healthy skin magazine - volume 5; issue 3

PreventingPneumoniain the ElderlyPopulation

PressureUlcer RiskAssessment

FREE CE!PAGE 18

PalliativeWoundCareNever Say “Zero”

Improving Quality of Care Based on CMS Guidelines

Volume 5, Issue 3

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HEALTHY SKIN

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

© 2008 Medline Industries, Inc. Healthy Skin is published by Medline Indus-tries, Inc. One Medline Place, Mundelein, IL 60060. 1-800-MEDLINE.

Meeting the highest level of national and international quality standards,Medline is FDA QSR compliant and ISO 13485 certified. Medlineserves on major industry quality committees to develop guidelinesand standards for medical product use including the FDA MidwestSteering Committee, AAMI Sterilization and Packaging Committeeand various ASTM committees. For more information on Medline,visit our Web site, www.medline.com.

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Improving Quality of Care Based on CMS Guidelines 3

6

Page 40

Page 34

Page 48

Survey Readiness11 Five Things You Need to Know about the New Quality

Indicator Survey (QIS)12 Why is Pressure Ulcer Risk Assessment So Important?62 Extreme Bathroom Makeover: Resident Safety Edition

Prevention20 Weʼre Spotting a Nationwide Trend24 A Focus on Prevention43 The Transfer Challenge48 Infection Control: Pneumonia53 Recommendations on Infection Prevention in Long-Term Care

Treatment30 When Negative is Positive36 Palliative Wound Care40 End-of-Life Care for Residents and Their Families46 Case Study: Debridement, Pain and Odor Control Using

a Hydrogel with a Superabsorbent Polymer Core Dressing54 Culture Change In Briefs57 Say Goodbye to Soap and Water61 10 Tips to Create a More Enjoyable Resident Dining Experience

Special Features5 Medline Announces Prevention Above All Discoveries Grant

28 Incorporating a Magnet Approach in Wound Care34 Special Guest Editorial: Never Say “Never,” Never Say

“Always,” Never Say “Zero”59 Bathing the Elderly with Dignity64 How to Thrive in a Tough Economy70 Why Canʼt We All Just Get Along?75 Medline Supports Breast Cancer Awareness 365 Days a Year

Regular Features6 Two Important National Initiatives for Improving Quality of Care

18 CE-Credit Crossword Puzzle: Why is Pressure Ulcer RiskAssessment So Important?

Caring for Yourself74 Building Unshakable Self-Confidence76 Recipe: Guacamole

Forms & Tools79 Pressure Ulcer Prevention Policy and Procedure84 Predicting Pressure Ulcer Risk86 Infection Control Activities and Their Relevance to

Pneumonia in LTC

HEALTHY SKIN

EditorSue MacInnes, RD, LD

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

Managing EditorAlecia Cooper, RN, BS, MBA, CNOR

Contributing EditorAndy J. Mills, MBA

Art DirectorMike Gotti

Copy EditorLaura Kuhn

Clinical TeamCynthia A. Fleck, RN, BSN, CWS, DAPWCA, MBA,FACCWSJanet L. Jones, RN, BSN, PHN, CWOCN,DAPWCAJoyce Norman, RN, BSN, CWOCN, DAPWCAElizabeth OʼConnell-Gifford, RN, BSN,CWOCN, DAPWCA, MBAAmin Setoodeh, BSN, RNDeb Tenge, RNC, MS, CWOCN,Licensed AdministratorJackie Todd, RN, BSN, CWCN, DAPWCA

Wound Care Advisory Board

Janie Arndt, MS, RN, CWOCN, CNS-BCAnn Blackett, MS, AP RN-BC, CNS, CWOCNMary R. Brennan, RN, MBA, CWONPatricia Coutts, RNPat Emmons, RN, MSN, CNS, CWOCNDawn R. Fortna, RN, BSPA, MSEd, CDE, CWOCNEvonne Fowler, RN, CNS, CWOCNLynne Grant, MS, RN, CWOCNDea J. Kent, RN, MSN, NP-C, CWOCNDiane Krasner, PhD, RN, CWCN, CWS,BCLNC, FAANAndrea McIntosh, RN, BSN, CWOCN, APNCathy Milne, MSN, APRN, CWOCN, CS, ANPLinda Neiswender, RN, BSN, CPNAnn H. Poplin, RN, MSN, FNP-C, CWOCNLynne Whitney-Caglia, RN, MSN, CNS, CWOCNLaurel Wiersema-Bryant, RN, BSN, BC, ANPLinda Woodward, RN, BSN, OCN, CWOCN

Improving Quality of Care Based on CMS Guidelines

Page 12

”

Dear Reader,Solutions. Thatʼs what everyone wants. How oftendo you hear “Donʼt keep telling me about the prob-lems if you canʼt suggest some solutions”?

I just went to a conference where an excellent groupof speakers laid out new regulations, discussedchanges in reimbursement, changes in healthcarepolicy, risk factors, economics, you name it. I endedup exhausted – and I had a really big headache.Then, I went back to work. I was welcomed with allthe problems that I had missed while I was out at themeeting. Sound familiar?

Letʼs make our lives easier. Itʼs time to share. Itʼs timeto learn from each other, provide support for eachother and focus on whatʼs really important: providingour residents with the best health care possible. Weʼrelucky to be a part of the changes that are taking placein every facet of health care. I can clearly see that thenext trend will be meetings not restricted by specialties,but crossing over the lines of hospital, nursing homeand home care to health care for the patient…patient-centered health care.

In this edition of Healthy Skin, there will be somecrossover of information by providers. Many of thearticles are long-term care focused and some are hos-pital-focused. Why? Because the concerns we all facewith quality are even more of a concern as the patientmoves from one setting to another. Letʼs take pres-sure ulcers. How much clearer can CMS get than the9th Scope of Work, released August 1, 2008 (seePage 6)? Pressure ulcers are one of the patient safetythemes for Quality Improvement Organizations. Pressureulcers are being considered a community problemand so the QIOs will be looking at nursing homes witha high incidence of pressure ulcers AND the corre-sponding hospitals in the same county. Why?Because the data supplied by the nursing home MDSand the data supplied by the hospital Present onAdmission Indicator is going to find the source ofpressure ulcers.

Now more than ever, communication between health-care settings is important. We can help each other bysharing what weʼve learned, communicating with eachother. Quality improvement can be a whole lot easierwith a team approach inside and outside of our corebusiness.

Please read about new nursing home initiatives, withthe Quality Indicator Survey that is currently beingrolled out in nine states with more soon to follow(Page 11). Learn about the importance of pressureulcer risk assessment, follow a patient from thehospital to the nursing home and learn along the way(1 CE credit available), on Page 12. To understandthe patient as an individual, we need to understandand know when to implement a palliative wound careplan (Page 36).

As we continue to learn about each other and shareideas, keep this in mind – one thing that will neverchange is our desire to hear from you, our readers.Weʼre always interested in knowing what you likeabout Healthy Skin, what you want to see more of orif you have an interesting story to share. Just send anemail to [email protected] and tell us whatʼson your mind.

Finally, one important opportunity that we hope eachand every one of you will consider: Medlineʼs Pre-vention Above All Discoveries Grant. Please take alook at Page 5 for more details. We look forward tohearing from you.

Sincerely,

Sue MacInnes, RD, LDEditor

4 Healthy Skin

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 give you ideas and tools for implement-ing their recommendations. For a summary of each of the above initiatives, see Pages 6 and 7.

“Now morethan ever,communicationbetween health-care settings isimportant.

Healthy Skin Letter from the Editor


Special Feature

Medline is proud to announce the creation of thePrevention Above All Discoveries Grant. Be sure tocheck out future editions of Healthy Skin for more detailson this exciting opportunity! To request additional information,please visit www.medline.com/special/paa/contact.asp.

Program outlineFocus

• To provide new intelligence and guiding knowledge tohealthcare institutions on successful targeted interven-tions that show evidence of reducing medical errors,risks, hazards and harms associated with healthcare-acquired conditions (identified by CMS in 2008IPPS rule).

• The results from these grants will inform providers,payers, policy makers and the public about howtargeted, evidenced-based interventions can:

– be successfully implemented in healthcare settings– lead to safer, better care for patients– reduce cost to the healthcare system

Objectives• Stimulate research that will increase the adoption of

evidence-based solutions into clinical practice to reducehospital-acquired conditions.

• Disseminate practical solutions to healthcare providersleading to a reduction in hospital acquired conditions

Award detail• Medline intends to commit up to $1 million in total costs

over several years to fund new grants focused on thehospital-acquired conditions that CMS has targeted.Grants can be pilot work to develop or apply solutionsto reducing HACs, or more rigorous empirical studies totest solutions on a larger scale. In either case, monitoringthe impacts of the intervention is essential. The granteeshould indicate whether they are submitting a pilot grantor an empirical study.

• Annually we will select qualified grant recipients to beawarded up to $25,000 each for pilot grants or

$100,000 each for an empirical study. We expect thatsome grantees will receive a pilot grant first todevelop/apply a solution in a feasibility study and thenapply for a larger grant to conduct an empirical studybased on the pilot grant. Others may just conduct a pilotgrant, and others who have already pilot tested asolution may apply for an empirical study as longas they present evidence from their pilot work.

• Because the nature and scope of the projects will varyfrom application to application, it is anticipated that thesize and duration of each award will also vary. Accord-ingly, funding will be dispersed in a tiered schedulebased on project durations and milestones.

• Grants will be awarded and funded in 2009 in severalareas – pressure ulcers, hand hygiene compliance,retained surgical objects, catheter-associated urinarytract infection, surgical site infection and other pertinentsafety and quality areas.

• An independent Review Panel, whose membersrepresent a breadth of research and practiceknowledge, will evaluate and score each application.The panel will consist of a multi-disciplinary team ofdistinguished representatives from academia, healthcareinstitutions and public and private organizations.

2008-2009 Grant program scheduleAugust 18, 2008: Program creation announced at

Prevention Above All conferenceNovember 1, 2008: Request for proposals announcedJanuary 5, 2009: Letters of intent dueFebruary 1, 2009: Notification, request for full proposalsApril 15, 2009: Full proposals dueJune 1, 2009: Notification of awards

Medline AnnouncesPrevention Above All

Discoveries Grant

6 Healthy Skin

Two Important National Initiativesfor Improving Quality of Care

Achieving better outcomes starts with an understanding of current qualityof 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. Thecontent 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. Reviews will focus on improvingcoordination across the continuum of care and evaluations of performance will include the contract, the programand the attribution of success to QIO interventions.

Quality Improvement Organization Program’s 9th Scope of Work ThemeThe 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 homeresidents and staff. The coalition has continued the campaign beyond its first-round end of August 25, 2008 for anadditional 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 existingquality 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 satisfactionsurveys into continuing quality improvements and increase staff retention to allow for better, more consistentcare 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 ExcellenceThe 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 Organization9th Round Statement of Work1

Advancing Excellence in America’s Nursing Homes2

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: 70.2% Goal 5: 31.7%

Goal 2: 44.8% Goal 6: 63.3%

Goal 3: 54.4% Goal 7: 40.9%

Goal 4: 39.4% Goal 8: 31.4%

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 ProtectionActivities 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: Care TransitionsActivities will focus on three Tasks:1. Community and provider selection and recruitment2. Interventions3. Monitoring

Theme #3: Patient SafetyActivities 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 homes

4. Improving inpatient surgical safety and heart failuretreatment in hospitals

5. Improving drug safety6. Providing quality improvement technical assistance to

nursing homes in need

Theme #4: PreventionActivities 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

The 9th Scope of Work Content Themes

Clinical Goals:Goal 1: Reducing high-risk pressure ulcersGoal 2: Reducing the use of daily physical restraintsGoal 3: Improving pain management for longer-term

nursing home residentsGoal 4: Improving pain management for short-stay,

post-acute nursing home residents

Operational/Process Goals:Goal 5: Establishing individual targets for

improving qualityGoal 6: Assessing resident and family satisfaction

with quality of careGoal 7: Increasing staff retentionGoal 8: Improving consistent assignment of nursing

home staff so that residents receive carefrom the same caregivers

Clinical and Operational/Process Goals

Participating nursing homes: 7,005Percentage of participating nursing homes*: 44.4%Participating consumers: 1,636

Represents a 4% increase inparticipation since January 2008.

Regular Feature


A CDC Resource for Battling Bugs in Long-Term Care

Maybe you read about the CDCʼs Campaign to PreventAntimicrobial Resistance in Healthcare Settings when it waslaunched in 2002. Almost six years later, the campaignʼsgoals are just as relevant as ever. Why not brush up on thecampaignʼs goals and explore its resources?

The campaign has four central goals: prevent infection, diagnoseand treat infection, use antimicrobials wisely and prevent trans-mission.1 To help meet these goals, the CDC offers specific toolsfor clinicians who treat hospitalized adults, dialysis patients,surgical patients, hospitalized children and long-term care residents.1

The CDC lists the following as basic steps that can be taken tohelp prevent infections and antimicrobial resistance amongnursing home residents1:

• Plan and implement influenza and pneumococcal vaccinecampaigns to prevent pneumonia.

• Use indwelling catheters only when necessary and followappropriate insertion techniques to reduce urinarytract infections.

• Reposition residents frequently and inspect pressure pointsfor redness or skin irritation to prevent pressure ulcers.

• Use recommended infection control precautions to preventtransmission of infectious agents from resident to resident.

• Practice hand hygiene and promote hand hygiene amongresidents and visitors.

For more information on the campaign, visithttp://www.cdc.gov/DRUGRESISTANCE/healthcare/default.htm.

Reference1 Centers for Disease Control land Prevention. Campaign to Prevent AntimicrobialResistance in Healthcare Settings. Available at: http://www.cdc.gov/DRUGRESIS-TANCE/healthcare/default.htm. Accessed August 7, 2008.

The Results are In!

We at Healthy Skin would like to thank the 310 of you whotook the time to complete our online readership survey!Weʼve learned a lot from what you had to say, and we wantedto share some of the results with you!

We were thrilled to see that 97 percent of you rated the rele-vance of the topics covered in Healthy Skin as “excellent” or“good.” Ninety-two percent of you gave the same ratings to theeducational opportunities provided in the magazine, and 93percent of you find the information in the magazine to be useful.

Weʼve learned that Treatment is the most-read section ofHealthy Skin, with 77 percent of you reading articles in thatsection. Seventy-one percent of you read Special Features, 55percent read Forms & Tools and 51 percent check out SurveyReadiness.

The last question we asked you was about your facilityʼs priorities.Hereʼs how you responded when asked if the following areaswere important to your facilities.Prevention: 83 percentSafety: 77 percentReimbursement: 54 percentEducation: 53 percent

Thanks again for your participation! We will use what we havelearned from you as we continue to create future editions ofHealthy Skin!

News Flash

©2008 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.

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Even if your state isn’t currently implementing the QIS,

the drill-down capabilities of abaqis® provide root cause

analysis on both a facility-wide and individual resident

basis, showing where you should focus your efforts for

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abaqis® is the only quality assessment and reporting

system for nursing homes tied directly to the QIS. It was

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That gives you a unique advantage in preparing for your

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

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a


By Andrew Kramer, MD

1. QIS is comingCurrently, there are nine states in the training program forstatewide rollout of the Quality Indicator Survey process.These are Connecticut, Florida, Ohio, Kansas, Louisiana,Minnesota, North Carolina, New Mexico and West Virginia.Two more states will be added by mid-2009. CMS has sent arequest for applications from other states to see who will benext as they roll QIS out nationwide over the next severalyears. For a brief overview of QIS and the QIS trainingprocess, go to www.cms.hhs.gov/SurveyCertificationGen-Info/downloads/SCLetter08-21.pdf.

2. QIS is based on researchThe methods used in QIS were developed at the University ofColorado in the early 1990s as a research protocol for evalu-ating the quality of life and quality of care provided to nursinghome residents. Under CMS contract, these methods wereadapted as the basis of the QIS process, making the surveyboth more objective and based on scientific methodology.Following a demonstration of this approach, CMS decided toimplement QIS nationwide.

3. QIS is more replicable and predictablethan the traditional survey

Larger, statistically valid samples of residents are reviewed inorder to obtain a more complete view of care in the facility.These random samples are taken from census residents, newadmissions and MDS data. Surveyors follow structuredprotocols that include scripted questions to ask of residents,family and staff. In comparison to the traditional surveyprocess, resident interviews, resident observation and familyinterviews make up a much larger portion of the revisedsurvey process.

4. QIS is technology-basedSurveyors are using sophisticated computer software sup-porting a very structured process. The software guides thesurveyor, provides a unified platform regardless of the state orthe individual surveyor, calculates the data and identifiestriggers of potential noncompliance based upon predeter-mined thresholds. Those triggers set the wheels in motion fora Stage 2 in-depth investigation process. The nursing homesurvey readiness goal is to know their areas of risk prior tothe survey process and work on continuous improvements toreduce or eliminate triggers for a Stage 2 investigation.

5. Providers have found that theQIS tools can be used for QA

By obtaining training in the QIS methods and using the QISapproach, nursing home staff have successfully used the QISprocess to assess the quality of care and quality of life of theirresidents in accordance with the federal code of regulations.They have found that using the QIS process year-round forQA not only helps to improve care, but also prepares them forthe survey continuously without mock surveys. For moreinformation, contact your state healthcare association or go towww.nursinghomequality.com.

Over the last several years, CMS has been developing andtesting a new revised survey process for long-term carecalled the Quality Indicator Survey, or QIS. This is one morestep to improve the quality of care and provide a more resident-centered focus. It is a federally approved survey process beingused by state surveyors and CMS regional offices. There iswidespread discussion and some confusion about this new survey.Here are five things you need to know about QIS:

5THINGS YOU

NEED TO KNOW

ABOUT THE NEW

QUALITY INDICATOR

SURVEY (QIS)

About the authorAndrew Kramer, MD is Head of theDepartment of Medicineʼs Health CarePolicy and Research Division at theUniversity of Colorado and the firstrecipient of the Peter W. ShaughnessyEndowed Chair in Health Care Policy. Hisresearch interests focus on strategies forimproving care provided to frail olderadults across the healthcare continuum.

He has authored more than 90 publications and pol icyreports, is a frequent advisor to the Centers for Medicare& Medicaid Services, Office of the Assistant Secretary forPlanning and Evaluation, Senate Committee on Aging andthe Institute of Medicine.

Survey Readiness

12 Healthy Skin

Why isPressure Ulcer

Risk AssessmentSo Important?

Letʼs examine what a resident and nursing student have to say!By Alecia Cooper, RN, BS, MBA, CNOR

My name is Euretha and I have a story to tell you. I think itcould help folks like you who work in nursing homes and hos-pitals alike. My granddaughter is studying to become a nurseand she thinks what she and I have learned about my experi-ence can help everyone. So I agreed to help.

I am 79 years old and have been in pretty good health all of mylife until I started getting feeble these last few months. Sincethe passing of Theodore, my beloved husband, three years

ago this past September, I have livedalone and got along pretty well caringfor myself. But as of late, I have beengetting “blue” more often than not. Idonʼt have much of an appetite and I canʼt get around as wellas before. I become dizzy in the early mornings and I havetaken a fall several times. Most of my friends are either too sickto get out much or they have passed on. These days, I just donot have many folks to talk to or visit with.

About 70 percent ofall pressure ulcersoccur in people 70years and older.1

argue with him. June and the kids found me a good spot, closeto our home, and we all agreed this would only be for a littlewhile. Also, June told me she would have my house painted andthe floors redone while I was gone, so it would be in mintcondition when I returned.

On September 1, I went tostay at Happy Valley NursingHome for what I thought wasonly temporary, no more thana couple of months. Today isThanksgiving Day and I hopethe kids get here soon as I just cannot bear the thought of beingaway from home on my favorite holiday. As hard as I triedto persuade him otherwise, Dr. Hill said I am not ready to leaveyet. You see, what I have not told you yet is that I had one ofthose dizzy spells 14 days after I came to Happy Valley.

