Healthy Skin Volume 11 Issue 1 by Medline Industries

Free CE Inside!

Improving Quality of Care Based on CMS Guidelines

Volume 11, Issue 1

Get Up to Speed on Health Care Reform Health Care in India

“Escape Fire” U.S. Health Care in Crisis Everything You Wanted to Know About Wound Centers

INTERACT! Reduce Readmissions 24%

Join the team!

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

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

ON THE COVER, Medline partners with Joseph Ouslander, MD, developer of the INTERACT Quality Improvement Program, to launch new training to prevent avoidable readmissions. Turn to page 22 to learn more.

Editor Sue MacInnes, RD Clinical Editor Margaret Falconio-West, BSN, RN,

Contents

APN/CNS, CWOCN, DAPWCA Senior Writer Carla Esser Lake Creative Director Michael A. Gotti Clinical Team Dionie Bibat, BSN, RN, WOCN Clay Collins, BSN, RN, CWOCN, CFCN, CWS, DAPWCA Lorri Downs, BSN, RN, MS, CIC Doreen Gendreau, MS, MSN(c), BS, RN CWCN Carrie Kozak, MSN, RN Rebecca Huff, MSN, RN Joyce Norman, BSN, RN, CWOCN,

DAPWCA Kim Kehoe, BSN, RN, CWOCN, DAPWCA

A New Year in Health Care: How Health Care Reform Will Affect You and Your Hospital in 2013. A straightforward, informative approach to understanding the implications of health care reform.

Jackie Todd, MBA, BS, RN,

Readmissions Can Hurt. INTERACT Can Help. Training is now available to implement the INTERACT Quality Improvement Program to enhance care and protect the bottom line at your facility by reducing unnecessary hospitalizations.

CWCN, DAPWCA Patty Turner, BSN, RN, CWCN, CWS

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

Understanding the Role of Outpatient Wound Centers. An interdisciplinary team of clinicians works with wound center patients to develop an aggressive treatment plan with the goal of healing in a timely fashion.

CE Article!

CE ARTICLE

Raising Kids and Healing Wounds. Learn to identify the stages of wound healing by comparing them to the phases of child development.

Improving Quality of Care Based on CMS Guidelines

Contents Compliance

12 A New Year in Health Care: How Healthcare Reform Will Affect You and Your Hospital in 2013

“An Ode to

28 phoid,” p.

22 Readmissions Can Hurt. INTERACT Can Help. Treatment

32 Understanding the Role of Outpatient Wound Centers 39 Hotline Hot Topic: Dressing Options to

Page 20

Support Debridement Special Features

7 Healthcare News

8 Diane Whitworth Chosen for HealthLeaders 20

20 “Escape Fire” Movie Sparks Hope for Damaged U.S. Health Care 28 An Ode to Typhoid

Page 54

43 Raising Kids and Healing Wounds 58 Pink Glove Dance Video Competition 2012 Winners Caring for Yourself

54 Don’t Just Sit There! Move for Your Health 62 Beat the Winter Blues 68 Recipe: Fudgy Low Fat Brownies Page 58 Forms & Tools

70 Environmental Checklist Observation Form 72 Hospital-Acquired Conditions (HAC) in Acute Inpatient Prospective Payment System Hospitals 78 Making Medical Devices Safer at Home 82 Infection Prevention and You in Long-Term Care 83 Infection Prevention and You at the Hospital Page 62

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Contributing Writers Beth Boynton, MS, RN

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

Clay Collins is a certified wound, ostomy, continence and foot care nurse through the WOCN certification board and a certified wound specialist through the American Academy of Wound Management. He has extensive experience in the home care setting, having served as administrator, clinical director and wound program director. He has developed and implemented advance wound care programs and served as an expert reviewer for best practice documents for the WOCN. Kim Kehoe BSN, RN, CWOCN, DAPWCA

Kim Kehoe is a board-certified CWOCN and an active member of the Wound, Ostomy and Continence Nursing Society, The Florida Association of Enterostomal Therapists, past director for the Southeast WOCN and a Diplomat in the American Professional Wound Care Association. She has over 28 years of nursing experience and over 19 years as a WOC nurse, consulting in many healthcare settings including acute care and home care. Wolf Rinke, RD, CSP

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

Patricia Turner has years of nursing experience in acute care, home care and outpatient wound care and served as a clinical coordinator at an outpatient wound center in New Jersey for 12 years. She is board-certified as a CWCN and also is certified as a CWS through the American Academy of Wound Management. Patty brings a wealth of experience in the development and implementation of wound care guidelines, competencies, and evidence-based policies and protocols as well.

Improving Quality of Care Based on CMS Guidelines

Healthy Skin Letter from the Editor

As we roll into 2013, it feels like the winds are changing. No, not quite the change of the winds in the movie “Mary Poppins,” when all of the stern nanny applicants were literally blown away to make room for Mary Poppins. This is more like a soft but steady breeze carrying the whisper of change. Healthcare reform represents that change. It has created a swell of uncertainty for the organizations you work for and the patients and families that look to you for care.

analysis committees, from chief nursing officers and even from Medline employees…all of which were complimentary.

For many reasons, I was grateful to wrap up 2012. In anticipation of the New Year, I elected to do a deep dive into healthcare reform. I knew parts but didn’t feel proficient on everything and needed to spend time identifying industry challenges so I could begin to think about ways Medline could provide strong solutions to some of the difficulties our customers would be facing. This deep dive took me to several high level meetings in Chicago and New York City. I didn’t go to the meetings so much to network, but instead to learn and be a student. Taking complicated subjects like healthcare reform and making it easy to understand is hard. I went to the Forbes Healthcare Summit, Strategic Imperatives Beyond Healthcare Reform, National Center for Healthcare Leadership and The Joint Commission Advisory Board meeting. I took notes, I wrote summaries, I diagramed and sketched out my ideas.

From a Medline sales representative: “…the VAT Leader raved about it and how simplified and unbiased it was. She sent it out to her supply chain team and three of them came into her office and said how much it helped them understand [healthcare reform].”

Then, I decided to write an article about what I had learned. For the first time in a very long time I wrote an article for The OR Connection (the sister magazine of Healthy Skin). The article was about healthcare reform and trends for 2013. What I didn’t expect was the incredible response. Readers were making copies and passing them around to other staff members. I received comments from value

Healthy Skin I www.medline.com

“Your article was right on target and really helpful in trying to ‘simplify’ a very complex topic. I have circulated the article to my leadership team.” “Great article on healthcare reform. Very informative and easy reading that makes it enjoyable as well as educational.”

As I was reviewing the content of this edition of Healthy Skin, I thought, why not include the healthcare reform article (page 12). Nothing like adding a little clarity to start out the new year. There are a couple of other things in this edition I’d like to point out. First, take a look at pages 20 and 21. A friend of mine, Dale Bratzler, oversees the physicians at the University of Oklahoma Medical School. Last November, Dale and I were talking about physicians and medical schools and different areas of healthcare working together. Dale told me about a film that he showed his medical students. He was quite passionate about it and said, “Sue you’re really going to like this film.” He was right. The film is called “Escape Fire.” It is about health care as it stands today, why it needs to change and how we need to find new ways to do health care. After watching this, you will want to push innovation more than ever. You will see your role in health care differently…I promise.

Readmissions and transfers of care to different provider segments are another burning issue spawned by healthcare reform. Take a look at a program that has demonstrated results of reducing hospital readmissions by up to 24%. The program, INTERACT, is the brain child of Dr. Ouslander of the Florida Atlantic University. The program is a continuous improvement program to train staff, including nurse’s aides, on early assessment and analysis of residents to prevent avoidable hospitalizations. Thirty-five different tools in a comprehensive program with a robust training and sustainability program is rocking the long term care world. Why wouldn’t hospitals want to partner with a long-term care facility that has outcomes on hospitalizations that match their your goals? Yes, the winds are changing. And although it is a steady breeze…it is not without gusts and some turbulence. Today we’re right smack in the middle of change. We are going to be challenged with thinking smarter, with doing more with less, of being more innovative… because the way things have been done in the past is just not going to work in the future. Aren’t you glad you have a part in molding the future? 2013 is a year of change. Health care the way we have known it will begin to transform and have a new identity. And we are all lucky to be part of it. Let’s go rock the world,

Sue MacInnes, RD Editor

Healthcare News

Nurses have highest honesty rating Nurses rank number one in honesty and ethics according to Gallupâ&#x20AC;&#x2122;s Nov. 26-29, 2012 poll of the perceived honesty and ethical standards of 22 professions. Pharmacists and medical doctors also scored high. Members of Congress and car salespeople ranked at the bottom in 21st and 22nd place, respectively. For the complete list, visit http://www.gallup.com/poll/159035/congressretains-low-honesty-rating.aspx.

Ratings of Honesty and Ethics % Very high/High Nurses

Pharmacists

Medical doctors

90 80 70 60 50 40 30

Gallup

20 1976 1979

1982 1985 1988

1991 1994

1997

2000 2003 2006

2009 2012

AHRQ issues toolkit to help reduce C. diff Clostridium difficile (C. diff) infection is a serious public health problem that has recently increased in both incidence and severity. Taking steps to reduce C. diff, the Agency for Healthcare Research and Quality (AHRQ) has issued a toolkit to help hospitals reduce C. difficile infections by reducing inappropriate use of antibiotics, which may contribute to infections. Boston University School of Public Health collaborated with Montefiore Medical Center and the Greater New York Hospital Association/United Hospital Fund to develop the toolkit for AHRQ and the Centers for Disease Control and Prevention. The toolkit incorporates lessons learned from hospitals that served as intervention sites. To download a copy of the kit, go to http://www.ahrq.gov/qual/cdifftoolkit.

