healthy skin volume 10 issue 2

©2012 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc. MKT212071 / LIT1011 / 30M / QG 5

Announcing ...

2012 Pink Glove Dance IIVideo Competition Begins

What you can do now to get ready!1. Get consent from your facility2. Gather your friends and coworkers to participate3. Start practicing

Win a Donation to Your Favorite Breast Cancer Charity*• First Place: $10,000• Second Place: $5,000• Third Place: $2,000

Contest opens: July 2Contest closes: September 28Winners announced: November 2

Watch for further details and song choices at www.pinkglovedance.com.

*Subject to review and approval by Medline Industries, Inc.

PGD

pinkglovedance.com

July 2!

Improving Quality of Care Based on CMS Guidelines

Free CE Inside! Volume 10, Issue 2

Wounds That Fall Between the Cracks

MAYO CLINICCollaboration & Communication

Lori PorterEmpowering

CNAs!

Diabetic Foot Ulcers & the Agony of the Feet

Pink Glove Dance II Video

Competition!Page 84

2012 VOLUM

E 10, ISSUE 2 HEALTHY SKIN

ww

w.m

edline.com

Top Trends6 Skin & Wound CareSurvey Results

Improving Quality of Care Based on CMS Guidelines 99

Resident Transfer Form Forms & Tools

ADDITIONAL INFORMATION(may be faxed to ED/hospital within 7-12 hours)

RESIDENT NAME:Last: First: MI: DOB:

/ /

Date Transferred to the Hospital: / /

TREATMENTS AND FREQUENCY:(include special treatments such as dialysis, chemo-therapy, transfusions, radiation, TPN, hospice)

DISABILITIES:(amputation, paralysis, contractures)

BEHAVIORAL or SOCIAL ISSUES and INTERVENTIONS:

FAMILY ISSUES: PAIN ASSESSMENT:

IMPAIRMENTS:(cognitive, speech, hearing, vision, sensation)

CONTINENCE: Bowel BladderLast bowel movement: Date: / /

ADLs:(mark I=independent; D=dependent; A=needs assistance)

BathingDressing Toileting/Transfers AmbulationEatingCan ambulate (distance) with

(assistive device or I)

IMMUNIZATIONS:Influenza Date: / /

Pneumococcal Date: / /

Tetanus Tet-Diphtheria Date: / /

PHYSICAL THERAPYResident is receiving therapy with goal of

returning home: Yes No- or -

Patient is LTC placement: Yes NoWeight bearing status: Non-weight Partial weight Full weightFall risk: Yes NoInterventions:

SKIN / WOUND CARE:High risk for pressure ulcer: Yes NoPressure ulcers:(stage, location, appearance, treatments)

Wound care sheet attached: Yes No

DIET:Needs assistance with feeding: Yes NoTrouble swallowing: Yes NoSpecial consistency: (thickened liquids, crush meds, etc.)

Tube feeding: Yes No

SOCIAL WORKER:

Telephone:( ) -

REASON FOR ORIGINAL SNF ADMISSION:

Bed hold: Yes Noname

RESIDENT TRANSFER FORM

© 2010. Florida Atlantic University

Join the team!

When it comes to hot topics in long-term care, you’re the experts!

You, our readers, are on the front lines of everything that happens in the healthcare industry – and we want to hear from you! Have you ever wished you could write an article that would be published in a large-circulation magazine? Now’s your chance. Healthy Skin is looking

for writers and contributors. Whether you’d like to try your hand at writing or offer suggestions for future articles, we want to hear what you have to say! You never know – the next time you open an issue of Healthy Skin, it might be to read your own article!

Contact us at [email protected] to learn more!

Healthy Skin

ON THE COVER, Lori Porter, co-founder of the National Association of Health Care Assistants (NAHCA), recently visited Chicago to film one of her latest motivational videos. Read more about Lori and her organization on page 44.


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

©2012 Medline Industries, Inc. The OR Connection is published by Medline Industries, Inc. One Medline Place, Mundelein, IL 60060. 1-800-MEDLINE.

Contents

16

36

20

44

Helping Women Cope with Caregiving. A new book helps women face the challenges of caring for their terminally ill husbands.

The Agony of the Feet: Prevention and Management of Diabetic Foot Ulcers. A step-by-step guide to keeping diabetic feet healthy and reducing the risk of amputation.

Mayo Clinic: Communication and Teamwork Set Them Apart. A private interview with CEO, Dr. Bill Rupp discussing the culture of safety at Mayo.

Lori Porter: Everything in Life I Learned in Long Term Care. Her early experiences in long-term care shaped her vision for working with nursing homes and nursing assistants.

EditorSue MacInnes, RD

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

Senior WriterCarla Esser Lake

Creative DirectorMichael A. Gotti

Clinical Team

Dionie Bibat, BSN, RN, WOCN

Clay Collins, BSN, RN, CWOCN, CFCN, CWS, DAPWCA

Lorri Downs, BSN, RN, MS, CIC

Rebecca McPherson, MSN, RN

Joyce Norman, BSN, RN, CWOCN, DAPWCA

Kim Kehoe, BSN, RN, CWOCN, DAPWCA

Elizabeth O’Connell-Gifford, BSN, MBA, RN, CWOCN, DAPWCA

Jackie Todd, RN, CWCN, DAPWCA

Wound Care Advisory Board

Christine Baker, MSN, RN, CWOCN, APN

Katherine A. Beam, DNP, RN, ACNS-BC

Amparo Cano, MSN, CWON

Jill Cox, PhD, RN, APN-C, CWOCN

Sue Creehan, RN, CWOCN

Donna Crossland, MSN, RN, CWOCN

Barbara Delmore, PHD, RN, CWCN, AAPWCA

Karen Keaney Gluckman, MSN, FNP-BC, APN, CWOCN

Anita Prinz, RN, MSN, CWOCN, CFNC, COS-C

Mary Ransbury, RN, BSN, PHN, CWON

Denise Robinson, MPH, RN, CHWOCN

Diane Whitworth, RN, CWOCN

CE ArTICLE!

4 Healthy Skin

Page 52

Page 32

Page 58

Page 14

Compliance

32 Unnecessary Hospitalizations Decline When Clinicians INTERACT

Prevention

10 Putting Research into Practice: The Pennsylvania Pressure

Ulcer Partnership

58 Preventing Surgical Site Infections

Special Features

8 2012 Prevention Above All Discoveries Grant Program

14 Findings of a National Survey: Opportunities to Improve Skin

and Wound Care

20 Mayo Clinic: Communication and Teamwork Set Them Apart

44 Lori Porter: Everything I Learned in Life I Learned in Long Term Care

47 Empowerment for CNAs

52 Wounds That Fall Between the Cracks

Regular Features

18 Patient Safety News: C. diff Infection Rates at Historic High

63 Product Spotlight: Replacement Surfaces – We’ve Got You Supported!

Caring for Yourself

16 Helping Women Cope with Caregiving

72 Get Rid of Worry Once and for All

78 Breast Cancer Fast Facts

79 Judy Pickett: Running for Her Life

90 Healthy Eating: Lillian Stafford’s Oriental Broccoli

Forms & Tools

93 Six Steps to C. diff Prevention

94 OSHA’s Bloodborne Pathogens Standard

96 Early Warning Tool (English)

97 Early Warning Tool (Spanish)

98 Resident Transfer Form

Contents

Breast cancer survivor Judy Pickett: Running for Her Life. Page 79


William Rupp, MDBefore becoming CEO of Mayo Clinic in Jacksonville, Fla., Dr. Rupp served two terms as CEO within Mayo Health System — at Luther Midelfort in Eau Claire, Wisc., and at Immanuel St. Joseph’s in Mankato, Minn. In addition to his administrative responsibili-ties, Rupp is a former practicing medical oncologist. Mayo Health System is a family of clinics, hospitals and health care facilities serving 70 communities in Minnesota, Iowa and Wisconsin.

Contributing Writers

Wolf Rinke, RD, CSPKeynote speaker, seminar leader, management consultant, executive coach and editor of the free electronic newsletter Read and Grow Rich, available at www.easyCPEcred-its.com. In addition he has authored numerous CDs, DVDs and books including Make It a Winning Life: Success Strategies for Life, Love and Business, Winning Manage-ment: 6 Fail-Safe Strategies for Building High-Performance Organizations. Reach him at [email protected].

Barbera Rozenboom, BSN, RN, CWONBarbara Rozenboom is a wound ostomy nurse with Iowa Health Home Care in Ur-bandale, IA. She has been a nurse for 30 years and certified as a WOC nurse for 13 years. She is an active member of the national Wound, Ostomy and Continence Nurses (WOCN) Society and currently serves as President of the Iowa WOCN affiliate.

Mary Mahoney, BSN, RN, CWONMary Mahoney is a wound ostomy nurse with Iowa Health Home Care in Urban-dale, IA. She has been a nurse for 28 years and certified as a WOC nurse for 18 years. She is an active member of the national Wound, Ostomy and Continence Nurses (WOCN) Society and currently serves as chair of the WOCN National Ostomy Committee.

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

Joseph Ouslander, MDJoseph Ouslander, MD, is Professor and Senior Associate Dean for Geriatric Programs at the Charles E. Schmidt College of Medicine at Florida Atlantic University (FAU) and Professor (Courtesy) at the Christine E. Lynn College of Nursing at FAU in Boca Raton, Florida. He is an internationally recognized geriatrician currently serving as a Health Policy and Aging Fellow, supported by a grant from Atlantic Philanthropies.

6 Healthy Skin

I think that we are always learning... I am learning now in this phase of my husband’s disease that words like “pres-sure points” and “turning” and “keeping the skin healthy”... mean more to me than ever. As a caregiver, I am passionate about the quality of the products I use... I would never sac-rifice quality for price. I use the best skin care products on my husband... yes, Remedy, and I am proud to say that.

Now I know what it means to lift and transfer and figure out how to do things without resources. I understand more than ever the word dignity... and how important it is for any patient to be treated with respect and understanding. I’m learning all about care coordination and miscommunica-tion... and how complicated and frustrating it is to make things happen and just do what you think is right.

So whether it is appropriate or not... I’ve included some things in this publication that have been helpful to me. I figure what I am learning should not be a secret, but should be shared so others can benefit from my “trial and error” learning and understanding.

My daughter Emily (choreographer of the original Pink Glove Dance) sent me a tweet from Katie Couric about a book called The Caregiving Wife’s Handbook. There are 40 million women who are caring for a family member with a critical illness. I know you are dealing with many patients whose primary caregiver could benefit from this handbook of guidance, too. I have a friend from a hospital system on

the East coast who just put her husband into hospice. I sent her a copy of the book...

I’ve also included information on certified nursing assis-tants... both their national organization and their leader, Ms. Lori Porter... who started her career as a CNA, and now dedicates her life to embracing and empowering nursing assistants... the largest employee population in long-term care (and also the population with the most turnover). They are caregivers... that’s what healthcare is all about... taking care of patients.

And then, there is also an enlightening article on the Mayo Clinic and an interview with their leader, Dr. Rupp, who kindly toured me through his facility and spoke to me about patients, transparency and building strong teams.

Everyone has tragedy in their life. A friend of mine once said, “no one gets out of here alive.” But what you do to make lives better... sharing your successes and secrets...making another’s life better... that is something to be proud of.

As always, with the utmost respect... Thank you. I will continue to learn and share…

Sue MacInnes, RDEditor

Healthy Skin Letter from the Editor

I am writing this in the month of May. May is Amyotrophic Lateral Sclerosis (ALS) Awareness Month, also known as “Lou Gehrig’s” disease. ALS is a progressive, neurodegenerative, fatal disease that affects

the motor neurons in the body. As the motor neurons become destroyed the patient loses the ability to move their body... while cognitively the patient is sharp as ever, physically the patient is trapped in their body. That was the diagnosis my husband of 30 years received on October 26, 2010. I am learning firsthand what it is like to be a caregiver. And, I have the utmost appreciation for all that you do... I’m a dietitian... not a nurse. I was not prepared to be the caregiver. But I am learning patience and humility.

Healthy Skin Letter from the Editor OPTILOCK™

Super Absorbent Wound Dressing

©2012 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.

Gentle on wounds, tough on exudateOPTILOCK’s super absorbent polymer

core absorbs moderate to heavy exudate,

locks in fluid—even under compression—

and protects periwound skin from maceration.

Non-adherent contact layer prevents the dressing

from sticking to the wound. Gentle removal and fewer

dressing changes mean greater patient comfort.

www.medline.com/wound-skin-care/optilock/

8 Healthy Skin

2012 Prevention Above All Discoveries Grant ProgramSupporting the adoption of solutions and interventions into everyday practice

In today’s healthcare environment, healthcare-acquired conditions, once considered a “side effect,” are no longer accepted. The government does not accept them, patients are not accepting them and the facilities themselves continually look for ways to build better systems to improve the quality of care. Knowing that clinicians in the field have some of the best ideas for improving care, Medline launched the Prevention Above All Discoveries Grant Program in 2008 as a way to help stimulate the gathering of solid evidence that supports the adoption of solutions into clinical practice. Through this innovative program, Medline has awarded more than $1.1 million in funding to front-line healthcare workers researching evidence-based solutions and interventions for the very conditions that CMS has declared as preventable.

Medline is accepting letters of intent from May 1 through June 30, 2012 for the 2012 Prevention Above All Discoveries Grant program and intends to award up to $1 million in grants for research on innovative ideas and evidence-based practices that will improve patient safety and quality of care. Healthcare providers interested in submitting letters of intent can apply for one of two funding categories: Pilot Grants of up to $25,000 for projects that can be completed within six months; or Empirical Study Grants of up to $100,000 for projects completed within 12 months.

How to apply for a grant More information about the grant program, as well as a sample letter of intent, can be found at www.medline.com/prevention-above-all/grants.asp. To submit a grant letter of intent, contact Toni Marchinski, grant coordinator, at [email protected] or call 866-941-1998.

“Historically, these research projects are great ideas that could significantly help in the fight against some of the toughest hospital-acquired conditions,” said Andrew

Kramer, MD, Head of the Department of Medicine’s Health Care Policy and Research Division at the University of Colorado and Grant Review Committee Chair.

“What’s unique about this funding is that it is all going to providers who are on the front lines of health care. The feedback this group gives us is critical to advancing healthcare technology.”


2011 Prevention Above All Discoveries Grant Recipients

Title: CAUTI Prevention Program

Institution: Piedmont Healthcare Philanthropy, North Carolina

Principal Investigator: Monica Tennant & Dee Tucker

Title: Incidence of Falls Among Oncology Patients Who Are Cared for by Family Caregivers within Their Home.

Institution: Siteman Cancer Center at Barnes Jewish Hospital, Missouri

Principal Investigator: Patricia Potter, RN, PhD, FAAN; Marilee Kuhrik RN, PhD; Nancy Kuhrik RN, PhD, Sarah Olsen RN, BSN.

Title: Quick Room Turnaround Time (QRTAT) Ultraviolet Light Disinfection for Decreasing HAI

Institution: Ohio State University Hospital, Ohio

Principal Investigator: Christina Liscynesky, MD & Julie E. Mangino, MD

Title: Warfarin Safety Pilot Program

Institution: Foundation for Quality Care, New York

Principal Investigator: Nancy Merlino Leveille, RN, MS & Darren M. Triller, Pharm.D.

Title: Sensor Technology for Tracking and Displaying Bed Elevation Data for Mechanically Ventilated Patients

Institution: University of Iowa Hospital, Iowa

Principal Investigator: Alberto Maria Segre, Philip Polgreen, Geb Thomas, Ted Herman

Title: Testing Patient Education Handbooks

Institution: Good Samaritan Hospital, Pennsylvania

Principal Investigator: Patricia Donley, RN, MSN, Stephanie Andreozzi, Doctorate in Physical Therapy

Title: Using GRASP as Home Treatment for Upper Extremity (UE) Paresis Post-Stroke

Institution: Abbotsford Regional Hospital, Canada

Principal Investigator: May Chan, B.OT, Janice Eng, Ph.D. PT, OT, Shu-Hyun Jang, M.Sc.OT

Title:

A Standardized Process of Preoperative Body Cleansing with Comfort Bath® Cleansing Washcloths

Compared to Sage® 2% Chlorhexidine Gluconate (CHG) Cloths to Reduce Prosthetic Joint Infections at

Cambridge Hospital

Institution: Cambridge Health Alliance, Harvard Medical Center, Massachusetts

Principal Investigator: Lou Ann Bruno-Murtha, DO, Virginia Caples, RN, CIC and Diane Lancaster, RN, PhD

Title: Falls Risk Assessment Study

Institution: Provena St. Joseph Medical Center, Illinois

Principal Investigator: Jackie Medland RN, PhD

Title: The Effectiveness of Team Training on Fall Reduction

Institution: Wellstar Health System, Georgia

Principal Investigator: Bethany Robertson, LeeAnna Spiva & Marcia Delk, MD

10 Healthy Skin

Putting Research into Practice:

The Pennsylvania Pressure Ulcer Partnership

Editor’s note: Medline has awarded up to $1 million in

Prevention Above All Discoveries research grants every year

since 2009. Grants are awarded to clinicians and researchers

all over the country. To learn more, go to www.medline.com/

events/prevention-above-all/grants.asp.

One recent recipient of a Medline Prevention Above All grant was a collaborative headed by Pamela A. Braun of the Pennsylvania Pressure Ulcer Partnership (PPUP), the Health Care Improvement Foundation representing the Hospital and Health System Association of Pennsylvania and the Hospital Council of Western Pennsylvania. Other states have taken on similar projects. For example, the New Jersey Hospital Association’s Pressure Ulcer Collaborative demonstrated a 70 percent reduction in the incidence of pressure ulcers when using their focused approach. Minnesota’s Safe Skin Program has

been able to not only reduce pressure ulcers, but to maintain that reduction for several years. Another collaborative that included 20 long-term care facilities in Austin, Texas, reduced their incidence of pressure ulcers and improved their process of care.