It was early that morning when I got out of bed to go to the bath-room. I lost my footing, slipped and fell hard on my right hip andit broke. We were not sure it was broken at first, but once I gotto the hospital, they were sure. I had surgery and a stay at thehospital and then came backto Happy Valley with thisdoggone bedsore on myother hip. It is not healing toowell. In fact, it just keeps get-ting worse. Those “blue”days have just been gettingworse. I thought I would cryall day when Dr. Hill let meknow that he now thinks thatthis bedsore could beinfected. But remember howI told you my family always comes through?

This whole situation worried my poor granddaughter to death, soshe talked to one of hernursing instructors whogave her an idea for aschool research project.Andyou know what that sweetthing did? She said sheneeded my help. Imaginethat. I get to help her figure out what could have prevented mybedsore from developing after I broke my hip.

I asked her how could I possibly help, and she told me that weneeded to go through every event from the time my injuryoccurred until the bedsore developed. She explained that shewould take every part of the story and research the preventionmeasures that, if they had been done, might have prevented thatbedsore from developing. To prove her point, she brought me anarticle to read that she found in one of her nursing journals. Thatarticle said that the experts say bedsores can be prevented in


Survey Readiness

About 1.5 million Americansreside in the nationʼs 16,400nursing homes on anygiven day. 2

Confinement to a bed or chairfor a week has been found toincrease the prevalence of pres-sure ulceration by 28 percent.5

Why is pressure ulcer riskassessment so important?Because it helps identify whichpatients or residents may benefitmost from preventable measures.3

The best way to prevent pressureulcers may be through the use ofevidence based of pressure ulcerrisk assessment tools.4

Then things got worse. I tripped walking back from the mailboxa few months back and skinned my arm, my nose and bruisedmy left hip. My whole body was bruised up pretty bad. Mydaughter June insisted that I go see my doctor, Dr. Hill. I havebeen cared for by Dr. Hill for more than 30 years and pretty muchthink he is one of the smartest doctors I know of, so when he toldme that he thought it was time for me to go live in a nursinghome, only for a while, so I could get stronger, eat better andfind out what was causing all these dizzy spells, I didnʼt much

Continued on Page 15


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most cases. If all this is true, then I think we need to all worktogether to prevent them from happening. Oh, I know that mis-takes can happen unintentionally. People can forget when theyare working so hard, under stressful situations, but letʼs find outwhat we can do to keep bad things from happening. Lord knowsI have nothing better to do to occupy my time these days. Hereʼsa look back at what was going on when that bedsore developed.

September 15, 20075:47 a.m.I remember that I had tossedand turned all night, and eventhough I was still so tired, Ijust could not fall back tosleep no matter how hard Itried. So I got up to use thebathroom and fix my den-tures so I could go to break-fast. Maybe I got up too fast, or I was dizzy for some reason, butas soon as my feet hit the floor, I slipped and fell hard on myright hip. I think I remember hearing something snap, but I wasnot certain. I yelled for help and that nice girl Sheila ran in andfound me lying on the floor. She told me not to move if possibleand she quickly ran to get some help. The head nurse came inand they got me stretched out as best they could and said theycalled my doctor and an ambulance was on the way to comeget me and take me to Mercy Medical Center so I could bechecked out.

7:46 a.m.The ambulance comes totake me to the hospital (1 hrand 59 minutes after theincident occurred). I lookedat the very small stretcher with that tiny mattress – I donʼt thinkit could have been more than one or two inches thick – and wor-ried how they were ever going to get me on and off that safely,but they did. And trust me, it was one of the most uncomfortablebeds that I have ever laid on. They strapped me in and got meinto the ambulance. I was in so much pain, but the emergencymedical personnel told me they could not give me anything todull it until I was checked out at the hospital. I could not evenhave anything to drink. I think that was the worst part, but theysaid if I needed to have surgery it could hurt me.

8:37 a.m.I am rolled off the ambulanceand rolled into the hospitalʼsemergency room. Finally,after some confusion, I ammoved from that tinystretcher to a bigger bed thatwas a little wider, but that mattress was not much better than theone before. They nurses and doctors told me that I had to lie stillwhile they checked me out, otherwise I might further injure my

hip. For what seemed like forever, they checked me out. Thenthey told me they had called Dr. Hill and that he was on his way,but had given them orders over the phone for me to have anEKG, a chest X-ray and an X-ray of my hip. Also, June and thekids had arrived by now and they let June come back to sitwith me for a while until it was time for me to go to theX-ray department.

For consideration:1. Was a pressure ulcer risk and skin assessment

performed and documented on admissionto the nursing home?

2. Was an admission pressure ulcer risk and skinassessment performed, documented and comparedto the assessment performed at the nursing home?

9:57 a.m.I am rolled down the hallwayto the X-ray department forthe X-rays that Dr. Hillordered. The boys moved me from my stretcher to a very hardand very cold table in a darkened room. A very nice lady camein and explained what was going to happen. Pictures were takenof my chest and hip and then those sweet boys came back andmoved me off that hard table and back to that uncomfortablestretcher and I was rolled back to the emergency room. When Igot back, Dr. Hill was waiting on me and the first thing I asked forwas a drink of water as I was so parched. I remembered that Ihad not had anything to drink since before 8 p.m. the night be-fore and nothing at all to eat since dinner. He said he knew thatI was dry, but it was unsafe to give me anything to drink until weknew whether I needed surgery. I asked if they could pleasehurry and find out.

Nurses need more education8:• Risk assessment (interpretation of Braden scale)• Pressure ulcer staging• Proper positioning (including bed and chair)• Effects of moisture on the skin (including incontinence,

humidity and maceration)• Pressure relieving products• Proper application and usage of prevention products

11:02 a.m.The nurse comes in to tell me that the X-rays show that my righthip was indeed broken and that the surgeon, a Dr. Cloud, or oneof his assistants would be here soon to discuss the plan for sur-gery with me. I was getting so tired of just laying in one spot forso many hours, but she explained to me that they had to keep mybody straight so I did not injure my hip more. I asked her whattime it was, and when she said 11:02, I realized that it had beenover six hours since I fell and that I had been in one position foras many hours. No wonder I was getting so stiff. If I could haveonly turned over and had a glass of water.

23.9 percent of residentsin long-term care developpressure ulcers at somepoint.1

A resident is most likely todevelop a pressure ulcerduring the first four weeksafter admission.6

Pressure ulcer incidence isover 60 percent for high-riskpatients with femoral fracturesand/or hip fractures.1

70 percent of nurses considertheir basic wound educationto be insufficient.8

Pressure ulcers are definedas areas of localized damageto the skin and underlyingtissue caused by pressure,shear, or friction.7

16 Healthy Skin

For consideration:1. Did the stretchers pads used in the ambulance

and in the emergency room have pressureredistribution capability?

2. Were pressure-relieving devices used to frequentlyreposition the patient?

11:35 a.m.Dr. Cloud comes in, intro-duces himself and explainsthat I need to have surgery.He was dressed in whatlooked like pajamas with awhite coat and a blue cap.He told me that he had beenin surgery all morning andthat he had one more proce-dure to finish and then hewould be able to get me all fixed up. I told him how sore I wasand how much pain that hip was giving me, so he told the nurseto give me a shot for pain and that he would go ahead and haveme moved to the surgery holding area, where they could get meready for surgery. About 20 minutes later, a boy who wasdressed like Dr. Cloud came in and told me he was there to rollme up stairs to where the Surgery Department was located. Isaid my goodbyes to June and the kids and they told me not toworry, that I was going to be fine. I told them I knew that, I justwanted to get this over with.

1:08 p.m.I am finally being rolled back to the operating room to get thisold hip fixed. They started an IV in the holding area and gaveme some medicine that was making me very drowsy. I nowhad on one of those blue hats, too. They moved me over toa table that looked just as uncomfortable as that gurney I hadbeen lying on for the past five or six hours. After that, I donʼtremember much, so I have to turn the story over to my grand-daughter to explain what happened in surgery.

For consideration:1. Each time the patient was moved from stretcher

to stretcher and table to table, were the staff welltrained in transfer and positioning techniquesthat reduce friction and shear?

Granny was positioned onher left hip, prepped anddraped with a full-body drapeand only her right hipexposed to the operative field. The procedure started at 1:45p.m. and was completed at 3:30 pm., lasting one hour and forty-five minutes. During the surgery, Granny has some reason-able blood loss and the hip was irrigated with antibiotic fluid. At3:45 p.m., after an immobilizer was positioned between her legs

to keep her in proper body alignment, she was rolled onto herbed and taken to the recovery room, where she remained fortwo hours until she was stable enough to be taken back to herown room. Iʼll let Granny tell you how she was feeling when shegot out of surgery.

For consideration:1. Was the OR table pad a pressure redistribution pad?2. Were all bony prominences and pressure points

padded appropriately to minimize pressure that mightoccur during a surgical procedure?

6:00 p.m.June and the kids were all waiting for me when I got to my room.There was a pitcher of water waiting and that was the first thingI wanted – a cold drink. My nurse for the evening came in and in-troduced herself and checked me out. They gave me some brothto eat a little later. My hip was beginning to hurt again, so theygave me some more pain medicine and I drifted back to sleep.I guess I was really tired because I slept more that evening thanI had in weeks. I woke up a few times during the night andneeded some more pain medicine, but then I went right backto sleep.

For consideration:1. Was the patientʼs skin thoroughly cleansed and

inspected after surgery before leaving the operatingroom to ensure that there was no pooled blood or prepsolutions under bony prominences?

September 16, 20077:00 a.m.Breakfast arrives and I am awake and ready to eat. Soon after-ward, the day shift nurse comes in and says she has to check meout head to toe. In doing so, she finds a big red mark on my lefthip and asked me if it hadbeen there before I arrived atthe hospital. I told her it had-nʼt been as far as I knew, butthat I had been falling easilyand bumping into things so itwas possible that I was thereand I didnʼt know it. Therewas still some paint from sur-gery and a few blood spotson my skin, so she got somesoap and water and cleanedme up real good. My grand-daughter can tell you whatcame out of all of this.

Common factors thatincrease the risk fordeveloping pressure ulcersinclude immobility, circulatoryproblems, infections,incontinence, passivityand decrease inconsciousness.

The greatest incidence ofnew-onset postoperativepressure ulcers for elderlypatients with hip fracturesoccur within the first twopostoperative days.5

Studies suggest pressurewounds occur within the firsttwo days after the insult andthat wounds occurring beyondthis time frame are caused bycontinuous soft tissue insultsin high-risk populations (thesemay go undetected for asmany as seven days).5

Pressure ulcers can developwithin two to six hours of theonset of pressure.1


For consideration:1. Should soap and water be used to cleanse patients

at high risk for development of pressure ulcers?

By now, you must know the rest of the story. Granny was in thehospital for five days after surgery and then returned to HappyValley Nursing Home. Thereddened area eventuallydeveloped into a Stage IIIpressure ulcer that is now in-fected. From my research,we have developed a proto-col for the prevention ofpressure ulcers that includes a community effort between thenursing home and acute-care facility to prevent facility-acquiredpressure ulcers. In Grannyʼs case, the ulcer could have devel-oped due to pressure, moisture, friction, shear, poor nutri-tion, tissue injury or tearing, but most likely from a combinationof all of these factors. Not all pressure ulcers are avoidable, butmany are. I encourage you to work closely within your medicalcommunity to make sure your pressure ulcer prevention meas-ures and protocols are up to date and that everyone is fullytrained to execute them appropriately.

Critical stepsCritical steps in pressure ulcer prevention and healing include8:

• Identifying the individual resident at risk fordeveloping pressure ulcers

• Identifying and evaluating the risk factors andchanges in the residentʼs condition

• Identifying and evaluating factors that can beremoved or modified

• Implementing individualized interventions to attemptto stabilize, reduce or remove underlying risk factors

• Monitoring the impact of the interventions• Modifying the interventions as appropriate

Avoidable vs. unavoidable pressure ulcersA pressure ulcer is avoidable if the facility did not do one ormore of the following9:

• Evaluate clinical condition and risk factors• Define/implement interventions consistent with

resident goals/standards of practice• Monitor/evaluate impact of interventions• Revise interventions

A pressure ulcer is unavoidable if it develops even though thefacility did all of the above.9

Risk factorsRisk factors for pressure ulcer development include8:

• Impaired/decreased mobility• Decreased functional ability• Co-morbid conditions

• Drugs that may affect wound healing• Impaired diffuse or localized blood flow• Resident refusal of some aspect of care and treatment• Cognitive impairment• Exposure of skin to urinary or fecal incontinence• Under-nutrition, malnutrition and hydration deficits• History of a healed ulcer

For Happy Valley NursingHome, they not only had toprovide care for Eurethaʼsmending hip, they also had todeal with her facility-acquiredpressure ulcer that hadbecome infected. Eurethawas now a much more com-plex resident with a much higher acuity, requiring more resourcesand services to be provided and at a higher cost burden for boththe payer and the provider. Added on top of this is the at-riskcondition for the development of additional complications, suchas additional pressure ulcers, deep vein thrombosis, pulmonaryembolism and additional infections.

Prevention is paramount. It begins with proper risk and skinassessment, combined with proper prevention measures(including the appropriate prevention products). The cement thatholds it all together is proper education and training of personnelacross the complete continuum of health care, including the com-munity of nursing homes, hospitals and emergency medicalprofessionals.

Refer to the Forms & Tools section, Pages 77 to 87, to learnmore about how you can prevent pressure ulcers at your facility.

This story is a fictional account based on the real-life experiencesof the author.

References1 Medical News Today. Clinical Trial Shows 96% Improvement In Pressure Ulcer HealingAmong Nursing Home Residents. Available at:http://www.medicalnewstoday.com/articles/39327.php. Accessed September 3, 2008.2 U.S. Department of Health & Human Services. CMSʼ Oversight of Nursing Homes: TheSpecial Focus Facility & Other Programs to Address Troubled Nursing Homes. Available at:http://www.hhs.gov/asl/testify/2007/11/t20071115d.html. Accessed September 3, 2008.3 Ayello E, Braden B. Why is pressure ulcer risk assessment so important? Nursing.2001;31(11):74-80.4 Walsh K, Bennett G. Pressure ulcers as indicators of neglect. Nursing & Residential Care.2000;2(11):536-539.5 Maklebust J. Pressure ulcers: The great insult. Nursing Clinics of North America.2005;40(2):365-389.6 LEEDer Group Inc. F-Tag 314: Making It Stick! Available at: http://leedergroup.com/bul-letins/f-tag-314. Accessed September 3, 2008.7 Lepisto M, Eriksson E, Hietanen H, Lepisto J, Lauri, S. Developing a pressure ulcer riskassessment scale for patients in long-term care. Ostomy/Wound Management.2007;53(10):34-38.8 Zulkowski K, Ayello E, Wexler S. Certification and education: Do they affect pressure ulcerknowledge in nursing? Advances in Skin & Wound Care. 2007;20(1):34-38.9 Ayello E. Pressure Ulcers as Quality Indicators: Risk and Liability. Presented at November2006 Canadian Association of Wound Care Conference.

When a Stage I pressureulcer develops, the risk foradditional ulcers on thesame individual is reportedto increase tenfold.5

All members of the healthcareteam need to know theirresponsibilities and how theirtasks relate to each other inthe prevention and manage-ment of pressure ulcers.

18 Healthy Skin

Why is Pressure Ulcer RiskAssessment So Important?

CE Credit Crossword Puzzle

Across4 Prevention includes the appropriate use of

prevention ______.6 The cement that holds it all together is proper

education and _____.9 Prevention begins with proper ___ and skin

assessment.10 Not all pressure ulcers are _______, but many are.12 23.9 percent of _____ in long-term care develop

pressure ulcers at some point.13 When a patient is admitted to the hospital, a pressure

ulcer risk and skin assessment should beperformed, documented and _______ to theassessment performed at the nursing home.

14 Pressure ulcers can develop within two to six _____of the onset of pressure.

17 __________ to a bed or chair for a week has beenfound to increase the prevalence of pressureulceration by 28 percent.

20 About ___ percent of all pressure ulcers occur inpeople 70 years and older.

21 70 percent of nurses consider their basic woundeducation to be _____.

22 Pressure ulcer risk assessment is importantbecause it helps identify which residents may benefitmost from _________ measures.

23 ___________ interventions to attempt tostabilize reduce, or remove underlying risk factorsshould be implemented.

24 Common factors that increase the risk fordeveloping pressure ulcers include immobility,circulatory problems, _____, incontinence, passivityand decrease in consciousness.

25 The best way to prevent pressure ulcers may bethrough the use of evidence based of pressure ulcerrisk __________ tools.

26 Personnel across the continuum of care should beeducated and trained, including nursing homes,_____ and emergency medical professionals.

Down1 It is important to identify and evaluate the

_____ _____ and changes in the residentʼscondition.

2 Staff needs to be properly trained on transferringtechniques that reduce ______ and shear.

3 Bony prominences and pressure points should bepadded appropriately to minimize pressure thatmight occur during a _____ procedure.

5 ________ _______ are defined as areas oflocalized damage to the skin and underlying tissuecaused by pressure, shear or friction.

7 About 1.5 million Americans reside in the nationʼs16,400 __________ on any given day.

8 A resident is most likely to develop a pressure ulcerduring the first _____ weeks after admission.

9 Pressure ulcers can lead to infections, which cannecessitate more _____ and services be provided.

10 Nurses need more education on proper ______ andusage of prevention products.

11 All members of the healthcare team need to know their_______ and how their tasks relate to each other in theprevention and management of pressure ulcers.

12 Stretcher pads should have adequate pressure_________ capabilities.

15 Studies suggest pressure wounds occur within the firsttwo days after the insult and that wounds occurringbeyond this time frame are caused by continuous__________ insults in high-risk populations.

16 Prevention is _____.18 Additional complications of pressure ulcers can include

deep vein thrombosis, pulmonary _____ and additionalinfections, just to name a few.

19 The greatest incidence of _____ _____ postoperativepressure ulcers for elderly patients with hip fracturesoccur within the first two postoperative days.


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15

10

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6

2

16

3

18

5

8

25

22

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14

www.medlineuniversity.com1. Register (free) or log in2. Click Free Courses tab3. Locate the puzzle and click Learn

More, then Begin Course4. Certificates are available online

after puzzle completion

To receive one hour of CE credit, enter your answersonline at www.medlineuniversity.com

We’re Spottinga Nationwide Trend…State-sponsored pressure ulcerprevention collaboratives

This is the kind of trend we can all embrace – state-spon-sored pressure ulcer prevention collaboratives! Read onto learn what five states (maybe yours?) are up to!

New JerseyNew Jersey is really the “trendsetter”here. The state had a pressure ulcerprevalence rate in fall 2004 that wasmuch higher than acceptable. Accord-ing to the Centers for Medicare & Medi-caid Services (CMS) Nursing HomeQuality Initiative, New Jersey healthcarefacilities had consistently held a pres-sure ulcer prevalence rate of 18 percentfor individuals at high risk, which isnearly five points higher than the national average.1 This ledto an ambitious collaborative led by the New Jersey Hospi-tal Association in which they achieved a 70 percent reductionin the incidence of pressure ulcers among participants intwo years.1 Their results were highly celebrated and pub-lished throughout the healthcare industry.

Working with its advisory panel, the New Jersey Hospital As-sociation (NJHA) developed a bundle of preventive practices,which included evidence-based protocols and practices thathave been tried and tested. The philosophy behind this isthat if one of these practices is proven effective, then groupinga number together should work even better. By applying thebundle to all patients and residents, the same high-qualitycare is delivered to all, no matter the caregiver or the setting.The Pressure Ulcer Collaborative bundle included:

• Completing a head-to-toe skin assessment withineight hours of admission

• Assessing risk factors, using the Braden Scale,within eight hours of admission and reassessing weeklyin long-term care (every 24 hours for at-risk patients andthose in acute care)

• Instituting appropriate prevention techniques for thosedetermined to be “at risk” (i.e., a score of 18 or loweron the Braden Scale), including the use of pressureredistribution surfaces.