Improving Quality of Care Based on CMS Guidelines

Diane Whitworth Chosen for HealthLeaders 20 In its annual HealthLeaders 20, HealthLeaders Media chooses individuals who are changing health care for the better. This is the story of Diane Whitworth, RN, CWOCN, who recently served on Medline’s Wound Care Advisory Board.

Diane began her career as a wound, ostomy and continence nurse about 22 years ago, and during the past six years, she has become a champion in the nationwide effort to prevent hospitalacquired pressure ulcers in her role as manager of the wound care team at St. Mary’s Hospital in Richmond, VA, part of the Bon Secours Health System. Diane said the rise in pressure ulcers is what originally motivated her. But also in the back of her mind was her grandfather who had his foot amputated because of a pressure ulcer that developed while he was recovering from a hip fracture. Whitworth said that St. Mary’s looked at its hospital-acquired pressure ulcer (HAPU) statistics on a yearly basis, but it wasn’t a concentrated focus. “We said, ‘This is totally unacceptable.’ We set up a goal and started our journey to zero. It was a pretty lofty standard, but that was the vision,” Whitworth said. Everyone in the hospital from board members and the chief nurse executive to the bedside nurse is now focused on preventing HAPUs. Whitworth said there needs to be a commitment that the resources will be there for prevention. If a patient needs a 8

Healthy Skin I www.medline.com

different bed surface, the staff nurses are empowered to get it for them. They do not need to wait for approval from the wound care nurse.

a stage I or stage II. We don’t even get to stage III or IV because we already determined that it was way too late, Whitworth said.

The hospital restructured its staff education process as well to be able to rate staff performance. St. Mary’s

The tool helps staff determine whether they did everything they could do to prevent a pressure ulcer. And what

The hospital’s HAPU rates dropped from 20 percent in 2006 to 2 percent in 2007, and are now around 0.5 percent. now has mandatory competencies and annual skills reviews on skin and pressure ulcer prevention. Each unit also has a skin champion who performs process data collection on a weekly basis. The skin champions review the care of five patients on their unit and evaluate the processes the team excels in or needs to work on. Some units may be good at turning but struggle with handoffs, so this brings it to the unit-level rather than setting a hospital-wide initiative to focus on turning. One of St. Mary’s most successful pressure ulcer prevention initiatives is its critical event analysis tool. Staff members use this tool immediately when a HAPU develops, while it is still

interventions they should be doing now. For example, did they get nutrition involved early enough? Did they do a risk assessment? Is the patient on a proper support surface? The hospital’s HAPU rates dropped from 20 percent in 2006 to 2 percent in 2007, and are now around 0.5 percent. St. Mary’s has also hit the elusive zero for a few months at a time. A key element of reaching that goal is knowing what you have in-house on a daily basis, she said. I don’t have to wait for quarterly visit. I can tell you I haven’t had any HAPUs for 30 days.

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

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oney-back guarantee – if you are not M completely satisfied with the your outcomes, we will provide a refund. ©2013 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.

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

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

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has the answer Together, the National Association of Health Care Assistants (NAHCA) and Medline are changing the employment landscape for nursing assistants through innovative programs that support leadership development. Care centers that join NAHCA have reported a 25 percent annual increase in retention translating to an estimated cost savings of $42,000.1

Join NAHCA Attract, develop and retain staff Improve staff morale and resident care Increase resident satisfaction and referrals Reduce unnecesary hospitalizations

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ÂŠ2013 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc. Documentation on file with NAHCA

www.medline.com/nahca

by Sue MacInnes

12 Healthy Skin I www.medline.com

Are you up to speed on healthcare reform and the impact it will have on you as a consumer and as a healthcare worker? 2013 may be one of the most impactful years weâ&#x20AC;&#x2122;ve had in healthcare since the 1960s when President Lyndon B. Johnson signed Medicare and Medicaid into law. Few people want to read the 906 pages of legislation that make up the Patient Protection and Affordable Care Act (PPACA) more commonly known as Obamacare, but many of us are curious about what healthcare reform really means and how it affects us.

Improving Quality of Care Based on CMS Guidelines 13

Maybe a little background is in order The burning purpose of the PPACA was to provide healthcare coverage to the millions of Americans who do not have insurance (actually, 48.6 million or 15.7% of the U.S. population as of 2011).1 Now here is the irony. The United States is the only country that does not have universal health care, and the cost of health care is expensive. According to the Organisation for Economic Co-operation Development, in 2010 the cost of health care per capita in the United States was $8,233 – far greater than other wealthy countries.2 In fact, the United States ranks first in expenditure per capita. Norway ranks second with a per capita healthcare spending rate of $5,388, or 65 percent of the average per capita cost for healthcare in the United States. Other wealthy countries in the world spend an average of $3,265 per capita on health care.2 And yet, much higher spending does not equal better healthcare quality in the United States. In the same 2010 report by the Organisation for Economic Cooperation Development, the United States ranked 32nd out of 34 countries on infant mortality and 27th in life expectancy.2 We spend more than any other country for health care but our outcomes are a poor reflection of the price we pay. And, with over 48 million uninsured, many Americans cannot afford to get wellness care or go to the doctor when

14 Healthy Skin I www.medline.com

they detect a problem. In many cases, people with serious illnesses are left either going to the Emergency Room for care or suffering with no resources. Can you imagine having a child that is ill and not being able to get them care because you have no insurance? Or what if it was you who had a lump or a pain or had diabetes or needed

dialysis…and you couldn’t afford it? There are women who have felt lumps in their breasts who are trapped and unable to get help because they can’t pay for care. For some, no insurance is a death sentence. Under healthcare reform, 30 million currently uninsured Americans will have the opportunity to get insurance.

cost of healthcare per capita: $ $ $ $ $ $ $ $ $ $ $ other wealthy $ United States2 $ countries2

8,233

3,265

the United states Is:

#32 on infant mortality #27 on life expectancy

higher costs

of 34 countries

≠

Better outcomes

How will 30 million people now get insurance? 1

Beginning in 2014, a person who does not have insurance will be able to “shop” for their own policy, just like car insurance, but with government-sponsored plans, like Medicaid or an exchange plan. There are some rules. • Medicaid will be available for individuals and families based on income. • Companies with under 50 employees are not required to provide health insurance coverage. Those who work for these companies will be able to participate in a new statebased competitive private health insurance plan known as an exchange plan. Exchange plans

will provide individuals and small businesses with a “one-stop shop” to find and compare affordable, private health insurance options.

• Based upon your income, the cost of health insurance could be capped at a certain percentage, earning you tax credits. 2

If a U.S. citizen does not get insurance, they will be penalized on their tax return. Large companies must meet specific minimum requirements on the mandatory healthcare insurance they offer.

What does all this mean? In addition to more Americans having coverage, the consumer will also have more choice. Information about healthcare providers is becoming transparent. You can look up infection

rates, pressure ulcers, mortality rates, patient experience scores, and just like Consumer Reports, rate the hospital options you have in your geographic area. This could conceivably mean that the “patient” might be more willing to go to a high-scoring hospital for an acute MI, versus a hospital that is closer to home. The rise of “consumerism” is changing how hospital systems are strategizing. You will see hospitals marketing more and more to the patient. With this will come a rise of “consumerism” as consumers exercise choice due to considerations of transparency, plans and pricing, as well as transparency around outcomes. They will pay for value. The big mystery will be how 30 million patients in exchange plans and Medicaid change the payor mix in

The rise of “consumerism” is changing how hospital systems are strategizing.

Improving Quality of Care Based on CMS Guidelines

– Cons = +Pros =

Corresponding decreases in revenue

Potential increases in revenue healthcare reform financial Pros

cons

required to do even more with less, as the exchanges and Medicaid will pay much lower than Medicare and private insurance? And so, 2013 will bring a shift in how hospitals get paid. Hospitals are strategizing around the advantages and disadvantages of healthcare reform.

Cons = Corresponding decreases in revenue

• R eplacement of more highly reimbursed lives (commercial insurance) with less highly reimbursed (Medicare, Medicaid, exchange plans) • Reduction in Medicare and Medicaid reimbursement rates - Lower Medicare growth rate

Pros and cons of healthcare reform from a financial point of view, as described by McKinsey3

- Decreased DSH (Disproportionate Share Hospital) payments

Pros = Potential increases in revenue

- Reduced Medicaid reimbursement

• I ncrease in utilization due to coverage expansion in governmentsponsored plans • R eduction in uninsured bad debt as the formerly uninsured join Medicaid and exchange plans • O ngoing demographic aging may also increase utilization on a per capita basis

16 Healthy Skin I www.medline.com

So, there is an uncertainty about how healthcare reform will affect the revenue of your organization. Value based purchasing Now, in addition to these financial and coverage changes, quality of care has never been more important. Value based purchasing is now in effect, and hospitals are competing against each other as well as themselves. Value based purchasing will be rated on how well core measures are met (which

include SCIP measures in the OR) and HCAHPS, or patient experience scores. Dollars that were available in previous years are now at risk, depending on how well your hospital scores. Patient experience scores not only affect payments. They also affect the image of the hospital in the community.

