NursingCenter.com. Images courtesy of Anatomical Chart Company. Lippincott Williams & Wilkins | Wolters Kluwer Health Businesses.

5mcc.comnursingcenter.com anatomical.com

90 Healthy Skin

Forms & Tools H1N1 Patient Handout


creo

Virus de la influenza A subtipo H1N1(anteriormente llamado de la «gripe porcina»)¿Qué es la gripe por H1N1?La gripe por H1N1, originalmente llamada «gripe porcina», es la enfermedad respiratoria que causa la infección por el virus de la influenza A subtipo H1N1. A este virus originalmente se le llamó virus de la «gripe porcina» puesto que se pensó que era muy similar a los virus que causan gripe en los cerdos (porcinos) en Norteamérica. El virus de la influenzaA subtipo H1N1 fue detectado por primera vez en humanosen los Estados Unidos de Norteamérica en abril del 2009.

¿Cómo se propaga la gripe por H1N1?La gripe por H1N1 es contagiosa y se propaga de persona a persona. El virus puede propagarse de manera similar a otrosvirus de la gripe; a través de la tos o de los estornudos. Una persona puede infectar a otra un día antes de presentar síntomasy durante siete o más días (más tiempo en los niños) después de haber enfermado. Existe la posibilidad de que una persona seinfecte al tocar una superficie contaminada con el virus si esta persona luego se pone las manos sobre la boca o nariz. Comercarne de cerdo no causa gripe por H1N1.

¿Cuáles son los síntomas de la gripe por H1N1?Los síntomas de la gripe por H1N1 incluyen fiebre, tos, dolor de garganta, nariz conmucosidad o tupida; dolor en el cuerpo, dolor de cabeza, escalofríos y fatiga. La mayoríade las personas que han tenido el virus se han recuperado sin necesitar tratamiento, peroha habido otras que han necesitado hospitalización, y también otras que han muerto.

¿Qué debo hacer si pienso que tengo gripe por H1N1?Si usted piensa que tiene síntomas de gripe quédese en casa y evite entrar en contacto conotras personas para no propagar la enfermedad. Es recomendable quedarse en casa por lomenos durante 24 horas después de que le haya pasado la fiebre, o si es posible, después de que le haya pasado la tos. Si está gravemente enfermo, o si pertenece a un grupo de alto riesgo para desarrollar complicaciones, entre en contacto con su proveedor de atención médica. Él determinará si es necesario que le hagan análisis o que tome tratamiento.

Busque atención médica de urgencias si presenta cualquiera de los siguientes signos (señas) de alarma:

• Dolor de cabeza

• Fiebre

• Fatiga

• Escalofríos

• Nariz con

mucosidad o tupida

• Dolor de garganta

• Tos

• Dolores corporales

Síntomas de A(H1N1)

Página1 5mcc.comnursingcenter.com anatomical.comTexto por cortesía del centro NursingCenter.com. Imágenes por cortesía de Anatomical Chart Company.Lippincott Williams & Wilkins | Wolters Kluwer Health Businesses.

En niños:• Respiración acelerada o dificultad para respirar• Tonalidad morada en la piel• No está tomando suficientes líquidos• No se despierta o no responde a las acciones• Está tan irritable que no quiere que lo alcen• Los síntomas como de gripe mejoran pero

luego reaparecen con fiebre y tos más fuerte.• Vómito intenso o persistente

En adultos:• Dificultad para respirar o sensación de «falta de aire»• Dolor o sensación de presión en el pecho o en

el abdomen• Mareo súbito• Confusión • Vómito intenso o persistente• Los síntomas como de gripe mejoran pero luego

reaparecen con fiebre y tos más fuerte.


H1N1 Español por los Pacientes Forms & Tools


creo

Página 2

¿Cómo es el tratamiento para la gripe por A(H1N1)?Los Centros para el Control y la Prevención de Enfermedades de los EE. UU.(CDC) recomiendan el uso de oseltamivir (nombre de marca Tamiflu) o dezanamivir (nombre de marca Relenza) para el tratamiento y la infección,o solamente para prevenir la infección por el virus de la influenzaA(H1N1). Estos medicamentos antivíricos también pueden prevenir complicaciones graves. Para el tratamiento, los medicamentos antivíricosfuncionan mejor si se comienzan a usar en un lapso de dos días despuésde que comienzan los síntomas.

• Tosiendo o estornudando sobre su brazo y evitando el contactocercano con personas que presentan síntomas respiratoriostales como tos o estornudos.

• Quedándose en casa cuando estáenfermo y descansando el mayor tiempo que pueda.

• Lavándose las manos con frecuencia con agua y jabóndurante 15 a 20 segundos ousando un limpiador para lasmanos con base en alcohol.

• No tocándose los ojos, nariz oboca, pues ésta es la maneracomo los gérmenes llegan hastanuestro cuerpo.

• Manteniendo limpias las superficiesy objetos (especialmente mesas,mesones, cerraduras de puertas)que puedan estar expuestos al virus.