Many tools and resources were identified to support theeffort, including a pressure ulcer prediction, prevention andtreatment pathway; a treatment product categories table; aturning and repositioning tool; baseline data elements andtools and senior leadership reports for monthly submission.

What are other states doing in an effort to follow in NewJerseyʼs footsteps?

VirginiaIn 2003, Virginia initiated a joint public-private partnership (supported throughresources from state, federal and pri-vate agencies) that had an overarchinggoal of delivering high-quality, easily ac-cessible geriatric education and training.This program focused primarily uponeducation of direct care providers and other practitioners whoattended a live, interactive videoconference that featured na-tionally known experts. The content of the educational pro-gram was drawn from nationally accepted guidelines anddiscussed appropriate procedures for wound cleansing,dressings, positioning techniques, proper nutrition and riskassessment protocols.2

20 Healthy Skin


The education did result in a reduction in pressure ulcers inthe study conducted in 2003, but apparently these resultswere not sustained. On January 10, 2008, the Virginia Pres-sure Ulcer Resource Team (VPURT), a statewide healthcarecoalition, issued a call to action to improve quality of carewithin the long-term care system by reducing what theyreferred to as one of the highest rates of pressure ulcers inthe country.3 VPURT has identified critical components forpressure ulcer prevention, including quality enhancement,regulatory effectiveness and resource revitalization. Theyhave also identified the following priorities for pressure ulcerprevention3:

• Make pressure ulcer prevention a key outcomeparameter for Pay for Performance

• Increase staffing levels to meet the critical needs ofthe residents for prevention of pressure ulcers

• Increase the pay of the direct care staff innursing facilities

• Increase the accountability of every healthcareprofessional in pressure ulcer prevention

• Make pressure ulcers a reportable event• Develop and implement a Uniform Patient

Transfer Form• Create an independent Center for Pressure Ulcer

Prevention Education• Redirect unused DMAS $10/day bed supplement

to pressure ulcer prevention in high-risk patients• Revise COPN for nursing facility beds to

emphasize quality

It appears that – in Virginiaʼs experience, at least – educationalone is not enough to prevent facility-acquired pressure ulcers.

WisconsinOn June 11, 2008, the WisconsinHealth Care Association announced acollaborative effort to certify 200 Wis-consin registered nurses who work inlong-term care as certified pressureulcer specialists. The following organi-zations are involved in this effort4:

• Wisconsin Department of Health and Family Services• Wisconsin Health Care Association• Wisconsin Association of Homes and Services

for the Aging

• Wisconsin Directors of Nursing Council• National Alliance of Wound Care• Wound Care Education Institute• West Bend Mutual Insurance• GuideOne Insurance• Golden Living• MetaStar• Kindred Health Care Foundation

Week-long certification courses will be offered this fall for 200registered nurses. Wisconsin long-term care facilities willhave the opportunity to send RNs at the cost of $1,000.The remaining course costs – approximately $2,500 – aredefrayed by the above-listed sponsors of the initiative.

IndianaOn August 25, 2008, the Indiana State De-partment of Health released the annual reportof the Medical Error Reporting System(MERS), which includes reported events forcalendar year 2007. According to the 2007report, 27 of the 105 reported events wereStage 3 or 4 pressure ulcers acquired afteradmission to the facility.5

Indiana health officials call pressure ulcers an example of asystem-based problem. It is not uncommon for a pressureulcer to develop in one facility and become worse or treatedin another facility. Reducing pressure ulcers requires closecare coordination between facilities and frequent, thoroughcare assessments. The Indiana State Department of Healthalso announced that they have already taken the followingsteps to address the pressure ulcer problem5:

• Developed and implemented the Indiana Health CareQuality Initiative - Pressure Ulcer Reduction Campaign,an 18-month collaboration between the University ofIndianapolis Center for Aging and Community, providerassociations and advocacy groups to provide a systems-based approach to reducing pressure ulcers. Theprogram provides education, training and technicalassistance to 150 healthcare facilities and agencieson best practices and systems for the prevention ofpressure ulcers

Continued

22 Healthy Skin

• Provided an alternating pressure, low-air-loss mattressand four pressure-reducing wheelchair cushions toevery nursing home in the state

• Held a conference in October 2007 for 1,167 healthcareproviders with national presenters on pressure ulcerreduction initiatives and experts discussing bestpractices for ulcer prevention and treatment.

It will be exciting to see the results of this comprehensivecommunity initiative!

PennsylvaniaOn August 25, 2008, Pennsylvaniaannounced that leading wound carespecialists, including national ex-pert Dr. Diane Krasner, will presentthe latest evidence in pressureulcer prevention and treatment atThe Pennsylvania Pressure Ulcer Partnershipʼs Kick-offConference on October 21. The kick-off event for thePhiladelphia area and overall statewide initiative are the re-sult of collaboration by The Health Care ImprovementFoundation, The Hospital & Healthsystem Association ofPennsylvania, the Hospital Council of Western Pennsylva-nia, ECRI Institute and Quality Insights of Pennsylvania.6

To prepare key staff to lead ongoing skin-safety efforts,healthcare organizations in Pennsylvania are encouragedto enroll multidisciplinary teams in the collaborative. After theconference, attendees will be engaged in additional activi-ties, including surveys, conference calls and improvementmonitoring, to support long-term improvement in pressureulcer prevention.

We have only mentioned five states in this article and ask foryour help to let us know what is going on in your state!Please send your state-specific collaboration information for

pressure ulcer prevention (PUP) for inclusion in future is-sues of Healthy Skin! Data may be submitted [email protected]. We will keep you updated on allstate-mandated PUP initiatives as data becomes available.

References1 Holmes A, Edelstein T. Envisioning a world without pressure ulcers.Extended Care Product News. 2007;122(8):24-29.2 Benghauser K, Cash K, Coogle C et al. The development of an educationalcollaborative to address comprehensive pressure ulcer prevention and treat-ment. Gerontology and Geriatrics Education. 2004;24(3).3 Virginia Pressure Ulcer Resource Team. Statewide Health Care Coalition:Reduction of Pressure Ulcers Seen as Essential to Improving Long-term CareQuality in Virginia. Available at: http://www.vpurt.org/. Accessed September 9,2008.4 Wisconsin Health Care Association. Innovative Collaboration Paves the Wayin Pressure Ulcer Prevention. Available at: http://www.whca.com/mediaroom/.Accessed September 9, 2008.5 IN.gov. ISDH: 2007 Medical Error Reporting System Report. Available at:http://www.in.gov/isdh/24056.htm. Accessed September 9, 2008.6 ECRI Institute. Philadelphia Conference Presents Latest Evidence-basedMedicine for Pressure Ulcer Prevention. Available at:https://www.ecri.org/Press/Pages/Pressure_Ulcer_Conference.aspx. AccessedSeptember 9, 2008.

©2008 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.www.medline.com

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24 Healthy Skin

A Focus on PreventionHighlights from the Prevention Above All Forum

On August 18 and 19, Medline brought together some ofhealth careʼs thought leaders for its Prevention AboveAll Forum to discuss healthcare policy changes andtheir implications for care. More than 80 chief nursing of-ficers, chief medical officers and healthcare quality execu-tives from across the U.S. attended the two-day forum. Aselect group of healthcare policy experts and professionalsprovided guidance and knowledge on patient safety strategiesand an innovative portfolio of targeted interventions thattranslate research findings into practical, evidence-basedsolutions to improve outcomes. Several of those speakersprovided important facts and advice on issues that arecurrently facing the long-term care community.

The key to cultural change: mutual cooperation built on realmutual respectWith CMS revamping reimbursementfor hospital-acquired conditions (HACs)and expanding implementation of theQuality Indicator Survey for long-termcare facilities into more states, it wasnʼt

too surprising to hear Keynote Speaker John J. Nance, JDopen the Prevention Above All Forum by saying “the coreculture of medical practice has to be drastically changed.”

Nance, founding member of the National Patient SafetyFoundation and author of Why Hospitals Should Fly: TheUltimate Flight Plan to Patient Safety and Quality Care,touched on how the October 1 CMS reimbursement mile-stone for HACs provides the opportunity for healthcareproviders to “re-commit” to improving patient safety bybecoming engaged professionals dedicated to barrierlesscommunication.

“Youʼre not only going to solve the CMS problems (of HACprevention),” said Nance. “But you are going to get to thepoint of asking doctors ʻWhy donʼt we have 100 percentcompliance on handwashing?ʼ and ʻIs it okay if my nursesremind you?ʼ That consistent cross-checking of each other,completely devoid of professional defensiveness, and a realcaring for each other as full members of a team dedicated tothe patientʼs best interests, is the key to safe practice.

Why Hospitals Should Fly by John Nance is available atwww.whyhospitalsshouldfly.com.

A new community approach to pressure ulcers In terms of healthcare policy changesand their implications for care, one withan astounding impact on long-term carediscussed at the forum was CMSʼs newcommunity approach to pressure ulcerprevention and care as outlined in the9th Scope of Work.

Previously, CMS reviewed captured MDS data to help iden-tify nursing homes that have high rates of pressure ulcers.With the CMS 9th Scope of Work, which took effect on Au-gust 1, CMS now directs QIOs to focus not only on nursinghomes with a high incidence of pressure ulcers, but to takea closer look at hospitals in the same county and hold themaccountable as well.

“It gets to the sense that pressure ulcers are a communityproblem,” said Dale Bratzler, DO, MPH, Medical Director ofthe Oklahoma Foundation for Medical Quality, speaking atthe forum. “CMS is actively working on building performancemeasures that will publicly report hospital pressure ulcerrates, particularly hospital-acquired pressure ulcers. Oncethey complete that, then I think there is going to be a strongincentive for nursing homes and hospitals to work togetherto figure out the best ways to prevent pressure ulcers.”

Learn more about the 9th Scope of Work by visitingwww.providers.ipro.org/index/9SOW_summaries - 39k.

Implications of the CMS Guide-lines on pressure ulcer preventionand treatmentThereʼs a great variability in terms ofhow organizations have prepared forthe October 1 deadline and where theyare at on that continuum of preparation.According to Diane Krasner, PhD, RN,CWCN, CWS, BCLNC, FAAN, Wound

and Skin Care Consultant, a lot of that preparedness comesdown to education.

“If you just look at the pressure ulcer part of the CMS ruling,thereʼs a high training and education component that eachfacility is going to have to grapple with,” said Krasner.

Nance

Krasner

Bratzler

Krasnerʼs presentation highlighted the need for nursesto receive more education on:

• Risk assessment (interpretation of Braden Scale)• Pressure ulcer staging• Proper positioning (including bed and chair)• Effects of moisture on the skin (including incontinence,

humidity and maceration)• Pressure-relieving products• Proper application and usage of prevention products

The following documents – currently in use at Krasnerʼsfacility, Rest Haven-York – are also available:

• Pressure Ulcer Protocol • Pressure Ulcer Protocol – Avoidable versus

Unavoidable Pressure Ulcers • Pressure Ulcer Notification Fax • Pressure Ulcer Risk Factors tracking chart • Wound Photo Documentation

If you are interested in receiving any of these documents,please email us at [email protected].

Surgical studies can inform LTC Heidi Wald, MD, MPH, along with herco-authors of the study “Indwelling Uri-nary Catheter Use in the PostoperativePeriod,” reviewed data from 35,904Medicare patients at 2,965 acute carehospitals across the United States todetermine the relationship betweencatheter use and postoperative out-

comes. “This was probably the first national study of reallywhatʼs going on in surgical patients,” Dr. Wald said. Althoughthe study was surgical in nature, its findings can certainlyinform long-term care as well.

Dr. Wald and her colleagues concluded that indwellingurinary catheters that are left in place for longer than twodays postoperatively may result in catheter-acquired urinarytract infections (CAUTI) as well as an increase in 30-daymortality and an increased length of stay.

To view the study, please visit http://archsurg.ama-assn.org/cgi/content/short/143/6/551.

APIC: Spreading knowledge, preventing infection Sometimes a few changes need to be made in order toclarify goals and continue to move toward them. KathyWarye, CEO of the Association for Professionals in InfectionControl and Epidemiology, Inc. (APIC) shared the associa-tionʼs recommendation of changing the title of InfectionControl Professional to Infection Preventionist withPrevention Above All forum attendees.

“Language creates culture, and if the goal is around prevention,then our name needs to incorporate prevention,” Warye said.

Warye distributed copies of APICʼs MRSA guidelines and aDVD on hand hygiene geared toward patients. To downloada copy of the DVD video, please visit www.cdc.gov/handhy-giene. For more APIC resources, please visit www.apic.org.


Be sure to visit the Prevention Above All Web site at www.medline.com/special/PAA/ for continued updates and additional resources.

Wald

26 Healthy Skin

Medline introduces six practical and targeted interventions tohelp improve outcomes. The programʼs strategically inte-grated portfolio of focused and achievable evidence-based so-lutions is designed to fit into the everyday processes andsystems most healthcare providers already have in place.

Target: Catheter-Associated Urinary Tract Infections (CAUTIs) The Prevention Above All Intervention: Silvertouch® CathetersA bundled solution of advanced silver technology with Med-lineʼs Silvertouch Foley catheters and educational training toreduce CAUTIs.

Silvertouch Foley catheters incorporate the power of silverthrough a patented process that binds silver ions to thecatheterʼs lubricious coating, delaying the onset of biofilm for-mation. Educational materials provide summarizations of themajor recommendations from the CDC and provide a policyand procedure template guide for proper catheterization. Alsoincluded are validation tools that can be utilized during trainingor re-education classes, and a troubleshooting guide book tohelp caregivers work through issues.

Target: Harm Avoidance and Patient SatisfactionThe Prevention Above All Inter-vention: Educational PackagingTo help reduce medical errors, Medline redesigned its AdvancedWound Care packaging in a format that allows each packageto serve as a 2-minute course on advanced wound care.

The innovative packaging design is an improved delivery andcommunication system to help healthcare professionals betterunderstand and more easily deliver wound care at the patient'sbedside. It replaces confusion with clear, step-by-stepinformation, eliminating the clutter and highlightingcritical information.

Target: Objects retained after surgeryThe Prevention Above All Intervention: RF DetectRF system designed to alert the OR nurse when a RF-taggedsurgical items remain in the patient before closing the procedure.

The system consists of three components: a micro RF tag em-bedded in gauze, sponges and towels and a sterile handheldwand that is connected to the third component, an easy-to-use, self-calibrating console. By passing the wand back andforth and side to side over the patient, hospital personnel will beable to accurately detect, within seconds, retained surgical dis-posables before site closure.

Target: Hospital-Acquired InfectionsThe Prevention Above All Intervention: Hand Hygiene Compliance ProgramA program of products that stresses appropriate applicationtechniques and education to achieve hand hygiene compli-ance while dramatically improving the skin condition of health-care workers.

The Hand Hygiene Compliance Program contains three prod-ucts – Sterillium Comfort Gel™, Medline Remedy™ productsand Aloetouch® exam gloves – clinically proven to nourish dryskin. The program includes an intensive educational moduledeveloped by an expert panel of infection control profession-als. Healthcare workers can earn up to four continuing edu-cation credits by completing the training program. Additionalcomponents include testing for skill and competency valida-tion through the use of Visirub and a UV light box. Patienteducation pamphlets, facility posters and a rewards programare also included to reinforce positive behavior change.

Target: Pressure UlcersThe Prevention Above AllIntervention: PressureUlcer Prevention ProgramA program of products, tools and resources to implementan effective prevention program and immediately beginreducing the incidence of pressure ulcers.

The Pressure Ulcer Prevention Program is a strategic productbundle to assist in reducing or preventing pressure ulcersand incontinence-associated skin conditions, which mayinclude dermatitis and skin tears. Products include Remedy™Advanced Skin Care Products, Ultrasorbs® AP Dry Pads,Restore®/Remedy™ Adult Brief, and Supra DPS alternatingpressure and low-air-loss mattresses.

Prevention Above AllTargeted interventions, practical solutions


This program also packages together education and train-ing tools so a healthcare team can implement an effectivepressure ulcer prevention program and immediately beginreducing the incidence of healthcare-acquired pressureulcers. Included are workbooks, patient and family educa-tion brochures and a rewards program.

Target: Wrong Site SurgeryThe Prevention Above All Intervention: S.T.O.P. DrapeA surgical drape set that incorporates a “Time Out” stickerstrip that must be removed prior to the surgical caseand provided to the circulating nurse to be placed on thepatientʼs chart.

The Medline S.T.O.P drape has a sticker in the shape of ared stop sign and tells the staff to stop, forcing them toperform the time-out required prior to beginning surgery. Thesticker provides a location to write and confirm the patientʼsname, procedure, site and side, date, time and surgeonʼsinitials. By requiring the surgeon to initial the sticker, thesurgical team is again reminded to perform the time-outimmediately prior to the incision, thus encouraging improvedcompliance with performing the time-out procedure.

Wayne Brannock of Lorien Health Systems inMaryland asks a question during a session.

Dr. Andrew Kramer speaks to Prevention Above All Forum attendees about patient safety.

Medline Chief Marketing Officer Sue MacInnes addresses attendees during the PreventionAbove All Forum.

Attendees review Medlineʼs Pressure Ulcer Prevention Program materials.

28 Healthy Skin

Incorporating a Magnet Approach in Wound Care

By Cindy Kiely, RN, MSN, CWOCN

Although the skin is the largest organ of the body, skin integrityhas rarely, if ever, been considered a fundamental aspect of pa-tient care. The development of a pressure ulcer was thought of asan unfortunate outcome during a patientʼs hospitalization. Today,pressure ulcers are considered a preventable occurrence ofunnecessary harm. There has never before been a time in healthcare in which pressure ulcers have been such a force to bereckoned with.

The revised Centers for Medicare & Medicaid Services (CMS)policies that take effect on October 1 reflect the social andeconomic concerns voiced regarding pressure ulcers. Pressureulcers are termed “never events” by CMS and the implementationof no reimbursement for facility-acquired pressure ulcers willundoubtedly have a huge financial impact. Facilities are scram-bling to implement and promote preventative measures, but thecosts of products and support surfaces may limit some facilitiesʼabilities to maintain a best-practice approach.

What is a “Magnet” approach?Incorporating a “Magnet philosophy” into a wound care programmay be one of the most cost-effective and interdisciplinaryapproaches to preparing for the new CMS guidelines. The AmericanNurses Credentialing Center (ANCC) awards Magnet status tohealthcare organizations that satisfy a certain set of criteriadesigned to measure the strength and quality of nursing care.1Magnet status is awarded to institutions that deliver outstandingpatient outcomes while simultaneously incorporating nurseinvolvement in data collection and decision-making in the patientcare delivery system. Magnet values an open communicationbetween nursing and leadership along with encouraging andrewarding them for advancing in nursing practice.

Assembling a team The first step in implementing a Magnet philosophy in wound careis to uncover the nursing staff who are attracted to the field. Thecreation of a wound care team can focus on the positives as wellas the negatives in a facilityʼs wound care approach. Assigningstaff without seeking their preference will surely doom the com-mittee. Asking the nurse manager who they feel may have an in-terest and then sending an invitational letter to that person makesa positive first impression. A team that is energetic and enthused

about the subject accomplishes more than a team that is forcedto participate.

Since the staff nurses are the ones with the most hands-onexperience with pressure ulcers, their opinions should be of ut-most importance. Distributing a confidential survey querying thenurses on their understanding of wound care and products cangenerate new approaches to education and training. The woundcare team would be able to generate information from the surveythat can help pinpoint the areas needing improvement and mayeven ignite new ideas. For instance, the creation and implemen-tation of pressure ulcer standing orders may facilitate treatmentmore rapidly than waiting for a physicianʼs order.

Special Feature


Letters of gratitude may spark additional confidence as well asinterest within the field of wound care. Acknowledging a nurseʼsexceptional preventative care may encourage ongoing qualitycare, thereby reducing that nurseʼs unitʼs incidence of pressureulcers. Simple acts of gratitude can empower the nurse.