Hospital-acquired conditions and readmissions Other financial incentives involve hospital-acquired conditions (HACS) – effective FY 2015 and readmissions – effective FY 2013. The chart on the opposite page summarizes the quality initiatives that affect your hospital now and in the years to come. Percentages increase as the years go on. Each of these comes with incentives to increase reimbursement if your organization performs well…or penalties for lesser performance. In some cases, such as value based purchasing, the penalties could be significant.

Percentages of Reimbursement Dollars Affected Under Health Care Reform

Fiscal Year

Value Based Purchasing

Hospital Acquired Conditions

Excessive Readmissions Penalty

2011

2012

2013

2014

1.25%

2015

1.5%

2016

1.75%

2017

2018

But with all of these things, an important aspect—maybe the most important—is the reputation of your organization. As performance scores are made public, it will be critical to market and engage the people in your community so that your organization is looked upon as the healthcare leader. Loyalty of patients and families and the reputation of your hospital are critical considerations. In 2013, you will see some trends occurring: 1

ospitals will be enacting broadH ranging cost control programs

including lean operations, back office cost control and clinical transformations.3 Hospitals are looking to cut $5-10 million a year in costs each year for 5 years. Hospitals will be thinking “big picture” about costs…increase quality, increase patient satisfaction, outcomes versus costs, cost variation by docs, supply chain squeezed. Areas of consideration:3

a. Hospital labor productivity b. Clinical cost variation

2019

c. O perational efficiency/lean methodology d. P urchasing and supply chain management

Improving Quality of Care Based on CMS Guidelines

What healthcare providers like you will be looking for in 2013

Cost saving is not always just “price.” It can also include efficiencies, guarantees, waste reduction, and better outcomes. Has your OR engaged in a lean assessment? Has innovation and thinking out of the box been a more broadly accepted way for the future in your organization? 6

Markets are consolidating.

Increased merger & acquisition activity to capture perceived scale and synergy benefits and support new business models.3 Has your hospital partnered with another recently, or been purchased or merged? 4

Given competitive pressures, hospitals must carefully decide which service lines to prioritize,3

e.g., orthopedics (one of the most attractive and fastest growing service lines of the future). 5

A hospital’s “brand” identity has more value than ever. Some hospital systems are investing heavily in a new look, new branding guidelines, new signage. They want to communicate their strengths on billboards and TV ads to gain consumer loyalty and community leadership.

18 Healthy Skin I www.medline.com

BETTER pricing

Cost reductions

Outcomes

Ways to improve the customer experience

Ways to improve market/consumer image

Ways to make their staff happy

ocial media is a real business S strategy and another way to

communicate and attract customers. 7

Accelerated strategy of hospitals employing physician groups to help hospitals lock up markets, to improve contracting margins, to control outcomes, etc.3 Provider groups are considering innovative incentive relationships3 (e.g., ACO-like or “clinical integration”), but they are cautious of appropriate strategic and business model rationale. Payors and providers are partnering to explore a variety of new reimbursement and risksharing models.

You are in a unique position because you will get to see how healthcare reform will unfold as both the consumer and the healthcare worker. Take notes because you are making history as the biggest changes in health care get underway.

References 1. Census: uninsured rate falls as young adults gain coverage and government programs grow. Huffington Post. Posted September 12, 2012. Available at: http://www. huffingtonpost.com/2012/09/12/censusuninsured-young-adults_n_1876862.html. Accessed December 12, 2012. 2. Health policies and data. Organisation for Economic Co-operation Development website. Available at: http://www. oecd.org/health/healthpoliciesanddata/ oecdhealthdata2012-frequentlyrequesteddata. htm. Accessed December 12, 2012. 3. Strategic Imperatives Beyond Healthcare Reform. Objective Health: A McKinsey Solution for Healthcare Services. Executive Breakfast Seminar. Presented September 13, 2012.

A Continence Management Program That’s as Unique as Your Residents A wide variety of tools to help you provide individualized continence care Incontinence is one of the most costly and labor intensive issues in nursing homes and long-term care facilities. Despite years of research and clinical efforts to improve it, the prevalence of incontinence remains high. Medline has created this Continence Management Program to help long-term care facilities develop individualized continence programs for residents and comply with Medicare regulations. The program includes: • RN/LPN workbook (with 4 CE credits available through www.medlineuniversity.com) • CNA workbook • Reproducible care plans, assessment guidelines and other quality assurance tools

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

“Escape Fire” Movie Sparks Hope for Damaged U.S. Health Care By Beth Boynton, MS, RN

“Escape Fire:

The Fight to Rescue American Healthcare”

is an exciting and timely documentary revealing the brokenness of the healthcare system in the United States and how it is linked to financial incentives. With a powerful combination of patient stories, objective data, and viewpoints of respected healthcare leaders, such as Drs. Don Berwick, Andrew Weil, and Dean Ornish, the movie raises critical awareness for creating the tipping point! This is key for the paradigm shift we need in our complex healthcare systems! 20 Healthy Skin I www.medline.com

Hello…..

Our System Is Not Working!

Most of us who have close ties to U.S. health care will be more validated than shocked, as we see poor outcomes every day that can be tied to wasted treatments, unsafe staffing levels, insufficient time, and delayed care that are rooted in financial gain for a few and limited resources for many. But, they are tough to explain and not necessarily even safe or appropriate to talk about freely. This film is easy to follow, well-researched, and compelling. As such, it provides an effective tool for educating consumers about underlying problems in our system and making it safe to discuss. And, we are all consumers! The term “Escape Fire” comes from the story of a quick thinking firefighter that did something different in a crisis and lived to tell about it, unlike his colleagues who all died. (The movie starts out with this story so I won’t spoil it for you with more details.) But, it is a great analogy for us, because solutions are right in front of us!

Some of the heroes in the movie: Steve Burd, CEO of Safeway: Created healthiness incentives for employees.

Wendell Potter, Former Head of Communications, CIGNA: Had an awakening about how he was contributing to suffering. Shannon Brownlee, Medical Journalist (formerly of US News & World Report) through research became aware of harmful aspects aka “dark matter” of our medical system. Sgt. Robert Yates, Infantry, U.S. Army, injured in Afghanistan and his courageous recovery both from his injuries and over medication. I do take issue with two aspects of “Escape Fire“: First, nurses, as usual, are under-represented. With at least ten physicians highlighted and only one nurse leader (briefly at that), it is a little hard to swallow. Especially since nurses have been championing prevention and healthcare education forever and nurse practitioners as family practice clinicians are examples of the solutions that indeed are right in front of us! In addition, many physical therapists, psychotherapists, chiropractors, and holistic health practitioners have been advocating for cost-effective, helpful solutions for ages. Diet, exercise, alignment and emotional support are all keys to health care!

Second, there are a couple of places that seemed to me to avoid accountability and blame…. like comments about the “system being bad, but people being good,” or people having “good intentions.” For the most part, I am OK with this and don’t believe that blaming people is an effective strategy, However, it is a fine line between blame and ownership and ownership is extremely important. In fact, Wendell Potter, one of the heroes noted above recognized his own contribution to the problem and stopped. Since this is so integral to the “Escape Fire” analogy, it is worth mentioning! I would challenge any high paid hospital, pharmaceutical, or medical device, or nurse executive, malpractice attorney, or physician specialist to examine the possibility of personal accountability! Despite these two criticisms, please see the movie! Let’s generate some buzz and get this movie in high schools, libraries, theatres, and living rooms across the country. There are lots of awesome talking points that will spark dynamic discussion and fuel a growing power of the people. That is the fire that will save our system from burning!

To see a trailer for the movie, visit www.escapefiremovie.com.

Readmissions can hurt.

INTERACT can help. ®

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

22 Healthy Skin

http://goo.gl/0gZ8w

Goals of INTERACT o improve care and reduce  Tpreventable hospital transfers o improve the management of  Tresidents with a change in condition

The Impact of INTERACT 1

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

Some hospital transfers are preventable

are can be improved, resulting in fewer C complications and reduced cost

inancial and regulatory incentives F are changing

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

Using INTERACT can lower the rate of unecessary 1 hospitilization by

24%

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

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

• FREE!

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



Improving Quality of Care Based on CMS Guidelines

Quality Assurance System

Admit it.

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

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

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

1-800-MEDLINE

| medline.com

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

Case Example

Sadie, a 96-year-old long-stay nursing home resident.

 Hospitalized for urinary tract infection (UTI) and dehydration

 Discharged back to the nursing home after four days

 Re-hospitalized seven days later for dehydration and recurrent UTI

Lab values at discharge from hospital

Lab values after one week back at nursing home

BUN = 16 Creatinine = 0.7

BUN = 58 Creatinine = 1.8

INTERACT Strategy: Prevent conditions from becoming severe enough to require hospitalization through early detection and evaluation.

Had the nursing home been using the INTERACT program, they would have been monitoring her lab values when she returned to the nursing home, discovered early on that she was dehydrated again and at risk of a recurrent UTI, provided treatment, and prevented the second hospitalization.