Pamela Braun’s team in Pennsylvania realized that the prevention of pressure ulcers was a national concern and priority for all areas of healthcare, and they set out to do something about it. According to national data from the AHRQ from 2006, there were over 503,000 hospital stays where a pressure ulcer was listed as a diagnosis. That represents an almost 80 percent increase in 13 years. With costs ranging up to $40,000 per episode, the dollars are significant.


Turning the focus to home, the Pennsylvania Partnership looked at reported instances of pressure ulcers in their state. The most notable was that 13.7 percent of high-risk long-term care residents had a pressure ulcer, whereas pressure ulcers were present in 3.5 percent of those considered to be a low risk. The Pennsylvania Partnership focused their efforts on the transition of care from the hospital to the long-term care facility and vice versa. Recognizing that pressure ulcers can develop quickly (within two hours according to CMS F-tag 314) the need for timely assessment, care planning, and prevention or treatment is paramount. This transition is also important as the Pennsylvania Patient Safety Authority reported more than half of all pressure ulcers were present on admission, which could mean that the pressure ulcers developed in another facility.

Over the past several years, the strong body of evidence regarding the prevention and care of pressure ulcers has grown to include general risk assessment, skin assessment (including those considered at low risk), pressure reduction techniques and devices, nutrition, skin care and actual wound care. No one doubts these approaches; however, the challenge lies in performing these practices consistently and accurately every day, every time by each staff member.

According to AHRQ, there was an almost 80 percent increase in 13 years in hospital stays where a pressure ulcer was listed as a diagnosis.

The Pennsylvania Partnership explored educational resources and offered monthly audio conferences given by several well-known wound care practitioners. Here is a list of the presenters and their topics:

•DianeKrasner,PhD,RN,CWCN,CWS,BCLNC,FAAN–“Communication Across the Continuum” and “Skin Changes at Life’s End: Final Consensus Statement (SCALE)”

•JanetBeitz,PhD,RN,CS,CNOR,CWOCN,CRNP,andBronwynne Carpico, MSN, RN, CCRN - “Educational Strategies and Resources for Healthcare Providers on Pressure Ulcer Prevention and Therapy”

•JanetBeitz–“TriggersandInterventionsfortheWaronPressure Ulcers”

•NancyCollins,PhD,RD,LD/N–“TheImportanceofNutrition in Wound Healing”

•AliceRocke,MD–“FacilitatingPhysicianEngagement”

•KarenLouKennedy-Evans,RN,CNS,FNP–“DocumentingPressure Ulcers through Photography”

•SusanGallagherCamden,PhD,MSN,MA,RN,CBNandMarsha Davidson, MSN RN CWOCN – “Pressure Ulcers in Special Populations: Bariatric and Home Health Patients”

12 Healthy Skin

The audio conferences were very popular, with an average of over 295 participants attending each one. The idea was not only to introduce new concepts, but also to continue the educational momentum throughout the entire study period with the hope of continuing far into the future with new staff and within each facility.

Real time data collection and distribution was felt to be a key factor in the success of the overall program. The 92 participating facilities were able to post results and trending information was available immediately. This part of the study looked only at hospitals, specifically focusing on the critical care, med-surgical and telemetry units. Participants were able to input their data, with little computer expertise, into a web-based portal. Their real-time results and trends allowed each unit to address issues and focus education and interventions on specific area needs. For example, if a unit had an increase in the incidence of pressure ulcers occurring on a certain shift, they were able to take that data, turn it into real solutions, and focus their education. They could also look at the products used for skin care and the support surfaces on that unit.

Looking at the critical care units, the incidence of pressure ulcers at the start of the data collection period was 10.9 percent and dropped to 6.6 percent (p=0.02) by the end of the study period. The pressure ulcer progression rate decreased from 5.3 percent to 1.4 percent (p=0.001). In the med-surgical units, the incidence decreased from 0.99 percent to 0.15 percent (p<0.01). All of these measures were statistically significant. Several process improvements were also observed. By the end of data collection, the ongoing pressure ulcer risk assessment and the ongoing skin assessments had increased dramatically. The at-risk patients were watched more closely and prevention measures were begun in a more timely fashion.

Taking this data to the bedside shows that the decrease in the incidence of pressure ulcers is attainable. The Pennsylvania Pressure Ulcer Partnership helped reiterate that good nursing care, along with solid evidence-based education and early prevention strategies as well as appropriate wound treatment, is of utmost importance.

By the end of data collection from results of the audio conference, the ongoing pressure ulcer risk assessment and the ongoing skin assessments had increased dramatically.

• Averagereductioninfacility-acquired pressureulcers:72.6%

• Averageannualsavings:$215,190

How does it work?With a compelling combination of products and education:1. Medline’s strategic product bundle, including skin care and incontinence products2. Medline’s free educational program for nurses and nursing assistants, including 4 CE credits for nurses plus online, interactive competencies


If you are interested in:

Implementing a program that allows you to achieve these results and sustain them over time

Reducing the incidence of pressure ulcers at your facility

Learning more about Medline’s Pressure Ulcer Prevention Program

Get results with Medline’s Pressure Ulcer Prevention Program (PUPP)

957 facilities have joined the program.Are you one of them?

1-800-MEDLINE l www.medline.comAsk your Medline representativeabout PUPP today!

14 Healthy Skin 14 Healthy Skin

To gather time sensitive data, more than 7,800 inquiries were emailed to hospitals across the country. Several nursing specialties were asked for their opinion regarding skin and wound care. A total of 420 respondents completed the survey, a 5.4% return, which is deemed a reasonable sampling of the market. (Typically, 3 to 5% is considered a good sampling.)

Top 6 TrendsSKIN & WOUND CARE SURVEY RESULTS

Top Six Take-Aways

1 4

5

6

2

3

27% of licensed staff assessed wounds accurately

66% of post-operative pressure ulcers start in the OR

89% of high risk patients consult with the wound care specialist once per month or less

7% of bedside nurses are above average in wound assessment, measurement, documenting and treating wounds

>1 in 10 patients that come through the ED has a chronic wound

Nursing Leaders felt that while over half of their staff in the Emergency Department (ED) and bedside licensed staff were knowledgeable in assessing wounds; only about 27% actually assessed wounds accurately. Only 22% of the staff was considered “very good” at documenting present on admission (POA) criteria. This translates into a great opportunity for education in pressure ulcer prevention and a focus on Medicare’s reimbursement structure for Hospital Acquired Conditions, one of which is pressure ulcers.

Nursing leaders reported that most of the pressure ulcers in their hospitals were found in the medical units and the critical care areas, reporting less than 4% in the surgical units. However, the OR nurses reported that 35% of their patients have existing pressure ulcers. Looking at the AORN Standards, which cite that 66% of post-operative pressure ulcers start in the OR, a prevention-targeted education program is needed.

OR nurses reported 86% of all their patients were at high risk for pressure ulcers, yet 89% consult with the wound care specialist only once per month or less. Only 11% regularly (weekly) meet with their wound care specialist.

Based on the wound care specialists’ responses, there is a great opportunity to help bedside nurses become more proficient in wound assessment, measurement, documenting and treating wounds. Overall, the wound care specialists they felt that just over 7% of bedside nurses were above average in these skills.

Discharge planning is another area of opportunity – 76% of the wound care specialists report that they receive at least one call from a patient after discharge, while 20% report more than 10 calls per week related to wound care issues.

The nurses from the emergency department overwhelmingly agreed that they base the risk for a patient to develop a pressure ulcer not on a validated assessment tool (which is used throughout the rest of the hospital), but on clinical judgment, and they rarely (yearly or never) consult with the wound care specialist. Greater than 1 in 10 of the patients that come through the ED has a chronic wound.

Bottom line: Education is key.

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

Reference

1. Kent DJ. Effects of a just-in-time education intervention placed on wound dressing packages. Journal of Wound, Ostomy and Continence Nursing.

2010; 37(6):609-614. ©2012 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.

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

In a study involving 139 nurses at eight different facilities, 88% who used a wound care product with an education guide attached were able to apply the dressing

to a wound correctly.1

MEDLINE’S REVOLUTIONARY SHOW-AND-TELL PACKAGING

www.medline.com/ep

16 Healthy Skin


Helping Women Cope with Caregiving

While Trying to Accept Their Husband’s Terminal Illness

Katie Couric is tweeting about it, and Jane Brody of The New York Times gives it high marks…

The Caregiving Wife’s Handbook is a resource you can pass along to families as an additional tool to help them cope with tragic illness.

More than 40 million women are the primary caregivers for an ill family member, often their own husband. Bookstores are filled with books on caregiving, but it’s rare to find good information for wives who are acting as caregivers for their terminally ill husbands. Psychotherapist Diana Denholm fills that void with The Caregiving Wife’s Handbook. It is a step-by-step communication guide to help wives cope with the many burdens placed on them as caregivers for their husbands.

Denholm cared for her own husband for almost 11 years, through colon cancer, congestive heart failure, and later a heart transplant. Much of her book is based on firsthand experience, as well as interviews with women caring for their terminally ill husbands. She shows how she and others have navigated around the most common obstacles, including driving, eating, sex, hygiene, and financial and legal matters. Readers also learn how to bring more balance, fun, and free time into their life as caregiving wife.

Traditionally, caring for a dying husband has been seen as a “wifely duty.” Although there are similarities in caretaking, caregiving for a dying husband is distinctly different, and the longer the dying process, the more complex the problems. On top of dealing with the tragedy, the wife must figure out how to make life work.

As you methodically follow Denholm’s six communication

steps, you will learn:

To ask questions you may not realize you need to ask

About issues that bother you and

a method for categorizing them

What you should and shouldn’t

discuss with your husband

How to make and prepare for a

date to talk about difficult topics

What to do if your

husband won’t talk

How to tell your husband why you

won’t talk about certain issues

18 Healthy Skin

While most types of healthcare-associated infections are declin-ing, C. difficile infections are at an all-time high. Although 94 percent of C. difficile infections occur in healthcare settings, few of them are due to hospital exposure, according to a new report from the Centers for Disease Control and Prevention. About 25 percent of C. difficile infections first present symptoms in hospital patients; 75 percent first show in nursing home patients or in people recently cared for in doctors’ offices and clinics.

The report highlights three programs showing early success in reducing C. difficile infection rates in hospitals. The 71 hospi-tals participating in the programs in Illinois, Massachusetts and New York decreased C. difficile infections by 20 percent in less than two years by following infection control recommendations. To download a copy of the report, go to: http://www.cdc.gov/mmwr/pdf/wk/mm61e0306.pdf.

C. difficile causes diarrhea linked to 14,000 American deaths each year. Those most at risk are older adults who take an-tibiotics and also receive medical care. When a person takes antibiotics, resident bactheria that protect against infection are destroyed for several months. During this time, patients can get sick from C. difficile picked up from contaminated surfaces or spread from a healthcare provider’s hands.

C. difficile causes many Americans to become sick or die.• DeathsrelatedtoC. difficile increased 400% between 2000 and 2007, due in part to a stronger germ strain.•MostC. difficile infections are connected with receiving medical care.• Almosthalfofinfectionsoccurinpeopleyoungerthan65, but more than 90 percent of deaths occur in people 65 and older.• Infectionriskgenerallyincreaseswithage;childrenareat lower risk.

PATIENT SAFETY NEWSPATIENT SAFETY NEWSPATATA IENT SAFETETE YTYT NEWS

C. diff Infection Rates at Historic HighNew CDC report offers facts and solutions

Source: Centers for Disease Control and Prevention Available at: http://www.cdc.gov/vitalsigns/hai/?s_cid=bb-vitalsigns-115

C. difficile moves with patients from one healthcare facility to another, infecting other patients.• HalfofallhospitalizedpatientswithC. difficile infections have the infection when admitted and may spread it within the facility.• Themostdangeroussourceofspreadtoothersis patients with diarrhea.• Unnecessaryantibioticuseinpatientsatonefacilitymay increase the spread of C. difficile in another facility when patients transfer.•Whenapatienttransfersfromonefacilitytoanother, healthcare providers are not always told that the patient has or recently had a C. difficile infection, so they may not take the right precautions to prevent spread.

C. difficile infections can be prevented.• Earlyresultsfromhospitalpreventionprojectsshow20 percent fewer C. difficile infections in less than two years with infection prevention and control measures.•C. difficile infection rates decreased by more than half in hospitals in England in three years by using infection control recommendations and more careful antibiotic use.

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Reference 1. Boyce J. When the patient is disharged: terminal disinfection of hospital rooms. Medscape Infectious Diseases. June 11, 2010. Available at: http://www.medscape.com/viewarticle/723217. Accessed March 1, 2012.


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20 Healthy Skin

MAYO CLINIC

Communication and TeamworkSet Them Apart


MAYO CLINIC

Medline’s Chief Marketing Officer Sue MacInnes, RD, recently had

the opportunity to meet with Dr. Bill Rupp, CEO of the Mayo Clinic

in Jacksonville, Florida. Here is some of the conversation that

resulted from that meeting as they discussed the culture of safety

at Mayo … followed by a guided tour of the hospital to see and

feel communication and teamwork in action …

22 Healthy Skin

SM: And you end up blaming yourself.Dr. Rupp: Yes. You blame yourself. The other thing that is a real challenge in our culture is communication. If you don’t communi-cate against the gradient a patient might die. And then you have high gradience in healthcare with doctors, nurses and others up and down the line. So, even in organizations as wonderful as Mayo, where our strength is that we are physician led, and our potential Achilles heel is that we are physician led. So challeng-ing against the gradient is a real issue. We are working hard to teach people to do that by getting them more comfortable with sharing information. It is a multi-year journey to get a culture to be that way.

SM: Do you think that Mayo is different because you are physician led?Dr. Rupp: I think we are different because we are all on the same team. We don’t have physician groups working for their own economic incentives that could potentially hurt the organization. One of the challenges in healthcare systems in the U.S. is when physicians are competing against hospitals. And the hospital that the physician works for is often the physician’s greatest competi-tor. So, they are not on the same team. I hope that healthcare reform brings us all together collaboratively, so that we’re all on one team.

SM: Where are the biggest Mayo sites and how does your facility fit into the rest of the Mayo system? Dr. Rupp: The three big sites are Rochester, Minn., Arizona and Florida. We are called three-shield academic centers: research, education and practice—with practice being our most important component. And we have a fair amount of basic scientific research on this campus and the other two campuses. We all have residents in education programs. Our push over the last couple of years has been to be one Mayo Clinic. We want to be standardized across our organization, so that if you come to Florida with a TIA, you’re going to get the exact same treatment and work-up as you would in Rochester or Arizona. We already do it in a number of areas. If you need a kidney or liver transplant, you get an identical work-up at all three sites. We have the same kind of surgery, and we have the same kind of post-op follow up in all three. In fact, we’re working on getting people listed to work at all three sites.

SM: Do the three sites ever get together?Dr. Rupp: Yes. We have what we call “councils,” where our trans-plant people from each site get together and standardize things.

Sue MacInnes: Dr. Rupp, is there anything you’d like to say to The OR Connection readers?Dr. Rupp: Let me start with a couple thoughts…

Healthcare professionals have historically been taught to work hard and study hard. And the culture is if you work hard enough and study hard enough you won’t make a mistake. But it doesn’t always happen that way.

I don’t know anyone who comes to work in the morning and says, “I think I’m going to screw up today and hurt somebody.” But it happens, because we are human beings and we have systems that are incredibly complex. We’ve created a culture of “work hard study hard” so that the conclusion is if you do make a mistake, you obviously didn’t work hard enough.


SM: But it must be hard. Don’t you have different cultures in each of the sites? Dr. Rupp: Yes, it’s very hard. But fundamentally it’s still a Mayo culture. So we’re very similar to start with. We go to great lengths to share information and procedures.

SM: How do we engage more healthcare facilities to get “top-down” leadership to be more transparent, especially understanding that many people might choose not to do that because it exposes too much?Dr. Rupp: First, when we are transparent, it makes the staff believe in us more because they know we’re not hiding stuff. Second, by the very process, we all admit that we are human and most of the time when we have mistakes; it’s the system that’s the problem. There is growing evidence that transparency leads to fewer losses – not more. The other thing that you will see with our quality boards is that we are transparent by mak-ing the boards available to patients and families, as well as staff. When numbers are not going right, the staff is all over it because everybody sees it.

SM: When did you start putting these numbers out? Dr. Rupp: Ten to 15 years ago. The idea came out of the Institute for Healthcare Improvement – like posting in ICU the number of days since the last ventilator problem.

SM: How long does it take for before the staff becomes OK with the transparency? Dr. Rupp: It takes a little time. In one of our major meeting rooms here we have quality boards on the wall with data on infection, financials and service. We put it up on a big poster board be-cause that room is the most common meeting room in the facility and everybody that goes in there says, “Oh, so that’s what they are watching.” We had visitors from other parts of the system who were initially shocked that we had that data so “publicly” displayed, and yet now it appears that other places are doing it as well.

SM: Were you the first place to put up these boards? Dr. Rupp: We were certainly one of the early places.

SM: Do numbers make you feel uncomfortable?Dr. Rupp: Yes and no. They just are. They increase the quality of the data and can increase the quality of care. In 2008 we said let’s get rid of ventilator-associated pneumonia. And typical of a very good medical center, I was told that we probably couldn’t do that because we have some sick patients. Well, in 2008 we had 14 cases, in 2009 we had seven, and in 2010 we had three. Last year we had one. So, we’ll get there. In 2008 we had 36 central line infections, in 2009 we had 18, in 2010 we had 10, last year we had six. So, by just putting the numbers out there we are affecting the quality of care.

Continued on page 25

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SM: I bet you are proud of that. Dr. rupp: Yes, I’m very proud of our staff, and yet our goal is to get our rates to zero.