Education, empowerment and supportThe Magnet approach relies upon evidence-based care. Woundcare can no longer take a “weʼve always done it that way”approach. For example, wet-to-dry dressings have been a populartreatment choice despite their detrimental side effects, such aspain and non-selective properties of removing granulation as wellas devitalized tissue. Education, empowerment and support ofthe nursing staff with evidence-based facts can encourage nursesto question the treatment ordered and encourage research-basedtreatments instead of “the old standby.”

The solutions to improving patient care are not always found fi-nancially. Empowering the nursing staff can bring forth greater re-wards fiscally along with improved patient outcomes. Encouragingnurse involvement and truly listening to their experiences can helpshape the culture of an entity as well as promote excellence incare.

Reference1 The Center for Nursing Advocacy. What is Magnet Status? Available at:http://nursingadvocacy.org/faq/magnet.html. Accessed August 6, 2008.

About the author Cindy Kiely, RN, MSN, CWOCN, is thewound specialist at Good Samaritan HospitalMedical Center. She has specialized in woundcare for almost 10 years and is a member ofthe Wound, Ostomy and Continence NursesSociety. Cindy has played an active role inhealth care by speaking to members of Con-gress regarding diabetic foot care as well ashaving been published on this topic.

What is Magnet status?Magnet status is an award given by the AmericanNursesʼ Credentialing Center to hospitals that satisfy ademanding set of criteria measuring the strength andquality of their nursing. Specifically, a Magnet hospital isone where nursing delivers excellent patient outcomes,where nurses have a high level of job satisfaction, lowstaff nurse turnover rate and appropriate grievance res-olution. There is nursing involvement in data collectionand decision-making in patient care delivery. Magnetnursing leaders value staff nurses, involve them inshaping research-based nursing practice and encour-age and reward them for advancing in nursing practice.Magnet hospitals have open communication betweennurses and members of the healthcare team and havean appropriate personnel mix to attain the highest pa-tient outcomes and optimal staff work environment.

Referencehttp://www.nursingadvocacy.org/news/2004feb/hopkins_billboard.html

30 Healthy Skin

When Negative is Positive: A Review of Negative

Pressure Wound Therapy

By Cynthia A. Fleck, RN, BSN, ET, WOCN, CWS, DAPWCA,and Lisa D. Frizzell, RN, BSN, ET, CWOCN

Treatment

Despite recent press, marketing efforts, and commercializa-tion of a “kit” in the last decade, [negative pressure woundtherapy, or NWT] is anything but new. The theories that weknow as modern day NPWT were arranged as a convenientkit of equipment and supplies, presented to the Food andDrug Administration (FDA), and approved as a device in 1995.

NPWT applies subatmospheric pressure or negative force tothe wound bed by means of a suction unit, dressing, a non-collapsible, fenestrated evacuation tube, and a transparentsemi-occlusive, vapor-permeable outer dressing or “drape”and is connected to a collection container. The concept is toturn an open wound into a controlled, closed wound while re-moving excess fluid from the wound bed, thus enhancing

circulation and disposal of cellular waste from the lymphaticsystem. It is considered for complex and difficult-to-manage wounds.

It is hypothesized that NPWT works clinically by removing ex-cessive interstitial edema, thereby decompressing the smallvessels and restoring local blood flow, removing chronicwound fluid that contains matrix metalloproteinases (MMPs)that can inhibit wound healing, and stimulating proliferation offibroblasts and endothelial cells and vascular smooth muscleby mechanically deforming the cells.

The clinical benefits include increasing local blood flow,decreasing bacterial colonization, facilitating the ability tomeasure and assess wound fluid, and increasing the rate ofgranulation tissue creation, contraction, and epithelialization.The wound is additionally uniformly drawn closed by ap-plying controlled, localized negative pressure. NPWT sup-ports granulation tissue formation through the promotion ofwound healing.1

Clinical indications: Who, what, where and whenA thorough assessment should be performed on every pa-tient considered for NPWT. Generally, NPWT can be consid-ered in a chronic wound if the wound size decreases by lessthan 30 percent after four weeks following debridementor if excessive exudate cannot be managed effectively withdaily dressing changes. Areas of contemplation include thepatientʼs ability to heal, nutritional assessment togetherwith albumin/pre-albumin levels, diabetes complications, andsystemic steroid, immunosuppressant, or anticoagulant use.Patient compliance with dressing changes and follow-upcare are important to determine prior to dressing applica-tion. Patients with a history of noncompliance with otherdressing regimes should be monitored closely. If the wound ison a bony prominence, appropriate pressure relievingand/or offloading measures should be initiated.


NPWT, when ordered by a surgeon or physician medicallydirecting the patientʼs wound care regime, is deemedappropriate for the following conditions:

• Acute wounds• Partial- and full-thickness burns• Surgically created wounds and surgical dehiscence—

Patients with other medical problems, i.e., diabetes,coronary artery disease, and renal disease, may bemore susceptible to wound dehiscence and delayedwound healing. NPWT may provide increased wound stability.

• Neuropathic (diabetic) ulcers• Venous or arterial insufficiency ulcers unresponsive

to standard therapy• Traumatic wounds (i.e., flap or meshed graft)• Pressure ulcers (stage 3 and stage 4).

Contraindications for NPWT include:• Necrotic tissue with eschar present if debridement

has not been attempted• Malignant or neoplastic diseases in the wound margin• Untreated osteomyelitis—The patient should be on

antibiotics to address the underlying infection• Presence of a fistula to an organ or body cavity

within the cavity of the wound• NPWT dressings should not be applied directly over

exposed blood vessels or organs.

NPWT can be utilized in a variety of care settings andapplied by any trained, licensed healthcare professional.The key word here is trained. Failure of NPWT is often dueto inadequate staff education and skill, particularly insmaller chronic care facilities. Work directly with your man-ufacturers and distributors to make sure that your staff isadequately trained, periodically inserviced, and has thenecessary tools to apply and remove the NPWT devicesafely and effectively.

Dressing changes should occur routinely every 72 to 120hours depending on the dressing type, amount ofdrainage, and physicianʼs order. In acute care, dressingsare typically changed on Monday, Wednesday, and Friday.If the wound is infected, however, dressing changefrequency should be increased to every 12 to 24 hours toassess any changes in wound status. NPWT should notbe off for more than two hours during a 24-hour period asmaceration of the periwound skin can occur. For the homecare patient, always provide an alternative dressing in casethe dressing becomes dislodged or there is a disruption inelectrical power. Dressings over meshed grafts are usuallyplaced in the operating room, typically left for three to four

days, then therapy discontinued before the patient isdischarged home.

Preparing the wound bedWounds treated with NPWT should be debrided, cleaned,and prepared as with any wound.2 If there is not a largeamount of necrotic tissue present or if gentle cleansing isindicated (pain in or around the wound; clean, granulatingwound bed), a noncytotoxic commercially prepared woundcleanser can be applied.


A thorough assessmentshould be performed onevery patient consideredfor NPWT.

TenderWet Active

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and debride necrotic wounds for up to 24 hours! Plus,

they won’t stick to the wound bed, reducing patient

discomfort at dressing removal.

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large-molecule proteins found in dead tissue and bacteria

are attracted to TenderWet Active's core. Even under

compression, TenderWet Active can retain large amounts

of fluid.

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than wet gauze therapy because TenderWet Active can be

left in place for up to 24 hours without drying out while

simultaneously providing a barrier against microorganisms.

By debriding necrotic tissue, absorbing and retaining

pathogens and keeping the wound moist, TenderWet

Active helps create an ideal healing environment.

To learn more about TenderWet Active andMedline’s complete line of advanced woundcare products, call your Medline representative,visit www.medline.com/woundcare or call1-800-MEDLINE.

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Before placing the dressing, the periwound skin should becarefully dried and prepared by using a skin prep or by cut-ting a thin hydrocolloid wafer to the exact shape of the wound.The actual NPWT packing dressing should be cut to fit thesize and shape of the wound bed, including tunnels and anyundermining. Often, more than one piece is necessary.

SettingsAccording to expert opinion, the optimal setting for NPWT is125mmHg.14 Pressures should be continually evaluatedbased on changes in wound status. Patients on anticoagu-lants, the elderly, or emaciated patients should be started ata lower setting (75 to 100mmHg) then adjusted up as toler-ated. There is also an option of continuous versus intermit-tent therapy. Continuous therapy is indicated if there issignificant discomfort during the intermittent therapy mode, ifthere are tunnels or undermined areas, if there are highlevels of wound exudate beyond the first 48 hours, or if it isa difficult site to maintain a seal, e.g., perirectal area,fingers, or toes. Intermittent therapy (five minutes on/twominutes off) has been shown to increase granulationtissue formation.

Sizes, shapes, types and configurationsAll suction systems used in the clinical setting have similarcomponents and mechanisms to provide a vacuum. Thecomponents include a suction drainage device, extensiontubing connecting the drain to an inlet port on the collectionunit, a vessel that provides the source of vacuum, an occlu-sive or semi-occlusive dressing or drape, and an exit portthrough which air is expressed. The factors that vary amongproducts are drain design, the power source used to createsuction, the dressings, and the method used to control andcontain wound fluid.

These systems rely on some form of vacuum pressure tocreate suction force. The power that creates a vacuum maybe a manually activated drum or a power-driven pump.Pumping devices may be stationary, a line-powered pump, ora portable device. There are currently several sizes and spe-cial versions of NPWT from which to choose.

References1. Fox J, Golden G. The use of drains in subcutaneous surgical procedures. The AmericanJournal of Surgery November 1978;132:573–4.2. Montgomery BA. Easy dressing of large, draining abdominal wounds using moisture vapor-permeable film. In: OʼLeary JT, Wontering EA (eds). Techniques for Surgeons. New York, NY:Wiley and Sons, 1985:417–8.3. Everett WG. Wound sinus or fistula? In: Wound Care. London, UK: William Heinemann Med-ical Books Ltd., 1985:84–90.4. Betancourt S. A method of collecting the effluent from complicated fistula of the small intes-tine. SG&O 1986;163:375.5. Clowes GH Jr, George BC, Villee CA Jr, Saravis CA. Muscle proteolysis induced by a circu-lating peptide in patients with sepsis or trauma. N Engl J Med 1983 Mar 10;308(10):545–52.6. Chariker ME, Jeter KF, Tintle TE, Bottsford JE. Effective management of incisional and cuta-neous fistulae with closed suction wound drainage. Contemporary Surgery Jun 1989;34:59–63.7. Nakayama Y, Soeda S. A new dressing method for free skin grafting in hands. Ann PlastSurg 1991;26:499–502.8. Brock W, Barker D, Burns R. Temporary closure of open abdominal wounds: The vacuumpack. Am Surg 1995;61:30–5.9. Blackburn J, Boemi L, Hall W, et al. Negative-pressure dressings as a bolster for skin grafts.Ann Plast Surg 1998;40:453–7.10. Kostiuchenok I, Kolker V, Karloc V, et al. The vacuum effect in the surgical treatment of pu-rulent wounds. Vestnik Khirurgil 1986;9:18–21.11. Argenta L, Morykwas M. Vacuum-assisted closure: A new method for wound control andtreatment: Animal studies and basic foundation. Ann Plast Surg 1997;38:553–62.12. Joseph E, Hamori CA, Bergman S, et al. A prospective randomized trial of vacuum-assistedclosure versus standard therapy of chronic nonhealing wounds. WOUNDS 2000;12(3):60–7.13. Fleck CA. Wound bed preparation: The good, the bad, and the ugly. Extended Care Prod-uct News 2003;86:24–7.14. Sibbald RG, Mahoney J, the VAC Therapy Canadian Consensus Group. A consensus re-port of the use of vacuum-assisted closure in chronic, difficult-to-heal wounds. Ost WoundManag 2003;49(11):52–66.15. Krasner DL. Caring for the person experiencing chronic wound pain. In: Krasner DL, Rode-heaver GT, Sibbald RG (eds). Chronic Wound Care: A Clinical Source Book for HealthcareProfessionals, Third Edition. Wayne, PA: HMP Communications, 2001:79–89.

Adapted from: Fleck CA, Frizzell LD. When negative is positive: a review of neg-ative pressure wound therapy. Extended Care Product News. 2004;92(2):20-25.

Reprinted with permission.


Failure of NPWT is often due to inadequate staff education andskill, particularly in smaller chronic care facilities.

34 Healthy Skin

Never Say “Never” Never Say “Always”

Never Say “Zero”

By Diane L. Krasner, PhD, RN, CWCN, CWS, BCLNC, FAAN

IntroductionThe wound worldʼs abuzz about zero: “Chasing Zero,” “Journeyto Zero,” “Never Events”* and other such slogans abound. ButI propose the opposite stance: Never say “zero” – especially when itcomes to pressure ulcers.

I remember the first time I heard Evonne Fowler, RN, CNS, CWONsay, “Never say ʻnever,ʼ never say ʻalwaysʼ” like it was yesterday. Wewere at the first Symposium on Advanced Wound Care, 21 years agoin Long Beach, California. This powerful phrase opened my eyes andI would quote Evonne countless times in the intervening years.

So today, I have another phrase to add to the wisdom: Never say“zero.” Hereʼs why. As of October 1, when the new CMS InpatientHospital Care Present on Admission (POA) Indicators/Hospital-Acquired Condition (HAC) Ruling goes into full effect, those of us inthe wound care community will be forced to confront the currently pop-ular notion that zero pressure ulcers should be the target for clinicaloutcomes in each and every one of our facilities (infection control

practitioners will face a similar problem with infections). But shouldzero pressure ulcers be set forth as the benchmark, the conceptualideal? Are all pressure ulcers avoidable? Is there evidence that pres-sure ulcers can be “reasonably prevented through the application ofevidence-based guidelines” (wording from the Deficit Reduction Act2005, DRA Section 5001[c])?

Are all pressure ulcers avoidable?The pressure ulcer literature contains both qualitative and quantitativeevidence to support the conclusion that not all pressure ulcers areavoidable. A literature search of the terms “skin failure,” “KennedyTerminal Ulcer” and “end-of-life pressure ulcer” will lead you to a grow-ing body of qualitative literature on skin conditions associated withend of life. Look for the Preliminary Consensus Statement on SkinConditions At Lifeʼs End that is being presented for public commentand review by the SCALE Expert Panel in fall 2008 (for furtherinformation contact [email protected]).

There is also a growing body of quantitative evidence that suggeststhat baseline pressure ulcer incidence rates exist even whenstandards of care are met. Dr. David R. Thomas explains:

Special Guest Editorial

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Epidemiological data demonstrates a stability in the incidence of pres-sure ulcers despite drastic improvement in understanding of pressureulcers, increased regulatory oversight and improvement in technolo-gies available for prevention of pressure ulcers …. No interventionstrategy has been reported that consistently and reproducibly reducesthe incidence of pressure ulcers to zero …. The published data onprevention of pressure ulcers does not support an assumption that allpressure ulcers are preventable.1

In an article by Bennett et al titled “The Increasing MedicalMalpractice Risk Related to Pressure Ulcers in the United States,”the authors state:

Most facilities will have stable prevalence and incidence rates. Hospitalprevalence rates of 1-2% and nursing home prevalence rates of 5 to10% occur typically in well run institutions with vigorous monitoringprograms.2

Dr. Jeffrey Levine recently wrote the following in a two-part seriesaddressing the new CMS ruling:

One of the issues challenging Medicare is that all pressure ulcers arenot avoidable, and it is unclear at this time which criteria will be usedto deem them as such.3

If evidence suggests that baseline prevalence and incidence ratesexist and that not all pressure ulcers are avoidable, benchmarking tozero pressure ulcers is neither evidence-based nor evidence-informedpractice.

The legal implications of zeroPressure ulcer litigation is on the rise and legal experts expect it to in-crease further once the HAC/POA ruling goes into full effect, just as itincreased after the OBRA Ruling in 1987.2 From a legal perspective,benchmarking to zero can be disastrous – when it comes to humanbehavior, zero anything is rare.

If a facility sets a goal of zero pressure ulcers, how do you explainand defend the facility when a pressure ulcer does occur? A more pru-dent approach from the legal perspective is to assume a certain baseprevalence and incidence of pressure ulcers in a facility and to ana-lyze data on a regular basis to assure that the base prevalence andincidence rates remain consistent. Facility-based prevalence and in-cidence rates can be extremely variable, depending on the patientpopulation, admitting patterns and catchment area. You should knowyour facilityʼs base prevalence and incidence rates – just like you knowyour own Social Security number. If the prevalence goes up, a rootcause analysis should be done and interventions put into place to ad-

dress any identified problems. Additionally, on an individual basis,each facility should put a plan in place to demonstrate an individualpatientʼs risk factors and comorbidities.4 This documentation, coupledwith a pressure ulcer policy and procedure that meets national andsetting-specific standards of care, will go a long way toward protect-ing your facility from litigation.5

So, in conclusion, remember: Never say “never,” never say “always”and never say “zero.”

* The IPPS FY 2008 Final Ruleʼs inclusion of “serious preventableevents,” also known as “never events,” included three such events:object left during surgery, air embolism and blood incompatibility. Notethat pressure ulcers were not designated as “never events.”

References1 Thomas DR. Are all pressure ulcers avoidable? JAMA. 2001;2(6):297-301.2 Bennett RG, OʼSullivan JO, DeVito EM. The increasing medical malpractice risk relatedto pressure ulcers in the United States. JAGS. 2000;48:73-81.3 Levine JM. Preparing for the new Medicare Reimbursement Guidelines: Part II – Doc-umentation of Altered Skin Integrity in the Hospital. Clinical Geriatrics. 2008 July: 17-20.4 Stotts NA, Wipke-Tevis D, Hopf HW. Co-factors in impaired wound healing. In KrasnerDL, Rodeheaver GT, Sibbald RG, eds. Chronic Wound Care: A Clinical Source Book forHealthcare Professionals. 4th ed. Malvern, Pa: HMP Communications; 2007.5 Krasner DL. Safeguarding your wound and skin care practice from litigation. ECPN.2007 April: 28-32.

About the authorDr. Diane L. Krasner is a board certified wound specialist with extensive ex-perience in wound, ostomy and incontinence care. She is a Fellow of the Amer-ican Academy of Nursing. Dr. Krasner is a wound and skin care consultant inYork, Pennsylvania and works part-time at Rest Haven - York as theWOCN/Special Projects Nurse.

Dr. Krasner is the lead co-editor of Chronic Wound Care: A Clinical SourceBook for Healthcare Professionals (4th edition, 2007, HMP Communications).She currently serves on the editorial boards of WOUNDS, Kestrel WoundProduct Sourcebook, The International Journal of Wound Care and WorldWide Wounds. Since 1992, Dr. Krasner has served on the board of Directorsand as an officer of several national wound care organizations, including theAmerican Academy of Wound Management, the Association for the Advance-ment of Wound Care and the National Pressure Ulcer Advisory Panel.

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36 Healthy Skin


End-of-life care goals

PalliativeWound

Care

By Eva Russell, RN, BS, CWS, FACCWS, CHPN

Wound care for terminally ill patients can becomplex and challenging. The goals for termi-nally ill patients with wounds are to alleviatesymptoms such as pain and odor, manageexudate, prevent deterioration of the wound andenhance quality of life.

Palliative wound care follows the guidelines setforth by the National Pressure Ulcer AdvisoryPanel (NPUAP), the Agency for HealthcareResearch and Quality (AHRQ) and Wound,Ostomy and Continence Nurses Society (WOCN).

Guidelines for wound care include:• Assessment• Treatment based on moist wound healing1

• Debridement if appropriate2

• Appropriate support surface selection• Prevention• Nutrition• Monitoring and documentation

Tools for careThe Pressure Ulcer Scale for Healing (PUSHTool, version 3) is one of two evidence-basedtools proven valid and reliable. The PUSH toolwas developed by the NPUAP as a “quickreliable tool to monitor the changes in pressureulcers over time.”3

The other-evidence based tool is the Bates-Jensen Wound Status Tool (originally known asthe Pressure Sore Status Tool), developed by Dr.Barbara Bates-Jensen.4 These tools provideall the essential components for assessment,monitoring and documentation.