Improving Quality of Care Based on CMS Guidelines 25

A Quick History of

INTERACT 1 Initial research: INTERACT was originally developed in 2006 by Joseph Ouslander, MD, professor and senior associate dean for Geriatric Programs at the Charles E. Schmidt College of Medicine at Florida Atlantic University. Dr. Ouslander and his project team began by studying 200 hospitalizations of residents from 20 nursing homes in Georgia to discover factors that contributed to potentially avoidable hospitalizations of residents.

eveloping tools: Based 2 D on the data they gathered, Dr. Ouslander and his team developed the INTERACT quality improvement program, which includes three types of tools to help avoid unnecessary hospitalizations: • Quality Improvement Tools • Communication Tools • D ecision support Tools (Care Paths) • Advance Care Planning Tools 3 Testing the tools: During a six-month period in 2009, Dr. Ouslander and his team continued their research by refining and testing the INTERACT program at 25 nursing homes in Florida, New York and Massachusetts.

They found that 2/3 of hospitalizations were potentially avoidable for the following reasons: • Lack of availability of medical directors, primary care physicians, nurse practitioners, physician assistants on-site • Inadequate assessment of acute changes in resident status • Lack of ability to initiate or maintain IV fluids at the nursing home • Transfer of residents who may have been more appropriately served with palliative or hospice care at the nursing home • Lack of in-house diagnostics (e.g., X-rays, labs) and access to emergency medications at the nursing home

INTERACT is funDed by: ational Institute of Nursing  NResearch / National Institute of Health (NINR/NH) enters for Medicare &  CMedicaid Services (CMS)  The Commonwealth Fund  Medline Industries, Inc.  PointClickCare  The Patient Centered Outcomes

INTERACT is a registered trademark and the INTERACT logo is a trademark of Florida Atlantic University.

26 Healthy Skin I www.medline.com

Meet Joseph Ouslander, MD Developer of INTERACT The senior associate dean for geriatric programs and professor at the Charles E. Schmidt College of Medicine at Florida Atlantic University, Dr. Ouslander is well known for his work on geriatric incontinence and continues to practice as a geriatrician on staff at Boca Raton Community Hospital. But he is perhaps best known for creating the INTERACT program. He said he was moved in medical school by a New England Journal of Medicine article describing the need for geriatricians. “This was an opportunity to go into a new area,” he recalls. Part of the appeal was “that geriatrics is a team sport.” “My experience in high school, especially with wrestling and football, helped instill that in me,” he said. A New Jersey native, he remembers how in his first year in high school, his geometry teacher looked at him and said, “You’re going out for wrestling.” “I lost 30 pounds freshman year. You competed as an individual and a team,” he remembers. “[It] changed my life.” That partnership approach has allowed Dr. Ouslander to have a good relationship with academics and policymakers, including Alice Bonner, PhD, RN, director of the division of nursing homes at the Centers for Medicare and Medicaid Services (CMS). “We tease him sometimes that even though he has an MD, he’s really a nurse deep down,” Bonner said. “He puts people first. He loves to teach. When he speaks, people really listen.” Reprinted with permission from McKnight’s Long-Term News

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Relieve Pressure on Vulnerable Heels HEELMEDIX™ Heel Protector

Pressure relief and skin protection all in one The heels are the most common site for facility-acquired pressure ulcers in long-term care, and the second most common site overall.1 According to clinical experts, the most effective aspect of pressure ulcer prevention for heels is pressure relief, also known as offloading.1,2 Offloading is achieved with heel protection devices that relieve pressure by elevating the heel. The HEELMEDIX Heel Protector is designed to help eliminate pressure, friction and shear on the skin by elevating the heel and redistributing pressure along the calf. The open heel design allows for airflow and easy monitoring.

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http://goo.gl/j94jS Fowler E, Scott-Williams S, McGuire JB. Practice recommendations for preventing heel pressure ulcers. Ostomy Wound Management. 2008;54(10):42:48.

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

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PART II â&#x20AC;&#x201C; Medline Intern in India

An Ode to

Typhoid by Azza Cohen

28 Healthy Skin I www.medline.com

Editor’s note: This is the second article in a two-part series about Medline summer intern and Princeton University student Alexandra (Azza) Cohen, who shares her experiences from a yearlong assignment helping children in India through a non-governmental organization (NGO) called Guria in the city of Varanasi. Her visit was sponsored by Princeton’s Bridge Year program, focusing on service and language study in developing countries.

“ 40.2°C, how much is that in Fahrenheit?” I asked. I couldn’t do the math, because I was so, so tired.

“ Azza, that’s over 104°F! You’re going to the hospital, now.” The next few days were a blur of needles and fevers and lots and lots of hand sanitizer. Finally, the blood test came back: strongly positive, acute typhoid fever. Great, I thought. What am I going to tell my mom? My time with typhoid is not something I look back upon fondly, but I did learn from it. After being admitted to Chirayu Hospital (admittedly, for the third time… the first two were the usual bouts of food poisoning that face all foreigners in the subcontinent), I expected the same type of care that cured me before. But typhoid is different. There’s only one way to cure food poisoning: drink enough (clean) water and wait until your body sorts it out. Typhoid risks complications, unexpected symptoms and the chance the bacteria are resistant to certain drugs.

The nurses in India have a long way to go in terms of infection control, but it is my hope that we can learn from the deepest, warmest, widest generosity I’ve ever experienced, and be reminded that being a true nurse must go beyond bandages.

Fortunately, my symptoms were awfully normal: high and recurring afternoon fevers, vomiting, swollen spleen, fatigue and the occasional hallucination. (I did, at one point, sincerely believe my mom had come to India and I had to pick her up from the airport. The doctor thought this was funny.) After a week, my fever streak broke with the help of antibiotics and ice packs. Treatment started and continued with a constant 0.9% sodium chloride IV injection for electrolyte replenishment and a strict B.R.A.T. (bananas, rice, apples, toast) diet for the two weeks I stayed there. As lucky as I was to go to a private hospital, I still felt the care was adequate at best; alarming at worst. The only sink was the one in the bathroom, so I couldn’t see if the staff washed their hands or not (likely the latter), so I insisted they use the hand sanitizer my friends brought me. No one wore scrubs. No one wore gloves. One nurse answered his cell phone with one hand while giving me a shot with the other. Often, I had reactions around the site of the IV and had to remind the nurses to clean and change it when it became red and swollen. Because I was attached to the IV, I couldn’t go to the bathroom without the nurses removing it. When I couldn’t find a nurse, I had to remove the IV myself. 30 Healthy Skin I www.medline.com

I was on bed rest for three weeks after discharge, and I had to get monthly tests for presence of the bacteria. When I went back for my final blood test in April, the nurses were asking each other how much blood was necessary to draw. I completely understood and completely surprised them when I sharply said, “Two. Two milliliters for the TyphiDot test. Even I know that, yaar (buddy), and I’m no doctor!” I did worry my parents and the program coordinators when I told them my diagnosis. I was offered a plane ticket home to be treated in the United States. I declined. Why? Because India is more than her (albeit scary) typhoid. It was refreshing when I went back to the United States and my pediatrician washed her hands in front of me, wore gloves and sterilized her equipment, yet I think a large reason why I was cured wasn’t just the antibiotics. India puts the “hospital” in hospitality. All the nurses were eager to quiz me on Hindi verb conjugations and blasted the latest Bollywood tunes to pass the time. The doctor reminded me to meditate and urged me to practice yoga when I regained my strength. Unsterile as it may be, when Saraswati, the hospital cook, wiped my tears with the edge of her sari, it meant more than any tissue ever could. I thank the nurses in the United States for their cleanliness, and I thank the nurses in India for their love

(and I don’t mean to say the viceversa doesn’t exist). I thank nurses everywhere for their dedication to helping and healing people; it’s a high calling and a stress I don’t know I could take. I urge nurses reading this to learn, as I did, from a culture where cleanliness is sometimes not an option. The nurses in India have a long way to go in terms of infection control, but it is my hope that we can learn from the deepest, warmest, widest generosity I’ve ever experienced, and be reminded that being a true nurse must go beyond bandages.

To learn more about Azza’s experiences in India, email her at azzaccohen@gmail.com or visit her blog at www.azzamasala.blogspot.com.

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

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Understanding the Role of Outpatient Wound Centers Patricia Turner BSN, RN, CWCN, CWS Outpatient wound centers are somewhat of a specialty unto themselves within the world of wound care. The focus of the center, types of patients treated, and the resources involved in running a center are specific to the outpatient population. Typically, the most common types of wounds seen in an outpatient setting are lower extremity ulcers, predominantly venous leg ulcers and diabetic foot ulcers. Many of these patients are affected by a quality of life issue. They are able to maintain their condition on an outpatient basis, but their quality of life is greatly impacted by the need to care for their wound on a daily, ongoing basis.

32 Healthy Skin I www.medline.com

Venous leg ulcers are the most common type of chronic wound, affecting an estimated 1 percent of the U.S. population. Venous leg ulcers are the most common type of chronic wound, affecting an estimated 1 percent of the U.S. population.1 Up to 85 percent of lower extremity ulcers are related to chronic venous hypertension.2 Diabetic foot ulcers are another common type of wound seen in the outpatient setting. An estimated 8.3 percent of the

U.S. population has diabetes,3 and up to 25 percent of people with diabetes will develop a diabetic foot ulcer.4 Understanding where these patients can go for ongoing care and treatment, and understanding the workings of an outpatient wound center, can better prepare us as clinicians and resources in the field of wound care.