• Practicando otros hábitos saludables;incluso dormir bastante, mantenerseactivo, tomar líquidos en cantidad ycomer alimentos saludables.

¿Qué puedo hacer para prevenir la gripe por A(H1N1)?Usted puede disminuir su riesgo de contraer gripe por A(H1N1) y de propagarotros virus de la influenza de la siguiente manera:

Escrito por Lisa Morris Bonsall, MSN, RN, CRNPTraducido por Marcela D. Pinilla, M.H.E., M.T. (ASCP)

Verifique con su proveedor de atención médica paradeterminar si la vacuna contra el virus de la influenza A(H1N1) es adecuada para usted.

Texto por cortesía del centro NursingCenter.com. Imágenes por cortesía de Anatomical Chart Company.Lippincott Williams & Wilkins | Wolters Kluwer Health Businesses.

5mcc.comnursingcenter.com anatomical.com

92 The OR Connection

Forms & Tools H1N1 Español por los Pacientes


creo

Adv

ance

d Ag

e C

HF L

ymph

edem

a O

besit

y O

rthop

edic

Proc

edur

es P

ain

redu

ced

by e

leva

tion

Pre

gnan

cy P

revi

ous

DVT

with

Phl

ebiti

s P

ulm

onar

y Em

bolu

s R

educ

ed m

obili

ty S

eden

tary

Life

style

Tra

umat

ic In

jury

Vas

cula

r Ulce

rs W

ork

Hist

ory

Arte

rial D

iseas

e C

ardi

ovas

cula

r Dise

ase

Dia

bete

s D

yslip

idem

ia H

yper

tens

ion

Inc

reas

ed p

ain

with

act

ivity

and

/or e

leva

tion

IIn

term

itten

t Cla

udica

tion

Obe

sity

Pai

nful

Ulce

r S

ickle

Cel

l Ane

mia

Sm

okin

g V

ascu

lar p

roce

dure

s/su

rger

ies

Adv

ance

d ag

e A

lcoho

lism

Che

mot

hera

py D

iabe

tes

Han

sen’

s Di

seas

e H

ered

ity H

IV, A

IDS

and

rela

ted

drug

ther

apie

s H

yper

tens

ion

Im

paire

d gl

ucos

e to

lera

nce

Obe

sity

Ray

naud

’s Di

seas

e, S

clero

derm

a S

mok

ing

Spi

nal C

ord

Inju

ry a

nd n

euro

mus

cula

r dise

ases

Mal

leol

us M

edia

l asp

ect o

f leg

sup

erio

r to

med

ial m

alle

olus

Are

as e

xpos

ed to

pre

ssur

e or

repe

titiv

e tra

uma,

or r

ubbi

ng o

f foo

twea

r L

ater

al m

alle

olus

Mid

tibi

al P

hala

ngea

l hea

ds T

oe ti

ps o

r web

spa

ces

Alte

red

pres

sure

poi

nts/

sites

of p

ainl

ess

traum

a/re

petit

ive

stre

ss D

orsa

l and

dist

al to

es H

eels

Int

er-d

igita

l M

etat

arsa

l hea

ds M

id-fo

ot (d

orsa

l and

pla

ntar

) T

oe in

terp

hala

ngea

l joi

nts

WO

UN

D B

ase:

rudd

y re

d; y

ello

w a

dher

ent o

r loo

se s

loug

h; g

ranu

latio

n tis

sue

pres

ent,

unde

rmin

ing

or tu

nnel

ing

are

unco

mm

on D

epth

: usu

ally

shal

low

Mar

gins

: irre

gula

r E

xuda

te: m

oder

ate

to h

eavy

Inf

ectio

n: le

ss c

omm

on

SURR

OU

ND

ING

SK

IN V

enou

s de

rmat

itis

(ery

them

atic,

wee

ping

, sca

ling,

cru

stin

g) H

emos

ider

osis

(bro

wn

stai

ning

) L

ipod

erm

atos

clero

sis; A

troph

y Bl

anch

e T

empe

ratu

re: n

orm

al; w

arm

to to

uch

Ede

ma:

pitt

ing

or n

on-p

ittin

g; p

ossib

le in

dura

tion

and

cellu

litis

Sca

rring

from

pre

viou

s ul

cers

, ank

le fl

are,

tine

a pe

dis

Inf

ectio

n: In

dura

tion,

cel

lulit

is, in

flam

ed, t

ende

r bul

la

WO

UN

D B

ase:

Pal

e; g

ranu

latio

n ra

rely

pres

ent;

necr

osis,

esc

har,

gang

rene

(wet

or

dry

) may

be

pres

ent

Dep

th: m

ay b

e de

ep M

argi

ns: e

dges

rolle

d; p

unch

ed o

ut, s

moo

th a

nd u

nder

min

ing

Exu

date

: min

imal

Inf

ectio

n: fr

eque

nt (s

igns

may

be

subt

le)