SM: So, you care about the number of individual incidents?Dr. rupp: The number of individual patients is important. If we have the lowest infection rate in the world and I am that one patient...

SM: I agree. Percentages are meaningless because the percentage could still mean a significant number of people. Dr. rupp: More than that. When you’re talking real numbers, you’re talking real people. At my previous position I shared patient names with board members. It showed that the numbers are people. And suddenly to the lay board members it became real – because they knew “Mary Smith” or “Paul Johnson.”

SM: Can you tell me a little about the patient/doctor relationship at Mayo?Dr. rupp: One of our ENT surgeons was in the operating room working on a patient with a basal skull lesion and he was getting near the end of the surgery when he got a call from the ICU. They told him a patient he had operated on two days before was bleeding. They asked him to come and look at it. And it became obvious very quickly that the patient was going to have to go back to the OR right away. So, the ENT surgeon called one of

the plastic surgeons in a very busy clinic and asked, “Can you get down here and finish this case for me, because I have to take care of another patient.” The plastic surgeon came down and finished the case while the ENT surgeon fixed the bleed on the other patient. When the ENT surgeon was done with the bleed-ing patient, he came back and kept the surgery line going. Rarely would a surgeon walk in on a patient that he has never seen before, like the plastic surgeon did, and finish the case. Mayo’s focus is on meeting the needs of the patient.

SM: It all stems from the belief that the patient is number one. You have to do everything for the patient. Dr. rupp: Another thing you’ll notice here is that our patient areas are very nice. Our administrative and doctor areas are also nice, but not like the patient area. We put the dollars into the patient area.

SM: Tell me about the Or. Dr. rupp: We had a challenge. We had a system that allowed us to do any case at any time, and it made life very unpredictable for our OR nurses. They might come in one day and get sent home early because there weren’t that many cases. And then the next day they would come in and be here until 10 or 11 pm. It is incredibly disruptive for somebody trying to run a family, pick up kids, etc. So, we changed to a system that is much more orderly with scheduling up to 24 hours in advance. We have rooms that run from 7 am till 5 pm, and we guarantee that those rooms will

ERASE CAUTI

26 Healthy Skin

be finished by 5 pm. We have one or two rooms that can run longer for emergencies, transplants, and the other things. But it’s confined to a small group of people who know they are on call for that evening and that they are at risk for running longer. So, we plan it that way. This has dramatically cut down on turnover. It’s made us a popular place to work. We now have a waiting list for people who want to work in our ORs.

SM: How many OR suites do you have? Dr. Rupp: 18.

SM: How many surgeries do you do?Dr. Rupp: Approximately 12,400 surgical procedures per year.

Sue: And what type of surgeries do you specialize in? Dr. Rupp: Very complex patients. We are a major transplant facil-ity. We do about 400 solid organ transplants a year. We do very complex cardiology procedures. As well as complex valves with very sick patients. If you think of health care as a pyramid, we do the very top of the pyramid. We do almost all the intra-cerebral bleeds for 100 miles around. Because we have people who can fish those clots out or coil the aneurysm, even when it is the most difficult thing. We have data that shows that we get the sickest and most complex patients in all of Florida.

SM: Describe some of the things that you’ve personally done to improve performance. Dr. Rupp: It’s my continuing role to focus on quality, safety and service. If you ask our staff what I’m about, they will tell you qual-ity, safety and service. Now, I don’t ignore a financial bottom line. I am responsible and accountable for producing a bottom line. But with a professional staff, that bottom line comes if we focus on quality, safety and service ... The dollars just follow.

SM: I’ve heard you referred to as the “barrier buster.” How did you get that name? Dr. Rupp: I think that my major job is to take down barriers. I keep telling our people that if you want me to come and fix your problem that’s pretty scary because I do not know anything about what you do on the frontline. So if you want me to fix your problem from the desk you are in real trouble. Now you work in it all the time and know about it. My job is for you to say that you have a problem or a barrier that is keeping you from making it better for patients or whomever else. Fine. I will help you get rid of that barrier but I’m not going to get lost in the details.

SM: So, you help them break down barriers that have been in place forever? Dr. Rupp: Yes. So much of what we do was done for a good reason sometime back. And yet things have changed and we’ve got all these things still in place that we’ve always done. To me, the most frightening words in health care are “We’ve always done it that way.”

SM: How can we improve the physician/nurse relationship? Dr. Rupp: One of the biggest ways is going to be simulation.

SM: Why do you say that?Dr. Rupp: I think simulation will revolutionize medical education. The ability to work in a simulation center is going to change much of what we do.

SM: Do you have a simulation center? Dr. Rupp: Yes, every one of the three major Mayo sites has one. For example, the ability for a team to practice putting in a central line, not just the doctor, but also the nurse who that doctor is go-ing to be working with, or the tech, or whoever it is. We are doing some interesting exercises right now on the deteriorating patient: the one who is starting to get real sick. And what does the team do with that? The ability to go in and do it in the simulation center, then later sit back with everybody and watch the video that we made. You can actually watch what worked well, what did not work well, what communication was good, what communication wasn’t good, and evaluate what you learned, and then do it all over again.


SM: How do you get the physician to do that – to take the time to do that? Dr. Rupp: That is part of our job as physicians. This is what is required at Mayo. If you are going to put in central lines in this institution, you have to go through the simulation center.

SM: Do you make the simulation center a requirement? For physicians?Dr. Rupp: Yes.

SM: Is that normal? Dr. Rupp: It is here! It’s a growing segment in the things we do. If we have an issue, we want to use simulation. You don’t get to say no. We simulate as much as we can. We have even had a housekeeping crew say, “We have a way of cleaning a room that might be faster and safer and we’d like to try it.” Great! Go to the simulation center.

SM: Do they act it out, work it through, and then demonstrate their findings? Dr. Rupp: Yes. And sometimes even more than that. What hap-pens in the simulation center is that we have mannequins and dummies. Our staff gets incredibly involved with these manne-quins. The mannequins do everything. They talk, and we even have one that will vomit on you.

SM: Are you serious? Dr. Rupp: I’ve seen incidents in simulations where after resusci-tation nurses don’t want to leave the “patient.” I think to myself, you know, it’s a dummy, but they still do not want to leave. People get incredibly involved in it.

SM: How long have you had the simulation center?Dr. Rupp: Mayo has had one in Rochester for about five or six years. Arizona got theirs three years ago. Our temporary one went up a year ago, and we’ve put 3,000 people through it so far.

SM: So this is a pretty new thing? Dr. Rupp: Yes.

SM: Have you seen a difference in the relationships?Dr. Rupp: Yes. It helps the relationships. There’s also a focus on the fact that we are not perfect at teamwork, but we try. Some-body asked me the other day, who are your superstars? And I said, “Superstars at Mayo do not do very well. We don’t have superstars. We have superstar teams.” In this day and age with medicine and its complexity a superstar cannot survive here alone. A superstar needs a team around him or her to provide great care. So the focus is on teamwork. We actually have cours-es on how to have conversations, especially with somebody who may be a little difficult. The book is called Crucial Conversations.


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1.Reference


SM: I’ll have to read it when I get home.Dr. rupp: Oh, it’s great. It teaches the skills for how to inter-act with difficult subjects. We teach doctors how to deliver bad news. How you handle an angry patient. It teaches skills that aren’t normally taught in our professional training.

Dr. rupp: Now, let’s take a walk. I’d like to show you some of our campus.

SM: Is this a new building? I really like the look of it. I love the workspaces outside the rooms. Dr. rupp: And there’s a workstation in each room as well. Here’s one of our quality boards.

SM: It’s out for everybody to see. They have not had a “Fall” since November. Dr. rupp: In this unit.

Dr. rupp: We belong to a patient satisfaction group called PRC. It includes more than 300 hospitals—mostly academic medical centers. We were the number one hospital in patient satisfac-tion in 2009 and 2010. We don’t have the 2011 results yet. So, among those 300 or so hospitals, we had the highest patient satisfaction of anyone.

SM: I love how you have this published like this. I love the nurse stations. That’s really good. Dr. rupp: You see that every room on the floor is identical. From the patient area, to the family area, to the staff area.

SM: They are good spaces. Dr. rupp: Yes. Especially, the staff area and their workstations.

SM: And the workstations are not on top of the patients. The rooms are spacious. Nice. This was well thought out. Dr. rupp: The hallways are pretty wide too. Over here is the cleaning supplies room. Every supply room is the same. Ev-erything is in the same place in every supply room. Nurses can float floor to floor, and the arrangement is all the same. They did this as a “lean” project. People used to come in here and spend 20 minutes looking for something, and when they found it, they did not bother to charge for it. Now they come in, get what they want, they charge for it, and go.

SM: You’ve done so much work. Dr. rupp: We have great people here.

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30 Healthy Skin

Dr. rupp: As you can see, our hospital is connected to our clinic buildings. Everything is together. So, for example, if you’re in your clinic office and the hospital calls and says, “Mr. Smith is not looking good,” you can literally be at the patient’s bedside in one to two minutes, or they’ll say, “Oh, no he’s doing fine,” and you can go back to your office.

Dr. rupp: This entire facility is literally built on a 100-year plan. So, everything can go up and flip over. The hospital is six sto-ries. It can go up 10 more. This building can go up six more stories, and then it can flip over and go up again.

SM: So, you build it for the future. That’s really smart. Dr. rupp: This is all about value, you know. The value goes into the patient. And it’s all these little kinds of things that dem-onstrate that.

SM: What have you learned about how to resonate with the people who can make a difference here, whether it’s the board or the staff?

Dr. rupp: Staff and healthcare professionals get turned on by making things better for their patients, by delivering better care. They don’t get turned on by saving money or making mon-

ey for the organization. In fact, they are naturally suspicious that you do that at the cost of hurting somebody or not giving somebody everything that we could. They get very turned on by making the quality better. And then over time, we get to teach that when you make the quality better you also save a lot of money ... and with that money we can then turn around and fund education. We have 169 residents right now. We funded about 110 of them this year. And we put $800 million into basic science research last year.

SM: I’d like to thank you again for being so generous with your time. It has been very enlightening. Dr. rupp: You are more than welcome. Come back any time.

View from Dr Rupp’s office. The best views are reserved for patient rooms.

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32 Healthy Skin

Unnecessary Hospitalizations Decline When Clinicians

INTERACT


INTERACT

In 2006, 23.5 percent of people admitted to a post-acute care skilled-nursing facility returned to the hospital within 30 days. Research shows that many of these hospitalizations are inappropriate, unavoidable or treatable outside the hospital setting. What’s more, the price tag is more than $4 billion per year.1

“CMS is focused on the triple aim of improving care, improving health, and reducing costs,” Dr. Ouslander said. “Reducing unnecessary hospitalizations of nursing home residents achieves all of these goals. Medicare and Medicaid payment reforms will change the current financial incentives in the system that favor hospitalization, and force geriatric care providers to work more closely together to coordinate care in a high quality and efficient manner.”

Joseph Ouslander, MD, professor and senior associate dean for Geriatric Programs at the Charles E. Schmidt College of Medicine at Florida Atlantic University, began researching unnecessary hospitalizations in 2006 under a project supported by the Centers for Medicare and Medicaid Services (CMS). Continued research followed in 2009 under a grant from the Commonwealth Fund.

Interventions to Reduce Acute Care Transfers (INTERACT)Dr. Ouslander and his project team began their research by developing a quality improvement program called INTERACT, an acronym for “Interventions to Reduce Acute Care Transfers,” designed to improve the identification, evaluation, and communication about changes in resident status in an effort to reduce potentially avoidable hospitalizations of nursing home residents.

The first phase of the study focused on nursing home residents in Georgia to discover factors that contributed to potentially avoidable hospitalizations and develop and test tools to reduce them. As a component of this study, 200 hospitalizations of residents from 20 nursing homes (10 with high and 10 with low rates of hospitalizations) were reviewed by Dr. Ouslander and an expert panel of experienced long-term care clinicians.

Two-thirds of the hospitalizations were potentially avoidable for the following reasons:2

• Substantially less availability of medical directors, primary care physicians and nurse practitioners or physician assistants on-site

• Inadequate assessment of acute changes in status

• Lack of ability to initiate or maintain IV fluids at the nursing homes

• Transfer of residents who may have been more appropriately served with palliative or hospice care at the nursing home


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Quality Assurance System

Similarly, lack of in-house diagnostic services (such as X-rays, labs) and access to emergency medications, often left nursing home staff no other choice than to send residents to the hospital.3

Dr. Ouslander and his team developed a toolkit after reviewing the hospitalizations, interviewing providers and gathering input from the panel. The tools fall into three categories:2

Communication tools

Care paths

Advance care planning tools

The tools were pilot-tested in three of the original 20 Georgia nursing homes with high rates of hospitalization. Use of the tools in the three facilities varied, however, despite only partial implementation, the tools helped facilitate a 50 percent overall rate of hospitalizations during the six-month intervention period.2

INTERACT II: Testing the tools4

During a six-month period in 2009, a multidisciplinary team led by Dr. Ouslander and funded by the Commonwealth Group, continued their research with a follow-up project to refine and test the INTERACT tools in 25 nursing homes in Florida, New York and Massachusetts. There was a 17 percent reduction in hospital admissions in the 25 nursing homes compared to the same time period the previous year.

Dr. Ouslander and colleagues concluded that the results of the INTERACT II quality improvement initiative were encouraging and the tools and strategies can assist nursing home staff to improve the quality of care they provide while also reducing the morbidity and expense of unnecessary hospitalizations among nursing home residents.

To download a complete set of the INTERACT II tools, go to http://interact2.net.

references

1. Ouslander JG & Berenson RA. Reducing unnecessary hospitalizations of nursing home residents. New England Journal of Medicine. 2011; 365(13):1165-1167.

2. Ouslander JG. Reducing potentially avoidable hospitalizations of nursing home residents: the INTERACT II project. Florida Medical Directors Association (FMDA) Progress Report. Fall 2009.

3. Brunk D. Study: hospitalizations can be reduced. Caring for the Ages. March 2009.

4. Ouslander JG, Lamb G, Tappen R, Herndon L, Diaz S, Roos BA, etal. Interventions to reduce hospitalizations from nursing homes: evaluation of the INTERACT II Collaborative Quality Improvement Project. Journal of the American Geriatric Society. 2011; 59(4):745-753.

1

2

3


36 Healthy Skin

The

AGONYof the FEET

Prevention and management of diabetic foot ulcers

Nearly 25 percent of people with diabetes will develop a diabetic foot ulcer during

their lifetime.1 These ulcers open the door to infection, and the longer a diabetic

foot ulcer persists, the greater the risk of hospitalization and possible amputation.

Diabetic foot ulcers lasting 30 days or longer actually carry a four-fold risk of

infection and 85 percent of lower limb amputations in people with diabetes are

preceded by ulceration.1 The good news is that at least 40 percent of amputations

in diabetic patients can be prevented with a team approach to wound care.2

Risk factors for diabetic foot ulcers include previous amputation, past history of

diabetic foot ulcers, peripheral neuropathy, foot deformity, peripheral vascular

disease, visual impairment, poor glycemic control and cigarette smoking.3 The

most common sites for diabetic foot ulcers are the toes, followed by the plantar

metatarsal heads and the heels.4

By Margaret Falconio-West, BSN, rN, APN/CNS, CWOCN, DAPWCA


FEET

CE ArtiClE

38 Healthy Skin

Keeping these facts in mind, it’s best to prevent diabetic foot ulcers all together. Multidisciplinary programs that focus on prevention, education, regular foot examinations, aggressive intervention and optimal use of therapeutic footwear have demonstrated significant reductions in the incidence of lower-extremity amputation.5

Foot inspection Foot inspection should be performed on bare feet in a well-lit room, and should include a dermatological assessment. Referral for specialty foot care is recommended if any of the following are discovered:3

• Drynessorcrackingofskin• Infectionbetweenthetoes(fungal)• Ulceration• Callusesorblistering• Temperaturedifferencesbetweeneachfoot• Structuraldeformities,includingclawtoes, hammertoesandCharcotarthropathy

It isalsoimportanttoinspectthepatient’sshoes,lookingforunusual wear or other signs that the shoes may be rubbing againsttheskin.

Neurologic Assessment More than 60 percent of diabetic foot ulcers are caused by underlying neuropathy as the result of hyperglycemia-induced metabolic abnormalities that lead to nerve cell injury and death.2 Diabetic neuropathy has no known cure. Treatment for dia-betic neuropathy focuses on slowing the progression of the diseasebykeepingbloodglucoselevelsundercontrol.

Autonomic neuropathy leads to a decline in the functionality of thesweatandoilglands,resultingindryskinthatissuscep-tible to tears and subsequent infection. Loss of sensation in the feet occurs as part of peripheral neuropathy and exacer-bates the development of ulcerations. When trauma occurs to someone with a loss of sensation in the feet, the wound can go unnoticed and progressively worsen as a result.4Thehigh-est rates of neuropathy are among people who have had dia-betesformorethan25years.Diabeticneuropathiesalsoap-pear to be more common in people who are unable to control their blood glucose, as well as those with high cholesterol and hypertension and those who are overweight.6

PreventingDiabeticFootUlcers

• Keepbloodsugarlevelsundercontrol.Poorly controlled diabetes leads to peripheral vascular disease and neuropathy.

• Checkfeetdailyforinjuryorsignsofpressure.

• Promptlytreatanywoundsthatmayappearon the feet.

• Washfeetregularlywithamildsoap,makingsure to dry thoroughly between the toes.

• ApplyapH-balancedmoisturizingcreamtofeet topreventdrynessandcrackingofskin.

• Makesurecallusesandingrowntoenailsare regularly treated by a foot care specialist.

• Makesureshoesfitwell.Shoesthataretootight can cause friction and shear that can lead to skinbreakdown.