To better understand how we, as clinicians, can utilize a wound center as part of the continuum of care, we will follow a patient through her treatment at an outpatient wound center.

Improving Quality of Care Based on CMS Guidelines

Wound centers are almost always considered an outpatient department of a hospital.

Mrs. Green is a 73-year-old patient with diabetes who was recently admitted to a community hospital with an episode of hyperglycemia. Her family had been visiting her and her husband for the holidays. One evening, Mrs Green had unusual symptoms of headache, confusion, and trouble seeing which rapidly progressed. Her family called 911, and an ambulance transported Mrs. Green to the hospital’s emergency department. She had very high blood glucose. Upon initial assessment, the admitting nurse noted a 2 x 1.5 cm wound on the plantar aspect of her right foot. Mrs Green’s medical condition was addressed, her blood sugar was returned to normal, and she was discharged with home care to take care of her wound. The home care nurses saw Mrs. Green for several weeks, utilizing standard wound care. With little to no improvement to the wound, the home care nurse referred Mrs. Green to the hospital outpatient wound center. Wound centers are almost always considered an outpatient department of a hospital. The hospital may choose to run the wound center or sign a contract with a wound management company to run the wound center. Advantages of a wound management company include access to specialized training, clinical practice guidelines, policy and procedures, and documentation and data collection

34 Healthy Skin I www.medline.com

that are standard across all the centers the company manages. Whether a management company is involved or not, the patient should expect to work with specialized clinicians to develop an aggressive treatment plan, with the goal of healing in a timely fashion. A referral to a wound center may come from the patient’s primary care physician, a home care nurse, or even as a referral after discharge from an acute care stay. Long-term care facilities also refer patients to outpatient wound centers for evaluation and treatment. Patients may even refer themselves! The goal is to visit to a wound center for specialized treatment from a staff that is knowledgeable in wound care. Mrs. Green’s nurse made an appointment for her to visit the outpatient wound center within a few days. The secretary at the wound center gathered some information over the phone from Mrs. Green regarding her wound and her health insurance. Since Mrs. Green had Medicare, there were no referrals or pre-authorizations needed, and the secretary explained to Mrs. Green that Medicare would be billed for the services at the wound center just like any other outpatient department of the hospital, and for a consultation with the physician at the center. The secretary explained to Mrs. Green that she would need to bring any previous

test results or studies and a list of all her current medications with her to the appointment. She told Mrs. Green to expect the first visit to be lengthy, since the nurse and doctor spend a lot of time with patients during the initial visit. Once the patient is scheduled for an appointment, the wound center administrative staff determines if the insurance company requires any referrals or pre-authorizations. The initial visit to a center is lengthy. The nurse and physician take a comprehensive history to make sure they understand and address all the potential factors that affect wound healing. The center staff gather information about past and current treatment for the wound and review any previous medical records or tests that may assist them with the wound’s history. The physician will perform a complete physical exam. Making sure to address all co-morbidities and conditions as he helps develop the patient’s treatment plan. When Mrs. Green arrives for her first appointment the receptionist gives her a health history form to fill out, and all paperwork is gathered and placed into her chart. The wound center nurse then escorts Mrs. Green to an exam room. She asks Mrs. Green a series of questions related to the onset and treatment of the wound and reviews her health history and list of

Most wound centers utilize a multidisciplinary approach. From receptionist to nurse to physician, each team member plays a role in the development of the patient’s treatment plan.

medications. The nurse also takes the dressing off the wound, cleans the area, and performs a comprehensive assessment of the wound. This includes measuring the wound, photographing it and documenting all of the findings. Finally, the physician comes in to review Mrs. Green’s chart with her as he begins to discuss options for the treatment of her wound.

the advantages of an outpatient center. The staff is able to make changes to their patient’s treatment plan based on outcomes. In today’s health care arena, outcomes-driven practice is a valued entity. The ability to measure outcomes also allows the wound center to be benchmarked against and compared to other existing centers, particularly when the center is run by a management company.

Most wound centers utilize a multidisciplinary approach. From receptionist to nurse to physician, each team member plays a role in the development of the patient’s treatment plan. The wound center nurse’s basic documentation of the condition of the wound includes wound location, wound measurement, tissue type, periwound skin condition, wound exudate or odor, and also photography. Generally, this information is added to a database that allows the staff to track the progress of the wound as the patient’s treatment plan progresses. This statistical analysis of progress is one of

The wound center physician discusses Mrs. Green’s treatment plan with her. He explains that because she has a lower extremity wound, he will be sending her for some studies to test the circulation of her leg, even though he can palpate her dorsalis pedal pulses. He also performs a monofilament test to determine the extent of neuropathy in Mrs. Green’s feet as he explains what neuropathy is and informs her about the importance of good footwear. He also lets her know that he will be making suggestions for her to see a pedorthist, someone who specializes in protective footwear, once the wound gets close to healing.

The physician sharply debrides the wound, removing all non-viable tissue and taking a tissue culture. The physician then orders lab tests for Mrs. Green to test her blood sugar control. The physician and nurse discuss options for offloading the area, and make a note to incorporate that into the plan of care after the circulatory studies come back. The wound center nurse then dresses the wound, arranges for Mrs. Green’s return visit to the center in two weeks and contacts the home health care agency that referred Mrs. Green to discuss the treatment plan and the wound care that will need to be done at home. Mrs. Green leaves the wound center with discharge instructions and patient education pamphlets on diabetes and foot care. The wound center physician explains that he will contact Mrs. Green’s primary care physician to discuss the visit and address any follow up on her diabetes medications, if needed. The comprehensive approach to wound care in an outpatient center includes workup for circulation,

Improving Quality of Care Based on CMS Guidelines

The wound center will see the patient often, to monitor the treatment plan, and to make changes according to the wound’s progress.

infection, nutrition, and most importantly, the treatment plan needs to address all co-morbidites that may be affecting the patient’s ability to heal. The wound itself will follow an algorithm of removing non viable tissue, when appropriate, and topical wound care that will address the wound’s needs in order to maintain a moist wound environment. Concurrent treatment that addresses the individual etiology of the wound is part of the comprehensive plan, such as offloading for diabetic foot ulcers, or compression therapy for venous wounds. The wound center should communicate to external team members, such as other departments that will be doing testing for the patient, other specialists who need to be involved, the patient’s primary care physician, or other caregivers, such as the home health care agency. The wound center will see the patient often, to monitor the treatment plan, and to make changes according to the wound’s progresses. The center will follow the patient closely until the wound heals. The clinical staff

36 Healthy Skin I www.medline.com

will collaborate with the patient’s caregivers and primary care physicians during the course of treatment. As the patient gets closer to healing, the staff will also consider the care and education necessary for the patient to maintain the healing state. Communication back to a patient’s primary care physician or caregiver is key to the maintenance of a healed wound. Mrs. Green’s wound went on to heal in a timely fashion with her visits to the wound center. Thanks to the home care nurse’s knowledge about wound center services, Mrs. Green had a positive experience and a positive outcome for her wound. Now that you have an understanding of how an outpatient wound center can be a destination of healing, you can begin to include it as another step in the continuum of care for patients with slow-to-heal wounds.

References 1. Collins L, Seraj S. Diagnosis and treatment of venous ulcers. American Family Physician. 2010;81(8):989-996. Available at: http://www.aafp. org/afp/2010/0415/p989.html. Accessed January 10, 2013. 2. Simon DA, Dix FP, McCollum CN. Management of venous leg ulcers. BMJ. 2004; 328(7452): 1358–1362. Available at: http://www.ncbi.nlm.nih.gov/pmc/ articles/pmc420292. Accessed January 10, 2013. 3. National Diabetes Statistics, 2011. National Diabetes Information Clearinghouse website. Available at: http://diabetes.niddk.nih.gov/dm/pubs/statistics/#fast. Accessed January 10, 2013. 4. Brem H, Sheehan P, Rosenberg HJ, Schneider JS, Boulton AJ. Evidence-based protocol for diabetic foot ulcers. Plast Reconstr Surg. 2006;117(7 Suppl):193S-209S; discussion 210S-211S. Available at: http://www.ncbi.nlm.nih.gov/pubmed/16799388. Accessed January 10, 2013.

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Identify Accurately, Document Consistently NE1™ Wound Assessment Tool

Wound measurement made easy The 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

Reference 1. Young DL, Esocado N, Landers MR, Black J. A pilot study providing evidence for the validity of a new tool to improve assignment of NPUAP stage to pressure ulcers. Advances in Skin & Wound Care. In press. ©2013 Medline Industries, Inc. NE1 is a trademark of Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc. Patent pending.

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

Standardize wound documentation. Revolutionize wound care. Start with a call to your Medline representative or 1-800-MEDLINE. www.medlinene1.com

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

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One call starts you on your way to becoming greensmart Francesca Olivier, Medlineâ&#x20AC;&#x2122;s corporate sustainability manager, is ready to work with you no matter where your facility is on your sustainability journey. Call her at (847) 643-3821 or email folivier@medline.com

ÂŠ2013 Medline Industries, Inc. greensmart is a trademark and Medline is a registered trademark of Medline Industries, Inc.