SURR

OU

ND

ING

SK

IN P

allo

r on

elev

atio

n D

epen

dant

rubo

r S

hiny

, tau

t, th

in, d

ry,

Hai

r los

s ov

er lo

wer

ext

rem

ities

Atro

phy

of s

ubcu

tane

ous

tissu

e E

dem

a: v

aria

ble;

aty

pica

l T

empe

ratu

re: d

ecre

ased

/col

d I

nfec

tion:

Cel

lulit

is N

ecro

sis, e

scha

r, ga

ngre

ne m

ay b

e pr

esen

t

NA

ILS

Dys

troph

ic

WO

UN

D B

ase:

pin

k/pa

le; n

ecro

tic ti

ssue

var

iabl

e; D

epth

: var

iabl

e E

dges

wel

l defi

ned

Exu

date

: usu

ally

smal

l to

mod

erat

e W

ound

sha

pe: u

sual

ly ro

unde

d or

obl

ong

and

foun

d ov

er

bony

pro

min

ence

SURR

OU

ND

ING

SK

IN N

orm

al s

kin

tone

s T

roph

ic ch

ange

s F

issur

ing

or c

allu

s fo

rmat

ion

Ede

ma:

with

ery

them

a m

ay in

dica

te h

igh

pres

sure

Tem

pera

ture

: war

m

NA

ILS

Ony

chom

ycos

is; d

ystro

phic

nails

; par

onyc

hia,

hyp

ertro

phy

Clin

ical

Fac

t She

et Q

uick

Ass

essm

ent o

f Leg

Ulc

ers

Veno

us In

suffi

cien

cy (S

TASI

S)

History Location Assessment

Arte

rial I

nsuf

ficie

ncy

Perip

hera

l Neu

ropa

thy

WO

CN

15

00

0 C

om

me

rce

Pa

rkw

ay,

Su

ite

C

M

ou

nt

Lau

rel,

NJ

08

05

4

(8

88

) 2

24

-WO

CN

We

b s

ite

: w

ww

.wo

cn.o

rg


Quick Assessment of Leg Ulcers Forms & Tools

Con

tinue

d on

pag

e 94


PAIN M

inim

al u

nles

s in

fect

ed o

r des

sicat

ed D

escr

ibed

as

thro

bbin

g, s

harp

, itc

hy, s

ore,

tend

er, h

eavi

ness

Wor

sens

with

pro

long

ed d

epen

denc

y

PERI

PHER

AL

PULS

ES P

rese

nt/p

alpa

ble

NO

N-I

NVA

SIV

E VA

SCU

LAR

TEST

ING

Cap

illar

y Re

fill:

norm

al (l

ess

than

3 s

econ

ds)

ABI

to ru

le o

ut a

rteria

l com

pone

nt

MEA

SURE

S TO

IMPR

OV

E V

ENO

US

RETU

RN (

Prov

ided

vas

cula

r stu

dies

hav

e ru

led

out s

igni

fican

t arte

rial d

iseas

e)

Sur

gica

l obl

itera

tion

of d

amag

ed v

eins

Ele

vatio

n of

legs

Med

icatio

ns E

xerc

ise E

duca

tion

Com

pres

sion

ther

apy

to p

rovi

de a

t lea

st

30m

m H

g co

mpr

essi

on a

t an

kle‘

**S

ee W

OCN

Clin

ical P

ract

ice G

uide

line

for C

ompr

essio

n Th

erap

y

PAIN I

nter

mitt

ent c

laud

icatio

n R

estin

g; p

ositi

onal

; noc

turn

al P

ainf

ul U

lcer

Par

esth

esia

s

PERI

PHER

AL

PULS

ES A

bsen

t or d

imin

ished

NO

N-I

NVA

SIV

E VA

SCU

LAR

TEST

ING

Cap

illar

y re

fill:

Dela

yed

(mor

e th

an 3

sec

onds

) A

BI <

0.9

TCP

O2

<40

mm

HG T

P >

30m

m H

G

MEA

SURE

S TO

IMPR

OV

E TI

SSU

E PE

RFU

SIO

N R

evas

cula

rizat

ion

if po

ssib

le M

edica

tions

to im

prov

e RB

C tra

nsit

thro

ugh

narro

wed

ves

sels

Life

style

cha

nges

(avo

id to

bacc

o, c

affe

ine,

rest

rictiv

e ga

rmen

ts,

cold

tem

pera

ture

s) H

ydra

tion

Mea

sure

s to

pre

vent

trau

ma

to ti

ssue

s (a

ppro

pria

te fo

ot w

ear)

Mai

ntai

n le

gs in

neu

tral o

r dep

ende

nt p

ositi

on P

ress

ure

redu

ctio

n fo

r hee

ls an

d to

es

PAIN D

ecre

ased

sen

sitiv

ity to

touc

h; if

pre

sent

, pai

n m

ay b

e su

perfi

cial,

deep

, ach

ing,

sta

bbin

g, d

ull,

shar

p, b

urni

ng o

r co

ol; a

ltere

d se

nsat

ion

not d

escr

ibed

as “

pain

” (n

umbn

ess,

war

mth

, pric

klin

g, ti

nglin

g)