Wound care for the dying patient may not be anoption or may impair quality of life if pain andrepositioning for the patient is not done with care.However, providing curative wound care may

Treatment

38 Healthy Skin

or gray tissue or as black eschar. Tissue that is moist yellow andstringy is usually referred to as slough. The most commontypes of wound debridement include sharp/surgical, mechanical,autolysis, polyacrylate and enzymatic agents.

There are also other forms of debridement, including maggottherapy, high-pressure fluid irrigation and ultrasonic mist, whichare typically not used in palliative wound care.7 Once necrotictissue is removed and the wound bed is pink or beefy red, odorwill be greatly reduced and exudate will be diminished.

The AHRQ guidelines discourage debridement of dry, stableeschar ulcers of the heel if there are no signs of edema,erythema or drainage.8 Treatment can include skin prep to thenecrotic area and wrapping the foot with gauze or bandages andelevating the heel to eliminate pressure. Evaluation of the heel

should occur every two tothree days for any changes.

An effective treatment toreduce odor before debride-ment is completed is the use ofmetronidazole, an anti-infec-tive. Kalinski et al showed asignificant response, (100 per-cent in odor elimination) with

10 patients on a 14-day treatment duration with odor reduc-tion response on day one.9 Metronidazole can be ordered in gelform for dry wounds or powder form for moist wounds from acompounding pharmacy or capsules can be crushed and placedon the necrotic areas of the wound bed. Silver dressings canalso be effective at reducing odor, as they are bacteriostatic.

Evaluating support surfacesSupport surfaces should be selected based on the needs of thepatient for prevention, treatment and comfort. There are multiplesupport surfaces for beds and seating. Factors to consider arepressure, friction, shear, weight of the patient, presence of awound and cost. The most common pressure-reducing supportsurfaces are foam, gel, alternating pressure, fluid-filled, low-air-loss and air-fluidized beds.2 Comfort of the patient should be aprimary consideration for palliative care.

Nutritional needsNutritional needs for palliative and terminal patients vary greatly.Decreased protein intake, muscle wasting, immunosuppressionand dehydration increase a patientʼs risk for developing pressureulcers. Encouraging small, frequent meals that include protein,

The goals for terminally ill patients withwounds are to alleviate symptoms such as pain and odor, manage exudate,prevent deterioration of the wound and enhance quality of life.

lead to wound healing, even among terminal patients.5 Initialassessment should include identifying the type of wound andcorrecting or modifying the causes of tissue damage.6

Addressing complicationsComplex wounds, such as fungating tumor wounds, occur asskin and supporting blood and lymph vessels are infiltrated by alocal tumor or spread from a primary tumor. These wounds canbe quite challenging because it is difficult to predict their course.They are often highly vascular and bleeding can be an issue.Using calcium alginate for its hemostatic properties can beeffective and having topical powder bandage on hand to stopbleeding is helpful. Secondary dressings for these wounds canbe difficult and knowing which products are available is invalu-able. This can be creative nursing at its best.

Edema is another challenge frequently seen in terminally illpatients and can compromise wound management. Diureticsand corticosteroids can reduce edema, depending on the cause.Exudate management is vital; using foams and highly absorbentproducts can prevent wound and skin deterioration.

Pain is often undertreated and needs to be the first considerationin wound care.5 Use of analgesics and opioids should be basedon pain severity and type of pain (whether pain is nociceptive –somatic or visceral – or neuropathic). Another consideration iswhether the patient is opioid naïve or has an analgesic history.The use of adjuvants such as tricyclic antidepressants, corticos-teroids, non-steroidal antiinflammatories, neuroleptics, antihista-mine, anticonvulsants and calcitonin for pain management areoften overlooked and can enhance traditional analgesics.

Debridement is often underutilized in terminal patients as it maybe seen as aggressive treatment. Debridement is the removalof necrotic tissue, exudate and metabolic waste from a wound toimprove or facilitate the healing process.2 Removing necrotictissue and slough also reduces odor and must occur for healingto take place. Necrotic tissue can present as moist yellow, green


providing sips of preferred fluid throughout the day and offeringany snacks that are tolerated are suggested for this patientpopulation.

Many wounds can heal at the end of life when wound care guide-lines are followed. Wound care is essential in providing effectivepalliative care for terminally ill patients with existing or developingwounds.5 While nurses may not change a terminal prognosiswith optimal wound care, they can make a positive impact onpatient comfort and quality of life.

References1 Bolten L. Operational definition of moist wound healing. Journal Wound OstomyContinence Nurs. 2007;34:23-29.2 Baranowski S, Ayello EA. Wound Care Essentials: Practice Principles. Philadelphia,Pa. Lippincott Williams & Wilkins; 2004.3 National Pressure Ulcer Advisory Panel. PUSH Tool Information & RegistrationForm. Available at: http://www.npuap.org/archive/pushins.htm. Accessed August 27,2008.4 Bates-Jensen B. Quality indicators for prevention and management of pressure ulcers in vulnerable elders. Annals of Internal Medicine. 2001;135:744-751.5 Hughes RG, Bakos AD, OʼMara A, Kovner CT. Palliative wound care at the end oflife. Home Health Management & Practice. 2005; 17:196-202.6 Kirshen C, Woo K, Ayello EA, Sibbald RG. Debridement: a vital component ofwound bed preparation. Advances in Skin & Wound Care. 2006; 19: 506-517.7 Gray M. Is larval (maggot) debridement effective for removal of necrotic tissue from chronic wounds? Journal Wound Ostomy Continence Nurs. 2008;35:378-384.8 Agency for Healthcare Research & Quality. Treatment of pressure ulcers, clinicalpractice guideline No 15. U.S. Dept of Health & Human Services, AHCPR PublicationNo.95-0652. Rockville, MD; 1994.9 Kalinski C, Schnepf M, Laboy D, et al. Effectiveness of a topical formulation con-taining metronidazole for wound odor and exudates control. Wounds. 2005; 17:84-90.

About the authorEva Russell, RN, BS, FACCWS, CWS, CHPN is the Director ofNursing at Samaritan Hospice in Marlton, New Jersey. As a woundcare specialist and certified hospice and palliative care nurse, Evahas developed palliative wound care policies and protocols and awound care team at Samaritan Hospice to enhance end-of-life care.She is a fellow of the American College of Wound Care Specialistsand is currently pursuing her MSN at Walden University.

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40 Healthy Skin

End-of-Life Care for Residents and Their Families

Dying is the final portion of the life cycle for all of us. Providing humane care topersons near the end of life is an essential part of medicine.1 Just because the healthcareteam has determined that the illness or disease process can no longer be controlledand medical treatment should be halted does not mean that the patient no longerrequires care.2 Every effort must be made to ensure that a resident's last days arespent in as much comfort and dignity as possible and according to the residentʼswishes.1 Although it is natural and happens to everyone, many caregivers areuncomfortable with death and do not have the proper training on how to deal withresidents who are in this final stage of life.3 The following are guidelines and tools forclinicians to use as they help residents and families through this difficult time.

In the final hours of life, care providers must be the support system for both the residentand their family. They not only provide physical care to the patient, but also act aseducators and advocates, offering calm and empathetic reassurance that is critical tohelping residents and families at this time. Clinical issues that often occur include themanagement of feeding and hydration, changes in consciousness, delirium, pain,breathlessness and secretions. These concerns are dealt with in similar fashions inboth the institutional and home healthcare settings. However, matters such asassuring privacy, cultural observances and communication can be more difficult inthe institutional setting. In anticipation of the event, it is imperative to inform the familyand other members of the healthcare team about what to do and what to expect. Caredoes not end until the family has been supported with their grief reactions and thosewith complicated grief have been assisted in receiving care.3

About the authorMegan Schramm, RN, CNOR, RNFA, currently a clinical nurse consultant, has been an RN for more than 10 years. Previously, she worked as a nurse at a number of acute care facilities and trauma centers.

References1 Lipson S. End of life care: A guide for seniors and caregivers. Available at:www.americangeriatrics.org/education/forum/endoflife.shtml. Accessed September 3, 2008. 2 National Cancer Institute. End-of-Life Care: Questions and Answers. Available at: http://www.cancer.gov/cancertopics/factsheet/Support/end-of-life-care. Accessed September 3, 2008. 3 Yox S (ed). The last hours of living: Practical advice for clinicians. Available at:www.medscape.com/viewarticle/542262. Accessed September 2, 2008.

Guidance for clinicians

By Megan Schramm, RN, CNOR, RNFA

Treatment


Resident status: What to look for3

• Decreasing function• Poor hygiene• Tired all the time• Bruising over bony prominences • Skin breakdown, wounds that donʼt heal• Anorexia• Poor food intake, “just not hungry”• Aspiration• Peripheral edema• Dehydration• Tachycardia• Hypertension followed by hypotension• Cooling of the peripheries• Bluing or cyanosis of the extremities• Mottling of the skin (livedo reticularis) • Dark urine followed by anuria• Increased drowsiness• Difficulty awakening• Unresponsive to verbal and then tactile stimuli• Verbally unresponsive or delayed and inappropriate responses• Early signs of cognitive failure (for example, day and night reversal)• Agitation, restlessness• Purposeless, repetitious movements• Moaning, groaning• Change in respiratory rate: more rapid at first and then slowing• Decreased tidal volume• Abnormal breathing patterns: Apnea, Cheyne-Stokes respirations,

agonal respirations• Loss of the ability to swallow• Incontinence of bowel and bladder• Facial grimacing• Loss of the ability to close oneʼs eyes

Rare, unexpected events3

• Bursts of energy just before death; the “golden glow”

Guidelines for communicating with family3

• Talk to the family in the appropriate setting: Bring the family to a private area, such as a conference room, where personal informationcan be shared and they are free to share their feelings and emotions.

• Ask what they understand: Make sure everyone is up to date on thestatus of their loved one.

• Tell the news: Be polite but donʼt try to “sugarcoat” the news. Come right to the point.

• Respond to their emotions with empathy: Families will express a wide variety of feelings: sadness, anger, relief. Let them know it is okay to feel the way they do.

• Conclude with a plan: Help the family to make arrangements such as funeral, financial or care of a spouse.

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Brianna and Monica drove to the back of Shady OakLong-Term Care Facility and got out of the car. Theyspent a few minutes gazing at the lake and taking in theserene environment before locking arms and walkingthrough the door. Today, after signing the appropriatepaperwork, they would officially change their employmentstatus at Shady Oak from nursing assistants to gradu-ate nurses.

They were halfway down the hallway to the Director of Nurs-ingʼs office when they heard heart-wrenching sobs comingfrom Sophiaʼs room. Sophia, a sweet lady in her mid-seventies,had been a resident at Shady Oak for several years and hadendeared herself to Brianna and Monica. They stopped,looked at each other and knocked softly on Sophiaʼs door.They entered Sophiaʼs room to find her lying in bed sobbinguncontrollably while gasping for air. Brianna gently graspedSophiaʼs hand while Monica instructed Sophia to take someslow, deep breaths. When her breathing was controlled,Monica asked Sophia why she was crying.

Sophia said she was scared because she had fluid in herlungs and needed to go to the hospital. She went on to saythat she didnʼt want to go to the hospital because when herfriend Nona went to the hospital she got sick andnever returned to Shady Oak. Sophia then started wailingthat she didnʼt want to go to the hospital and she didnʼt wantto die. Monica again told Sophia to take some slow, deep

breaths. When she started to relax, they explained to Sophiathat she needed to go to the hospital so they could do tests,including a chest X-ray, so she could get medication thatwould help the fluid in her lungs go away.

Sophia asked Brianna and Monica to go with her to the hos-pital. They explained they could not go with her, but reas-sured her that she would receive excellent care. Thetransport team arrived and rolled a stretcher into Sophiaʼsroom. The nurse on duty handed the transport team had acopy of Sophiaʼs record as well as the nursing notes andmedication record while Brianna and Monica assisted theteam in moving Sophia onto the stretcher. As she was beingwheeled out the door, the girls reiterated to Sophia shewould receive wonderful care at the hospital and they wouldsee her soon.

Improving transfers Residents of long-term care facilities are diverse in age andprimary diagnosis. Common reasons for these residents tobe transferred to acute care facilities include pneumonia,influenza, urinary tract infections, fluid volume depletion,heart failure and injury. According to a literature review, eld-erly residents of long-term care facilities are most vulnerablewhen transferred to an acute care facility for treatmentbecause of physical and or cognitive impairments that placethe elderly population at risk for developing complicationssuch as delirium, pressure ulcers or a functional decline dur-

The TransferChallenge

By Jayne Barkman, RN, BSN, CNOR

Prevention

Minimize fear,facilitate communication

44 Healthy Skin

ing hospitalizations. Approximately 25 percent of elderlylong-term care residents are hospitalized annually and 12percent of this population will die during their acute care stay.

When a resident requires acute care, explaining why thehospitalization is needed as well as what to expect in thehospital – along with reassurance that good care will beprovided – will help minimize the residentʼs fears. A report-ing tool, such as a standardized form or checklist, should beused when transferring a resident to verify that all pertinentinformation about the resident is provided during the transferto facilitate communication between the long-term and acutecare facilities regarding the condition and needs of the resident.

If your facility does not have a checklist or a similar reportingtool that is used when a resident is transferred from your facilityor to your facility, ensure you have the information listed below.

Reference1 Malone M, Danto-Nocton E. Improving the hospital care of nursing facility residents.Annals of Long Term Care: Clinical Care and Aging. 2004;12(5):42-49.

About the authorJayne Barkman, RN, BSN, CNOR, has 29 years of perioperativeexperience in various roles, including surgical technologist, staffnurse and clinical educator. She currently works as a clinicalnurse consultant.

When transferring a resident to an acute care facility, provide1:

• A written description of the acute problem and chief complaint

• Current vital signs• Current medication administration record (not the

monthly computerized orders)• List of resident allergies• Recent nursing notes• Progress notes from the physician, physician assistant

or nurse practitioner• Recent laboratory and diagnostic test results• Status of skin integrity and pressure ulcers• Information on what comforts and agitates the resident• Family and/or emergency contact information for

the resident

When receiving a resident from an acute care facility, obtain:• Summary of the hospital admission• Procedures performed• Laboratory and test results• Updated list of medications, including discontinued meds• Follow-up appointments, suture removal or dressing

changes the resident may need• Status of surgical wounds or pressure ulcers• Dietary changes, supplemental oxygen, pain control

or specialized equipment needed for the resident

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Visit www.medline.com/interiors to explore all of ourfurnishing options. While you’re there, don’t forgetto try our Living Spaces Virtual Designer, a handyonline tool that can help you create your own residentrooms – free of charge! Of course, our InteriorsSpecialists are waiting to help you as well.

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46 Healthy Skin

Debridement, Pain and Odor Control Using a Hydrogel with a Superabsorbent Polymer Core Dressing*

ProblemAnalysis of our wound healing rateswith the digital planimetry** woundtracking program revealed we weredebriding wounds anywhere from fiveto 10 weeks. There were significantcomplaints of wound pain and peri-wound damage with our currentdebridement methods.

MethodologyCurrent methodology methodsincluded alginates, gels, enzymes andan occasional surgical debridement. Anew hydrogel dressing* comprising aknitted polyprylene fabric cover withan absorbent core containing super-absorbent polymers, saturated withRingerʼs solution, was utilized. Thepres-saturated pads come in differentsizes and styles. The pad was placedon the wound and covered with asecondary dressing and changedevery day and as needed if soiling orstrikethrough occurred.

RationaleMaintaining a moist wound environ-ment will facilitate debridement ofnecrotic tissue through autolysis or“autolytic” debridement. Ringerʼs solu-tion is isotonic and skin friendly,containing sodium, potassium, cal-cium and chloride. Wound odor oftenincreases with necrotic tissue and canbe offensive to the patient and staff.

OutcomesAll patients showed significantimprovement in seven to 10 days withsoftening and liquefication of necrotictissue. All the wounds were debridedin four weeks. There were no com-plaints of pain or other complications.Once the wound bed was prepped,the patients were advanced to anotherdressing.

Case study: MRMR is an 87-year-old male who presents with aStage IV pressure ulcer on his sacrum. Other med-ical diagnoses include diabetes, PDV, dementia,HTN and malnutrition. MR was admitted from thehospital on May 8, 2007 with this chronic sacralpressure ulcer. The wound measured 9.1 cm x 5.3cm by 0.1 cm with a thin layer of yellow slough anda nongranular wound bed. The periwound skin wasindurated with rolled edges. The hydrogel super-absorbent polymer core dressing was used to treatthe wound; the periwound skin was treated withOlivamine-containing repair cream.*** Diapulsetreatment with six peak power by 600 frequency for30 minutes six days per week was also performed.On July 10, 2007, the wound showed significantprogress and edges were starting to advance. Sig-nificant improvement was also noted on the peri-wound skin. Because of the continued progress,the wound care team felt that the current treatmentregimen should continue. The wound was resolvedon November 13, 2007.

Case study: TMThis 69-year-old female was admitted on May 24,2007 with diagnoses including a CVA with righthemiplegia, dementia, diabetes, Parkinsonʼs dis-ease, a Stage IV pressure ulcer on the left heel anda Stage IV sacral pressure ulcer. The sacral pres-sure ulcer measured 4 cm x 6 cm c 3 cm with pres-ence of necrotic slough and significant erythema tothe periwound skin. The inner wound bed hadbrownish necrotic tissue. The initial treatment in-cluded irrigating the wound with an antimicrobialcleanser**** and the hydrogel superabsorbentpolymer core dressing. The periwound skin wasprotected with the Olivamine-containing repaircream.*** By May 29, 2007, the sacral wound bedhad significant granulating tissue, limited scatteredyellow slough and the periwound with no erythema.By November 30, 2007, the sacral pressure ulcerwas decreased in size to 1 cm x 1 cm x 0.4 cm.

Sacrum 5/8/07

Sacrum 5/29/07

Sacrum 7/10/07

Sacrum 11/13/07 resolved ulcer

Sacrum 10/9/07

CASE STUDY


Case study: NHNH is a 76-year-old bedbound female who pres-ents with diagnoses of Alzheimerʼs, CAD, HTN andbreast cancer with left mastectomy. She is at highrisk for the development of pressure ulcers andpresents with multiple pressure ulcers, including anecrotic tissue-filled sacral wound. The initial treat-ment included cleansing the wound and varioustreatments of silver sulfadiazine cream, Miconazolecream and an enzymatic debriding agent.***** OnOctober 23, 2007, the wound care team observedsignificant change in the sacral pressure ulcer withinduration and increase in necrotic tissue. Treat-ment was changed to the hydrogel with a super-absorbent polymer core dressing, diapulsetreatment and antibiotic coverage. On November13, 2007, the sacral pressure ulcer was filled withgranulation tissue.

Case study: LGLG is a 75-year-old male who was admitted withdiagnoses of CAD, renal failure, sacral pressureulcer and bilateral BKA with multiple surgicalwounds to the right stump. The sacral pressureulcer measured 15 cm x 10 cm x 3 cm with yellow-ish-grayish slough. The initial treatment includedhydrogel superabsorbent polymer core dressingand protecting the periwound skin with an Oli-vamine-containing zinc barrier paste.****** Dia-pulse treatment of six peak power by 600frequency for 30 minutes six days per week wasalso performed. On May 19, 2007, the sacral pres-sure ulcer was re-evaluated and improvement wasobserved with a decreased amount of necrotic yel-low slough and treatment continued. By May 29,2007, the sacral pressure ulcer measured 12 cm x8 cm x 0.6 cm. On June 6, 2007, the dressing waschanged to an antimicrobial dressing as the woundwas thought to have a high bacteria load. OnMarch 11, 2008, the sacral wound was progress-ing well.

Conclusion This polyacrylate pad not only main-tained a moist environment, it alsoabsorbed exudate and odor,decreased pain in the wound bed andwas non-irritating to the periwoundskin. The digital planimetry improvedthe way we document our woundprogress and brought our wound teamcloser together.