• Considerelectivesurgerytocorrectstructural deformities that cannot be accommodated by therapeutic footwear.

• Regularlyassessprotectivesensationinthe feetusingtheSemmes-Weinsteintestwith a monofilament.


Types of Diabetic Neuropathy6

Diabetic peripheral neuropathy can involve all three types of nerve dysfunction: sensory, autonomic and motor.

• Sensorydysfunctionresultswhenthepatientdevelopsa lack of protective sensation, particularly on the feet. Those withsensoryneuropathycansustainaninjuryandnever even feel it.

• Autonomicdysfunctionleadstoreducedperspiration,which compromises the skin’s integrity. Dry skin can easily develop crackswithoutpropermoisturization,andthiscanleadto skinbreakdownandinfection.

• Motorneuropathydevelopsinpatientswithfoot deformitiessuchasbunions,hammertoesandclawtoes. Footulcerstendtodevelopontheseareas,whichare exposedtoexcessivefriction.Analteredgaitresultingfrom foot deformities also can lead to unusual points of friction and ulcer formation.

The neurological assessment should include the Semmes-Weinsteintestandoneofthefollowing:vibrationusingatuningfork, pinprick sensation, ankle reflexes or vibration perception threshold(VPT).Abnormalitieswithanyoftheseassessmentsshould prompt a referral to a neurologist.3

Semmes-Weinstein test.TheSemmes-Weinsteintestusesa monofilament, or nylon strand specifically calibrated in stiff-ness to represent a baseline level of sensation. It is placed againstthefootuntilitbendsslightly.Atthispoint,theclinicianasksthepatientifheorshefeelsanything.Apersonwithnor-mal sensation should be able to feel the pressure of the mono-filament. If the patient does not feel the pressure in at least four out of ten predefined areas, it is reasonable to assume that diabetic neuropathy is present, and extra precautions should be taken to protect the foot. In fact, many prospective stud-ies have confirmed that loss of pressure sensation using the monofilament is highly predictive of subsequent ulceration.

Tuning fork. The tuning fork is a widely used, inexpensivemethod for testing vibratory sensation over the tip of the great toe on each foot. If the patient can no longer feel the vibra-tionwhentheforkcontinuestovibrate,heorsheisatriskforulceration.

Ankle reflexes. Ankle reflexes are tested with the patientkneelingor restingon a tablewith the ankles in a neutralposition.Theankleisthenstruckwithatendonhammer.Totalabsence of an ankle reflex is regarded as an abnormal result.

Vibration perception threshold (VPT). The biothesiometer or neurothesiometer is a handheld device to measure vibration perception. With the patient lying on his back, the stylus of the instrument is placed over the top of the big toe. The amplitude is increased until the patient can detect the vibration, and the resultingnumberisknownastheVPT.AVPTgreaterthan25 volts is considered abnormal, putting the patient at risk for ulceration.

TestsforVascularAssessment3Peripheral vascular disease (PVD) is a contributing factor associatedwithrecurrentdiabeticfootulcersinupto50per-cent of cases. Cell abnormalities develop in the arteries inside the calf as a consequence of the persistent hyperglycemic state. Smoking, hypertension and hyperlipedemia are otherfactors that commonly contribute to the development of PVDinpeoplewithdiabetes.2 The vascular assessment should include palpation of the posterior tibial and dorsal pedis pulses anddeterminationof thepatient’sankle-brachial index (ABI),if indicated.1Abnormalitieswitheitheroftheseassessmentsshould prompt a referral to a vascular specialist.3

Using foot assessment results to create a treatment plan2

Afterthoroughlyassessingthepatient,youmaywishtoassigna foot risk category according to the chart on the next page, as recommended by the Task Forces of the Foot Care Inter-estGroupof theAmericanDiabetesAssociation. Twootherpopular tools for classifying diabetic ulcers are the Wagner Ul-cerClassificationSystemandtheUniversityofTexasWoundClassificationSystem.

Semmes-Weinstein Test

40 Healthy Skin

What to do if a diabetic foot ulcer developsThe aim of therapy should be early intervention to allow prompt closure of the lesion and prevent recurrence once it heals. Once an ulcer has formed, rest, pressure relief and debridement are considered vital to the healing process.5 There are multiple ways to offload pressure from the wound, including contact casting, half shoes, removable cast walkers, wheelchairs and crutches. Overall wound condition, required frequency for assessment, presence of infection and patient compliance are all factors to consider when choosing the appropriate offload-ing device.2 When evaluating a diabetic foot ulcer, it is impor-tant to document the size, depth, appearance and location of the wound throughout treatment.5

Choosing wound dressingsProper selection of wound dressings is another important aspect of managing diabetic foot ulcers. Published clinical evi-dence is largely lacking regarding comparisons between the effectiveness of various dressings, however, clinical experience shows that maintaining a moist wound environment, absorb-ing excessive exudate, daily wound inspection and not in-creasing the risk for infection are critical for healing.2

Patients with diabetic foot ulcers are at significantly higher risk for infection, complications, and unfortunately, amputations. For these reasons, extra caution should be taken when select-ing a dressing for these wounds. Once the wound has been assessed, the appropriate dressing can be selected based on the characteristics presented.

There are many wound care dressings on the market today. Due to all the variables with each individual and each wound, there are many options, but the pneumonic DIMES will help you choose a dressing. DIMES is well-published and it is a great guideline based on product function.8 (See table on page 42).

Prompt medical attention is indicated if there is a deep infec-tion with abscess, cellulitis, gangrene or osteomyelitis. Even without osteomyelitis, reconstructive surgery to correct bone abnormalities may be necessary to achieve final healing of the diabetic foot ulcer, especially if the deformities are subject to excessive pressure from ambulating or rubbing against shoes.5 Save Those Feet: Wound Salvage TeamsDiabetes around the world results in one major limb ampu-tation every 30 seconds, or more than 2,500 limbs lost per day. Consultation with a multidisciplinary limb salvage team can be critical to facilitate timely diagnostic assessment and appropriate interventions – to do everything possible to prevent amputation.9

The core of the team typically starts with clinicians caring for the structural and surgical aspects of the foot (podiatric sur-geons) along with clinicians caring for the vascular integrity of the lower extremity (vascular surgeons). For a more compre-hensive care model, other specialties of the team may include internal medicine, endocrinology, infectious disease, physical therapy, plastic surgery, nursing, emergency medicine and prosthetics.9

Risk Definitions Recommended Suggested Category Treatment Follow-up

0 No loss of pressure Patient education including Annually sensitivity, no PVD, advice on proper footwear. no foot deformities

1 Loss of pressure - Consider specialized footwear. Every 3-6 months sensitivity with or - Consider surgery if deformity without foot deformity cannot be managed with shoes. - Continue patient education. 2 Loss of pressure - Consider specialized footwear. Every 2-3 months sensitivity and PVD - Consider vascular consultation (with a specialist) for combined follow-up.

3 History of ulcer or - Same as category 1 Every 1-2 months amputation - Consider vascular consultation (with a specialist) for combined follow-up if PVD is present.


HEELMEDIX™ Heel Protector Pressure relief and skin protection all in one

The heels are the most common site for facility-acquired pres-sure ulcers in long-term care, and the second most common site overall.1 According to clinical experts, the most effective aspect of pressure ulcer prevention for heels is pressure relief, also known as offloading.1,2 Offloading is achieved with the use of pillows or heel protection devices that relieve pressure by elevating the heel.

The HEELMEDIX Heel Protector is designed to help eliminate pressure, friction and shear on the skin by elevating the heel. Made of soft, suede-like material on the inside and easy-to-clean nylon on the outside. Adjustable straps are soft against vulnerable skin. Includes a mesh laundry bag with patient ID label to simplify washing and sorting.

Relieve Pressure on Vulnerable Heels


1Fowler E, Scott-Williams S, McGuire JB. Practice recommendations for preventing heel pressure ulcers. Ostomy Wound Management. 2008;54(10):42:48.

2Langemo D, Thompson P, Hunter S, Hanson D, Anderson J. Heel pressure ulcers: stand guard. Advances in Skin & Wound Care. 2008;21(6):282-292.

Straight-back strapping provides extra room, ventilation and protection against foot drop

50% lessfrictionthan the leading

competitor3

Criss-cross strapping isolates the foot and floats the heel

1-800-MEDLINElwww.medline.comMentionthisadtoreceivea10%discountonyourfirstHEELMEDIXorder

42 Healthy Skin

Seven Basic Skills of a Limb Salvage Team9

The interdisciplinary limb salvage team uses seven basic skills to improve the quality and efficiency of patient care, thereby seeking to improve overall outcomes and reduce amputation rates.

1. Hemodynamic and anatomic vascular assessment and revascularization as necessary2. Neurologic workup3. Site-appropriate wound culture technique4. Wound assessment that includes grading and staging of infection and ischemia5. Site-specific bedside and intraoperative incision and debridement6. Initiation and modification of culture-specific and patient-appropriate antibiotic therapy 7. Appropriate postoperative monitoring to reduce the risk of reulceration and infection

ConclusionProjections indicate that 366 million people worldwide will have diabetes by 2030 – more than three times the number of peo-ple who had diabetes in 2000.2 With this expected surge in diabetes, patient education and prevention and management of complications will become even more critical to prevent dia-betic foot ulcers and possible amputations.

References1. A Cascade of Events. Diabetic Foot Ulcers. Evidence-Based Medicine. Available at: http://www.diabetesfootulcer.com. Accessed May 1, 2012.2. Clayton W & Elasy TA. A review of the pathophysiology, classification, and treatment of foot ulcers in diabetic patients. Clinical Diabetes. 2009; 27(2):52-58. Available at: http://clinical.diabetesjournals.org/content/27/2/52. full. Accessed May 1, 2012.3. Boulton AJM, Armstrong DG, Albert SF, Frykberg RG, Hellman R, Kirkman MS, et al. Comprehensive foot examination and risk assessment. Diabetes Care. 2008; 31(8):1679-1685. Available at: http://www.ncbi.nlm.nih.gov/pmc/ articles/ PMC2494620/?tool=pubmed. Accessed May 2, 2012. 4. Jain A. A new classification of diabetic foot complications: a simple and effective teaching tool. The Journal of Diabetic Foot Complications. 2012; 4(1):1-5. Available at: http://jdfc.org/2012/volume-4-issue-1/a-new- classification-of-diabetic-foot-complications-a-simple-and-effective- teaching-tool/. Accessed May 1, 2012.5. Frykberg RG. Diabetic foot ulcers; pathogenesis and management. American Family Physician. 2002; 66(9):1655-1662.6. U.S. Department of Health and Human Services. National Institute of Diabetes and Digestive and Kidney Diseases. Diabetic Neuropathies: The Nerve Damage of Diabetes. Available at: http://diabetes.niddk.nih.gov/dm/pubs/neuropathies. Accessed May 3, 2012.7. Sherman JJ. Diabetic foot ulcer assessment and treatment: a pharmacist’s guide. U.S. Pharmacist. 2010;35(6):38-44. Available at: http://www.uspharmacist.com/content/d/feature/i/1076/c/21151. Accessed May 4, 2012.8. Okan D, Woo K, Ayello EA, Sibbald G. The role of moisture balance in wound healing. Adv Skin Wound Care. 2007;20(1):39-53.9. Bharara M, Scimeca CL, Fisher TK, Kimbriel HR, Mills JL, Armstrong DG. How to form a diabetic limb salvage team. Podiatry Today. 2010; 23(6):64-68. Available at: http://www.podiatrytoday.com/how-to-form-a-diabetic- limb-salvage-team. Accessed May 7, 2012.

The DIMES Model for Wound Assessment

D Debridement, the first step in preparing the wound to heal includes both cleansing and debriding necrotic material from the wound bed. With diabetes, the risk for infection is increased, so the need to prevent infection is also increased. There are many methods of debridement, however, the polyacrylate dressing is an efficient debriding agent that encompasses both autolytic and a method of mechanical debridement.

I As mentioned before, infection must be assessed and addressed immediately in individuals with diabetes. Systemic antibiotics may be indicated, but should always be used with caution, even in the person with diabetes. The number of antimicrobial dressings on the market has increased in the last several years, and so have the choices. Ionic silver is well accepted as an ingredient to address bioburden. The key to success is using an appropriate carrier dressing. A wound with minimal drainage could benefit from a hydrogel, but when diabetes is involved, an ionic silver hydrogel may be the best option. If the wound has drainage, a silver alginate or silver foam may be the better choice.

M The next component of wound bed preparation is to address the moisture balance, with the goal being to maintain an optimally moist wound bed. Based on the amount of drainage; an alginate, foam, hydrogel, or transparent film could be what the wound needs. Also consider that many products are available with and without an antimicrobial.

E After the first three components are addressed, the next step is to consider the edge environment. This is where “active” dressings come into play, such as collagen and extra cellular matrix dressings. Usually made of bovine (or porcine or avian) sources, these dressings help the body move toward healing.

S Supportive products, such as secondary dressings, are key to healing. They help the primary dressing stay in place. There are adhesive products such as bordered gauze or tapes. Silicone-based “tapes,” which are truly atraumatic upon removal, can be another viable option, though no adhesive dressing is really ideal, especially for someone with diabetes. Remember, the secondary dressing should not be the source of additional trauma. Consider a rolled gauze to wrap around an extremity to hold the primary dressing in place. Also, elastic netting is ideal as an atraumatic secondary dressing for individuals with diabetes.


8. Which of the following is a test used to perform a neurological assessment?

a. Semmes-Weinstein

b. Electrocardiogram

c. Vibration perception threshold (VPT)

d. Both a and c

9. How many limbs are amputated every day around the world?

a. 1,500

b. 3,000

c. 2,500

d. 450

10. Which of the following is a key specialist on a limb salvage team?

a. Pulmonologist

b. Vascular surgeon

c. Podiatric surgeon

d. Both b and c

True/False

1. Diabetic foot ulcers commonly occur on the toes. T F

2. More than 75 percent of diabetic foot ulcers are caused by underlying neuropathy. T F

3. Motor neuropathy develops in patients with foot deformities such as bunions, hammertoes and claw toes. T F

4. Offloading pressure is important for proper healing of diabetic foot ulcers. T F

5. One way to help prevent diabetic foot ulcers is to keep blood sugar levels under control. T F

Multiple Choice

6. Referral for specialty foot care is recommended if which of the following are discovered?

a. Dryness or cracking of skin

b. Ulceration

c. Structural deformities, including claw toes, hammertoes and Charcot arthropathy

d. All of the above

7. Which are the three types of nerve dysfunction?

a. Sensory, autonomic and motor

b. Peripheral, sensory and motor

c. Sensory, autonomic and metatarsal

d. None of the above

The Agony of the FeetPrevention and Management of Diabetic Foot Ulcers

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44 Healthy Skin 4 Healthy Skin

Lori PorterEverything I Learned in Life

I Learned in Long Term Care


Turn the clock back to the early 80s in Pineville, Missouri. Lori Porter was a high school dropout with dreams of running away to become a soap opera star. When her mother demanded she get a job, Lori said, “Well, there’s only three places to work in this town, the chicken plant, the nursing home or the dairy cone.” Thoughts of the first two options turned Lori’s stomach – smelly chickens at the plant and creepy old people with yellow fingernails at the nursing home. Lori said she would apply at the dairy cone.

But her mother had other plans for Lori. She already had a job lined up for her at the nursing home where she worked as the manager of dietary. Lori would be a dish washer. Although she was unhappy about having to work at the nursing home, Lori was at least thankful that she could hide in the kitchen and avoid contact with any of the old people. If one of them happened to wander into the kitchen on occasion, Lori quickly got on the intercom to call for a nurse to come STAT! The last thing she would ever want to be, she thought to herself, was a nursing assistant.

One day, however, Lori really had a taste for a can of soda from the vending machine on the other end of the building, so she bravely ventured out of the kitchen and walked to the break room. There sat three nursing assistants complaining about their jobs, saying things like, “butt wipers, that’s what we are.” It was at that moment that Lori began to change her mind about the nursing assistant role. It bothered her that the very people who did the most for the nursing home residents – turning them, bathing them, helping them eat –had such a poor opinion of themselves.

Well, you might already have an idea about what happened next. Before she knew it, Lori was a nursing assistant, although at first it was against her will. Because she was doing such a good job in the kitchen, Lori was provided the opportunity to pick up some hours as a nursing aide. She hated every minute of it, convinced she would just walk out one day, until she met Mrs. Punton, a resident who noticed Lori’s bad attitude and called her on it. Lori said it was the most ashamed she ever felt. She made a complete turnaround and took on a whole new positive outlook.

After continuing as a nursing assistant for several years, Lori went on to become a nursing home administrator, and ultimately co-founder of the National Association of Health Care Assistants (NAHCA). It was those early experiences at the nursing home that shaped her vision for working with nursing home employers and their nursing assistants to reduce turnover, advance quality and improve CNA morale throughout long-term care. Porter says, “regardless of the position we hold in long-term care the best way to ensure quality is to ensure administration and the frontline are working together in a mutually supportive and respectful culture.”

Turn the page to read more about how NAHCA continues to inspire nursing

assistants today.

There sat three nursing

assistants complaining

about their jobs, saying

things like, “butt wipers,

that’s what we are.”

It bothered her that the

very people who did

the most for the nursing

home residents – turning

them, bathing them,

helping them eat – had

such a poor opinion of

themselves.

46 Healthy Skin

Empowermentfor


Unfortunately, data shows turnover rates are regularly in the 100 percent range across the country,3 and this high turnover results in poor quality of care and decreased quality of life among nursing home residents.4

Why is turnover so high? Over the last three decades, findings from numerous studies indicate that job satisfaction is significantly associated with job turnover among nursing assistants.4

In preparation for her own study of nursing assistant turnover in 12 Maryland nursing homes, Nancy Lerner culled the literature for reasons why nursing assistants become dissatisfied with their jobs. Here is what the literature showed:4

Poor relationships with co-workers. Job satisfaction increased when nursing assistants had positive relationships with coworkers and work was performed as a team rather than individually.