PERI

PHER

AL

PULS

ES P

alpa

ble/

pres

ent

NO

N-I

NVA

SIV

E VA

SCU

LAR

TEST

ING

Cap

illar

y re

fill:

Nor

mal

NO

TE: L

EAD

may

co-

exist

with

neu

ropa

thic

dise

ase

MEA

SURE

S TO

ELI

MIN

ATE

TRA

UM

A R

educ

tion

of s

hear

stre

ss a

nd o

ffloa

ding

of n

euro

path

ic w

ound

s (b

edre

st, c

onta

ct c

astin

g, o

rthop

edic

shoe

s) U

se o

f ass

istiv

e de

vice

s to

pro

vide

sup

port,

bal

ance

and

ad

ditio

nal o

ffloa

ding

App

ropr

iate

foot

wea

r T

ight

glu

cose

/glyc

emic

cont

rol

Agg

ress

ive

prev

entio

n/tre

atm

ent o

f inf

ectio

n (d

ebrid

emen

t of

cal

lus

and

necr

otic

tissu

e; p

harm

acol

ogic

treat

men

t whe

n ap

prop

riate

) R

evas

cula

rizat

on if

isch

emic

Com

plica

tions

: Cel

lulit

is, o

steo

mye

litis,

gan

gren

e, C

harc

ot

fract

ure

Goa

ls: a

bsor

b ex

udat

es, m

aint

ain

moi

st w

ound

sur

face

DRY

, NO

N-I

NFE

CTED

, NEC

ROTI

C W

OU

ND

Kee

p dr

y

INFE

CTED

WO

UN

D/D

RY O

R M

OIS

T N

ECRO

SIS

Ref

erra

l for

pot

entia

l sur

gica

l deb

ridem

ent/a

ntib

iotic

ther

apy

OPE

N W

OU

ND

/NO

N-N

ECRO

TIC

Moi

st w

ound

hea

ling;

Non

-occ

lusiv

e dr

essin

gs A

ggre

ssiv

e tre

atm

ent o

f any

infe

ctio

n

Use

dre

ssin

gs th

at m

aint

ain

a m

oist

sur

face

, abs

orb

exud

ates

an

d al

low

eas

y vi

sual

izatio

n

Cau

tious

use

of o

cclu

sive

dres

sings

Clin

ical

Fac

t She

et Q

uick

Ass

essm

ent o

f Leg

Ulc

ers

Veno

us In

suffi

cien

cy (S

TASI

S)

Perfusion Topical Therapy

Arte

rial I

nsuf

ficie

ncy

Perip

hera

l Neu

ropa

thy

WO

CN

15

00

0 C

om

me

rce

Pa

rkw

ay,

Su

ite

C

M

ou

nt

Lau

rel,

NJ

08

05

4

(8

88

) 2

24

-WO

CN

We

b s

ite

: w

ww

.wo

cn.o

rgRe

vise

d: N

ovem

ber 2

4, 2

009

94 Healthy Skin

Forms & Tools Quick Assessment of Leg Ulcers


ARE

AS

AN

D IT

EMS

FULLY IMPLEMENTED

PARTLY IMPLEMENTED

NOT IMPLEMENTED

N/A

CO

MM

ENTS

ENTR

Y T

O F

AC

ILIT

Y

Infe

ctio

n C

on

tro

l Sig

nag

e at

En

try

(rel

ated

to

sc

reen

ing

for c

om

mu

nic

able

dis

ease

s)

Han

d H

ygie

ne

Stat

ion

at

entr

ance

UN

IT L

EVEL

Clie

nt

asse

ssed

bef

ore

en

try

for r

isk

fact

ors

(fev

er,

cou

gh

, dia

rrh

ea, r

ash

, dra

inag

e)

Wri

tten

po

licy

and

pro

ced

ure

for c

lien

t ass

essm

ent

Incl

ud

es: d

rain

age,

co

ug

h, f

ever

, co

nti

nen

ce, a

bili

ty t

o

follo

w h

ygie

ne

mea

sure

s

Pro

tect

ive

equ

ipm

ent

avai

lab

le

G

love

s

M

asks

G

ow

ns

A

lco

ho

l-b

ased

han

d ru

b s

tati

on

s

G

og

gle

s/ey

e p

rote

ctio

n

C

lean

er fo

r clie

nt

equ

ipm

ent

Wri

tten

Po

licie

s fo

r Dre

ss C

od

e:

In

clu

des

no

jew

elle

ry (r

ing

s o

r bra

cele

ts)

N

o n

ail e

nh

ance

men

ts

APP

END

IX II

I – A

UD

IT T

OO

L (A

)