References 1 Brugisser R. Bacterial and fungal absorptionproperties of a hydrogel dressing with a superabsorbent polymer core. J Wound Care.2005;14(9). 2 Konig et al. Enzymatic versus autolytic debridement of chronic leg ulcers: a prospectiverandomized trial. J Wound Care. 2005;14(7). 3 Paustian C, Stegman MR. Preparing thewound for healing: the effect of activated polyacrylate dressings on debridement. Ostomy/Wound Management. 2003;49(9):34-43.

* TenderWet from Medline Industries, Inc.,Mundelein, IL

** PictZar Digital Imaging by BioVisual Technologies Inc., Brooklyn, NY

*** Microklenz from Carrington Laboratories, Inc., Irving, TX

**** Remedy Skin Repair Cream from Medline Industries, Inc., Mundelein, IL

***** Remedy Calazime from Medline Industries,Inc., Mundelein, IL

****** Accuzyme from Healthpoint, Fort Worth, TX

Sacrum 10/23/07

Sacrum 11/13/07

Sacrum 5/19/07

Sacrum 5/29/07

Sacrum 3/11/08

Carline Joseph, RN, ANP, Anne Captain, PTA, Paul Rosenstock, MD, Kay Gittens CNA, Phyllis Quinlan, MSN DONSephardic Nursing CenterBrooklyn, NY

Elizabeth OʼConnell-Gifford, MBA, BSN, RN, CWOCN, DAPWCAMedline Industries, Inc.Berne, NY

48 Healthy Skin

OverviewPneumonia is a common infection and a major cause of morbidity, mortality andhospitalization among nursing home residents.1,2 It is especially common inwinter and early spring months when respiratory diseases are prevalent.3 Themost common cause of bacterial pneumonia in LTC residents is Streptococcuspneumoniae. Other bacterial causes of pneumonia include Chlamydia pneumo-niae, Legionella pneumophila, and Mycoplasma pneumoniae. Respiratory virusessuch as Influenza virus can also cause pneumonia.4

Infection Control:

PNEUMONIA

Streptococcus


Careful selection and use of antibiotics is an importantstrategy for discouraging the emergence of antibioticresistant bacteria.6,7 Today, bacterial resistance to flouro-quinolones is seen more commonly among nursing homeresidents than among the community-dwelling elderly popula-tion.5 Antibiotic resistance is encountered in the treatment ofpneumonia. In particular, Strep. pneumoniae strains havebecome increasingly resistant to antibiotics such as penicillin,erythromycin, trimethoprim-sulfamethoxazole, cephalosporins,and fluoroquinolones.4 The significance of bacterial resistanceto antibiotics is that treatment of infections caused by suchbacteria can entail the use of multiple antibioitics and mayrequire hospitalization.

Outbreak prevention and controlTo prevent pneumonia, follow the steps below: 1. Identify residents at risk. These are residents who:1,2,9,10,11

• Are older • Live in close proximity to others • Are confined to bed • Have had a recent hospitalization • Experience episodes of aspiration (Residents with

dementia, stroke, or feeding tubes are particularly at risk.)

• Develop viral respiratory infections, especially Influenza.• Have certain chronic conditions

– Pulmonary diseases such as asthma, bronchitis, – ephesema, bronchiectasis, as well as those who smoke– Heart disease – Alcoholism – Malnutrition – Immunosuppression

2. Immunize these residents with polyvalent Streptococcal vaccine.6,8

3. Reduce opportunities for transmission by separating residents with symptoms of active pneumonia from asymptomatic residents at risk of becoming infected.

Practical guide to quality improvementEffective infection control is essential for preventing transmissionand outbreaks of pneumonia.

Part 1: Vaccination against Pneumococcal pneumonia1. Develop an administrative framework for vaccination.

a.Designate a single person to be responsible for the nursing home's vaccination plan (e.g., your infection control practitioner).

b.Establish standing orders for pneumococcal vaccination.4

c.Develop written policies covering vaccine administration for residents.

2. Establish a vaccination program using the ACIP vaccination algorithm for all residents.

a.Seek consent from the resident or family member to provide vaccination at admission. Give the vaccination to residents aged >65 years upon admission when4:

– There is no prior documentation of pneumococcal vaccination.

– Prior vaccination was administered when the residentwas <65 years of age and >5 years have elapsed since first dose.

3. Use the time of yearly influenza vaccination as an opportunityto identify residents in need of the pneumococcal vaccine.4

Keep in mind that the influenza vaccine is administered yearly, whereas the pneumoccocal vaccine is most often given only once.4Administering both vaccines together is safe.

4. Keep resident vaccination records available and up to date. 5. Use a centralized vaccination log in addition to recording

vaccination information in a part of your clinical record thatwill not be thinned.

Part II: Organizational strategies for treatment and outbreak controlAlthough pneumonia outbreaks are uncommon, they haveoccurred in nursing homes with low vaccination rates.6,8 Useactive surveillance to identify outbreaks, and have a plan forcontrolling the spread of infection should an outbreak occur inyour facility.1. Develop a written policy for managing a pneumonia

outbreak. This policy should: a.State your specific activities for pneumonia surveillance.

Prevention

Continued

50 Healthy Skin

b.State the criteria for pneumonia diagnosis (e.g., confirmation by cultures of blood or pleural fluid).7

c.State the criteria for cluster identification (e.g., finding three people on the same ward who have developedpneumonia-like symptoms).

d.Assign responsibility for outbreak management to a particular individual (e.g., your infection control practitioner).

e.Develop isolation standards for the occurrence of pneumonia.

2. Use routine surveillance to detect pneumonia outbreaks early. Look for residents with pneumonia-like symptoms.13

a.Single shaking chill b.Fever c.Pain with breathing d.Sputum producing cough (may be dry initially) e.Dyspnea

3. Notify the facility medical director whenever there is a suspected case of pneumonia.

4. Develop and maintain a complete infection control record of suspected cases, including:

a.Name, age, and sex. b.Influenza and pneumococcal vaccination status. c.Date of symptom onset. d.Date personal physician notified. e.Room location (i.e., wing, floor, and room number). f. Major underlying medical conditions. g.Initial signs and symptoms (e.g., temperature, pulse,

respirations, etc). h.Diagnostic results (e.g., chest x-ray, lab results). i. Interventions and treatments provided. j. Outcome.

References1 Vergis EN, Brennen C, Wagener M et al. Pneumonia in long-term care: Aprospective case-control study of risk factors and impact on survival. Archives ofInternal Medicine. 2001;161(19):2378-81. 2 Muder RR. Pneumonia in residents of long-term care facilities: Epidemiology,etiology, management, and prevention. American Journal of Medicine.1998;105(4):319-30. 3 Pneumococcal disease. In: Centers for Disease Control and Prevention. Epi-demiology and Prevention of Vaccine-Preventable Diseases, 7th Edition (ThePink Book). Atlanta, GA. 2003. 4 Centers for Disease Control and Prevention. Prevention of pneumococcal dis-ease: Recommendations of the advisory committee on immunization practices(ACIP). Morbidity and Mortality Weekly Report. 1997;46(RR-8):1-25. 5 Kupronis BA, Richards CL, Whitney CG, Active Bacterial Core SurveillanceTeam. Invasive pneumococcal disease in older adults residing in long-term carefacilities and in the community. Journal of the American Geriatrics Society.2003;51(11):1520-25. 6 Nuorti JP, Butler JC, Crutcher JM et al. An outbreak of multidrug-resistant pneu-mococcal pneumonia and bacteremia among unvaccinated nursing home resi-dents. New England Journal of Medicine. 1998;338(26):1861-68. 7 Palleres R. Treatment of pneumococcal pneumonia. Seminars in RespiratoryInfections. 1999;14(3):276-84. 8 Centers for Disease Control. Outbreak of pneumococcal pneumonia among un-vaccinated residents of a nursing home - New Jersey, April 2001. Morbidity andMortality Weekly. 2001;50(33):707-10. 9 Musher DM. Pneumococcal pneumonia including diagnosis and therapy of in-fection caused by Penicillin resistant strains. Infectious Disease Clinics of NorthAmerica. 1991;5(3):509-21. 10 National Institute of Allergy and Infectious Diseases. Fact Sheet: Pneumococ-cal Pneumonia. August 2001. 11 ReichmuthKJ, Meyer KC. Management of community-acquired pneumonia inthe elderly. Annals of Long-Term Care. 2003;11(7):27-31. 12 Bernstein JM. Treatment of community-acquired pneumonia-IDSA guidelines.Chest. 1999;115(3):9S-13S. 13 Pneumococcal pneumonia. In: Beers MH, Berkow R, eds. The Merck Manualof Diagnosis and Therapy. 17th edition. Merck & Co. 2003. 14 Centers for Medicare and Medicaid Services. New Pneumonia GuidelinesCan Improve Care. 9/8/00. 15 Centers for Medicare and Medicaid. Pneumonia National Project Overview.

Reprinted with permission from the Texas Department of Aging and DisabilityServices.

Influenza

Be sure to check out our Form & Tool on pneumonia control on Page 86!

©2008 Medline Industries, Inc. Medline and Silvertouch are registered trademarks of Medline Industries, Inc.

Catheter-associated urinary tract infections (CAUTI) represent

approximately 40 percent of all healthcare-acquired infections.1

Silvertouch® Foley catheters from Medline can help you stack

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Every Silvertouch catheter is lined inside and out with ionic silver,

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References 1. http://cdc.gov/ncidod/dhqp_uti.html

* In-vitro test data on file.

To learn more about Silvertouch catheters, contactyour Medline representative or call 1-800-MEDLINE.

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Don’t gamble with patient safety.


Now more than ever, hand hygiene compliance is crucial.

Beginning October 1, 2008, the Centers for Medicare &

Medicaid Services will no longer be reimbursing for eight

hospital-acquired conditions, including urinary tract, surgical

site and bloodstream infections.1 We know that hand

hygiene is the number one line of defense against hospital-

acquired infections.2

There’s no such thing as

“overeducating” when it

comes to hand hygiene.

Enhance your current

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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 representative or visit

www.medline.com/handhygiene.

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For all the lives you touch.

References1 Centers for Medicare & Medicaid Services. Medicare program; changes to the hospital inpatient prospective payment systems and fiscalyear 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. Healthcare Purchasing News. Available at:http://www.hpnonline.com/inside/2003-11/1103hygiene.htm. Accessed November 20, 2007.

ads_v2.qxd:Layout 1 3/17/08 2:16 PM Page 3


In May 2008, the Association for Professionals in InfectionControl and Epidemiology (APIC) issued five steps everyresident and their family can take to become their ownadvocate and reduce the risk of developing an infectionduring a facility stay.

1. Infection Prevention and Control ProgramAsk the long-term care facility (LTCF)/nursing home about theirinfection prevention and control program. Talk with the assignedinfection prevention and control professional (ICP). Discuss thestrategies in place in the facility for infection prevention.

2. Hand HygieneGerms may be present on a resident, visitor and/or staff andalso on many surfaces in healthcare facilities including bedrails, over-bed tables, wheelchairs, walkers, faucets and eventhe TV remote control. Residents, visitors and staff can carrythese germs on their hands. Proper hand hygiene is essential.Hand hygiene means washing hands with soap and water for15 seconds to 20 seconds or using a 60 percent alcohol handsanitizer. It is not impolite to insist that anyone who is givingcare or touching a resident practice hand hygiene. This includesdoctors, nurses, nursing assistants and visitors. In caring forresidents with memory loss, it is important to remember thateveryone needs to help with resident hand hygiene.

3. AntibioticsIf antibiotics are being given, ask the reason antibiotics wereprescribed. Once prescribed, the full course of medicationshould be taken as directed. Donʼt insist on antibiotics if thedoctor doesnʼt advise them because overuse can lead toresistance and other problems.

4. Urinary CathetersSometimes urinary catheters are necessary; however they cansignificantly increase the risk of infection. Urinary cathetersshould be removed as soon as they have fulfilled the need forplacement. Ask about the need for a catheter. If you are a familymember and help to give care to the resident, talk to the ICPabout what you should do to prevent an infection.

5. Immunizations It is very important to have up-to-date immunizations. Onadmission to a nursing home, a resident should be askedabout their immunization status and offered any immunizationsthey need. This includes the Pneumococcal pneumonia vaccineif not already done before admission and the influenza vaccine.Family and visitors should also make sure they receive the fluvaccine during flu season to minimize the risk of transmissionto residents. Ask the facility about the influenza program fornursing home staff.

Source: The Association for Professionals in Infection Control andEpidemiology, Inc. (APIC)

APICʼs mission is to improve health and patient safety by reducingrisks of infection and other adverse outcomes. The Associationʼs morethan 11,000 members have primary responsibility for infectionprevention, control and hospital epidemiology in health care settingsaround the globe, and include nurses, epidemiologists, physicians,microbiologists, clinical pathologists, laboratory technologists andpublic health practitioners. APIC advances its mission through edu-cation, research, collaboration, public policy, practice guidance andcredentialing.

Recommendationson Infection Prevention

in Long-Term Care

Prevention

54 Healthy Skin

Thornapple Manor, a 138-bed facility located inHastings, Michigan, provides skilled and intermediatecare for residents. For more than 100 years, ThornappleManor had been addressing continence with reusable clothproducts, most recently a cloth brief with rubber backingand snap closures. When the CMS guidelines for TagF315 were revised, the staff considered switching to dis-posable briefs. This coincided with a major renovationwherein “neighborhoods” replaced institutional hallways.

Thornapple Manor had never seen a need to move todisposable briefs because they had so few skin issues dueto incontinence. Jackie Schantz, DON suspects this could betraced to good skincare protocols and their policy of open-airing on a cloth underpad when residents were in bed,which allowed air to flow to the skin. However, this also

Treatment

Culture Change In BriefsUsing disposable undergarments to boost satisfaction and protection

By Deb Tenge, RNC, MS, CWOCN, Licensed Administrator

meant that many bedridden residents would be nude fromthe waist down during the day. This didnʼt fit the new resi-dent-centered culture, however – after all, these residentswould not have been nude in bed at home. In the past, somefamilies had questioned why their loved one was not allowedto wear clothes under the sheets. The new disposable briefsallowed the residents to be clothed in bed, improving dignityand comfort. Also bolstering dignity was the fact that the newdisposable briefs were trim enough to be virtually invisibleunder clothing.

Another positive result was odor control, thanks to the poly-mer used in most brands of disposable absorbent briefs. Thehighly absorbent polymer powder helps to neutralize urineodors in addition to absorbing fluids.


A shadow box containing itemsimportant to the resident hangsoutside each room at Thornapple.

The entry to Thornapple Manor

Education plays a big part in good skin care at Thornap-ple. The CNAs are all knowledgeable about proper skincleansing, performing skin checks, the importance ofnutrition and hydration and moisturizing and protectingwith barrier products. Bathing assistants are also on thelookout for changes in the skin. “All staff has a focus onskin,” says Jackie. “Pressure ulcers are not allowed here.”

Obviously, this type of conversion affects the budget inseveral ways. With disposables comes a monthly cost,but laundry costs at Thornapple were reduced substan-tially. This savings reflects an 18,000 pound drop permonth in laundry. Thornapple Manor realized approxi-mately 160 hours of labor savings per pay period.

One costly problem that was solved was the issue ofsewer system blockage from cleansing wipes. The facil-ityʼs policy now is to provide incontinence care and thenplace the wipes within the soiled disposable incontinenceproduct to be thrown away. This has saved the facilitydollars in plumbing mishaps.

Thornapple Manor has seen improvements in: • Odor control• Skin integrity• Family satisfaction• Resident satisfaction

Thornapple Manor has continued to keep abreast of theneeds of their community and also maintain regulatorystandards set by the State of Michigan. They have targetedthe needs of their residents and have demonstratedregulatory compliance with F315 and at the same timeremained cost effective in the challenging reimbursementworld of long-term care.

About the authorDeb Tenge, RNC, MS, CWOCN, Licensed Administratorhas a career in health care that spans 25 years, with 13years in the acute hospital setting. The past 12 years ofher career have focused on the long-term care arena. Shewas an executive quality assurance nurse for a 31-facilitychain in Iowa and assisted facilities in maintaining com-pliance with state and federal regulations.

Ruth Hoffman, seven-yearCNA at Thornapple, pulls incontinence supplies.


The 100 percent breathable side panels in Restore/Remedybriefs don’t just keep your residents more comfortable. Improved airflow also helps to reduce skin irritation.

Skin nourishment is built right into every Restore/Remedydisposable brief. That’s because each brief’s inner liner is coated with Medline’s Remedy™ Skin Repair Cream. Using a combination of the Remedy skincare line and theRestore/ Remedy brief has shown to keep the pressureulcer incidence rate and IAD prevalence rate consistentlydown in a facility.1

The absorbent UltraCare core helps provide maximum dryness for improved comfort and healthier skin. And theanti-leak cuffs perform effectively better than standard cuffs,which help to protect clothing and bedding. The cloth-likeouter cover is comfortable against the skin, helping to minimize rash or irritation.

Skin-safe closures with “grab anywhere” technology allow for the best possible fit and also reduce waste. Now caregivers can quickly check and refasten briefs.

Restore/Remedy is a unique product of its kind on the mar-ket with skin nourishment built right in.

For more information about Restore/Remedy dispos-able briefs, contact your Medline representative orcall us at 1-800-MEDLINE.

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.

www.medline.com

It's another level of comfort andprotection


Say Goodbye to Soap and Water

Bathing modifications for senior skin

Can you name the largest organ in the human body? Liver?Nope. Intestines? Nada. Believe it or not, the skin coversapproximately 1.5 to 2 square meters on the average adult.1 Allof that coverage provides a protective barrier between the envi-ronment and our bodies. It also mirrors the health status of theperson, giving greater insight into physical, social and psycho-logical status.2 Although skin care is important at all ages, theelderly have particular concerns that need to be recognized andtreated effectively.3

Dry skin is common in the elderly. As we age, our skin begins tothin. As a result, the structures of the dermis are not as wellprotected and can be easily damaged.4 The thinner the skin, theless it is able to retain moisture, thus leading to dry skin. Thinnerskin often contributes to pressure ulcers and skin tears. Theseconditions can contribute to infection, as any break in the skincan allow bacteria to enter.

It is very important to keep older skin clean; however, manysoaps and cleaning products can lead to dryness and itching.More importantly, they can strip the acid mantle, which canlead to dryness, infection and itching. Whatʼs more, water ac-tually has the effect of a drying agent.3

Here are some hygiene guidelines to follow when caringfor elderly individuals:• Avoid soaps that can strip the skin of its acid mantle.3• Try not to use lather-rich products, as they often contain harsh

detergents that can quickly dry out the skin.4• Use products that contain moisturizing agents.3• Avoid extremes in temperature. Very hot or very cold water

can be damaging to the skin.4• Be sure to dry the skin thoroughly, using a soft cloth.4

The regular use of moisturizers, especially after washing, canhelp to lessen dry, itchy skin.3 These creams help seal in thebodyʼs natural moisture.4

Here are some ways to help moisturize residents4:• Humidify the air.• Apply a generous amount of moisturizing cream on the skin.• During the day, especially if the resident spends time outdoors,

apply sunscreen.

The key to good skin care is one-on-one attention to details.Most of the routine skin care nursing home residents require canbe provided by the staff who care for them daily. Protocols andprocedures for bathing, turning them regularly and keeping theirskin moisturized will go a long way toward preventing manyof the skin problems of the elderly.5

References1 New World Encyclopedia. Skin. Available at:http://www.newworldencyclopedia.org/entry/Skin. Accessed September 10, 2008. 2 Pritchard B. Care of the skin in the elderly person. British Journal of Healthcare Assistants. 2007;1(3):110-112.3 Starner L. Elderly skin care- what you need to know. Available at: http://EzineArticles.com/?expert=Lynn_Starner. Accessed August 21, 2008.4 British Association of Dermatologists. Looking after elderly skin – a simple guide.Available at: www.bad.org.uk/healthcare/guidelines/elderly_skin_care.pdf AccessedAugust 21, 2008.5 Norman RA. Caring for aging skin: a geriatric dermatologistʼs expert advice on skin care for LTC residents. Nursing Homes. 2003 April.