Little potential for personal growth and development. An individual nursing assistant’s potential for personal growth and development was another factor identified frequently in the literature as influencing job satisfaction. Facilities with insufficient orientation programs and a lack of ongoing training opportunities were noted to have increased nursing assistant turnover.

Lack of recognition. Another reason for dissatisfaction is frustration over a lack of recognition from managers and among the nurses that nursing assistants were working with directly.

So how can employers address these causes for job satisfaction among nursing assistants and decrease turnover?

One answer is through help from the National Association of Health Care Assistants (NAHCA). Former nursing assistants Lori Porter and Lisa Cantrell developed solutions and formed the association in 1995 as a way to share their solutions with long-term care administrators and help nursing assistants gain self confidence and great job satisfaction.

Unlike other associations, in which members join and pay their dues individually, with NAHCA, administrators join and pay a flat membership fee for all nursing assistants in their facility.

Poor relationships with coworkers and lack of teamwork? Check! NAHCA helps facilities overcome this obstacle. Each long-term care facility that joins NAHCA creates its own chapter of the association led by a leadership team of nursing assistants selected by the facility’s administrator and/or director of nursing.

High turnover of nursing assistants is a challenge skilled nursing facilities have been facing for decades. In 2002, there were 1,458,000 people in nursing homes across the United States.1 More than 75 percent of these individuals require assistance with four to six activities of daily living.2 And nursing assistants perform the majority of these tasks.

Empowerment for CNAs

48 Healthy Skin

This group of leaders is responsible for ensuring membership materials are distributed to members, and they work to implement NAHCA-approved programs. The leadership team also holds monthly team meetings and NAHCA membership meetings.

Little potential for personal growth and development? Not the case with NAHCA’s web-based Virtual Campus of Care (NVCC), which provides education and professional development for NAHCA members. There are 120 courses available in four levels of difficulty. Students are required to complete 100 professional points in each of the four levels (100, 200, 300 and 400) for a total of 400 professional points to graduate from the academy.

NAHCA also offers two certification programs through its Virtual Campus of Care:

Geriatric Care Specialist: This program enhances knowledge and skills in the field of geriatric care. Each year 12 hours of in-service education must be completed to maintain certification.

Certified Preceptor: This program assists the CNA or ALC in becoming an expert in the training and orientation of new CNAs and ALCs. Course topics include team-building, communication, coaching, motivation, mentoring and leadership.

recognition for a job well done? NAHCA also offers a host of opportunities for facilities to recognize their nursing assistants locally and nationally with 18 annual Key to Quality awards. National winners receive their awards at the NAHCA Annual Conference. Centers routinely support nursing assistants’ attendance at the conference through sponsorships.

Meet NAHCA Member Donna AdairTo really show how NAHCA’s approach helps engage nursing assistants in their careers, Healthy

Skin had the opportunity to interview eight-year NAHCA member Donna Adair.

“Before joining NAHCA, I never really thought of myself as having a career,” Donna said. “I had a job that I liked, but now I know I have a profession to be proud of. And once

I realized it was a very fulfilling career, I was on a mission to make sure my coworkers realize that, too.”

Donna earned the Preceptor Certification, and she uses her knowledge to mentor other nursing assistants at her employer, Warrensburg Veterans Home in Warrensburg, Missouri. She has

1

2

Data shows turnover rates are regularly in the 100 percent range across the country.3

Donna Adair after accepting her National NAHCA Team Leader of the Year award at the 2011 NAHCA Annual Conference.



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50 Healthy Skin

NAHCA’s vision is of a long term care system:

•thatisfilledwithprofessionalCNAs,dedicatedtoprovidingthehighestlevelofcarewithintheirscope and responsibility.

•thathasexperiencedCNAsservingasmentorsfornewnursingassistantsenteringthefield.

•wherenursingassistantsperformasprofessionalsandarerecognizedasprofessionals.

•wheresocietyhonorsandrecognizesCNAprofessionalsastruenationalheroes.

NAHCA Cofounder, Lori Porter, shares her experiences in her book, Everything I Learned in Life... I Learned in Long Term Care.

Enjoy and understand the great dedication and love shared between the elderly and those who care for them. Each chapter concludes with a Life’s Lesson. The stories communicate the message through humor, tears, laughter and empathy.

To order a copy of the book, visit www.nahcacareforce.org or call 1-800-784-6049.

been a nursing assistant for 19 years, and she joined NAHCA when she began working at the veterans home.

In addition to earning Preceptor Certification, Donna has also served as president of her local NAHCA chapter, and during her terms as president, Donna’s chapter also won Leadership Team of the Year and Facility of the Year. Donna has also served on the National NAHCA Leadership Team, and most recently she became the only nursing assistant ever to be appointed to the Advancing Excellence in Nursing Homes board of directors, representing NAHCA.(Note: NAHCA is one of the founding members of Advancing Excellence.)

Donna said the NAHCA chapter at the Warrensburg Home is very active with very enthusiastic members. And it’s no coincidence that turnover is very low as a result. The majority of the nursing assistants have worked there at least five years.

Meet NAHCA Member Pam Conder

Pam Conder has been a nursing assistant at Good Samaritan in Ottumwa, Iowa for seven years, and a member of NAHCA for three years. She said the educational offerings provided by NAHCA are a major

benefit, and she has completed the Mentoring Program. Due to her involvement with NAHCA, Pam said, “My biggest reward is helping my facility and coworkers stay positive.” Through NAHCA, she has also learned how to advocate for residents on a local and national level, and she now understands reimbursement issues and how Medicare and Medicaid play a big role in operating a skilled nursing facility.

references

1. National Center for Health Statistics. Health, United States, 2004. U.S. Department of Health and Human Services.

2. National Center for Health Statistics. Health, United States, 2004. U.S. Department of Health and Human Services.

3. Mukamel DB, Spector WD, Limcangco R, Wang Y, Feng Z & Mor V. The costs of turnover in nursing homes. Med Care. 2009; 47(10):1039-1045. Available at: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2761533. Accessed May 1, 2012.

4. Lerner NB. Factors which influence job satisfaction in nursing assistants in nursing homes. 2010. Available at: http://archive.hshsl.umaryland.edu/handle/10713/942. Accessed April 30, 2012.

Pam helped establish the NAHCA Leadership Team at Good Samaritan, and she has served on the safety committee and the pain committee. She currently serves as secretary on the state steering committee for NAHCA and previously served as vice president, which has allowed her to travel to Washington, DC to participate in lobbying efforts. “Anyone who isn’t involved with NAHCA, needs to get involved,” she said.

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52 Healthy Skin

Wounds that fall between

Intertrigo: “A superficial inflammatory skin disorder involving any area of the body where two opposing skin surfaces can touch and rub or chafe.”4

Standardizing identification for better care

CRACKSthe


Years ago, if a wound care nurse was told that there would be technology available to allow the nurse to visit 25 home care wound patients a day, the response likely would have been a scoff, a funny face, or a comment such as, “that’s a pipe dream.” Fast forward to Iowa Health Home Care in January 2009, when that technology dream became a reality. Iowa Home Health, which covers all of Iowa, has an average daily census of 750-800 wound care patients. Three WOC nurses utilize the home care nursing assessment, digital wound photo, and patient information as a means to monitor the wound, the wound care protocol, and associated regula-tory documentation.

More data, more inconsistency

During the course of reviewing an average of 25-30 patients daily for several months, one of the WOC Nurses noted wide-spread inconsistency in documentation of lesions that are located in the intergluteal cleft. These lesions are character-ized by a linear slit, may be partial or full thickness, and may have maceration along the edges. The hallmark feature is the linear nature of the injury.

Scope of the problem

Accuracy of wound classification along the continuumis necessary for several reasons:

•Woundmanagementprotocolsandinterventions depend on an accurate identification of etiology.

•Reimbursementguidelines,regulatoryrequirements,andlitigation issues are affected by accurate documentation.

•Benchmarkingdata,suchasprevalencerateshavelittlevalue if the lesions are not classified consistently.1

Pressure ulcers result from pressure and/or shear and tend to be located over a bony prominence. 2 on behalf of a panel of experts introduced a proposal for a conceptual framework to delineate between superficial moisture and friction injury and deep tissue damage. Langemo, Hanson, Hunter, and Thomp-son indicate that moisture lesions are typically located

By Mary Mahoney, BSN, RN, CWON andBarbara Rozenboom, BSN, RN, CWON

This is a 72-year-old patient with a history of chronic renal

failure. The patient receives dialysis treatment three times

a week, sitting in a chair four hours at a time. The patient

has been on oral antibiotics for an upper respiratory infec-

tion and developed loose, incontinent stools since starting

treatment. The patient’s weight is 135 pounds.

AssessmentOn the admission assessment the nurse noted that the patient has a partial thickness, moist linear slit in the intergluteal fold. The peri wound skin appears thin and fragile.

54 Healthy Skin

in natal clefts, such as the intergluteal cleft, and not located over a bony prominence.3 Wolf, Oumeish and Parish defined Intertrigo as “A superficial inflammatory skin disorder involving any area of the body where two opposing skin surfaces can touch and rub or chafe.”4

The word ‘intertrigo’ comes from the Latin inter (between) and terer (to rub) and reflects the rubbing together of skin against skin to create maceration and irritation” (2011, p. 173). Incon-tinence-associated dermatitis was defined as “an inflammation of the skin that occurs when urine or stool come into contact with perineal or perigenital skin” (Langemo, et al, 2011). By these definitions, it is clear there are marked differences in the etiology of pressure ulcers, incontinence-associated dermati-tis, moisture lesions, and intertriginous lesions.

Factors to Consider

For each of the patients described here, how would you determine the etiology of the ulceration? What factors would you consider in determining the cause of the wound? Why is it important to identify the wound correctly? What terminology would you use to describe the lesion?

Conclusion

These are questions we ask ourselves each time we consult on patients with similar inter gluteal cleft lesions. We have found that even amongst trained wound care professionals we could not come to a consensus on the etiology and termi-nology of these particular ulcers.

In 2010, a group of nine gluteal wound photos were posted on Survey Monkey. The photos were reviewed by 100 wound care nurses who were asked to classify the wounds as pres-sure, moisture, incontinence-associated dermatitis or skin tear. Survey analysis revealed only “slight agreement” between the wound care nurses’ classification of the photos. Given these results, the authors of this article collaborated to present a consensus session at the 2011 Wound Ostomy Continence Nurse (WOCN) Conference. The participants in the session reached agreement on five of 10 statements pre-sented. It was obvious there is a clear need for consensus definitions and guidelines for differentiation between moisture, incontinence-associated dermatitis, intertriginous and pres-sure- related lesions.

Wounds that fall between

CRACKSthe


This is an 80- year-old patient who has a history of a CVA.

The patient is bedbound and incontinent of urine and stool.

Caregivers apply incontinence garments to contain urine and

stool. The head of the patient’s bed must be elevated for

aspiration precautions. The patient weighs 195 pounds.

AssessmentOn the admission assessment the nurse noted that the patient has a partial thickness, moist, linear slit in the inter gluteal fold. The peri wound skin is moist and reddened. There is an intact fluid-filled blister located on the right upper buttock lateral to the linear slit.

This is a 68- year-old patient admitted with a history of back

pain who reports a decrease in activity level due to the back

pain. The patient spends most of the time in bed and is

incontinent of urine and occasionally of stool. The patient’s

weight is 225 pounds.

AssessmentOn the admission assessment the nurse noted that the patient has a partial thickness, moist, linear slit in the inter gluteal fold. The peri wound skin is dry and discolored.

A second consensus session will be conducted at the Wound Ostomy Continence Nurses Society 44th Annual conference June 9-13, 2012 in Charlotte, NC. The session is entitled, “Glu-teal Cleft Skin Damage: Consensus Session 2 - Tomorrow is Here.” The goal of this session is to develop a pragmatic and useful consensus statement concerning these “wounds that fall between the cracks.” Please join us at the conference. To download a conference brochure, visit http://2012.wocn.org.

References

1. Mahoney M, Rozenboom B, Doughty D, Smith H. Issues Related to

accurate classification of buttocks wounds. Journal Wound Ostomy

Continence Nursing. 38 (6): 1-8.

2. Sibbald G, Krasner D, Woo K. Clinical management extra: pressure

ulcer staging revisited: superficial skin changes & deep pressure ulcer

framework. Advances in Skin and Wound Care. 24(12): 571-580.

3. Langemo D, Hanson D, Hunter S, Thompson P. Clinical management

extra: incontinence and incontinence-associated dermatitis. Advances

in Skin and Wound Care. 24(3):126-140.

4. Wolf R, Oumeish Y, Parish L. Intertriginous Eruption. Clinics in Derma-

tology. 29: 173-179.


Change your CULTURE.Change your BRIEF.

A culture change is sweeping through long term care. It honors

individuals. It’s where “the way we’ve always done it” is replaced

by “How would you like us to do it?”

The importance of personal choices and care is a central

theme of the culture change movement. Asking a resident to fit

into your routines is the old way; adapting to fit individual needs

is the new way.

Medline is proud to provide you videos, tools and educational

resources to help you identify and nurture changes that keep

your facility moving forward.

In continence care, fostering a culture of change means using

a brief that is designed with each individual’s needs in mind. It

must deliver dignity and comfort. And the idea of “one size fits

all” is replaced by choosing one that will FitRight.

http://www.medline.com/fitright

Make the change to FitRight.

The all-new FitRight brief helps accelerate your culture of patient-centered care.

• Designedwithindividualinmind

• Morehigh-techfeaturesforhighperformance

• Discreet,comfortable,garment-likefitandfeel

• 4Dcorewithodorprotectionfordrynessanddignity

Ask your Medline rep for a free sample and more about the FitRight story.

1-800-MEDLINE I www.medline.com

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

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

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

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

TM

58 Healthy Skin

Preventing Surgical Site Infections

The Importance of CommunicationAcross the Continuum of Care


CommuniCation. On the surface it seems like such a simple concept; especially critical when caring for patients and preventing costly readmissions. And yet how can communication break in today’s world with so many advanced communication tools?

First, “good communication requires a commitment from the top down and bottom up, making a statement about the way the organization does business. The rallying point should be around behavioral standards and their relationship to patient safety.”1 “The Joint Commission has reported that the primary root cause of over 70 percent of sentinel events was communication failures.”2

We must focus on a culture of safety that stretches across the continuum of care. Communication struggles occur not only between departments within acute care facilities but externally when transitioning patients to long-term care providers, physicians and home care agencies. Surgical patients, who leave the hospital with healing wounds, can be particularly affected by communication issues concerning appropriate post-discharge care to prevent surgical site infection.

“Surgical site Infections can be more elusive than other healthcare-associated infections since most do not appear until several weeks after the patient is discharged from an acute care facility.”3 As America grays and the 79 million baby boomers retire in the United States (that is equal to nearly the entire population of Germany retiring over the next 20 years), pushing Medicare costs into the trillions over the next decade.4 Preventing surgical site infection (SSIs) and the opportunities for quality improvement across the continuum of care has never been more important.

The Facts • Up to two percent of patients undergoing clean surgical procedures (e g., hernia repair, hip replacement) and 10 percent of patients undergoing clean-contaminated surgery (e g., colorectal) develop surgical site infections.7

• Patients who develop surgical site infections have a higher risk of death and prolonged post operative course.6

• PatientswhodevelopSSIsareup to60percentmore likely to spend time in the ICU, up to five times more likely to be readmitted to the hospital and twice as likely to die compared to patients without surgical site infections.7

• Surgicalsite infectionsarebelievedtoaccountforupto$10 billion per year in healthcare costs.6

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

60 Healthy Skin

Geriatric patients are not necessarily at risk for surgical site infections simply because of their age. However, older patients with complex health care needs have an increased susceptibility to surgical site infection. A study by Kaye et al revealed that patients age 65 and older who acquire an surgical site infection face greater mortality risks, a 2.9 times longer postoperative hospital stay, and 1.9 times greater hospital charges (mean of $43,970).6

Risk factors for Surgical Site Infection Among Patients 65 and Older 5 •Durationofsurgery•Woundclassification•Obesity•Diabetes•Tobaccouse•Malnutrition•Comorbidconditions(e.g.,COPD)•Lackofprivateinsurance•Admissiontosurgeryfromalong-termcaresetting•Weakenedimmunesystem

Healthcare organizations, including the Centers for DiseaseControl and Prevention (CDC), Society for HealthcareEpidemiology of America (SHEA), Association for Professionals in InfectionControl (APIC), the InfectiousDiseases Society ofAmerica (IDSA), the American Healthcare Association (AHA),theInstituteforHealthcareImprovement(IHI),theWorldHealthOrganization (WHO), the Center for Medicare and MedicaidServices(CMS)SurgicalCareImprovementProject(SCIP),alongwiththeAmericanCollegeofSurgeons(ACS)allhavepublisheddocuments on ways to prevent surgical site infection prevention. TheNationalPatientSafetyGoalsimplementedin2010byTheJointCommissionhasbeguntoshiftpreventingSSIstoabroadapproach including a focus on postoperative care.