LON

G T

ERM

CA

RE A

UD

ITA

UD

IT P

ERFO

RMED

BY

___

____

____

____

____

____

___

DA

TE:_

____

____

____

____

__A

REA

AU

DIT

ED :_

____

____

____

____

____

____

____

__

INFE

CTI

ON

PRE

VEN

TIO

N A

ND

CO

NTR

OL

BES

T PR

AC

TIC

ESFO

R LO

NG

TER

M C

ARE

AN

D C

OM

MU

NIT

Y C

ARE

IN

CLU

DIN

G H

EALT

H C

AR

E O

FFIC

ES A

ND

AM

BU

LATO

RY C

LIN

ICS


Long Term Care Infection Prevention Audit Forms & Tools

Con

tinue

d on

pag

e 96

Can

adia

n C

omm

ittee

on

Ant

ibio

tic R

esis

tanc

e (2

007)

Infe

ctio

n P

reve

ntio

n an

d C

ontr

ol B

est P

ract

ices

for

Long

Ter

mC

are,

Hom

e an

d C

omm

unity

Car

e in

clud

ing

Hea

lth C

are

Offi

ces

and

Am

bula

tory

Clin

ics


creo

ARE

AS

AN

D IT

EMS

FULLY IMPLEMENTED

PARTLY IMPLEMENTED

NOT IMPLEMENTED

N/A

CO

MM

ENTS

Sig

nag

e fo

r han

d w

ash

ing

Sig

nag

e fo

r alc

oh

ol-

bas

ed h

and

rub

Sig

ns

sho

win

g h

ow

to

was

h h

and

s

Sig

ns

sho

win

g H

ow

to

use

alc

oh

ol-

bas

ed h

and

rub

Staf

f can

iden

tify

wh

en to

use

han

d h

ygie

ne:

B

efo

re re

sid

ent

care

B

efo

re a

sep

tic

pra

ctic

es

Aft

er re

sid

ent

care

Aft

er c

on

tact

wit

h b

od

y flu

ids

or m

uco

us

mem

bra

nes

Aft

er c

on

tact

wit

h c

on

tam

inat

ed e

qu

ipm

ent

Re

sid

ent

equ

ipm

ent

has

reg

ula

r cle

anin

g s

ched

ule

C

om

mo

des

B

P C

uff

s

Sl

ing

s

G

luco

met

ers

C

lean

ers

use

d a

re a

pp

rop

riat

e an

d u

sed

acc

ord

ing

to

man

ufa

ctu

rer’s

reco

mm

end

atio

ns

con

cen

trat

ion

c

on

tact

tim

e

Cle

an p

roce

du

res

use

ste

rile

su

pp

lies

e.g

. Wo

un

d c

are

Cat

het

eriz

atio

n

Re

sid

ent

Pers

on

al C

are

Equ

ipm

ent

is la

bel

ed

and

sto

red

saf

ely

APP

END

IX II

I – A

UD

IT T

OO

L (A

)

LON

G T

ERM

CA

RE A

UD

IT

(CO

NTI

NU

ED)

INFE

CTI

ON

PRE

VEN

TIO

N A

ND

CO

NTR

OL

BES

T PR

AC

TIC

ESFO

R LO

NG

TER

M C

ARE

AN

D C

OM

MU

NIT

Y C

ARE

IN

CLU

DIN

G H

EALT

H C

ARE

OFF

ICES

AN

D A

MB

ULA

TORY

CLI

NIC

S

96 Healthy Skin

Forms & Tools Long Term Care Infection Prevention Audit

Can

adia

n C

omm

ittee

on

Ant

ibio

tic R

esis

tanc

e (2

007)

Infe

ctio

n P

reve

ntio

n an

d C

ontr

ol B

est P

ract

ices

for

Long

Ter

mC

are,

Hom

e an

d C

omm

unity

Car

e in

clud

ing

Hea

lth C

are

Offi

ces

and

Am

bula

tory

Clin

ics


creo

APP

END

IX II

I – A

UD

IT T

OO

L (A

)

LON

G T

ERM

CA

RE A

UD

IT

(CO

NTI

NU

ED)

ARE

AS

AN

D IT

EMS

FULLY IMPLEMENTED

PARTLY IMPLEMENTED

NOT IMPLEMENTED

N/A

CO

MM

ENTS

LAU

ND

RY

La

un

dry

is t

ran

spo

rted

in a

cle

an m

ann

er

Soile

d la

un

dry

in s

eale

d b

ags

Cle

an in

seg

reg

ated

man

ner

Lau

nd

ry is

so

rted

by

staf

f wea

rin

g P

PE

H

and

hyg

ien

e is

ava

ilab

le in

lau

nd

ry a

rea

Ed

uca

tio

n is

pro

vid

ed t

o la

un

dry

wo

rker

s o

n

pro

tect

ive

pra

ctic

e

Imm

un

izat

ion

is o

ffer

ed to

lau

nd

ry w

ork

ers

for

Hep

atit

is B

WA

STE

Pu

nct

ure

Res

ista

nt

Shar

ps

con

tain

ers

are

use

d

W

ritt

en p

olic

ies

refle

ct w

aste

seg

reg

atio

n

Sh

arp

s co

nta

iner

s n

ot

mo

re t

han

3/4

fille

d

Sh

arp

s co

nta

iner

s ar

e ac

cess

ible

an

d s

afe

HEA

LTH

Y W

ORK

PLA

CE

D

ocu

men

tati

on

of s

taff

tu

ber

clin

e sk

in t

ests

are

kep

t

Do

cum

enta

tio

n o

f sta

ff im

mu

niz

atio

n is

kep

t:

Fl

u S

ho

ts

MM

R

TD

P

H

ep B

INFE

CTI

ON

PRE

VEN

TIO

N A

ND

CO

NTR

OL

BES

T PR

AC

TIC

ESFO

R LO

NG

TER

M C

ARE

AN

D C

OM

MU

NIT

Y C

ARE

IN

CLU

DIN

G H

EALT

H C

ARE

OFF

ICES

AN

D A

MB

ULA

TORY

CLI

NIC

S


Long Term Care Infection Prevention Audit Forms & Tools

Con

tinue

d on

pag

e 98

Can

adia

n C

omm

ittee

on

Ant

ibio

tic R

esis

tanc

e (2

007)

Infe

ctio

n P

reve

ntio

n an

d C

ontr

ol B

est P

ract

ices

for

Long

Ter

mC

are,

Hom

e an

d C

omm

unity

Car

e in

clud

ing

Hea

lth C

are

Offi

ces

and

Am

bula

tory

Clin

ics


creo

APP

END

IX II

I – A

UD

IT T

OO

L (A

)

LON

G T

ERM

CA

RE A

UD

IT

(CO

NTI

NU

ED)

ARE

AS

AN

D IT

EMS

FULLY IMPLEMENTED

PARTLY IMPLEMENTED

NOT IMPLEMENTED

N/A

CO

MM

ENTS

Wri

tten

po

licie

s o

utl

ine

wo

rk e

xclu

sio

ns:

Der

mat

itis

on

han

ds

D

isse

min

ated

sh

ing

les

Init

ial d

ays

of a

co

ld

Dia

rrh

ea

Eye

infe

ctio

n u

nti

l tre

ated

Wri

tten

po

licy

ou

tlin

es B

loo

db

orn

e Pa

tho

gen

Fo

llow

-u

p (S

har

ps

inju

ry o

r blo

od

sp

lash

)

Edu

cati

on

is p

rovi

ded

to

sta

ff a

nn

ual

ly o

n In

fect

ion

p

reve

nti

on

an

d C

on

tro

l

Edu

cati

on

is p

rovi

ded

on

risk

ass

essm

ent,

rou

tin

e p

ract

ices

an

d e

qu

ipm

ent

clea

nin

g

Rate

of S

taff

Flu

vac

cin

atio

n y

ear_

____

__

Ra

te o

f Res

iden

t Fl

u v

acci

nat

ion

OU

TBRE

AK

MA

NA

GEM

ENT

W

ritt

en p

olic

ies

iden

tify

no

tific

atio

n p

roce

ss fo

r cl

ust

ers

of s

ymp

tom

s o

r ou

tbre

aks

Wri

tten

po

licie

s an

d p

roce

du

res

exis

t fo

r man

agin

g

ou

tbre

aks

In

clu

din

g t

oo

ls fo

r tra

ckin

g c

ases

an

d a

co

mm

un

icat

ion

pla

n

IN

FEC

TIO

N P

REV

ENTI

ON

AN

D C

ON

TRO

L B

EST

PRA

CTI

CES

FOR

LON

G T

ERM

CA

RE A

ND

CO

MM

UN

ITY

CA

RE IN

CLU

DIN

G H

EALT

H C

ARE

OFF

ICES

AN

D A

MB

ULA

TORY

CLI

NIC

S

Forms & Tools Long Term Care Infection Prevention Audit

98 Healthy Skin

Can

adia

n C

omm

ittee

on

Ant

ibio

tic R

esis

tanc

e (2

007)

Infe

ctio

n P

reve

ntio

n an

d C

ontr

ol B

est P

ract

ices

for

Long

Ter

mC

are,

Hom

e an

d C

omm

unity

Car

e in

clud

ing

Hea

lth C

are

Offi

ces

and

Am

bula

tory

Clin

ics


creo

MEDLINE’S HAND HYGIENE COMPLIANCE PROGRAM

FOR ALL THE LIVES YOU TOUCH.

Now more than ever, hand hygiene compliance is crucial. As of October 1, 2008, the Centers for Medicare & MedicaidServices no longer reimburses hospitals for eight hospital-acquired conditions, including catheter-associated urinarytract infections, surgical site infections and bloodstream infections.1 We know that hand hygiene is the numberone line of defense against hospital-acquired infections.2

There’s no such thing as “overeducating” when it comes to hand hygiene. Enhance your current strategy with Medline’s Hand Hygiene Compliance Program!