H ot l i n e

T O P I C

G N I S DRES NS O I T P T O R O P P U TO S IDEMENT R B E D Kim Kehoe BSN, RN, CWOCN, DAPWCA Question: Many of our physicians order daily wet-to-dry gauze or topical enzymatic therapy for wounds that present with necrotic tissue. Are there any dressing options available to support debridement that do not have to be changed daily? Answer: After completing a skin and wound assessment and a comprehensive assessment of the patient, it is para-

mount to determine and document the etiology of the wound. We must then address patient-centered concerns, including pain, that affect wound repair and determine if the wound is treatable, the blood supply is adequate and that there are no critical cofactors that would prevent wound repair. If all of these factors apply, the first step in wound healing is removal of necrotic tissue that can impede the growth and proliferation of healthy granulating tissue.

Saline dressings A wet-to-dry gauze dressing utilizing normal saline is an example of mechanical debridement, which is non-selective, often painful and may damage granulation tissue. Correct technique consists of lightly packing saline-moistened (not dripping wet) gauze to the wound bed and allowing it to dry on the wound, trapping debris. Once dry, usually four to six hours after application, the dressing is removed along with

Improving Quality of Care Based on CMS Guidelines

H ot l i n e

T O P I C Are you facing a skin or wound care challenge with a patient or resident and need more clinical information? Call Medline’s Educare Hotline at the debris, the wound is cleansed, and the saline-moistened gauze reapplied. If performed correctly, wet-to-dry gauze debridement requires dressing changes for several days to weeks, three to six times a day. Topical enzymatic therapy Topical enzymatic therapy is a selective method of debridement. Today the only enzyme available in the United States is collagenase, which is derived from clostridium bacteria. Collagenase digests collagen in necrotic tissue by dissolving the collagen “anchors” that secure the avascular tissue to the underlying wound bed. Enzyme therapy does not directly affect the pathogen levels or pH levels in the wound bed.1 The frequency of enzyme application is at least daily and may be twice daily. In addition, collagenase requires a prescription. Medical grade honey Medical grade honey dressings also promote selective debridement. Available in many forms, including hydrogel, paste, impregnated gauze, hydrocolloid and alginate, honey supports a moist wound environment and facilitates the process of autolytic debridement, the body’s natural debridement process. These modern wound care dressings contain active Leptospermum scoparium manuka honey and have been shown to promote rapid debridement through multiple mechanisms of action,

40 Healthy Skin I www.medline.com

1-888-701-SKIN (7546) to speak with one of our clinical nurses Monday through Friday, 8am to 5pm CST.

including the dressing’s high osmotic potential.2 Manuka honey’s high sugar content leads to osmosis, causing the movement of fluid from low to higher concentration of sugar and subsequently drawing lymph fluid and exudate to the wound surface, picking up and removing large molecule proteins such as devitalized tissue and helping reduce odor. In addition, in vitro evidence has shown that honey is an effective agent for preventing biofilm formation and that pseudomonal biofilms were disrupted following application of manuka honey.3 Medical-grade honey is indicated for partial or full-thickness wounds, leg ulcers, pressure ulcers, first- and second-degree burns, diabetic foot ulcers, surgical and trauma wounds, minor abrasions, lacerations and minor scalds and burns.

alternative to the aforementioned debridement options. Autolytic debridement is facilitated by modern moist interactive dressings. Medical-grade honey dressings provide a moist wound environment that promotes autolytic debridement and wound bed preparation to support repair and healing. Further research is needed, as medical-grade honey is a newer topical strategy that is becoming more popular through evidence-based information. Try it, document the products’ effectiveness and convince yourself and your patients and residents. References: 1. Fleck CA, and Chakravarthy D. Newer Debridement Methods for Wound Bed Preparation. Advances in Skin & Wound Care. July, 2010: 313-15. 2. Gethin G, Cowman S. Manuka honey vs hydrogel-a prospective, open label, multicentre, randomized controlled trial to compare desloughing efficacy and healing outcomes in venous ulcers. J Clin Nurs 2009;18: 466-74. Available at: http://www.ncbi.

Contraindications include third-degree burns and individuals with a known sensitivity to honey or bee venom. While dressing change frequency depends on the amount of wound drainage, medical-grade honey may be left in place for up to seven days, offering a cost-effective and efficient

nlm.nih.gov/pubmed/18752540. Accessed January 10, 2013. 3. Mitchell G, Seguin, DL, Asselin A, Doziel E, Cantin AM, et al. Staphylococcus aureus sigma B-dependent emergence of small-colony variants and biofilm production following exposure to Pseudomonas aeruginosa 4-hydroxy-2-heptylquinoline-N-oxide. BMC Microbiology;2010; 10(Special section):1.

Versatel

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Adheres Gently, Minimizes Pain Versatel Contact Layer Wound Dressing is a conformable, flexible, translucent silicone wound contact layer. Channels in the dressing allow fluid to easily transfer to an absorbent secondary dressing.

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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.

Contact your Medline representative or call 1-800-MEDLINE (1-800-633-5463) for the opportunity to try Versatel for yourself. http://goo.gl/imosd

ÂŠ2013 Medline Industries, Inc. Versatel is a trademark and Medline is a registered trademark of Medline Industries, Inc.

42 Healthy Skin I www.medline.com

CE Article

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

Raising Kids and Healing Wounds by Clay E. Collins, BSN, RN, CWOCN, CFCN, CWS, DAPWCA, FACCWS

As a proud father of three sons I have an “experiential” understanding of the process of raising children. Beginning at birth and continuing through adulthood, the art of parenting is a continual learning process. Many books have been written about the subject of parenting, but none of us come into this world with this knowledge pre-programmed. It must be learned. Whether by observing our own parents and others during our developmental years or through parenting classes and books in which we seek out additional knowledge and “pearls of wisdom,”

we each eventually adopt a system that works best for us and our children and the unique circumstances and cultures that influence the process of child rearing. The hope, of course, is that we will one day raise fully developed, well-adjusted, mature young men and women that are able to make their way in this ever-changing world utilizing their unique gifts, talents and abilities based on the lessons and values instilled in them during their years under our wing.

As a clinical educator and wound specialist I find myself drawing from many experiences and lessons learned from my years of parenting to help me form a more “real-life” picture of the processes occurring during wound healing. For those of you who are wondering if my many years as a nurse have finally forced me off the deep end, just bear with me for a moment and let me explain.

Improving Quality of Care Based on CMS Guidelines

The wound healing and child development analogy

A sound understanding of the phases of wound healing can help with understanding what is going on behind the scenes, just as understanding the stages of child development may explain behaviors in your children

Similarities between wound healing and child development Just as there is a systematic process of child development that is occurring whether parents are aware of it or not, there is also a systematic process of wound healing occurring behind the scenes. As nurses, we may not learn the simple principles of wound healing and our experiential knowledge about managing wounds may be inadequate or incorrect. This can lead to problems in “parenting” wounds and helping them to grow into well adjusted, adult scars. Just as a sound understanding of the phases of child development can help you understand what is really going on when your three-year-old questions everything with “why, why why…”, or when your 16-year-old decides you are the dumbest human being on the planet. Just as an overview of the stages of child development can explain 44 Healthy Skin I www.medline.com

these behaviors in your children, a sound understanding of the phases of wound healing can provide a better understanding of what is going on beneath the skin. Wound healing. Bleeding occurs

immediately following any acute injury extending beyond the epidermis. In response, a series of events is initiated, with the initial goal to stop the bleeding. As the clotting pathways are activated to form a clot, the capillaries also begin to vasoconstrict. This clot formation and, more importantly the breakdown of the clot, (a process called fibrinolysis), is a critical event in the wound healing process. It is also the precipitating event that initiates the entire healing cascade. Without bleeding, clot formation, and fibrinolysis, the body does not respond appropriately to an injury. This explains why chronic

wounds such as pressure ulcers, neuropathic ulcers (diabetic foot ulcers), venous ulcers, and arterial ulcers often require assistance to move through the phases of wound healing. If there is no initial injury that results in bleeding, the healing cascade will not be activated within the body. This is the primary difference between an acute wound and a chronic wound. Partial thickness wounds. The phases

of wound healing are also dependent on the depth of injury. When faced with a partial thickness injury that extends through the epidermis and into, but not through, the dermis, the body will respond with a brief inflammatory phase followed by regeneration of the damaged tissue. This regenerative capability is limited to partial thickness wounds and results in no scar tissue formation.