Surgical site infection prevention measures across the continuum of care

Preoperatively

• Implementpoliciesandpracticesaimedatreducingthe risk of SSIs that meet evidence based standards • Knowledgeofthepatient’shighestriskfactorsforthe surgery type and mitigating what is feasible • Educationofpatient,healthcareprovidersandcare givers on prevention • AppropriateAntibioticTiming,Selection,andDuration • SkinPreppreoperatively • Decolonization • HairClipping • EffectiveHandHygiene

Intraoperatively

• ImplementationofaSurgicalSafetyChecklist •MaintainNormothermia • Skinprepintraoperatively • Tightglucosecontrol •WoundIrrigation-physicalremovalofclotsanddebris • ExcellentSurgicalTechnique/Maintainingaseptic technique •MaintainasepticOREnvironment -Trafficcontrol -Cleaning,DisinfectionandSterilization -Airflow/TemperatureControl

Postoperatively

• Utilizeappropriatedressingandwoundcaretechniques • EducatepatientsandcaregiversonSSIpreventionand wound care • Provideappropriatepreprintedmaterials • Accountabilityforpreventionrestsatalllevelsofthe organization • Reportsurveillancedatatoallinternalandexternalkey stake holders

With increasing longevity and an aging population in many parts of the world, healthcare organizations must prepare for the complex healthcare needs that older patients face.


For protection from unintentional hypothermia in patients undergoing surgery, PerfecTemp is an excellent alternative to forced-air warming systems.

While other systems use disposable blankets to force warm air on top of patients, PerfecTemp’s unique surgical table pads offer:

• Efficient underbody warming as effective as forced-air systems for preventing unintentional hypothermia1 (SCIP Measure #10)

• Pressure redistribution to help avoid pressure ulcers (CMS Hospital-Acquired Condition)

• Complete patient access

• Silent operation

• Reduced staff time

• No blowing air

PerfecTemp™

OR Patient Warming System

Are You in Compliance with SCIP and CMS?

©2012 Medline Industries, Inc. Medline and PerfecTemp are registered trademarks of Medline Industries, Inc.

s to forcenique

sonal

ure

Flexible and durable carbon heating element for uniform heating.

Underbody Warming for All Patients and Procedures

References1. Egan C, Bernstein E, Reddy D, et al. A Randomized Comparison of Intraoperative Warming With the LMA PerfecTemp and Forced Air During Open Abdominal Surgery.

Ask your Medline representative for moreinformation about the PerfecTemp OR Patient Warming System

1-800-MEDLINE I www.medline.com

62 Healthy Skin

Postoperatively “the actual surgery may be over, but the surgical process continues. All surgical procedures require postoperative care, even if those surgical procedures were conducted in the ambulatory or office-based surgery setting and the postoperative care will take place at home or in the long- term care setting. This is the crucial stage in the surgical process for the patient, a stage when complications such as a surgical site infection can slow the healing process.”5

Dressing and wound care becomes the focus at this stage. The CDC advises the following when considering wound and dressing care in the post operative patient.5

1. Has the surgical incision been closed vs. left open to be closed later or left open to heal by second intention? • Whenasurgicalincisionisclosed(mostare)theincisionis usually covered with a sterile dressing for 24 to 48 hours. • If the incision is leftopenat theskin level fora fewdays before it is closed (delayed primary closure) the incision is packed with a sterile dressing. • Iftheincisionisleftopentohealbysecondintention,itisalso packed with a sterile moist dressing and covered with a sterile dressing.2. Use sterile gloves, equipment, and sterile technique when changing dressings on any type of surgical incision.3. Protect the sterile dressing for 24-48 hours postoperatively.4. Wash hands before and after dressing changes and upon any contact with the surgical site.5. Educate the patient and family regarding proper incision care and symptoms of a surgical site infection.

Performance improvement efforts need to report surgical site infections to all key stakeholders across the continuum of care. The infection preventionist is a key resource in this process. All healthcare organizations should have processes for surgeons and nurses to follow for reporting post operative infections. Patients have been acquiring surgical site infections for as long as surgeries and procedures have been performed. It is estimated that 60 percent or more of the surgical site infections are preventable and should become far less common.”5

As we look to the future, healthcare professionals across the continuum must work as one healthcare team placing the patient in the center and building redundancy into to care process to make it easier for transitioning care from the acute care setting to home or long-term care.

References1. O’Daniel M & Rosenstein A. Professional communication and team collaboration. In: Hughes RG, ed. Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Rockville, MD: Agency for Healthcare Research and Quality, U.S. Department of Health and Human Services; 2008. Available at: www.ahrq.gov/qual/nurseshdbk/ docs/O’DanielM_TWC.pdf. Accessed April 18, 2012.

2. The Victorian Quality Council Guide: Promoting effective communication among healthcare professionals to improve patient safety and quality of care. July 2010. Available at: www.health.vic.gov.au/quality. Accessed April 18, 2012.

3. Thomas K. Hospitals get aggressive , and infections plunge, Hospitals and Health Networks. April 2012. Available at: www.hhnmag.com. Accessed April 18, 2012.

4. Dawson S. Graying America gets wired to cut healthcare cost. Reuters. April 13, 2012. Available at: www.Reuters.com. Accessed April 18, 2012.

5. Gaudette V, ed. Clinical Care Improvement Strategies: Preventing Surgical Site Infections. Oakbrook Terrace, IL: Joint Commission on Accreditation of Healthcare Organizations; 2010. Available at: http://www.jointcommissioninternational.org/ Books-and-E-books/Clinical-Care-Improvement-Strategies-Preventing-Surgical- Site-Infections/1520/. Accessed April 24, 2012.

6. Anderson DJ, Kaye KS, Classen D, Arias KM, Podgorny K, Burstin H, et al. Strategies to prevent surgical site infections in acute care hospitals. Infection Control and Hospital Epidemiology. 2008;29:S51-S61.

7. Gagliardi AR, Eskicioglu C, McKenzie M, Fenech D, Nathens A, McLeod R. Identifying opportunities for quality improvement in surgical site infection prevention. American Journal of Infection Control. 2008; 37 (5):398-402.

replacement Surfaces: We’ve Got You Supported!by Jackie Todd, rN, CWCN, DAPWCA

Product Spotlight: TheraTech + TheraTech EqualizeAire®

When it comes to support surfaces, understanding what the surfaces offer is the key to determining which one is the right fit for specific patient needs. Having pressure redistribution surfaces available for at-risk patients is key to any pressure ulcer prevention program. Also having the appropriate therapeutic surface available “on demand” is an added bonus when trying to intervene quickly for patients who have developed skin breakdown. From admission to discharge, Medline has a support surface line-up that can meet the wide range of patient needs. Following is a spotlight on our TheraTech and TheraTech EqualizeAire® support surfaces to help take the guess work out of making the right choice for the right patient for the right reason.

64 Healthy Skin

Item Features risk Level* Weight Capacity Warranty

TheraTech 7500• 5 zones

• Visco top layer• 2 layer Visco Heel

High Risk-Multiple Stage II pressure ulcers

450 lbs. 7 years


• HR foam top layer• Visco Heel

High Risk-Stage II pressure ulcers

425 lbs. 6 years


• HR foam top layerHigh Risk-Stage I pressure ulcers

425 lbs. 5 years

Table 1

TheraTech SeriesThe TheraTech Series features anatomically zoned cellular construction that contributes to outstanding pressure redistribution, greatly reduced shearing effects and a cool sleep surface. These surfaces accomplish this by maximizing immersion and envelopment to gently cradle patients at high risk for pressure ulcer formation. Fig. 1 - Each zone is constructed of different sized cells made up of various densities of foam to promote maximum weight redistribution while providing exceptional comfort and anatomical support. Fig. 2 - There are independent load-bearing cells that are strategically placed to allow for maximum contouring to the patient’s body. This reduces interface pressure and thus capillary closure. By being able to move independently as the patient moves, this divided structure of the cells in each module provides the capability to essentially eliminate shearing forces in comparison to traditional foam surfaces. Fig. 3 - The channels between the cells running vertically and horizontally allow for airflow, which reduces heat and moisture build-up. This decreases metabolic need of the patient’s skin cells as well as the risk for maceration.

Available TheraTech MattressesThere are three levels of the TheraTech Series mattresses available, depending on the patient’s weight and degree of risk for pressure ulcers. Table 1 shows the three levels, their features, indicated patient risk level, weight capacity and warranty available.

AddedbenefitsoftheTheratechseriessurfaces:

• Anti-microbial foam and cover

• Fire resistant, fluid proof, tear resistant, easy-to-clean cover

• Three-sided zipper for easy cover replacement as well as flap cover over zipper to prevent fluid penetration

• Four-way stretch cover to improve conformability and reduce friction and shear

• Gentle slope of extra soft heel section helps maximize weight redistribution for delicate heel tissue

• Firm rails provide added stability to improve ingress and egress as well as help prevent entrapment

• Fireproof barrier meets stringent code requirements

• Attached handles for ease in patient handling

Fig. 1 Fig. 2 Fig. 3



TheraTech 7500 Mattresses Our Most Advanced Therapeutic Foam Mattresses

•Fiveanatomicallydesignedpressure-relief zones work in conjunction with the tri-layered foam design to match the shape of the body.

•Thevisco-elasticmemoryfoamtoplayerincreasescomfort and completely conforms to the body’s contours.

•Independentload-bearingcellscradlebonyprominencesto relieve pressure and shear.

•Aslopedheelsectionfeaturestwolayersofvisco-elasticmemory foam to help redistribute pressure.

•Stretchcoverstretchesinalldirectionstoreducefrictionand shear.

•7"mattressdepthhasover16%morefoamthanstandard hospital mattresses.

1-800-MEDLINE l www.medline.com Contact your advanced wound care specialist today and schedule a trial of our TheraTech 7500 Mattresses

©2012 Medline Industries, Inc. Medline is registered trademark of Medline Industries, Inc.

The tri-layered foam design features an anatomic top layer for envelopment,

a sculpted middle layer for added pressure redistribution, and a supportive

base for comfort

Five anatomically designed pressure-reliefzones work in conjunction with the tri-layeredfoam design to match the shape of the body.

The visco-elastic memory foam top layer increasescomfort and completely conforms to the body’s contours.

Independent load-bearing cells cradle bony prominencesto relieve pressure and shear.r.r

A sloped heel section features two layers of visco-elastic Subject: Male 6'0" 190 lbs. Average Pressure: 11.34 mmHg*

Entire top layer features conforming memory foam.

©2012 Medline Industries, Inc. NE1 is a trademark of Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc. Patent pending.

Wound measurement made easyThe NE1 Wound Assessment Tool is a proven way to accurately measure and record wound characteristics, featuring a unique right angle design to see length and width measurements at the same time. It also contains areas to record the type of wound, plus the date, time and clinician’s name.

Key benefits• Increase accuracy of wound assessment

by more than 100 percent1

• Standardize wound documentation• Drive appropriate reimbursement due

to more accurate wound assessment

NE1™ Wound Assessment Tool Accurate identification, consistent documentation

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

Winner ofNational HCA Innovators

Award

Reference1. Young DL, Esocado N, Landers MR, Black J. A pilot study providing

evidence for the validity of a new tool to improve assignment of NPUAP stage to pressure ulcers. Advances in Skin & Wound Care. In press.

Camera not included.

www.medlinene1.com

NEW 10 pack available!


NE1™ Wound Assessment Tool Accurate identification, consistent documentation

Camera not included.

TheraTech EqualizeAire SeriesThe TheraTech EqualizeAire series surfaces provide pressure redistribution all the time and therapy on demand when you need it. Constructed of a set of interconnected foam cells encased in enveloping memory foam, these surfaces feature highly effective self-adjusting technology to help maximize weight redistribution. In addition, an optional easy- to-use control unit or pump turns the mattress into alternating pressure surface on demand. The surface uses a unique valve system that allows air to move from cell to cell as the patient moves in bed. This feature allows the surface to conform to the patient’s height, weight and body build. Each cell is made up of different densities of foam that allow the surface to accommodate the patient’s body contours and constantly adjust to movement, which in turn optimizes weight redistribution. Available in two versions, either nine or twelve cells, this advanced surface can meet the mattress replacement pressure redistribution and treatment needs of patients with minimal to the very high risk. From pressure redistribution to Stage IV pressure ulcers, now there is a low-cost alternative to high-cost capital and rental surfaces. TheraTech EqualizeAire series surfaces provide the same efficacy of expensive powered therapeutic rental surfaces. They also help eliminate the need to move surfaces around in the facility in order to meet specific patient needs. Less moving means a decrease in the risk for staff injuries. It also helps eliminate the need for costly storage of therapy surfaces when they are not in use.

Available TheraTech EqualizeAire MattressesThere are two levels of the TheraTech Series mattresses available. Table 2 shows the two levels and their features.

Flammability StandardsAll TheraTech surfaces feature fire barrier fabric as a standard feature that meet Federal Flammability Standards and all components meet California Flammability Standards.

Special OptionsAll TheraTech surfaces can be custom made to specific sizes and widths to meet customer needs and requirements. As safe patient handling and environments is a major focus, the surfaces can also be made with a custom Saf-T-Side Raised Edge Option which is designed to help reduce patient falls. Exit-Entry cutouts enable patients to sit up and get in and out of bed when they want to.

ConclusionA comprehensive pressure ulcer prevention program is essential to maintaining skin integrity. Effective support surfaces are a key component of any prevention program. Assess the whole patient, their degree of risk, and specific needs, and then determine which surface best meets those requirements. The TheraTech and TheraTech EqualizeAire surfaces provide the breadth of surface technology needed to provide pressure redistribution and therapy across the care continuum.

TheraTech EqualizeAire 9000 TheraTech EqualizeAire 12000

• Nine 5-inch air cells dynamically adjust to patient profile

• Four anatomically designed pressure redistribution zones

• Foam top comfort layer with super soft sloped heel zone

• Firm perimeter helps keep patient centered in bed and assists with ingress and egress

• Zippered four-way stretch cover allows for better patient immersion and features a non- skid bottom with transport handles

• Optional pump adds alternating pressure therapy

• 500 -lb. weight capacity

• 12 5-inch air cells dynamically adjust to patient profile

• Six anatomically designed pressure redistribution zones

• Two-layer foam topper features enveloping visco elastic memory foam

• Heel zone with sloping air tubes reduces pressure in critical heel area

• Firm perimeter helps keep patient centered in bed and assists with ingress and egress

• Zippered four-way stretch cover allows for better patient immersion and features a non-skid bottom with transport handles

• Optional pump adds alternating pressure therapy

• 500 -lb. weight capacity

Table 2


•Twelve5”aircellsdynamicallyadjusttothepatient’sprofile.

•Firmperimeterpromotesaddedstabilityforsafepatienttransfers and helps reduce the risk of entrapment.

•Nylexultra-stretchcoverstretchesinalldirections,allowingthe mattress to completely conform to the body. This material is fluid proof, tear resistant, and easy to clean.

•Cellscontainthreelayersoffoamthatcreate anatomical zones to mirror the body for maximum pressure redistribution.

•Sixanatomicallydesignedpressurereliefzones.

•Optionalpumpaddsalternatingpressuretherapywith a 5-minute cycle time.

•Antimicrobialfoamandcover.

©2012 Medline Industries, Inc. Medline and EqualizeAire are trademarks of Medline Industries, Inc. are registered trademarks of Medline Industries, Inc.

Medline’s EqualizeAire mattresses are for high-risk patients for prevention through stage IV pressure ulcers.

Heel section features gently sloping air tubes which significantly reduce interface

pressures in this sensitive area.

Entire top layer features conforming memory foam.

Optional pump adds alternating pressure therapy featuring a

5 minute cycle time.

EqualizeAire™ 12000 Self-Adjusting Mattresses Self-Adjusting, Convertible, Pressure-redistribution Mattresses

1-800-MEDLINE l www.medline.com Contact your advanced wound care specialist today and schedule a trial of our EqualizeAire 12000 Mattresses

EqualizeAire™ 12000 Self-Adjusting Mattresses Self-Adjusting, Convertible, Pressure-redistribution Mattresses remedy with Phytoplex has more skin care

solutions than ever, all enriched with the Phytoplex proprietary botanic matrix:

•HydratingCleansers,gentle,phospholipid-basedandsulfate-free; available as a spray, foam or gel

•Hydraguard,a24%siliconecreamthatishighlymoisture repellent and smooths gently on fragile skin

•NourishingSkinCream,ablendofemollientsincludingsafflower oleosomes, all-natural oils, plant extracts and NO petrochemicals

•Z-GuardProtectantPaste,formulatedwithpurewhite petrolatum and zinc oxide and without potential irritants such as menthol

•AntifungalClearOintment,with2%miconazole nitrate in a clear petrolatum base amended with soothing botanicals. (Not for use on scalp, nails or on children under 2 years of age.)

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


The Remedy for Sensitive Skin

Medline Remedy with Phytoplex

Introducing Ultrasorbs AP Dry Sheet technology in a larger size (40 x 90) suitable for the OR table.

CHALLENGE:• Perioperative-relatedpressureulcersare affected by immobility, pressure and moisture.• Incidenceofpressureulcersoccuringasa result of surgery has been as high as 66%.1

MEDLINE’S SOLUTION:• UltrasorbsAPhasbeenclinicallyshownto help maintain skin integrity as part of an overall pressure ulcer prevention program.2

• UltrasorbsAPisnowavailableasaDrySheet for the OR.

New! ULTrASOrBS® AP Dry Sheet for the ORAdvanced technology for ongoingmoisture management.

Patented SuperCore® absorbent sheet is thermo-bonded to provide better pad integrity, excellent skin dryness andexceptional absorbency.

Air-permeable backsheet for betterskin comfort and compatibility withunder-patient warming

AquaShield film trapsmoisture, providingbetter leakage protection.

©2012 Medline Industries, Inc. Ultrasorbs and Medline are registered trademarks of Medline Industries, Inc. www.medline.com/incontinence/drypads/ultrasorbs.asp

For a free sample, contact your Medline sales representative

72 Healthy Skin

Get rid of

WORROnce and for all

Wolf J. rinke, PhD, rD, CSP

To me worrying is like backward goal-setting. Because when you worry you are vividly imagining all of the things you do not want to have happen! And boy, do we like to worry. According to one study four out of five Americans said that they worry. (That’s 80 percent of us doing the backward goal-setting thing.) The poll, conducted by Barna Research, asked adults what are “the most pressing challenges and difficulties you

face.” Among those who worried, 28 percent said that they worried about finances, 19 percent identified health, 16 percent mentioned career issues, followed by parenting concerns (11 percent), family relationship issues (seven percent) and goal accomplishment challenges (seven percent).