The Hand Hygiene Compliance Program includes: • An instructor’s manual that takes the guesswork

out of planning lessons• A customizable plug-and-play CD that contains

presentations, posters and more• Forms and tools to serve as reminders and

reinforcements• A cost calculator to help you determine the cost

of prevention vs. the cost of an infection• A rewards program to recognize those who

complete the course• Patient and family education materials• CE-credit courses for staff• A how-to guide on enhancing your presentation skills

For an on-site presentation of the Hand Hygiene Compliance Program and our Healthy Hands Product Bundle, contact your Medline representativeor visit www.medline.com/handhygiene. References

1 Centers for Medicare & Medicaid Services. Medicare program; changes to the hospitalinpatient prospective payment systems and fiscal year 2007 rates. Available at:www.cms.hhs.gov/AcuteInpatientPPS/downloads/CMS-1533-FC.pdf. Accessed November 20, 2007.

2 Davis D, Sosovec D. The value of products that improve hand hygiene and skin. Health-care Purchasing News. Available at: http://www.hpnonline.com/inside/2003-11/1103hy-giene.htm. Accessed November 20, 2007.



creo

How 4 square inches of Puracol® Pluschanged chronic wound care.

Forever.

This is Puracol Plus Micro-

Scaffold as seen through an

electron microscope. Its open,

cellular structure allows easy

fibroblast migration.2 The high

strength of the MicroScaffold2

also assists in establishing a

fresh wound bed. Each Puracol package is

a 2-Minute Course™ in

Advanced Wound Care.

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

Chronic wounds tend not to heal when unbalanced levelsof elastase and MMPs (inflammatory enzymes) destroy thebody’s own collagen and growth factors.1

But apply Puracol Plus and help restore nature’s balance.

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

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

©2010 Medline Industries, Inc.Puracol is a registered trademark of Medline Industries, Inc.Medline is a registered trademark of Medline Industries, Inc.


Bariatric Assessment : Homecare / Long Term Care Facility

Current Desired Comments

Cane Weight Capacity

Walker Weight Capacity

Walker Width

Wheelchair Weight Capacity

Wheelchair Width

Power Chair Weight Capacity

Power Chair Width

Crutch Weight Capacity


Transfer Board Weight Capacity

Patient Lift Weight Capacity

Sling Weight Capacity

Transfer Sheet

Stand Assist Lift

Stand Assist Device

Stretcher


Grab Bars

Bath Bench Weight Capacity

Wall Mounted Sink Weight Limit

Toilet Weight Bearing Limit

Toilet Rails/Commode Weight Capacity

Bathtub/Shower Weight Limit


Patient Seating/Chair Weight Limit

Patient Seating/Chair Width

Patient Seating/Chair Seat Height


Dining Chair Weight Capacity

Dining Chair Width

Dining Table Weight Limit

Dining Table Stability

Pathway Around Table Width

Enteral Feeding, Longer Tubes

Dining Facilities

Is your facility ready to accept bariatric patients or residents? Here's a checklist to help you assess your current equipment and

supplies.

Mobility Equipment

Bathroom

Patient Environment

Patient Handling


Bariatric Assessment Forms & Tools



Bariatric Assessment : Homecare / Long Term Care Facility


Bed Hi-Low Height

Bed Weight Capacity

Bed Sleeping Area Width

Bed Sleeping Area Length

Side Rail Weight Capacity

Bed Scale Weight Capacity

Overbed Table Weight Capacity

Pathway Around Bed Width

Dressing Chair Width

Dressing Chair Weight Cap.

Mattress Weight Capacity

Proper Size/Fit Bedding

Pressure Reducing Mattress

Alternating Pressure Mattress


Doorframe Width

Shower Door Width

Hallways/Narrow Passages

Emergency Exit Width

Front Stair/Walkway Width


Large Blood Pressure Cuffs

Scale Weight Limit

CPAP Therapy

Digital Wrist Cuff Monitor

Synchro Pump


Skin Lotions

Powders

Wound Care


Patient Clothing

Towels

Briefs

Sleeping Facilities

Skin Care

Patient Apparel

Monitoring Devices

Entrance, Exit Points

102 Healthy Skin

Forms & Tools Bariatric Assessment


creo


Ultrasorbs® AP Premium DryPads

With Ultrasorbs® AP, you can count on the Power of One:

• One pad for healthy skin: The innovative backsheet allows air to flow through the pad while still acting as a barrier to moisture. The result is optimal skin dryness and comfort.

• One pad for lower cost: Ultrasorbs AP are so strong and absorbent that they eliminate the need for multiple pads.

• One pad for easy care: Can be used on both standard and air-support therapy beds!