I like to think of this process much like when a child falls and scrapes his/her knee. There is a brief inflammatory response evidenced by the screaming and crying that usually occurs but generally, after a little TLC and maybe a kiss, everything is better and the child goes back to playing as if nothing ever happened. Partial thickness wounds do not need to proceed through the remaining phases of wound healing due to the body’s ability to regenerate when faced with this type of injury. As

these wounds heal we refer to them as epithelializing. Full thickness wounds. With full

thickness wounding, however; in which the body has lost the epidermis and the dermis, the injury extends into the subcutaneous and possibly deeper layers of tissue such as muscle, and maybe even to the bone. These deeper wounds are referred to as full thickness wounds. All wounds, regardless of etiology, are initially classified according to the depth of

Understanding wounds PARTIAL THICKNESS WOUND: Injury through epidermis and into the dermis Healing: Body regenerates itself with no additional intervention End Result: No scar tissue

FULL THICKNESS WOUND: Injury through dermis and into deeper tissue, possibly muscle or bone Healing: Body replaces lost tissue with granulation tissue, with little to no additional intervention required End Result: Scar tissue

CHRONIC WOUND: Full thickness wounds that have not proceeded through the normal phases of wound healing Healing: Intervention is required to move wound though all phases of healing to achieve closure

injury. It is important to identify if the wound is partial thickness or full thickness so you have an understanding of what to expect as the wound heals. Will it regenerate or will it have to granulate? Full thickness wounds heal differently than partial thickness wounds, as the body must replace the lost tissue with granulation tissue and form a scar. Acute wounds healing by primary intention, such as surgical wounds, typically proceed through the phases of wound healing in an orderly, systematic fashion with little intervention required. The CDC recommends that surgical wounds be covered with a dry, sterile dressing for the first 24-48 hours1. Sometimes, however, as a result of infection or other complicating factors such as poor nutrition or underlying co-morbid conditions, these acute wounds may fail to proceed through the healing process and become chronic wounds. Chronic wounds. These wounds have

not proceeded through the phases of wound healing in an orderly fashion and require our assistance in moving through the phases as quickly as possible to achieve wound closure. Chronic full thickness wounds may take weeks or even months to heal. As a wound care specialist I have spent months helping a patient heal their wound and have often felt like a proud parent as I watch these wounds move through the phases of the healing process and grow up into fully functioning, well-adjusted, “adult” scars.

End Result: Full scar tissue

Improving Quality of Care Based on CMS Guidelines

Nurses can help these wounds move through the phases of wound healing much like parents help their children move through the phases of child development. For example, a chronic, full thickness wound will need to complete all phases of wound healing beginning with the inflammatory phase, into the proliferative phase, and eventually ending with the maturation phase with the goal being to establish a fully matured scar. Inflammatory phase. Babies enter

this world in the full “inflammatory phase,” with drainage coming from every orifice, including places no one knew were able to produce such mass quantities of drainage. From dirty diapers, spitting up everywhere, snotty noses and other things too gross to mention, it is a full- time job just keeping them cleaned up, fed and happy so they are not continually screaming and their parents can get a couple of hours of much needed sleep. Wounds in the inflammatory phase are often heavily exudating, may have an odor, especially in the presence of an infection, may have necrotic tissue and require a lot of attention and frequent dressing (“diaper”) changes. During this phase of wound healing there are many things going on behind the scenes that clinicians need to be aware of in order to promote wound healing.

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The inflammatory phase of wound healing is very important in the life of a wound. Following hemostasis, as the healing cascade is initiated, the wound moves into the inflammatory phase. During this phase we observe a vasodilation as the capillary beds open up to allow plasma and blood back into the site of injury to start the clean up process. This phase is observed clinically by the presence of edema, erythema and exudates. The wound bed is exposed to an influx of cytokines, growth factors and leukocytes in the form of neutrophils, macrophages and lymphocytes designed to prepare a clean wound bed for ultimate closure. The inflammatory phase typically lasts from one to three days after an injury. Wounds that have necrotic tissue and/ or develop infection will experience a prolonged inflammatory response and delay in healing. Studies indicate a link between the duration of the inflammatory phase and the development of excessive scar tissue.2 This makes it imperative to work toward getting the wound debrided and free of bacteria as quickly as possible so it can move out of the inflammatory phase into the proliferative phase where active wound healing occurs.

Babies enter this world in the full “inflammatory phase,” with drainage coming from every orifice, just like wounds in this phase are heavily draining

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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.

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Protect skin from IAD Incontinence of urine and/or stool puts individuals at greater risk for skin breakdown and incontinence-associated dermatitis (IAD). Skin and wound care experts recommend using a pH-balanced skin cleanser, skin moisturizer and moisture-repellent skin barrier for those at risk for IAD.1

Reference 1. Lambert D. Prevention of incontinenceassociated dermatitis in nursing home residents. Annals of Long-Term Care: Clinical Care and Aging. 2012;20(5):25-29.

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Contact your Medline sales rep, call 1-800-MEDLINE, or visit medline.com to discover how Aloetouch cleansing wipes can help treat and prevent IAD at your facility. ©2013 Medline Industries, Inc. Aloetouch is a registered trademark and Medline is a registered trademark of Medline Industries, Inc.

Wounds in the “proliferative phase” go through granulation, contraction and epithelialization to begin healing, just like kids who constantly consume nutrients to help them grow

Proliferative phase. The proliferative

phase of wound healing is the phase where wounds are actively healing and growing new tissue. In relation to raising kids, I picture this phase occurring after potty training. The number of dressing changes (dirty diapers) has decreased and they are becoming more independent. As they proceed through the toddler years and into adolescence they are actively growing new tissue to the point that we can often see them grow on a daily basis! During this phase, kids, just like wounds, are consuming all of the nutrients they can in order to continue growing. I remember when I had three teenage boys, and my wife would go to the grocery store. As soon as she would pull into the garage, after spending more money than I even wanted to know about, the boys would race to the car to bring in the food so they could see how fast they could eat everything! This inevitably resulted

in complaints the following day that there was no food in the house. Or, after spending hours preparing a family dinner, and each boy eating two to three helpings, it never failed that 30 minutes later one would say, “Mom, I’m hungry!”

the process of contraction in order to minimize the size of the defect for a tight, compact scar. Once the granulation tissue has filled the wound with epithelial cells at the margins, the wound has a moist platform of tissue across which to migrate.

During the proliferative phase of wound healing , which typically lasts 14-21 days, the body attempts to close the wound as quickly as possible through a process that includes granulation, contraction and ultimately epithelialization. In wounds healing via secondary intention wound healing, granulation tissue must form to fill the wound from the base. The growth of granulation tissue is dependent on a variety of factors: oxygen levels within the wound bed, nutritional status, patient age, gender, diabetes, infection and arterial insufficiency, just to name a few. Problems with any of these areas can inhibit the formation of new tissue. As the wound fills with granulation tissue, the body simultaneously begins

Maturation phase. After the wound has been resurfaced with epithelial cells it enters the third and final phase of wound healing is the maturation phase. At this point in the process many nurses describe the wound as being “healed.” However, it is important to understand that although this wound may be closed, it is just entering the maturation phase.

When my boys were younger I used to think my job would be done when they turned 18. Boy, was I wrong! I have since learned that this maturation phase is in many ways more difficult than the inflammatory phase. Every person matures at a different rate, and wounds are the same. The maturation phase typically begins after wound

Improving Quality of Care Based on CMS Guidelines 49

Just because a scar has formed does not mean the “maturation phase” of wound healing is over – just like parenting is not complete although a young adult looks in appearance as though he is all grown up

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closure (around day 21) and may continue for well over 12 months. So, just because children look all grown up does not mean they are mature. And just because a scar has formed does not mean that the maturation phase of wound healing is over. The maturation phase for wounds is also referred to as the remodeling phase. During this phase of wound healing, the body takes the poorly organized type III collagen that it rapidly produced to close the wound and remodels it into type I collagen that is better organized and has much better tensile strength. Studies have shown that even after a wound is fully matured it will never reach more than 80 percent of the tensile strength of the original tissue.3 If I were to introduce you to my teenage son you might think that he looks like a grown man. He might think he is a grown man. But, I know him and I can assure you that he is in no way mature! We spend many years raising our children and make a significant investment of time and money hoping that one day they will be prepared to go out into the world and make their own way. But, if we judge them based on appearance or on how grown up they think they are and we kick them out of the nest too soon, how long does it take for them to mess everything up and come running back home? Then, we have to start all over and try again. Nurses do this all too often with wounds. They get them closed, and because they appear “healed,” they kick them out into the big bad world to fend for themselves before they are mature enough to make their way. They come running back home as

an open wound again, and we start all over. If we were to think of these wounds as our children we might realize that a grown son or daughter still needs nurturing and protection from the world as they are becoming mature enough to fend for themselves.

Now do you see what I mean? By viewing the process of wound healing in the context of being a parent, things become a little clearer. Our goal when managing chronic wounds is to enable the wound to proceed as quickly as possible from the inflammatory phase (what I call the potty training phase), into the proliferative phase (from toddler to adolescence), and then continue to nurture and protect them as they go through the maturation process. If we are good wound parents, we will be able to proudly say that we helped to raise a fully developed, well-adjusted adult scar that is ready to make its way in the world as a productive part of the body again. I hope this thinking will help you remember these phases as much as it has helped me. References 1. Hahler B. Surgical wound dehiscence. MEDSURG Nursing. 2006; 15(5): 296-300. Available at: http://www.medsurgnursing.net/ ceonline/2008/article10296301.pdf. Accessed January 8, 2013. 2. Gauglitz GG, Korting HC , Pavicic T, Ruzicka T, Jeschke MG. Hyptertrophic scarring and keloids: pathomechanisms and current and emerging treatment strategies. Molecular Medicine. 2011; 17(1-2): 113–125. Available at: http://www.ncbi.nlm.nih.gov/ pmc/articles/PMC3022978. Accessed January 8, 2013. 3. Heitzman J. Foot care for patients with diabetes. Topics in Geriatric Rehabilitation. 2010; 26(3):250-263. Available at: http://www.nursingcenter.com/lnc/ journalarticle?Article_ID=1047440. Accessed January 8, 2013.

Improving Quality of Care Based on CMS Guidelines

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.