Research further indicates that women tend to worry more than men. For example, in a study of 1,044 women in the U.S. conducted by Bruskin Audits and Surveys Worldwide, 50


WORROnce and for all

percent reported that they experience anxiety symptoms and worry for a period of more than six months. In addition, one out of 10 women describes herself as having “unrealistic” or “excessive worry.”

What makes these findings startling is that most of us appear to have little to worry about. In fact, 78 percent of the Barna Research poll’s respondents rated themselves as completely or mostly satisfied with their lives.

I find our propensity for worrying particularity perplexing, since only eight percent of our worries are “legitimate”—that is, they are under our control. The other 92 percent are “worthless worries” also known as the coulda, shoulda, woulda syndrome. That’s when you engage in “catastrophizing” convincing yourself that a stomachache means that you have an ulcer and an “angry” look by your spouse means that you are about to get a divorce. Worthless worry is when we try to solve what can’t be


Visit www.medlineuniversity.com for 24 nursing home administrator courses.

Topics include: •QIS•Diabetes•InfectionControl•PressureUlcerPrevention•SpendManagement•WoundandSkinCare

©2012 Medline Industries, Inc. Medline and Medline University are registered trademarks of Medline Industries, Inc.

Follow usBe the first to know when we add new courses and content.

Access courses on your computer,iPhone or iPad.

Download a QR Code Reader app

Launch the QR app

Scan this QR Code or visit http://www.medlineuniversity.com

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50 FREE NAB-approved credits now available at Medline University.

“

“Excellent.


solved because it has already happened, will never happen or is simply not under our control.

According to psychiatrist Edward M. Hallowell, worry can depress us, destroy our relationships, and sap our energy and joy of living. Struggling with perpetual “what if” scenarios can make us physically sick with back pain, recurring headaches and digestive disorders. It may even weaken the immune system, leading Dr. Hallowell to conclude that chronic, persistent worry is just as dangerous as high blood pressure.

Of course you can do what I do, and reduce this 8-step “Worry Buster” process down to 2 steps:

Step 1 What will happen if I worry about this really well? If the answer is “nothing,” quit worrying. If on the other hand, you can impact the outcome, go to step 2.

Step 2 Do something—anything—now. Then quit worrying!

If you still need more help, here are seven “Action Steps” that will help you take getting rid of worries to the next level:

1. Share Your Worry with OthersWhen worries seems to go out of control, talk them through with a trusted friend, a mentor or even your pet — hey, at least your pet won’t talk back. Be sure to reciprocate so that your worry support team is there for you when you need them.

2. Realize That Certainty is a MythRecognize that the only certainty is death. Given that most of us are not very interested in that option, make a commitment to get comfortable with uncertainty. Focus your mental energies on the joy you get from uncertainty and begin to celebrate it as part of the unique human experience. Just think, how boring life would be if everything was certain.

3. Make Worrying a “Snap”If you find that all of the above still don’t work, start wearing a rubber band on your left wrist. When you find yourself worrying, snap the rubber band—it’ll remind you, in a somewhat painful way, to quit worrying. Another technique that seems to work real well for one of my coachees is that when she gets stuck in a serious worry phase she records her worries on an old-fashioned tape recorder. (Yes they are still around.) Then she takes the tape out of the recorder, goes to her husband’s workshop, finds a big hammer and smashes the tape -- getting rid of those worries once and for all. (Hey, tapes are cheaper than wasting your precious brain power.)

4. Take a Worry BreakStill not working? Set a timer for a specified time—let’s say 10 minutes—and now worry “real good.” Play the “what if” game to the max. Get it all out of your system. When the 10 minutes are up, refocus your energy on something that will disconnect you from your worries.

Step 1 Clarify what it is that you are worried about. The best way to do this is to write it down, because it gets it out of your head. Step 2 Ask yourself if there is anything you can do to affect the situation. If not, it’s a worthless worry -- skip to Step 8. If you can affect the situation, go to the next step.

Step 3 Identify the worst possible outcome. Step 4 Ask yourself if you can live with the worst possible outcome. If so, go to Step 6. If not, go to the next step.

Step 5 Do everything in your power to solve the problem right now. Step 6 Make an action plan that will solve the problem entirely or minimize its bad consequences.

Step 7 Take action.

Step 8 Quit worrying. Either it’s too late or worrying won’t make a bit of difference.

Not to worry -- pun intended -- I have delineated an eight-step process to help you get rid of worries once and for all:

76 Healthy Skin

5. DisconnectDisconnect yourself from worrying by doing something that will totally absorb you. Try jogging, meditation, yoga, tai chi, getting a massage, playing a game of tennis, deep breathing, taking a walk, going to the movies--anything that disconnects you from your worries and allows you to totally relax.

6. Just Let GoDone it all, and still worrying? Just say no--I mean just let go. Let go of the feeling that you have to be in control--you are not! Realize that the harder you try, the less likely that will happen. Make a commitment to “go with the flow.” Convince yourself by re-evaluating prior worries; you may find that ultimately things do tend to work out for the best.

7. LaughIf all else fails make yourself laugh. Here is a bit of humor to make that happen:

Why Worry?There only two things to worry about;either you are well or you are sick.If you are well, there is nothing to worry about;If you are sick, there are only two things to worry about;either you will get well or you will die.If you get well, there is nothing to worry about.If you die, there are only two things to worry about;either you will go to Heaven or you will go to Hell.If you go to Heaven, there is nothing to worry about.If you go to Hell, you will be so busy shaking hands with friends, you will not have time to worry.

© 2012 Wolf J. Rinke

Dr. Wolf J. rinke, rD, CSP is a keynote speaker, seminar leader, management consultant, executive coach and editor of the free electronic newsletter Read and Grow Rich, available at www.easyCPEcredits.com. In addition he has authored numerous CDs, DVDs and popular books including Make It a Winning Life: Success Strategies for Life, Love and Business, Winning Management: 6 Fail-Safe Strategies for Building High-Performance Organizations; Don’t Oil the Squeaky Wheel and 19 Other Contrarian Ways to Improve Your Leadership Effectiveness; and Leadership: Helping Others to Succeed, available at www.WolfRinke.com. His company also produces a wide variety of quality pre-approved continuing professional education (CPE) self-study courses, such as Beat the Blues--How to Manage Stress and Balance Your Life, (28 CPEUs) from which this article was excerpted. CPE courses are available in both print and electronic formats at www.easyCPEcredits.com. Reach him at [email protected].

Done it all, and still worrying? Just say no -- I mean just let go. Let go of the feeling that you have to be in control -- you are not!”“

Minimizes pain and potential tissue trauma. Versatel is a conformable, flexible, translucent silicone wound contact layer. Channels in the dressing allow fluid to easily transfer to an absorbent secondary dressing.

Gentle The silicone coating allows for gentle adhesion and eliminates potential trauma when removed.

Conformable Flexible, pliable design conforms to body contours, improving patient comfort.

Fluid transfer Designed to allow wound fluid to easily transfer into a secondary dressing.

Translucent Allows easy viewing of the wound upon application and between dressing changes.

©2012 Medline Industries, Inc. Versatel is a trademark and Medline is a registered trademark of Medline Industries, Inc.

Contact Layer Wound Dressing

Versatel™

Contact your Medline representative or call 1-800-MEDLINE (1-800-633-5463) for the opportunity to try Versatel for yourself.

Motivation to fight harder

CAnCER

reasons to celebrate

1 U.S. Breast Cancer Statistics. BreastCancer.org website. Avail-able at: http://www.breastcancer.org/symp-toms/understand_bc/statistics.jsp. Accessed February 6, 2012.

.......................................

2 Breast Cancer Statis-tics. The Breast Cancer Society, Inc. website. Available at: http://www.breastcancersoci-ety.org/aboutbreastcan-cer/factsandstatistics/breastcancerstatistics/. Accessed February 6, 2012.

.......................................

3 What are the key statistics about breast cancer? American Cancer Society website. Available at: http://www.cancer.org/Cancer/BreastCancer/DetailedGuide/breast-cancer-key-statistics. Accessed February 6, 2012.

Death rates from breast cancer have been decreasing since 1999 in women under 50.1

About 1in 8 U.S. women will develop invasive breast cancer in her lifetime.1

In 2012 about 226,870 new cases of invasive breast cancer will be diagnosed in women3

39,510 women will die from breast cancer in 20123

In 2011, there were more than 2.6 million breast cancer survivors in the U.S.1

There is a 100% survival rate after treatment for those who are diagnosed and treated during the earliest stage of breast cancer. 2

fastfactsAnCER

1 U S Breast Cancer

1:8

BREAST

Running for Her

Life


Running for Her

Life

Judy Pickett

By Jennifer Freedman

With just a hint of the sun on the horizon, Judy Pickett laces up her running shoes, pulls on a windbreaker and heads out her front door.

“Running is a part of me,” Pickett explains. “I love the time to decompress, pray and be alone.”

Pickett considers every mile she logs a gift. The 48-year-old wife and mother battled three bouts of breast cancer over a five-year span.

(continued)

80 Healthy Skin

It was November of 1996, when Pickett discovered her first lump. She was 33 and teaching high school science and weekly aerobics classes. She was the picture of health and happiness, but her body was under attack.

“On Thanksgiving Day, we were having a holiday dinner and I had an itchy armpit,” says Pickett. “When I scratched it, I found a lump in my armpit and I knew that it wasn’t supposed to be there.”

At such a young age and with no family history, it took three doctors and three months for Pickett to get a mammogram. The testing led to a grim diagnosis.

“My doctor called at 5 p.m. on a Friday and I was home alone,” remembers Pickett. “He told me I had adenocarcinoma, stage two breast cancer. It was such a shocker. I really did not expect it. I was fine until my husband, Tod, came home and I told him. Then we both started crying and held each other. It was very scary. I thought to myself ‘this sort of thing is not supposed to happen at 33.”

Pickett was emotional. A mom of three boys, the youngest just nine months old, she knew she had to fight back. She had surgery to remove the affected breast and nine cancerous lymph nodes, then nine months of chemotherapy and six weeks of radiation treatments.

During treatment, Pickett says she relied mostly on Tod for support. He would accompany her to every appointment he could. He would talk to the nurses and even bring them gifts. Pickett also credits the nurses for helping her get through her rough days of treatment. In particular, she remembers her first oncology nurse at the infusion clinic.

“We didn’t know how my body would react after the first chemo treatment, so she gave me her home phone number and said to call her if I needed to. It was a Friday afternoon and that night I was so sick. I called her on Saturday morning and she talked me through it. She told me everything would be okay and called in a prescription for an anti-nausea medication. She was truly compassionate.”

Five months after completing chemotherapy, Pickett entered her first Susan G. Komen Race for the Cure in Sacramento.

The race experience left her feeling so good that she decided to keep running. She started the Pink Ribbon Running Club and set a goal to run 100 benefit races in five years, supporting breast cancer awareness and research and spreading a message of hope for cancer survivors.

“I wanted to demonstrate that breast cancer victims can not only survive, they can thrive,” says Pickett.

But, in 1999, she hit a speed bump that would truly test her endurance. The cancer was back. Pickett wondered how this could be happening.

“It was really devastating,” Pickett says. “I had to psyche myself up to go through it all again.”

Her doctor recommended oophorectomy — surgery to remove her ovaries — where most of the estrogen in the body is made. Because estrogen makes hormone-receptor-positive breast cancers grow, reducing the amount of estrogen in the body or blocking its action can help shrink the hormone-receptor-positive cancers. Eight weeks post-op and Pickett was on the

PASSING THE TORCH: During treatment for her third bout of breast cancer, Pickett ran three races and carried the Olympic Torch

for the 2002 Salt Lake City games.



Remember...

To get your mammogram.Visit medline.com

Pink merchandise from Medline helps support the National Breast Cancer Foundation.

82 Healthy Skin

“running was my coping mechanism,” says Pickett. “It was something that I could actually control during my cancer treatment.”

THE HEAT IS ON: By 2004, Pickett completed her one-hundredth race and was named one of eight running “Heroes” for 2004 by Runner’s World magazine. To date, she has run in 44 states, in 136 races alongside more than two million participants, including 200,000 survivors.

road again, running for her life. She ran ten races in ten weeks, winning the survivor division eight times.

“Running was my coping mechanism,” says Pickett. “It was something that I could actually control during my cancer treatment.”

But there were more hurdles. In August 2001, Pickett had a second recurrence of the disease. She found a lump during a self examination and it was on the same side. The cancer came back again.

“This time it felt different,” says Pickett. “I was not as emotionally distraught because deep down I knew it could happen again. I really felt like kicking it.”

Pickett had surgery to remove the lymph node and six rounds of chemo. While in treatment, she ran three races and carried the Olympic Torch for the 2002 Salt Lake City games.

By 2004, Pickett completed her one-hundredth race and was named one of eight running “Heroes” for 2004 by Runner’s

World magazine. To date, she has run in 44 states, in 136 races alongside more than two million participants, including 200,000 survivors. Her goal is to run in all 50 states.

“I am fortunate in that I feel strong and well enough to train and run races with other survivors so that I may spread my message to women with or without cancer,” says Pickett. “Medical research has made great strides in cancer therapy, which is allowing me to make great strides in my races and my life. Every time I cross a finish line, I’m declaring that life after breast cancer is not just about surviving, but also about thriving. It’s saying publicly to women everywhere that they can literally take steps to make their dreams come true.”

Now a 10-year survivor, Pickett is teaching physical education and coaching track at a middle school in Sacramento. She says her life experience has enhanced the way she teaches.

“I tell my students to have strength and courage and hope – no matter what,” says Judy. “I want them – and every young person out there to know – it is okay to question and persist. Be an advocate for your own health. It’s been 15 years since I was diagnosed and I’m still here. The longer I go cancer-free, the more inspirational I become.”

Pickett’s Pink Ribbon Cancer Fund, which she and Tod started in 1999, has provided more than $72,000 in scholarships to high school seniors in the greater Sacramento are who have an immediate family member with cancer.

ALL IN THE FAMILY: Pickett was 33 and her youngest son, Zach, was just nine months old when she was first diagnosed with breast cancer. When he turned one, she brought him with her to the hospital. “I remember the radiation oncology nurses played with him and took care of him,” said Pickett. “They were great.”

Yes, They’re Genuine.

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

©2012 Medline Industries, Inc. Medline is a registered trademark and Pink Pearl is a trademark of Medline Industries, Inc.

Yes, They’re Genuine.Yes, They’re Genuine.

Only Medline’s Pink Pearlaloe, nitrile and breast cancer awareness.

pinkglovedance.com

Announcing ...


Whatyoucandonowtogetready!1.Getconsentfromyourfacility2.Gatheryourfriendsandcoworkers toparticipate3.Startpracticing

WinaDonationtoYourFavoriteBreastCancerCharity*• First Place: $10,000• Second Place: $5,000• Third Place: $2,000




PGDJuly 2!

pinkglovedance.com

Some of last year’s PGD Video contestants!

Gwinnett Medical Center, Duluth, GA

Oakwood Care Center, Clear Lake, IA

Highland Hospital, Rochester, NY

San Juan Medical Foundation, Farmington, NM

St. Patrick’s Residence, Naperville, IL

Program for Healthcare

©2012 Medline Industries, Inc. greensmart is a trademark and Medline is a registered trademark of Medline Industries, Inc.

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

1

2

4

3Identify Green Products and StrategiesWith the help of your Program Manager, you will identify products, services and education that are right for your facility.

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

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

The greensmart approach for reaching your unique goals:

One-on-one sustainability guidance and services

ONE CALL STArTS YOU ON YOUr WAY TO BECOMING GrEENSMArT

Francesca Olivier, Medline’s corporate sustainability manager, is ready to work with you no matter where your facility is on your sustainability journey. Call her at (847) 643-3821 or email [email protected]

Introducing

Abby!Nothing is more special than the birth of a child.

Labor & delivery nurse Abby helps create the best

birth experiences. She comforts baby and mom

with her words, touch and kindness. Her patients

feel happy and cared for—even pampered. Abby

communicates with an understanding ear, helps the

mom-to-be express her wishes and advocates for

her needs. Abby is a true healthcare professional,

delivering the quality care that helps keep her

hospital the favorite in the community.

To order your own Abby doll, visit www.scrubs123.com

The greensmart approach for reaching your unique goals:

ToToT orviviv sisi ititi w

88 Healthy Skin

Denise Robinson Earns Three Nursing Awards

Denise Robinson, MPH, RN, CHWOCN, is the recipient of three nursing awards for 2012. She is currently Patient Care Director at New York Presbyterian/Columbia Hospital in New York City. She also serves on Medline’s Wound Care Advisory Board.

In March she accepted the Outstanding Achievement in the Advancement of Wound, Ostomy and Continence Nursing award at the Second Annual Wound and Vascular Symposium at New York Presbyterian/Columbia.

In honor of Nurses Week, she accepted the New York Presbyterian Clinical Excellence Award in Nursing Leadership, and in June she will be recognized by the NY/NJ Nurse.com as a 2012 Nursing Excellence Regional Finalist in the Patient and Staff Management Category. Congratulations, Denise!

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

Problem: Peristomal Irritation

Solution: Marathon® Cyanoacrylate Liquid Skin Protectant

Peristomal irritation can lead to decreased wear time, pain and embarrassment about leakage. So it only makes sense to do everything you can to protect the peristomal area. Marathon Liquid Skin Protectant helps protect

against irritation and maceration by creating a barrier

against moisture and chemical assault.

