Strategies for Managing Incontinence Challenges and Related Wound Care

Management

Presented by Steve Salomon, RN, MBA

Principle Business Enterprises, Inc.

NASVH Winter Conference 2012

Does the cheapest product give you the best outcome ?

WHO WOULD BUY A TIRE FOR $10 ?...AND IF YOU DID…

WHAT WOULD YOU EXPECT ???

Objectives:

Identify trends in patient population for incontinence issues including obesity.

Understand new regulatory guidelines: Present on Admission (POA).

Impact of new regulations – Present on Admission (Acute Care), F-Tags 314 and 315 – and what this means for LTC.

Understand how Incontinence can impact wound care/ skin care/ slips and falls.

Address new clinical studies to use when implementing an incontinence program and looking at how product selection can impact quality of care.

Understand related costs of care when dealing with a patient with incontinence.

Growth in Aging Population…

1998

Obesity Trends* Among U.S. AdultsBRFSS, 1990, 1998, 2007

(*BMI 30, or about 30 lbs. overweight for 5’4” person)

2007

1990

No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

Overweight and obesity are known risk factors for:

diabetes coronary heart disease high blood cholesterol stroke hypertension gallbladder disease osteoarthritis (degeneration of cartilage and bone of joints) sleep apnea and other breathing problems some forms of cancer (breast, colorectal, endometrial, and kidney) Obesity is also associated with: stress incontinence (urine leakage caused by weak pelvic floor

muscles) psychological disorders, such as depression increased surgical risk increased mortality

Wound Care/ Present on Admission (POA)

POA Indicator General Requirements

Present on admission (POA) is defined as present at the time the order for inpatient admission occurs

– Conditions that develop during an outpatient encounter, including emergency department, observation, or outpatient surgery, are considered POA

POA indicator is assigned to – Principal diagnosis– Secondary diagnoses – External cause of injury codes (Medicare requires reporting only if E-

code is reported as an additional diagnosis)

Present on Admission

Wound CareF-Tag 314

Intent of Tag F314Intent of Tag F314

Predicated on the LTC facility providing adequate Predicated on the LTC facility providing adequate care and services to:care and services to:– Promote the Promote the preventionprevention of pressure ulcer development of pressure ulcer development– Promote the Promote the healinghealing of pressure ulcers that are present of pressure ulcers that are present– Prevent development ofPrevent development of additionaladditional pressure ulcerspressure ulcers– A A “paper trail”“paper trail” can follow intent can follow intent

The “Bottom” Line….The “Bottom” Line….

•The care process should include efforts to stabilize, reduce or remove underlying risk factors •To monitor the impact of the interventions •To modify the interventions as appropriate.

CMS Guidelines

F-Tag 314: AssessmentF-Tag 314: Assessment

Prompt admission evaluation helps identify:Prompt admission evaluation helps identify:– The resident at risk of developing a pressure ulcer The resident at risk of developing a pressure ulcer – The resident with existing pressure ulcersThe resident with existing pressure ulcers– Areas of skin at risk for skin breakdownAreas of skin at risk for skin breakdown– Pre-existing signs of deep tissue damagePre-existing signs of deep tissue damage

F-Tag 314: AssessmentF-Tag 314: Assessment

• Deep Tissue InjuryDeep Tissue Injury– Purple or very dark areas that are surrounded by profound Purple or very dark areas that are surrounded by profound

redness, edema, or induration suggest that deep tissue redness, edema, or induration suggest that deep tissue damage has already occurred and additional deep tissue damage has already occurred and additional deep tissue loss may occur.loss may occur.

F-Tag 314: F-Tag 314: Factors that increase susceptibility to Factors that increase susceptibility to develop or not heal pressure ulcers:develop or not heal pressure ulcers:

– A healed ulcerA healed ulcer History of a healed ulcer is important.History of a healed ulcer is important.

– Areas of healed Stage III or IV pressure ulcers are more Areas of healed Stage III or IV pressure ulcers are more likely to have recurrent breakdown.likely to have recurrent breakdown.