About the authorLaura Ballinger, CNA, has been working with the elderly since1989. She has worked at Signature HealthCARE Of Columbia, Ten-nessee for the past 13 years. Laura knows how important skin careis for the elderly. She strives every day to ensure her residentsʼ well-being, and a major part of that goal is good skin care.

By Laura Ballinger, CNA

Treatment

The soft cloths are formulated specifically for use in the

perineal area to combat and prevent perineal dermatitis.

• Soft washcloths and Spunlace wipes will not irritate skin

• Gentle cleansers (BZK) help to reduce bacteria and

control odors

• Dimethicone seals in moisture

• Product can be heated for added comfort

For additional information please contact yourMedline sales representative or call1-800-MEDLINE.

www.medline.com

Rub-a-dub-dubwithout the tub.

Make incontinencecare easy for your

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ReadyBath® TPC

ReadyBath® TPC (Total Perineal Care) washcloths are

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HS_ads_v5_i2.qxd:Layout 1 4/11/08 5:47 PM Page 4


By John Vest, CNA

How to make bath time more pleasant for everyone

Special Feature

Bathing is such a simple ritual, one many of ustake for granted. Most of us can not only bathe our-

selves, but do so when and where we want to. We cantake as much or as little time as we want and no one will

disturb us. Sadly, due to the importance of bathing and thelarge volume of nursing home residents who need assistance,

if not total care, this basic routine often succumbs to the forces ofinstitutionalization. Baths must be scheduled, worked within tighttime frames, accomplished quickly and performed one after theother in the most efficient way possible. Over the years, somebathing equipment has even become more high-tech rather thenrelaxing and inviting.1

Of all activities performed by nursing assistants, bathing is themost time-consuming and strenuous. Often, battles must befought with resistant residents, leading to resident frustration.Bathing facilities are often noisy and cramped. Privacy is com-promised and, in the hurry to "get it done," one of life's more re-laxing pleasures is anything but.1

When asked about their bathing experiences, many residents feelthat it is a stressful exercise rather then a restful part of the day.Even residents who can bathe themselves sometimes cite a fearof being walked in on by staff. Overall, some residents feel thatdignity has been removed from bathing.1

Adding dignity back into bathingThere are many things that can be done to preserve dignity andindependence when bathing. If they are able to do so, residentsshould be encouraged to bathe or shower themselves. Thebathing area should be prepared appropriately by the care-giver – keeping in mind that each residentʼs needs and abilitiesare different.

Bathing the Elderly with Dignity

60 Healthy Skin

Even if the resident needs complete assistance, simply askingthem when they want to bathe, rather then telling them when theywill be bathing, goes a long way. If addressed early in the day orshift, a convenient time for both resident and caregiver canoften be found.2

Underlying conditionsIt is important to remember that some medical conditions, such asAlzheimerʼs disease or dementia, can contribute to residents beingagitated or combative. When bathing these residents, try to main-tain a routine and stay calm. Try to bring the resident to the bathat the same time each day, preferably with the same person. Pre-pare everything ahead of time – run the bath, test the water andhave towels and a robe handy. Although it is not easy, especiallywhen there is more then one person to bathe, it helps if staff canremember that these people are not deliberately trying to frus-trate them. They truly might not know when they lastbathed and may feel confused, frightened or embarrassed.3

Take it slowMaybe the desired outcome wonʼt happen the first time, but withpatience, a little more is achieved with each intervention. Care-givers need to try to make bathing a calming experience. It is allright to start by just sitting and talking in the bathroom if the resi-dent is resisting bathing. After a while, you could say, "This bathwater is so nice and warm, and a bath would make you feel sogood" or "Iʼm going to wipe your face now, thereʼs something onyour cheek." If they resist, donʼt push. Try again each day – sametime, same routine. Take it in stages: One day, wash the feet, thenext day, the face. Often it is more effective to sponge one areathan to try to bathe the entire person.3

Adjustments for safetySome residents have a fear of water or showers and will fightagainst attempts to wash or bathe them. The most common fearis that they will fall. There are many assistive devices available toreduce the risk of falls. Stepping out of a shower can sometimesbe problematic for seniors. Grab bars and a shower mat are somehelpful tools to ensure safety. Seats can also be installed in show-ers. Be sure to securely install handles or grab bars in the showerarea to provide stability – donʼt rely on wobbly towel racks. Alsobe sure the area just outside the shower stall has a rubber matplaced on it to halt slipping. If the mat is thin enough, walkers orwheelchairs can be used right up to the shower entrance.4,5

Allow for modestyModesty is another major issue. Help residents understand thatthere is nothing wrong with this. If they are able to undress and

bathe themselves, simply do whatever other preparations are nec-essary and leave them alone. Be sure to make them aware thatstaff is nearby if they need anything and ensure that call bell pullsare close enough for them to reach if needed. If the residentrequires assistance with bathing, do not undress him fully. Justwash one area of the body at a time while keeping the residentpartly covered.4

An alternative to traditional bathing Pre-moistened, disposable wipes might be a good alternative tothe traditional bath for residents who are less ambulatory or morecombative. These wipes gently cleanse the skin and help reducecross-contamination from the reusable plastic basins used in basinbaths. There are wipes designed to meet specific needs, such astotal perineal care and antibacterial formulations. For maximumresident comfort, you can warm them before use.

The fostering of independence while maintaining resident safetyand providing for good personal hygiene are the goals of bathing.Staff shortages and the increasingly large elderly population donot make these objectives easy to achieve.

References1 Piner WD. Restoring dignity to bathing: The Spa at Arbor Acres provides a totalbathing experience. Nursing Homes. 2003 June.2 Caregiverʼs Home Companion. Timely Tip: Elder Bathing. Available at:http://www.caregivershome.com/news/timely_tip.cfm?UID=16&StartRow=61. Accessed August 28, 2008. 3 Caregiverʼs Home Companion. Ask an Expert – Elderly Behavior: How to OvercomeBathing Resistance. Available at: http://www.caregivershome.com/community/askex-pert_full.cfm?UID=101. Accessed August 28, 2008. 4 Elderly Care Tips. Washing An Elderly Person. Available at: http://www.elderly-caretips.info/Washing%20An%20Elderly%20Person.php. Accessed August 28, 2008.5 LifeTips. How do I know if my bathroom is safe? Available at:http://eldercare.lifetips.com/faq/41644/0/how-do-i-know-if-my-bathroom-is-safe/index.html. Accessed August 28, 2008.

About the authorJohn Vest, CNA, has been working in the medical field since 1983.He is currently employed at Signature HealthCARE of Columbia,Tennessee.


Tips to Create a More

EnjoyableResident Dining

Experience

Compiled by Healthy Skin staff

1. Serve food that smells and looks good, and serve it at the proper temperature.1

2. Include menu items based on residentsʼ own recipes.2

3. Offer a choice of foods at mealtimes.1

4. Plan menus so that foods are not repeated often. This can help prevent residents becoming bored with their meals.2

5. Serve finger foods, such as chicken nuggets, to residents who might be having trouble using their utensils.2

6. Dietary staff and nursing assistants can make eating more pleasurable by chatting and interacting with residents.3

7. Form a “resident food council” as a forum for residents to offer feedback on dining services, voice concerns and try new food items.2

8. Staff should be quick to offer residents help with their food – opening milk and yogurt cartons, buttering bread, etc.3

9. Consider offering native ethnic foods to residents who might have had them as a large part of their daily diet before coming to your facility.4

10. Display individual residentsʼ food preferences.3

References1 Medicare. Nursing Home Checklist. Available at:http://www.medicare.gov/Nursing/Checklist.asp. Accessed August 27, 2008.2 Illinois Council on Long Term Care. Nutrition: Strategies for Helping Residentsat Risk. Available at: http://www.nursinghome.org/fam/fam_016.html. AccessedAugust 27, 2008.3 Evans B, Crogan N, Armstrong Shultz J. Quality dining in the nursing home:the residents' perspective. J Nutr Elder. 2003;22(3):1-16.4 Sarfaty C. Nursing home focuses on ethnic needs. Home News Tribune. Avail-able at: www.alamedacenter.com/docs/HomeNewsTribuneArticle.pdf. AccessedAugust 27, 2008.

10Treatment

62 Healthy Skin


The bathrooms in your facility might seem innocent enough,but to some elderly residents they can become more of anobstacle course than a convenience. What can you do to makethem a safer, more convenient place to visit?

Color Close your eyes and picture an institutional bathroom. What is theprimary color you see? Many of us see a lot of white, and that canbe a problem for nursing home residents. Residents who have poorcolor discrimination might have trouble locating a white toilet seat ifthe flooring is also light or white, and male residents might havetrouble voiding into a toilet while standing if they have difficulty iden-tifying where the toilet stops and the flooring begins.1

Here, grab thisIdeally, toilets should be placed so that a staff member can stand oneither side of the resident.1 Angled grab bars are preferable to stan-dard horizontal grab bars, which are typically shorter and requirethe resident to have more upper body strength.1 With angled grabbars, residents can grasp the bar at a lower position and then moveup the bar, which can also increase transfer independence.1

Gain traction The National Institute on Aging suggests placing non-skid mats,strips or carpet on all bathroom surfaces that could possibly getwet.2 Donʼt skimp in this area – environmental hazards, such as wetfloors, account for 16 to 27 percent of falls in nursing homes.3,4

Raise the seatOSHA recommends using toilet seat risers for independentresidents as well as partially weight-bearing residents who arecooperative, can sit up unaided, have upper body strength are ableto bend their hips, knees and ankles.5

Bath boards and benchesThese devices can aid in resident transfer. OSHA recommendsplacing clothing or material between the residentʼs skin and theboard to help reduce friction and skin tears.5 For added residentcomfort, choose models with padded seats or back support.

Universally accessible sinks Making bathroom sinks accessible to all residents helps themremain independent in their grooming.1 Residents in wheelchairscan easily access sinks that have space under the bowl or that areaccessible from the side.1 While youʼre at it, you might want to takea look at the faucets on your sinks. Single-control faucets can proveproblematic for residents with poor grasping ability. Instead, chooseblade handles.1 Adjustments should also be made so that residentsin wheelchairs can see the mirrors placed above bathroom sinks.

References1 Maben PA. Designing a better bathroom: making bathrooms and toilet rooms safer and more comfortable. Nursing Homes. 2003 March. 2 National Institute on Aging. AgePage: Falls and Fractures. Available at:http://www.nia.nih.gov/HealthInformation/Publications/falls.htm. Accessed August 20,2008.3 National Center for Health Statistics. Health, United States, 2005. Hyattsville, Md: National Center for Health Statistics; 2005.4 Rubenstein LZ, Robbins AS, Schulman BL, Rosado J, Osterweil D, Josephson KR.Falls and instability in the elderly. Journal of the American Geriatrics Society.1988;36:266-78.5 Occupational Safety & Health Administration. Ergonomics: Guidelines for NursingHomes. Available at:http://www.osha.gov/ergonomics/guidelines/nursinghome/final_nh_guidelines.html. Accessed August 20, 2008.

Extreme Bathroom Makeover: Resident Safety Edition

Survey Readiness

64 Healthy Skin

How to Thrive in a Tough Economy

By Wolf J. Rinke, PhD, RD, CSP

Unless you are on another planet, it is likely that your organization has already gonethrough several “downsizings” or “rightsizings,” as your boss might like to call them.

Time to get depressed, right? Wrong!


Time to put yourself in the driverʼs seat of your career bydeveloping new skills that will enable you to take advantageof the opportunities that are unfolding before your veryeyes – opportunities that will enable you to not only survive,but thrive in this tough economy.

Think projectsOld organizations were organized by departments andposition titles. Today, projects accomplish most work. Tothrive in a project environment, recognize that work getsdone primarily by three distinct specialties. First, there arethe resource providers. These are the folks who developand supply talent or money. Your human resource manager

and financial officer would fit into this category. Next are theproject managers. They are responsible for making surethat the talent and resources are organized in such a waythat the project gets done. Next is the talent. These are thepeople who have the skills to get the job done, such asnurses, OR techs and other front-line healthcare profes-sionals. To thrive in this tough economy, it is important thatyou master “winning management” skills so that you canperform equally well in the project manager or resourceprovider role. (For details read my Winning Management:6 Fail-Safe Strategies for Building High-PerformanceOrganizations book.)

Think globalGlobalization is accelerating at a nanosecond pace. To takeadvantage of globalization, you must dramatically increaseyour cultural awareness. If you are now employed in aprimarily “homogeneous” organization and are not at least90 percent satisfied, seek employment in a multiculturalorganization. Donʼt know where to start? Get a copy ofFortuneʼs latest issue of either 100 Best Companies to WorkFor (typically published in February) or Americaʼs MostAdmired Companies (typically issued in March of everyyear) and apply to any of the companies listed. Want to stayin health care? Not a problem, there are many on either list.For example, Methodist Hospital System is in the number10 spot on the 2008 100 Best Companies to Work For andManor Care is in the number one spot for the HealthcareMedical Facilities Group in the 2008 Americaʼs MostAdmired Companies.

Equally important, learn a foreign language. If youʼre notfluent in at least one foreign language, you will be in trouble

Special Feature

real soon. And put your languageto work by traveling to a countrythat speaks the language of in-terest to you. Youʼll really learn tospeak it, become culturally sen-sitive whether you want to or notand will bring back a ton of great ideas to accelerate yoursuccess curve dramatically.

Become an effective team player and leaderLike it or not, teams are the way lots of work is being accomplished in todayʼs organizations. Being effective inthis environment requires that you learn how to empowerothers and master leadership and winning managementskills, and be equally comfortable and effective in a supportive role as in a leadership role. (For more, read myDonʼt Oil the Squeaky Wheel and 19 Other Contrarian Waysto Improve Your Leadership Effectiveness book.)

Focus on delivering exceptional quality serviceDelivering exceptional quality service is not an option, butrather a survival strategy. We must be absolutely clearabout who provides us with our paycheck. No, itʼs not yourboss or even your organization. It is the person you serve –an external or internal “customer.” As a litmus test of howcustomer-focused you are, look back at your calendar forthe last week to find our how much actual time youʼve spentwith your external or internal customers. If you are notspending at least one third of your time with your “cus-tomers,” you are messing up.

Become a problem solverOne of the best ways to position yourself for advancementor pay increases is to become a problem solver. In thistough economy, you can simply no longer expect to be com-pensated for time, only for results and problems solved. Soactively look for a problem that impacts negatively on thebottom line then put a team together and solve it. Then, letothers know (especially the powers-that-be) what a greatjob your team did and how much your team improved theprofitability of your organization. If you do that consistently,you will be ready to be promoted or negotiate for an increase in pay. (If youʼd like help with that, devour my Win-Win Negotiation CPE program.)

Think of yourself as self-employedSeeing yourself working forone company for the rest ofyour career is, to say it gently,crazy! Itʼs just not going to

happen! In this tough economy, itʼs important that you seeyourself as “self-employed,” or “renting” your services outto someone else (your employer). To get started, pretendthat you are an entrepreneur or a consultant who is sellingservices to a client (your employer). To make this realistic,compute your daily compensation. Be sure to add about 30percent for benefits. Then get in the habit of asking yourself“Have I created value today that exceeded my daily com-pensation?” Repeat that question every day you are atwork. You may even find it helpful to place a nice-lookingsign on your work station that asks “How are you creating$_____ of value today?”

The other side of the coin is to keep asking “How have Iʻgrownʼ in my job today?” To make this happen, think ofgoing to work each day with a “briefcase” of skills and com-petencies. At the end of the day, check your briefcase to seeif there is more in it than at the beginning of the day. If, dayafter day, what you bring to work is the same as what you take home, itʼs is time to move on to a more challeng-ing “assignment.”

Get in the habit of asking yourself,“Have I created value today that exceeded my daily compensation?”

Become an expert networkerOne of the most powerful skills you can develop is to become a highly effective networker, both inside and outsideof your organization. When it comes time to find a newassignment, your network, more than anything else, will determine how fast youʼll find your next dream job. To testyour networking effectiveness, ask yourself who you havebeen eating lunch with during the past week. If it is prettymuch the same people, you are missing tremendous net-working opportunities. Get in the habit of eating lunch with

IN THIS TOUGH ECONOMYyou can simply no longer expect to becompensated for time, only for results

and problems solved.

66 Healthy Skin

different people three out of five days a week, to sit with peopleyou donʼt know at meetings and to attend conferences thatare sponsored by groups other than yours.

Check yourselfTo assess how well you are achieving a competitive advantagein this tough economy, ask yourself the following diagnosticquestions:

Am I learning?If you are not constantly learning new things, your value inthe marketplace is diminishing rapidly.

Am I being taken advantage of?Your employer is taking advantage of you if you consistentlysacrifice your long-term development to put out short-term“fires.” Donʼt let your ego get the better of you when you arebeing told that you are so critical to the organization that “wecanʼt do without you.” Hogwash! No one is indispensable.Never, ever get caught in persistent short-term traps at theexpense of your long-term development.

If my job was open today, would I get it?Itʼs important that you “benchmark” your skills all of the time.

ASK YOURSELF...

• Am I learning?• Am I being taken advantage of? • If my job was open today,

would I get it? • Am I adding value?• Am I good at selling? • Am I energized by change? • Does my résumé focus

on contributions?




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

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fit your specific needs. We provide:

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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.

www.medline.com

Bringing it home to you


One way to do that is to look at the want ads to find out whatthe marketplace is looking for. If you do not possess theskills that the marketplace is looking for, itʼs time to investmore in yourself.

Am I adding value?How long does it take you to answer this question? If youare unable to answer it immediately, in fewer than two orthree sentences, you can assume that no one else knowshow you contribute value either. In that case, you are a likelytarget during the next downsizing.

Am I good at selling?Many healthcare professionals see no need to become excellent at selling. The reality is that you sell all the time.You sell your patient on getting better, you sell your boss ona raise and you sell your team members on an idea. Inaddition, you do the same at home with your spouse, childrenand even your pets. Since it is something you do all ofthe time, I recommend that you get good at it. No, wait, Irecommend you get great at it! So start looking for a qualitysales program and attend it this year!

Am I energized by change?If you are still fighting or resisting change, you are in trouble.All indications are that change will continue to accelerate at“hyper speed,” so you might as well start welcoming it.

Does my résumé focus on contributions?Finally, to check how focused you are on contributions, getout your résumé and check for specific outcomes, specificimpact on the organization and variety and content of work,projects and leadership experiences. Are you impressed?Would you hire this person? If so, congratulations!

The most important concept of all time: Take actionThere is one more skill that you need to master. This one ismore important than all the others. Itʼs the one skill that,when all else fails, will determine whether you will thrive inthis tough economy. The skill is to take action! Action letsyou know whether what youʼve tried works. If it does, domore of it. If it does not, try something else and start thesame process all over again. Soon youʼll find yourself suc-ceeding faster than you have ever thought possible. Andwhatever you do, avoid fretting about having failed – thereis no such thing, unless you make the same mistake overand over again. Action gets you away from bemoaningchange and mourning the lack of job security. Action will

liberate and empower you. Action will get you to grow,change and adapt. Action will provide you with virtual jobsecurity, will enable you to achieve the competitive advan-tage and assure that you thrive in this tough economy.

About the authorDr. Wolf J. Rinke, RD, CSP is a keynote speaker, seminarleader, management consultant, executive coach and editor ofthe free electronic newsletters Make It a Winning Life andThe Winning Manager. To subscribe, go to www.Wolf Rinke.com.He is the author of numerous books, CDs and DVDs includingWinning Management: 6 Fail-Safe Strategies for Building High-Performance Organizations and Donʼt Oil the Squeaky Wheeland 19 Other Contrarian Ways to Improve Your LeadershipEffectiveness, available at www.WolfRinke.com. His companyalso produces a wide variety of quality pre-approved continuingprofessional education (CPE) self-study courses availableat www.easyCPEcredits.com. Reach him at [email protected].