Marathon, a cyanoacrylate, bonds to the skin surface, integrating with the epidermis on a molecular level to seal in moisture. While other skin protectants may fl ake off, Marathon stays in place, offering robust protection and increased wafer wear time.

Stoma site before treatment with Marathon.1

Same stoma site aftertreatment with Marathon.1

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

1. Data on fi le

© 2012 Medline Industries, Inc. Medline and Marathon are registered trademarks of Medline Industries, Inc.

Congratulations!

CO1_HealthySkin22.indd 88 5/11/12 6:30 PM

We inadvertently left out photo credit for the photos that appeared with the case study, “Chal-lenges of Preventing Moisture Associated Skin Damage in the Intensive Care Units Using No Sting Spray Skin Protectant,” which appeared in Volume 10, Issue 1 of Healthy Skin. The photographer for all photos was A. Chenel Trevellini, RN, MSN, CWOCN.

Oops! Correction

Now on Medline University

A new online education course: “Proper Perioperative Positioning to Prevent Patient Injuries”

PLUS an interactive virtual simulation competency!

register at www.medlineuniversity.com to get started.

90 Healthy Skin

Healthy Eating

Ingredients1 pkg broccoli cole slaw1 6-oz pkg slivered almonds1 7.25-oz jar sunflower seeds4 green onions, thinly sliced1 pkg chicken-flavored ramen noodles, crushed

Crush the uncooked ramen noodles and toss all the ingredients together. Add dressing and toss immediately before serving for a great crunchy texture. The next day it’s still very good, but the ramen will have lost its crunch.

Broccoli is a nutrition star. Its resumé of vitamins and miner-als includes beta carotene, vitamin C, calcium, fiber, and phyto-chemicals, specifically indoles and aromatic isothiocynates. Some suggest broccoli other cruciferous vegetables may be responsible for boosting certain enzymes that help to detoxify the body, even helping to prevent cancer, diabetes, heart disease, osteoporosis and high blood pressure.

Ready-to-use broccoli slaw is available in most grocery stores’ packaged salad aisle. It’s long shreds of broccoli stems (and sometimes some other veggies, too) that you can substitute for the shredded cabbage in traditional cole slaw, or as the main ingredient in this delicious salad.

Lillian Stafford’s Oriental Broccoli

Nutrition Information

Servings: 6Calories: 391Fat: 35.8Sodium: 156mgFiber: 3.2g

The Medline employee cookbookis $10. To purchase your own copy, please e-mail Judy at [email protected].

2

Dressing½ C canola oil (light virgin olive oil works, too)3 T vinegar1 T soy sauce3 T sugar1 chicken flavor packet (from the ramen noodles)

Whisk or shake to thoroughly mix the ingredients together. Set aside until ready to serve the salad.

Diane Seminary is a 15-year Medline veteran who works closely with the manufacturing team in Medcrest. Born here, her family is originally from Quebec, which she still visits every summer. The salad’s namesake is the daughter of Bill Stafford from Medline warehouse B02, who introduced it to Diane’s family. “This salad is light and carries well for any picnic adventure.” Enjoy.


The following pages contain practical tools for implementing patient-focused care practices

at your facility.

Forms & Tools

Infection Control Six Steps to C. diff Prevention.............................................93OSHA’s Bloodborne Pathogens Standard........................94

Preventing Unnecessary Hospitalizations Early Warning Tool (English)................................................96Early Warning Tool (Spanish)............................................97Resident Transfer Form....................................................98

Introducing the new BioCon™- 700 The future of bladder ultrasound technology

Minimize unnecessary catheterizationResearch has shown that 80 percent of urinary tract

infections acquired at healthcare facilities are associated

with an indwelling urethral catheter.1 This type of infection

is known as CAUTI, or catheter-associated urinary

tract infection.

Avoiding unnecessary catheter use

is a primary strategy for preventing

CAUTI, and clinical guidelines

recommend the consideration of

alternatives to catheterization.2

Bladder scanners accurately

assess bladder volumes,

and many urinary

catheterizations

can be avoided.3

1. Lo E, Nicolle L, Classen D, Arias A, Podgorny K, Anderson DJ, et al. SHEA/IDSA practice recommendation: strategies to prevent catheter-associated urinary tract infections in acute care hospitals. Infect Control Hosp Epidemiol. 2008;29:S41-S50.

2. Stokowski, LA. Preventing catheter-associated urinary tract infections. Medscape Nursing Perspectives. February 3, 2009.

3. Stevens E. Bladder ultrasound: avoiding unnecessary catheterizations. Med/Surg Nursing. 2005; 14(4):249-253.

©2012 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.www.erasecauti.com/bladder-scanner


C. diff Prevention Forms & Tools

Prescribe and use antibiotics carefully. About 50 percent of all antibiotics given are not needed, unnecessarily raising the risk of C. difficile infections.

Test for C. difficile when patients have diarrhea while on anti-biotics or within several months of taking them.

Isolate patients with C. difficile immediately.

Wear gloves and gowns when treating patients with C. difficile even during short visits. Hand sanitizer does not kill C. difficile, and hand washing alone may not be sufficient.

Clean room surfaces with bleach or another EPA-approved, spore-killing disinfectant after a patient with C. difficile has been treated there.

When a patient transfers from one facility to another, notify the new facility if the patient has a C. difficile infection.

6to C. diff Prevention Steps

1

2

3

4

5

6Source: Centers for Disease Control and Prevention Available at: http://www.cdc.gov/vitalsigns/hai/?s_cid=bb-vitalsigns-115

94 Healthy Skin

Forms & Tools Bloodborne Pathogens

• Implement the use of universal precautions(treating all human blood and OPIM as if knownto be infectious for bloodborne pathogens).

• Identify and use engineering controls. Theseare devices that isolate or remove the blood-borne pathogens hazard from the workplace.They include sharps disposal containers, self-sheathing needles, and safer medical devices,such as sharps with engineered sharps-injuryprotection and needleless systems.

• Identify and ensure the use of work practicecontrols. These are practices that reduce thepossibility of exposure by changing the way atask is performed, such as appropriate practicesfor handling and disposing of contaminatedsharps, handling specimens, handling laundry,and cleaning contaminated surfaces and items.

• Provide personal protective equipment (PPE),such as gloves, gowns, eye protection, andmasks. Employers must clean, repair, andreplace this equipment as needed. Provision,maintenance, repair and replacement are at nocost to the worker.

• Make available hepatitis B vaccinations to allworkers with occupational exposure. This vac-cination must be offered after the worker hasreceived the required bloodborne pathogenstraining and within 10 days of initial assignmentto a job with occupational exposure.

• Make available post-exposure evaluation andfollow-up to any occupationally exposed work-er who experiences an exposure incident. Anexposure incident is a specific eye, mouth,other mucous membrane, non-intact skin, orparenteral contact with blood or OPIM. Thisevaluation and follow-up must be at no cost tothe worker and includes documenting theroute(s) of exposure and the circumstances

Protections Provided by OSHA’sBloodborne Pathogens StandardAll of the requirements of OSHA’s BloodbornePathogens standard can be found in Title 29 of theCode of Federal Regulations at 29 CFR 1910.1030.The standard’s requirements state what employ-ers must do to protect workers who are occupa-tionally exposed to blood or other potentiallyinfectious materials (OPIM), as defined in the stan-dard. That is, the standard protects workers whocan reasonably be anticipated to come into con-tact with blood or OPIM as a result of doing theirjob duties.

In general, the standard requires employers to:

• Establish an exposure control plan. This is awritten plan to eliminate or minimize occupa-tional exposures. The employer must preparean exposure determination that contains a listof job classifications in which all workers haveoccupational exposure and a list of job classifi-cations in which some workers have occupa-tional exposure, along with a list of the tasksand procedures performed by those workersthat result in their exposure.

• Employers must update the plan annually toreflect changes in tasks, procedures, and posi-tions that affect occupational exposure, andalso technological changes that eliminate orreduce occupational exposure. In addition,employers must annually document in the planthat they have considered and begun usingappropriate, commercially-available effectivesafer medical devices designed to eliminate orminimize occupational exposure. Employersmust also document that they have solicitedinput from frontline workers in identifying, eval-uating, and selecting effective engineering andwork practice controls.

FactSheetOSHA’s Bloodborne Pathogens StandardBloodborne pathogens are infectious microorganisms present in blood that cancause disease in humans. These pathogens include, but are not limited to, hepatitis Bvirus (HBV), hepatitis C virus (HCV), and human immunodeficiency virus (HIV), thevirus that causes AIDS. Workers exposed to bloodborne pathogens are at risk forserious or life-threatening illnesses.


Bloodborne Pathogens Forms & Tools

This is one in a series of informational fact sheets highlighting OSHA programs, policies or standards. It does not impose any new compliance requirements. For a comprehensive list of compliance requirements of OSHA standards or regulations, refer to Title 29 of the Code of FederalRegulations. This information will be made available to sensory-impaired individuals upon request.The voice phone is (202) 693-1999; the teletypewriter (TTY) number is (877) 889-5627.

under which the exposure incident occurred;identifying and testing the source individual forHBV and HIV infectivity, if the source individualconsents or the law does not require consent;collecting and testing the exposed worker’sblood, if the worker consents; offering post-exposure prophylaxis; offering counseling; andevaluating reported illnesses. The healthcareprofessional will provide a limited written opin-ion to the employer and all diagnoses mustremain confidential.

• Use labels and signs to communicate hazards.Warning labels must be affixed to containers of regulated waste; containers of contaminatedreusable sharps; refrigerators and freezers containing blood or OPIM; other containersused to store, transport, or ship blood or OPIM;contaminated equipment that is being shippedor serviced; and bags or containers of con-taminated laundry, except as provided in thestandard. Facilities may use red bags or redcontainers instead of labels. In HIV and HBVresearch laboratories and production facilities,signs must be posted at all access doors whenOPIM or infected animals are present in thework area or containment module.

• Provide information and training to workers.Employers must ensure that their workersreceive regular training that covers all elementsof the standard including, but not limited to:information on bloodborne pathogens and dis-eases, methods used to control occupational

exposure, hepatitis B vaccine, and medical eval-uation and post-exposure follow-up procedures.Employers must offer this training on initialassignment, at least annually thereafter, andwhen new or modified tasks or proceduresaffect a worker’s occupational exposure. Also,HIV and HBV laboratory and production facilityworkers must receive specialized initial training,in addition to the training provided to all work-ers with occupational exposure. Workers musthave the opportunity to ask the trainer ques-tions. Also, training must be presented at aneducational level and in a language that work-ers understand.

• Maintain worker medical and training records.The employer also must maintain a sharpsinjury log, unless it is exempt under Part 1904 --Recording and Reporting Occupational Injuriesand Illnesses, in Title 29 of the Code of FederalRegulations.

Additional InformationFor more information, go to OSHA’s BloodbornePathogens and Needlestick Prevention Safety andHealth Topics web page at: https://www.osha.gov/SLTC/bloodbornepathogens/index.html.

To file a complaint by phone, report an emergency,or get OSHA advice, assistance, or products, con-tact your nearest OSHA office under the “U.S.Department of Labor” listing in your phone book, orcall us toll-free at (800) 321-OSHA (6742).

Occupational Safetyand Health Administrationwww.osha.gov 1-800-321-6742

For assistance, contact us. We can help. It’s confidential.

DSG 1/2011

96 Healthy Skin

Forms & Tools INTERACT - Early Warning Tool

If you have identified an important change while caring for a resident today, please circle the change and discuss it with the charge nurse before the end of your shift.

Name of Resident ______________________________________

Seems different than usual

T alks or communicates less than usual

Overall needs more help than usual

Participated in activities less than usual

A te less than usual (Not because of dislike of food)

NDrank less than usual

Weight change

Agitated or nervous more than usual

T ired, weak, confused, or drowsy

Change in skin color or condition

Help with walking, transferring, toileting more than usual

Staff_________________________________________________

Reported to ___________________________________________

Date _____ / _____ / ________ Time ________________

EARLY WARNING TOOL“Stop and Watch”

If you have identified an important change while caring for a resident today, please circle the change and discuss it with the charge nurse before the end of your shift.

Name of Resident ______________________________________

Seems different than usual

T alks or communicates less than usual

Overall needs more help than usual

Participated in activities less than usual

A te less than usual (Not because of dislike of food)

NDrank less than usual

Weight change

Agitated or nervous more than usual

T ired, weak, confused, or drowsy

Change in skin color or condition

Help with walking, transferring, toileting more than usual

Staff_________________________________________________

Reported to ___________________________________________

Date _____ / _____ / ________ Time ________________

EARLY WARNING TOOL“Stop and Watch”

© 2010. Florida Atlantic University Adapted from Boockvar et al., J Am Geriatr Soc 48:1086 (2000) © 2010. Florida Atlantic University Adapted from Boockvar et al., J Am Geriatr Soc 48:1086 (2000)


INTERACT - Herramienta de Advertenci Precoz Forms & Tools

Si usted ha identificado un cambio importante al cuidar a un residente en el día de hoy, haga un círculo alrededor del cambio y discútalo con la enfermera a cargo antes de finalizar su turno.Nombre del residente_______________________________

Parece diferente de lo habitual Seems different than usual

Habla o se comunica menos de lo habitual Talks or communicates less than usual

En general, necesita más ayuda de la habitual Overall needs more help than usual

Participó en actividades menos de lo habitual Participated in activities less than usual

Y

Comió menos de lo habitual (y no porque no le gustaba la comida) Ate less than usual (Not because of dislike of food)

Bebió menos de lo habitual Drank less than usual

Cambio en el peso Weight change

Más agitado o nervioso de lo habitual Agitated or nervous more than usual

Parecía cansado, débil, confundido o somnoliento Tired, weak, confused, or drowsy

Tuvo un cambio en el color o en la condición de la piel Change in skin color or condition

Necesitó más ayuda para caminar, transferirse, asearse de lo habitual Help with walking, transferring, toileting more than usual

Personal _____________________________________________

Notificado a ___________________________________________

Fecha _____ / _____ / ________ Hora ________________

HERRAMIENTA DE ADVERTENCIA PRECOZ“Pare y observe”

Si usted ha identificado un cambio importante al cuidar a un residente en el día de hoy, haga un círculo alrededor del cambio y discútalo con la enfermera a cargo antes de finalizar su turno.Nombre del residente_______________________________

Parece diferente de lo habitual Seems different than usual

Habla o se comunica menos de lo habitual Talks or communicates less than usual

En general, necesita más ayuda de la habitual Overall needs more help than usual

Participó en actividades menos de lo habitual Participated in activities less than usual

Y

Comió menos de lo habitual (y no porque no le gustaba la comida) Ate less than usual (Not because of dislike of food)

Bebió menos de lo habitual Drank less than usual

Cambio en el peso Weight change

Más agitado o nervioso de lo habitual Agitated or nervous more than usual

Parecía cansado, débil, confundido o somnoliento Tired, weak, confused, or drowsy

Tuvo un cambio en el color o en la condición de la piel Change in skin color or condition

Necesitó más ayuda para caminar, transferirse, asearse de lo habitual Help with walking, transferring, toileting more than usual

Personal _____________________________________________

Notificado a ___________________________________________

Fecha _____ / _____ / ________ Hora ________________

HERRAMIENTA DE ADVERTENCIA PRECOZ“Pare y observe”

© 2010. Florida Atlantic University Adapted from Boockvar et al., J Am Geriatr Soc 48:1086 (2000) © 2010. Florida Atlantic University Adapted from Boockvar et al., J Am Geriatr Soc 48:1086 (2000)

98 Healthy Skin

Forms & Tools Resident Transfer Form

RESIDENT TRANSFER FORMSENT TO: (Name of Hospital)

SENT FROM: (Name of Nursing Home) Date: / / Unit:

RESIDENT:Last Name First Name MI

DOB: / /Language: English Other: Resident is: SNF/rehab Long-term

CONTACT PERSON:(Relative, guardian or DPOA/Relationship)

Is this the health care proxy? Yes NoTelephone:( ) -Notified of transfer: Yes NoAware of diagnosis: Yes No

DEVICES / SPECIAL TREATMENTS:IV/PICC linePacemakerFoley CatheterInternal DefibrillatorTPNOther:

AT RISK ALERTS:NoneFalls Pressure Ulcer Aspiration Wanderer Elopement

Seizure Harm to: Self OthersRestraintsLimited/non-weight bearing: Left Right Other:

ISOLATION / PRECAUTION:MRSA VREC-DiffOther:

Site:Comment:

WHO TO CALL TO GET QUESTIONS ANSWERED ABOUT THE RESIDENT?Telephone:( ) -

Form Completed By:

Report Called In By: Report Called To:

REASON FOR TRANSFER (i.e., What Happened?)

List of Diagnoses:

VS: BP HR RR T pOx FS glucose Time Taken: : AM/PM

Allergies: Tetanus Booster (date): / /Usual Mental Status: Usual Functional Status:

Alert, oriented, follows instructions Ambulates independentlyAlert, disoriented, but can follow simple instructions Ambulates with assistance Alert, disoriented, but cannot follow simple instructions Ambulates with assistive deviceNot alert Not ambulatory

Please see SBAR form for additional information

CODE STATUS: DNR DNH DNI Full Code

MD/NP/PA IN NURSING HOME:MD NP PA

Telephone:( ) - Pager:( ) -

name

name title

name

name

title name title

title signature

name

CAPABILITIES OF THE NURSING HOME TO CARE FOR THIS RESIDENT:IVF therapy IV antibiotics MD/NP/PA follow up visit within 24 hours Q shift monitoring by an RN Other:

NURSING HOME WOULD BE ABLE TO ACCEPT RESIDENT BACK UNDER THE FOLLOWING CONDITIONS:ED determines diagnosis, and treatment can be done in NH VS stabilized and follow upOther: plan can be done in NH






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©2012 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc. MKT212071 / LIT1011 / 30M / QG 5

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