Assess Nutrition StatusAssess Nutrition Status

PreventionPrevention

• Place at risk individuals on a pressure Place at risk individuals on a pressure reduction surfacereduction surface

• Reduce pressure for chair-bound individuals Reduce pressure for chair-bound individuals • Gel or air is more effective than foam Gel or air is more effective than foam • Relieve pressure under heels using pillows Relieve pressure under heels using pillows

or other devicesor other devices• Use incontinence skin barriersUse incontinence skin barriers

Treatment of Pressure UlcersTreatment of Pressure Ulcers

• Reduce friction and shearReduce friction and shear• Reduce/relieve pressureReduce/relieve pressure

• Low air loss/air fluidized may improve healing Low air loss/air fluidized may improve healing ratesrates

• Shift immobile patients in chair every hour and Shift immobile patients in chair every hour and limit out of bed timelimit out of bed time

• Ensure adequate nutritional and fluid intakeEnsure adequate nutritional and fluid intake• Product selection is criticalProduct selection is critical

SummarySummary

Employ Standards of CareEmploy Standards of Care

Communicate to residents, providers, familyCommunicate to residents, providers, family

Demonstrate competencyDemonstrate competency

Treat underlying etiologyTreat underlying etiology

If patient fails 2-4 weeks therapy, consider referralIf patient fails 2-4 weeks therapy, consider referral

Prevention is key –reduce mechanical forces, ensure Prevention is key –reduce mechanical forces, ensure adequate nutrition and hydrationadequate nutrition and hydration

Keep educated on productsKeep educated on products

IncontinenceF-Tag 315

Why did CMS revise the standards ?

F Tag 315 Requirements

Understand how Incontinence can impact wound care/ skin care/ slips

and falls and related risk management…

Incontinence…and it’s Impact on Wound Care…

• Urinary incontinence affects 38% of women and 17% of men age 60 and older. • Perineal skin damage secondary to incontinence has been reported to occur in 31% of acute care patients and 41% of long-term care patients.• Perineal dermatitis has been reported to increase risk for UTIs, microbial skin infections, and pressure ulcers. • Fecal incontinence has been documented as one of the most common risk factors for pressure ulcer development.

Slips and Falls…

Slips and Falls…

According to the American Academy of Orthopedic Surgeons:

30% of all people over the age of 65 fall each year.

50% of older adults hospitalized with a hip fracture are unable to return home or live independently again.

      

Slips and Falls…

In 2003, 1.5 million people 65 and older lived in nursing homes. If current rates continue, by 2030 this number will rise to about 3 million.

About 5% of adults 65 and older live in nursing homes, but nursing home residents account for about 20% of deaths from falls in this age group.

Each year, a typical nursing home with 100 beds reports 100 to 200 falls. Many falls go unreported.

As many as 3 out of 4 nursing home residents fall each year. That’s twice the rate of falls for older adults living in the community.

Patients often fall more than once. The average is 2.6 falls per person per year.

About 35% of fall injuries occur among residents who cannot walk.

Prevent Falls with a good Exercise Program….

Slips and Falls

Understand related costs of care when dealing with a patient with

incontinence and it’s impact on wound care

Cost of Care…

% of the population with UI & OAB

Over 200 Million dollars in expense due to Skin Irritation, UTI and Falls because of UI and OAB…

Address new clinical studies to use when implementing an incontinence program and

looking at how product selection can impact quality of care…

Associated costs of care…The Iceberg Theory…

Dressings/ Tape ? Gloves ? Skin Breakdown ? Creams/ Lotions ? Pain Medications ? Sleep Medications ? Reporting/ Legal ? Physician/ Hospital ? Rest/ Sleep through the night ? Patient Dignity ? Caregiver time ? Product Cost/ Frequency of Care Linen and Trash ?

Linking Incontinence with Wound Care…

New studies completed New studies in progress Collaboration between wound and skin care

clinicians

Looking at Skin Barrier Function…

Objectives:

Identify trends in patient population for incontinence issues including obesity.

Understand new regulatory guidelines: Present on Admission (POA).

Impact of new regulations – Present on Admission (Acute Care), F-Tags 314 and 315 – and what this means for LTC.

Understand how Incontinence can impact wound care/ skin care/ slips and falls.

Address new clinical studies to use when implementing an incontinence program and looking at how product selection can impact quality of care.

Understand related costs of care when dealing with a patient with incontinence.

Contact Information…

Steve Salomon, RN, MBA

305 South Ladd Court

Daniel Island, SC 29492

843-737-1053

ssalomon@pbenet.com