70 Healthy Skin

Two out of three employees feel that the flow of communication between

the departments of their facility is poor.

All information is important, but different

disciplines value and prioritize it in different ways.

Two out of three employees feel that the flow of communication between

the departments of their facility is poor.


Does your facility have a failure to communicate?If it does, youʼre not alone. Surveys show that two out of three employeesfeel that the flow of communication between the departments of their facilityis poor.2

First and foremost, healthcare providers, no matter what their discipline,want to give their patients the best possible care. If this is true, why arethere so many problems? It all comes down to communication.

Nursing homes often say that hospitals transfer all of their complex prob-lems to them. Hospitals claim that nursing homes never seem to send theright paperwork with their patients. Certainly it is not always this bad, but weare all guilty of similar thoughts from time to time.2

Although important, communication takes time – time that many peoplesimply do not feel they have.

Healthcare facilities are only getting bigger. Many hospitals are part of alarger system that not only includes acute care facilities but outpatient serv-ices, doctorsʼ offices, rehabilitation centers and long-term care facilities.Departments that need to communicate many be a floor away from eachother or miles apart in different buildings. Even with email and phones soreadily available, important information still gets forgotten.2

How can you help your own facility?So what can you do? There is no one simple solution for breaking down thebarriers of communication between healthcare providers of differentorganizations. Improvements need to be tailored to the needs of eachfacility. However, there are some basic guidelines that we can all follow.

First of all, the information that is truly important and necessary needs to beidentified. So often, time is wasted sifting through documents and repeatingthe same piece of information over and over. All information is important,but different disciplines value and prioritize it in different ways. Communi-

Why Can’t We All Just Get Along?

By Dayna Lowe, Clinical Instructor

Improving relationships between healthcare organizations

Special Feature

cation checklists for different departments could be devel-oped so that only necessary information is shared andnothing is missed. They would ensure the sharing of “need toknow” rather then “nice to know” information.2

Properly conducted team-buildingexercises can dramatically improve howwell department heads and staff mem-bers work with each other. Typically, thisrequires the use of an outside profes-sional with experience getting fellowemployees to unite as a team. Part ofthese exercises could also include staffrotating to other facilities to see “how theother half lives.” Not only does this giveeveryone a better understanding of whatother facilities do, it also gives employ-ees a more rounded perspective of howthe work of the organization is con-ducted and the importance of sharinginformation between departments. Itis also a great way fo different organ-izations to get to know one another.2

Facilities need to look into available com-munication technology and train theirstaff how to use communication toolsproperly. Without adequate education,these tools can be used incorrectly,causing more problems then they solve.

As we plunge headlong into the 21stcentury, health care will only continue toget bigger and more complex. Staff willbe expected to provide skilled services faster then everbefore. Administrators and managers of these organizationsmust set good examples for their staff. They must be ableto put aside any personal differences and work with one

another. They must communicate in an efficient and propermanner. Last but not least, they need to ensure that the bestpossible communication tools are available and that their staffhas adequate training on their use. Staff must learn to workwith new technology and with each other. They must

remember that this is all done for thegood of the patient.

References1 Plsek P. Interdepartmental communication in alarge hospital. Available at: http://www.plexusinsti-tute.org/ edgeware/archive/think/main_tales9.html.Accessed September 2, 2008.2 Katcher BL. How to improve interdepartmental communication. Available at: www.discovery-surveys.com/articles/itw-017.html. Accessed September 2, 2008.3 Spring Valley Hospital Medical Center. High marksfor prompt ER care. Available at: http://valleyhealth.uhspublications. com/winter2007/story2.html. Accessed September 2, 2008.

About the authorDayna Lowe has been a surgical tech-nologist for six years. She currentlyworks at a hospital in Florida and as anInstructor of Surgical Technology atCentral Florida Institute.

72 Healthy Skin

Communication checklistsfor different departmentscould be developed so that only necessary information is sharedand nothing is missed.

As the bariatric population of the country grows, the likeli-

hood that you will have more obese patients admitted to your

facility increases. But bariatric patients can’t use patient aids

designed for smaller people. You want to give bariatric pa-

tients the freedom to move around, not be forced to stay in

bed because he or she didn’t have a wheelchair or walking

aid to use. You also don’t want to risk patient or staff injury by

using equipment not rated for bariatric use.

Medline has a complete line of bariatric patient aids, including:

• Wheelchairs (up to 700 lb capacity)

• Walkers (500 lb capacity)

• Canes (500 lb capacity)

• Crutches (650 lb capacity)

• Bath benches (550 lb capacity)

• Transfer benches (550 lb capacity)

• Commodes (up to 850 lb capacity)

Call your Medline rep or go to www.medline.com tofind out more. And check out Medline’s other bariatricproducts, including patient lifts, pressure-reducingmattresses, briefs, furniture and more.

www.medline.com

Residents come in allshapes and sizes.


74 Healthy Skin

The greatest obstacle to successThe fear of failure is the single greatest obstacle to success inadult life. Taken to its extreme, we become totally preoccupiedwith not making a mistake, with seeking for security above allother considerations. The experience of the fear of failure is inthe words of “I canʼt,” “I canʼt.” We feel it in the front of the body,starting at the solar plexus and moving up to the rapid beating ofthe heart, rapid breathing and a tight throat. We also experiencethis fear in the bladder and in the irresistible need to run to thebathroom.

The fear of rejection holds you backThe second major fear that interferes with performance andinhibits expression is the fear of rejection. We learn this when ourparents make their love conditional upon our behavior. If we dowhat pleases them, they give us love and approval. If we do some-thing they donʼt like, they withdraw their love and approval–which we interpret as rejection.

The roots of a Type A behaviorAs adults, people raised with conditional love become preoc-cupied with the opinions of others. Many men develop TypeA behavior that is characterized by hostility, suspicion and anobsession with performance to some undetermined high stan-dard. This is expressed in the attitude of “I have to,” “I have to,” and is associated with the feeling that “I have to work harder and accomplish more in order to please the boss” who has become a surrogate parent.

The most common trapMore than 99 percent of adults experience both these fears offailure and rejection. They are caught in the trap of feeling,“I canʼt,” but “I have to,” “I have to,” but “I canʼt.”

The key to peak performanceThe antidote to these fears is the development of courage,character and self-esteem. The opposite of fear is actually love,self-love and self-respect. Acting with courage in a fearful situa-tion is simply a technique that boosts our regard for ourselves tosuch a degree that our fears subside and lose their ability toaffect our behavior and our decisions.

Action exercisesHere are two things you can do to increase your self-esteem andself-confidence and overcome your fears. First, realize and accept that you can do anything you put yourmind to. Repeat the words, “I can do it! I can do it!” whenever youfeel afraid for any reason. Second, continually think of yourself as a valuable and importantperson and remember that temporary failure is the way you learnhow to succeed.

Reprinted with permission from www.mercola.com.

By Brian Tracy

Caring for Yourself


Every three minutes a woman in the United States isdiagnosed with breast cancer. The chance of developinginvasive breast cancer at some time in a woman's life isabout 1 in 8.¹ These are startling statistics, but behind thesenumbers are people — sisters, daughters, mothers, grand-mothers, neighbors and friends. Any one of the 182,460women who will be diagnosed with invasive breast cancerthis year could be someone we love. Although mammo-grams are among the best forms of early detection, morethan 13 million American women over the age of 40 havenever had one.2 The Centers for Disease Control recommendthat women begin having yearly mammograms at age 40.

These facts form the foundation of Medlineʼs “Together WeCan Save Lives through Early Detection” campaign. Medlineis on a mission to change the future by taking action now.2008 marks the third year that Medline has partnered withthe National Breast Cancer Foundation (NBCF), whichprovides grants to hospitals and healthcare organizationsthat offer free mammograms for underprivileged women. Todate, Medline has donated $350,000 to the NBCF to giveback to customers and their communities, help promoteearly detection of breast cancer and ultimately save lives.

Spreading the wordTo keep early detection on everyoneʼs minds, Medlinesponsors a number of outreach projects throughout theyear and distributes several products and programs topromote awareness.

AORN breakfast forumIn March, Medline hosted a breakfast forum for 900 periop-erative nurses at the annual meeting of the Association ofperiOperative Registered Nurses (AORN) in Anaheim, Calif.Featured speaker, Dr. Marla Shapiro, author of Life in theBalance: My Journey with Breast Cancer and renownedCanadian on-air medical expert, delivered a dynamic pres-entation on coping with stress, balancing life and battlingbreast cancer. Visit www.medline.com/aorn/2008 to learnmore about the event.

Beyond the Shock® DVDMedline, in partnership with the NBCF, distributes freecopies of the DVD “Beyond the Shock,” a step-by-step guideto understanding the diagnosis of breast cancer. More than70 leading oncologists contributed to the content. To requesta copy, contact Jennifer Freedman at (847) 643-4358 [email protected].

Angel dollAngel, the second-born in Medlineʼs family of nurse dolls,promotes infection prevention and she also sports pinkscrubs and a pink ribbon to support breast cancer awareness.The Angel doll is distributed by Medline at trade shows andlarge customer events.

Pink ribbon productsMedline sells several pink ribbon products, including aBreast Cancer Awareness Rollator and bath bench, a pinkribbon lab coat and special scrubs available onscrubs123.com. A customerʼs purchase of these productssupports Medlineʼs partnership with the NBCF. Visitmedline.com or scrubs123.com or contact your Medlinesales representative for more information.

For more information on Medlineʼs breast cancerawareness campaign, visit www.medline.com/bcaor contact Jennifer Freedman at 847-643-4358 [email protected]

References: 1. American Cancer Society. Cancer Reference Information. “What Are the KeyStatistics for Breast Cancer?” Available at: http://www.cancer.org/docroot/CRI/content/CRI_2_4_ 1X_What_are_the_key_statistics_for_breast_cancer_ 5.asp.Accessed July 15, 2008. 2. The Breast Cancer Site. About Breast Cancer page. Available at:http://www.thebreastcancersite.com/clickToGive/boutbreastcancer.faces?siteId=2&link=ctg_bcs_aboutbreastcancer_from_home_maincolumn.

Medline Supports Breast CancerAwareness 365 Days a Year

Together We Can Save Lives Through Early Detection Breast Cancer Campaign

76 Healthy Skin

Holy Guacamole!You can make this avocado salad smooth or chunky depending on your preference.

Guacamole (4 servings)Prep time 10 minutesReady in 10 minutes

3 avocados - peeled, pitted and mashed 1 lime, juiced 1 teaspoon salt 1/2 cup diced onion 3 tablespoons chopped fresh cilantro 2 roma (plum) tomatoes, diced 1 teaspoon minced garlic 1 pinch ground cayenne pepper (optional)

In a medium bowl, mash together the avocados, lime juiceand salt. Mix in onion, cilantro, tomatoes and garlic. Stir incayenne pepper. Refrigerate 1 hour for best flavor, or serveimmediately.

Nutritional InformationServings Per Recipe: 4Amount Per ServingCalories: 264Total Fat: 23.3gCholesterol: 0mgSodium: 601mgTotal Carbs: 16.4gDietary Fiber: 8.8gProtein: 3.7g

www.allrecipes.com

Healthy Eating


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

FORMS & TOOLS

Pressure Ulcer PreventionPolicy and Procedure ..................................79Predicting Pressure Ulcer Risk ....................84

Infection ControlInfection Control Activities and Their Relevance to Pneumonia in LTC ..................86


Medline’s Pressure Ulcer Prevention Program

Systematic efforts at education, heightened awareness and specific

interventions by interdisciplinary healthcare teams have demon-

strated that a high incidence of pressure ulcers can be reduced.1

The main challenges to having an effective pressure ulcer prevention

program are lack of resources, lack of staff education, behavioral

challenges and lack of patient and family education.2

Medline’s comprehensive Pressure Ulcer Prevention Program offers

solutions to these challenges to promote the reduction of pressure

ulcers with clinical and educational resources, assessment tools

and a complete compatible product line designed to work alone

or complement your existing program.

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 professional staff and nurse technicians

• 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

To join the fight against pressure ulcers and for moreinformation on the Pressure Ulcer Prevention Program,please contact your Medline sales representative ofcall 1-800-MEDLINE.

www.medline.com

Join the program to reduce pressure ulcers.

The Pressure Ulcer Prevention Program. Pressure ulcerprevention made easy.

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.


Pressure Ulcer Prevention Policy and Procedure Forms & Tools

Pressure Ulcer Prevention Personnel: All accountable for patient care Patient outcomes:1. Maintenance of intact skin in the patient who is at risk for breakdown.2. Patient/caregivers verbalize knowledge of pressure ulcer risk factors, assessment, prevention and early treatment.

Early and ongoing assessment of patients at risk for skin breakdown is essential. Prevention involves not only identification of patients at risk but also a detailed plan of interventions which address and minimize the effects of each risk factor.

High Risk Diagnoses: Factors That Contribute To PressureUlcer Development

� Peripheral Vascular Disease� Myocardial Infarction� Stroke� Multiple Trauma� Musculoskeletal

disorders/Fractures� GI Bleed� Spinal Cord Injury� Paraplegia � Neurological disorders (e.g.,

Guillain Barré, multiple sclerosis)

� Those with unstable and/or chronic medical conditions (e.g., diabetes, renal disease, cancer)

� History of previous pressure ulcer

� Preterm neonates

� Age greater than 75� Existing pressure ulcer� Immobility � Those having a procedure

which immobilizes them for greater than one hour

� Bed linen � Devices (e.g., oxygen tubing,

splints, TEDs stockings)� Sedation � Sensory deficits � Nutritional deficits/Weight loss � Excessive exposure to

moisture (e.g., incontinence, excessive perspiration, wound drainage)

� Those exposed to friction and shearing

80 Healthy Skin

Forms & Tools Pressure Ulcer Prevention Policy and Procedure

Nursing Diagnosis

Asessement/evaluation Interventions/key points

1. Identify patients at risk for developing apressure ulcer upon admission and daily for at-risk patients or with any change in condition.

1. Determine an adult patient's risk for developing a pressure ulcer by using theBraden Risk Assessment. A patient is considered at risk if theirBraden score is: 15-18 = Mild risk 13-14 = Moderate risk 10-12 = High risk 9 or below = Very high risk 2. Advance your patient to the next risk level inthe presence of:A. Age over 75 B. Chronic illness C. Hemodynamic instability (e.g., diastolicblood pressure less than 60 mmHg). 3. Utilize the Nursing Care Plan to individualizespecific prevention interventions. 4. Initiate Pressure Ulcer Treatment Protocol atthe first sign of skin breakdown. 5. Consult WOC nurse when current plan ofcare does not meet the needs of the patient.

2. Assess specific vulnerable pressure points. A. Supine: occiput, sacrum, heels B. Sitting: ischial tuberosities, coccyx C. Side-lying position: trochanters D. Reddened areas which do not fade within30 minutes E. Dusky or cyanotic areas F. Under devices (i.e., TEDs, pneumoboots,splints, collars, tubing)

2. Inspect the skin at least every 8 hours. A. Avoid vigorous massage over bony prominences. B. Patients with dark pigmentation will demonstrate a cyanotic area, warmth or complain of pain over the bony prominence.

3. Assess skin for exposure to moisture fromintervals incontinence, wound drainage perspiration.

3. Cleanse and dry skin at routine intervals orand at the time of soiling, using a low residue soap.A. Initiate the Incontinence Protocol in the incontinent patient. B. Moisturize dry skin with lotion.


Nursing Diagnosis

4. A. Assess mobility and activity status.

B. Identify sitting status.

4. A. 1. Maintain or increase patient's level of activity, mobility and range of motion unlesscontraindicated. 2. Schedule regular and frequent turning andrepositioning at least every 2 hours (e.g., alternating supine, left lateral and right lateralpositions). 3. Individualize to the patient's needs basedon risk and level of mobility. B. For sitting position in bed (head of bedgreater than 30°), cardiac chair or wheelchair: 1. Assist/instruct patient to shift weight atleast every 15 minutes. 2. Reposition at least every 30 minutes if patient cannot independently perform pressure relief exercises every 15 minutes. 3. Consult PT/OT for assistance in seating,positioning and wheelchair cushion options.

5. Assess nutritional status. 5. Due to increased protein needs for healing,consult Nutrition Services for a nutritional assessment and plan at the earliest sign ofskin breakdown.

6. Identify factors that increase shearing, fric-tion and/or pressure. A. Shearing: Tissue layers sliding against eachother; e.g., sliding down in bed. B. Friction: Skin rubbing against other sur-faces; e.g., elbows and heels rubbing againstsheets. C. Pressure/friction: e.g., heels resting on mat-tress, devices such as oxygen tubing, cervicalcollars, casts.

6. A. 1. Keep head of bed less than 30° unlesscontraindicated. 2. Promote proper positioning, transferring andturning techniques. B. 1. Use reusable underpad, trapeze or liftsheet to lift, not drag, patient. 2. Utilize pillows or positioning devices to prevent skin surfaces from rubbing together. C. 1. The immobilized patient should have heelssuspended off bed by using pillows or heel suspension boots.2. Heel and elbow protectors are best used forreducing friction and should not be used forpressure reduction. 3. Pad devices when it is not contraindicated.

Pressure Ulcer Prevention Policy and Procedure Forms & Tools

82 Healthy Skin

Nursing Diagnosis

Adapted from North Memorial Health Care’s Pressure Ulcer Prevention Protocol.

ReferencesBryant R. Acute and Chronic Wounds. 2nd ed. St. Louis: Mosby; 2000. Frantz RA. Evidence-based protocol: Prevention of pressure ulcers. Journal of Gerontological Nursing. 2004;30(2):4-11. Hobbs BK. (2004). Reducing the incidence of pressure ulcers: Implementation of a turn-team nursing program. Journal ofGerontological Nursing. 2004;30(11):46-51. Makelbust J, Sieggreen M. Pressure Ulcers: Guidelines for Prevention and Management. 3rd ed. Pennsylvania: Springhouse; 2001.Wound, Ostomy and Continence Nurses Society. Guidelines for the Prevention and Management of Pressure Ulcers.Glenview, Ill; 2003.U.S. Department of Health and Human Services. Pressure ulcers in adults: Prediction and prevention clinical practice

guideline. 1992.

7. Assess patient/family knowledge of pressureulcer prevention, risk factors and early treatment.

7. A. Teach patient/family about the causes andrisk factors for pressure ulcer development andways to minimize risk. B. The patient or caregiver, or both, should understand the importance of the following: 1. Conduct regular inspection of skin over bonyprominences. (Individuals can use a mirror if necessary to inspect their own skin.) 2. Follow appropriate skincare regimens. 3. Use measures to reduce friction/shearing. 4. Avoid vigorous massage of bony prominencesor reddened area. 5. Include routine turning, repositioning and theuse of pressure-reducing devices if patient isconfined to bed and/or chair. 6. Avoid use of donut-type devices. 7. Maintain adequate nutrition and fluid intakeand monitoring for weight loss, poor appetite orgastrointestinal changes that interfere with eating.8. Program for bowel and bladder management.9. Promptly report healthcare changes and nutritional problems to healthcare providers.

Forms & Tools Pressure Ulcer Prevention Policy and Procedure


Nope – it’s a nursing home!

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Our Feels Like Home™ line of textiles includes everything from

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Feels Like Home products don’t stop at luxury – they’re practical,

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To learn more about the Feels Like Home line, pleasecall 1-800-MEDLINE, visit www.medline.com or speakto your Medline sales representative

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Is This a Four-Star Hotel?

84 Healthy Skin

Forms & Tools Predicting Pressure Ulcer Risk

Predicting Pressure Ulcer Risk Forms & Tools


86 Healthy Skin

Forms & Tools Infection Control

Infection Control Activities and Their Relevance to Pneumonia in LTC


Infection Control Forms & Tools

Reprinted with permission from the Texas Department of Aging and Disability Services

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healthy skin magazine - volume 5; issue 3

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