To learn more about Ultrasorbs® AP view the online video at www.medline.com/incocare

Soft, non-woven topsheet– softer against skin for increased comfort

Advanced SuperCore® absorbent sheet– thermo-bonded to provide better pad

integrity and superior skin dryness

AquaShield film– traps moisture, providing better

leakage protection

Innovative backsheet– air permeability means better skin comfort

THE ULTIMATE ONE

Join the team!

When it comes to hot topics in long-term care,

you’re the experts!

You, our readers, are on the front lines of everything thathappens in the healthcare industry – and we want to hearfrom you! Have you ever wished you could write anarticle that would be published in a large-circulationmagazine? Nowʼs your chance. Healthy Skin is looking

for writers and contributors. Whether youʼd like to try yourhand at writing or offer suggestions for future articles, wewant to hear what you have to say! You never know – thenext time you open an issue of Healthy Skin, it might beto read your own article!

HEALTHY SKIN

Contact us at [email protected] to learn more!

Content KeyWeʼve coded the articles and information in this magazine to indicate which national quality initiativesthey pertain to. Throughout the publication, when you see these icons youʼll know immediately thatthe subject matter on that page relates to one or more of the following national initiatives:

• QIO – Utilization and Quality Control Peer Review Organization• Advancing Excellence in Americaʼs Nursing Homes

Weʼve tried to include content that clarifies the initiatives or gives you ideas and tools for implement-ing their recommendations. For a summary of each of the above initiatives, see Pages 10 and 11.


creo



Survey Inside

No More Skin Tears

Free CE! Skin Assessment & OASIS-C

BanishBacteria

Exclusive:Diane Krasneron Skin Care At Life’s End


Volume 8, Issue 1

VOLUME 8, ISSUE 1

HEALTHY SKINw

ww

.medline.com

PRESSURE ULCER PREVENTION IN LONG-TERM CARE

Learn more about continuous quality improvement for the prevention of avoidable pres-sure ulcers and F-Tag 314 citations, factors leading to pressure ulcers in long-term carefacilities and comprehensive pressure ulcer prevention strategies and solutions.

Sign up at www.medline.com/PUPP-webinar

M A R C H4th 12:00 pm - 1:00 pm16th 1:00 pm - 2:00 pm24th 11:00 am - 12:00 pm

A P R I L6th 12:00 pm - 1:00 pm15th 1:00 pm - 2:00 pm21st 11:00 am - 12:00 pm

M A Y6th 12:00 pm - 1:00 pm14th 1:00 pm - 2:00 pm20th 11:00 am - 12:00 pm

J U N E3rd 12:00 pm - 1:00 pm10th 1:00 pm - 2:00 pm23rd 11:00 am - 12:00 pm

INNOVATION IN THE PREVENTION OF CAUTI

M A R C H3rd 2:00 pm - 3:00 pm10th 11:00 am - 12:00 pm12th 2:00 pm - 3:00 pm17th 12:00 pm - 1:00 pm24th 12:00 pm - 1:00 pm31th 11:00 am - 12:00 pm

A P R I L6th 2:00 pm - 3:00 pm8th 11:00 am - 12:00 pm13th 12:00 pm - 1:00 pm15th 2:00 pm - 3:00 pm26th 12:00 pm - 1:00 pm28th 11:00 am - 12:00 pm

M A Y5th 12:00 pm - 1:00 pm10th 11:00 am - 12:00 pm11th 2:00 pm - 3:00 pm18th 2:00 pm - 3:00 pm21st 12:00 pm - 1:00 pm24th 11:00 am - 12:00 pm

J U N E7th 11:00 am - 12:00 pm9th 2:00 pm - 3:00 pm11th 12:00 pm - 1:00 pm18th 12:00 pm - 1:00 pm21st 11:00 am - 12:00 pm22nd 2:00 pm - 3:00 pm

Join your colleagues from around the country to learn more about strategies to preventcatheter-acquired urinary tract infections as well as Medline’s ERASE CAUTI system.

Hosted by Connie Yuska, RN, MS, CORLNand Lorri Downs, RN, BSN, MS, CIC

Free WebinarsNew Techniques for Pressure Ulcer Prevention,

Hand Hygiene and CAUTI Prevention

MKT210055/LIT575R/25M/SEL5©2010 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.

M A R C H5th 12:00 pm - 1:00 pm19th 12:00 pm - 1:00 pm

A P R I L2nd 11:00 am - 12:00 pm23rd 11:00 am - 12:00 pm

M A Y14th 11:00 am - 12:00 pm19th 12:00 pm - 1:00 pm

J U N E14th 11:00 am - 12:00 pm17th 12:00 pm - 1:00 pm

As the number one defense against healthcare-acquired conditions, hand hygiene playsan important role in the prevention of infections. Learn how hospitals and healthcarefacilities are combining best-in-class products and education to achieve hand hygienecompliance while dramatically improving the skin condition of healthcare workers.

HAND HYGIENE COMPLIANCE IMPROVEMENT STRATEGIES

Sign up at www.medline.com/handhygiene

Sign up at www.medline.com/erase/webinar.asp


creo