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

Donâ&#x20AC;&#x2122;t Just Sit There! Move for Your Health

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Had an exhausting day? Think you deserve to kick back and relax? You might want to think again. If you’re like most people nationwide, you’ve spent more than half of your waking hours sitting or inactive for long stretches of time—at work, at school, in the car or watching TV or another type of screen. Maybe it’s time to try standing up instead of putting your feet up. Scientists estimate that Americans ages 12 and up now spend most of their time—about 8 to 10 hours a day—sitting and doing things that require little energy. The groups who sit the most are teens and older adults.

What’s so bad about sitting? Sedentary behavior—which usually means sitting or lying down while awake—has been linked to a shorter lifespan and a wide range of medical problems. Studies have found that any time you get up and move, you’re improving your chances for good health. “Some of us are sort of forced into sedentary lifestyles by our jobs, by school or by commuting,” says Dr. Donna Spruijt-Metz, who studies childhood obesity at the University of Southern California. “But research suggests that breaking up sedentary time with even short bouts of activity— like getting up from your desk and moving around—is associated with

smaller waist circumference and other indictors of good health.” When you’re upright and active, even briefly, your body is at work. “You’re engaging a wide range of systems in your body when you move throughout your day,” says Dr. Charles E. Matthews, who studies physical activity and cancer risk at NIH. “Your muscles are contracting, you’re maintaining your balance, and you’re resisting the force of gravity.” When you’re sitting, Matthews says, “muscle contractions go way down, and your body’s resistance to gravity decreases.” When you sit for long periods, your body adapts to the reduced physical demand and slows down its metabolism. When metabolism slows, you burn fewer calories and boost the chance that extra energy will be stored as fat. The best way to raise your metabolism is simply by moving. The more you move, the better. A new study led by NIH’s Dr. Steven Moore looked at data on more than 650,000 adults, mostly age 40 and older. The researchers found that leisure-time physical activity was linked to a longer life expectancy, regardless of how much people weighed. “We found that even a low level of physical activity—equivalent to about 10 minutes a day of walking—was associated with a gain of almost 2 years in life expectancy. High levels of activity— equivalent to about 45 minutes a day of walking—were associated

...leisure -time physical a linked to ctivity was a expectan longer life cy, regar dless of how m uch peop le weighed . with a gain of 4 years or more,” says Moore. The outcomes weren’t so positive for those who were both overweight and did no exercise. “People who were obese and inactive lost about 7 years of life compared to normal weight people who were active,” Moore says. The many benefits of moderate to vigorous activity have been much studied. Moderate to vigorous exercise gets your heart pumping and boosts blood levels of “good” cholesterol. Moving at moderate to vigorous intensity also strengthens your bones and muscles and lessens your risk for a wide range of health problems, including stroke, diabetes, certain types of cancer, osteoporosis and arthritis. That’s why the experts recommend that adults aim to exercise at least 2 and a half hours a week at moderate intensity or 75 minutes a week at a vigorous level. You might exercise at moderate intensity for 30 minutes, 5 days a week, or try 45 to 60 minutes, 3 days a week. If your goal is to exercise for a half hour a day, you might break that up into

Improving Quality of Care Based on CMS Guidelines

shorter periods (of at least 10 minutes at a time) that add up to 30 minutes. Although the benefits of intense activity are clear, less is known about the longterm impact of sedentary behavior. Since most people engage in a range of activities throughout each day, it can be challenging to tease apart the effects that sitting and non-exercise activity can have over time. An NIH-funded study by Matthews and colleagues found that extended periods of sitting might take a toll on your lifespan even if you exercise. The decade-long study looked at more than 240,000 adults. “Even those who were exercising a lot—7 or more hours per week—had an elevated risk for death from all causes or from cardiovascular disease if they also watched a large amount of TV (more than 7 hours per day),” says Matthews. “It suggests that a substantial amount of exercise may not always protect against the adverse effects of prolonged sitting.” “Sedentary behavior is not simply the opposite of physical activity,” says Dr. John Jakicic, who studies the biology of exercise at the University of Pittsburgh. “It’s not as if you’re either sitting and doing nothing or you’re physically active. There’s a gray zone that includes light activity,” such as standing up, casual walking or grocery shopping. Scientists have had difficulty accurately monitoring how long and at what intensity people are actually moving each day. More than a decade ago, most studies of everyday activity relied on self-reports—like questionnaires or diaries of physical activity—which can be inaccurate.

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Today, mobile technologies—such as smart phone apps and electronic activity monitors— are helping scientists gather better data. Study participants wear these small devices all day long. They provide data on what people are actually doing as they move throughout their day. “Is it really the sedentary behavior that causes harm? Or is it the lack of physical activity at the right intensity that’s the problem? I don’t think we have the answers yet,” says Jakicic. With the help of new technologies, Jakicic and others are working toward answers.

more and sit less,” says Spruijt-Metz. “Don’t use the phone or email if you can take a walk and talk to someone in person. Get yourself a step-counter and try to get in 10,000 steps a day. There are many ways to add movement without going to the gym.”

“Based on findings we’ve seen in several studies to date, I think it’s a combination of lower levels of sedentary behavior and higher levels of activity that provide the most benefit,” says Matthews.

The bottom line is, look for opportunities to be active throughout your day. Get moving as much as you can!

“You can alter your routine just a little bit every day so you’ll move

Source: National Institute of Health, http://newsinhealth.nih.gov/issue/ Dec2012/Feature1

MEDLINE’S REVOLUTIONARY SHOW-AND-TELL PACKAGING

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

Medline’s Educational Packaging offers all the information you need, step by step, short and sweet, to help the Medline dressing do its job of healing. In a study involving 139 nurses at eight different facilities, 88% who used a wound care product with an education guide attached were able to apply the dressing to a wound correctly.1

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

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Pink Glove Dance

Competition VIDEO

Lexington Medical Center wins with 15,000+ votes

2012! Tens of thousands of doctors, nurses, firefighters,

cheerleaders and even entire towns joined forces to produce videos for the 2012 Pink Glove Dance Video Competition, which featured dancing hospital CEOs, bopping nuns, and octogenarians popping wheelies in their wheelchairs, all for a good cause.

First Place

Lexington Medical Center, West Columbia, SC Medline will donate $10,000 to Lexington Medical Centerâ&#x20AC;&#x2122;s breast cancer charity of choice, the Vera Bradley Foundation for Breast Cancer.

Improving Quality of Care Based on CMS Guidelines 59

Medline Product Manager Emily Somers (second from right) and Medline Chief Marketing Officer Sue MacInnes (far right) present a check for $10,000 to Catherine Hill, Executive Director of the Vera Bradley Foundation for Breast Cancer (second from left). Also pictured, Lexington Medical Center CEO Michael Biediger (far left).

With more than 200,000 votes cast in the competition, Lexington Medical Center in West Columbia, S.C., won first place with almost 15,000 votes. This marks the second consecutive year Lexington Medical Center won the competition. Their creative video focused on a young nurse’s battle, and ultimate victory, over breast cancer, including her first time skydiving, as well as more than 700 hospital staff and a number of breast cancer survivors, all dancing in pink gloves to Katy Perry’s hit song “Part of Me.” Second place was captured by Penn State Milton S. Hershey Medical Center in Hershey, Pa., with more than 8,000 votes. Penn State Hershey’s entry features more than 600 faculty, staff, patients, survivors and the Nittany Lion, all donning pink gloves and dancing to Katy Perry’s song “Part of Me” in support of breast cancer awareness and prevention. The video was produced completely by in-house hospital staff. “We had fun making the video, especially knowing it was for a good cause and that many of the participants have been touched by breast cancer in some way,” said Kathleen 60 Healthy Skin I www.medline.com

Law, RN, director of nursing, perioperative services. “We’re excited that our efforts brought awareness to the important issue of breast cancer and will support the good work of the Pennsylvania Breast Cancer Coalition.” The Carle Foundation in Urbana, Ill., took home third place honors with more than 6,000 votes. Carle’s video features more than 600 medical center staff, 50 departments and 12 breast cancer survivors, all dancing in pink gloves to Katy Perry’s hit song “Part of Me” in an effort to show that no one is alone in the fight against breast cancer. Employees with Carle at the Fairchild and Vermilion sites in Danville were involved, as well. The video was developed, coordinated and filmed in part by in-house hospital staff, with additional production from Shatterglass Studios. “We appreciate the opportunity to raise awareness and funds for breast cancer research in our community, and are thrilled to have placed in this national competition,” said James C. Leonard, MD, president and CEO of The Carle Foundation.

Carle received almost 6,000 votes out of more than 200,000 votes cast during the three-week competition. To date, there have been more 17,000 views for Carle’s video. “Congratulations to the winners, and to all of the competing organizations, for honoring the hundreds of thousands of men and women who are diagnosed each year with breast cancer,” said Andy Mills, president of Medline. “The passion and energy displayed by the thousands of participants is infectious and inspiring. They are all helping to make Medline’s Pink Glove Dance a ‘movement’ in every sense of the word.” In all, more than 60,000 people from hospitals, nursing homes, schools and other organizations in 42 U.S. states, Puerto Rico and Canada participated in the three-week competition. Sponsored by Medline — the world’s leading manufacturer of exam gloves — the national competition quickly became a national social media phenomenon with more than 3.2 million views, 200,000 votes and thousands of tweets, blogs and texts.

Second Place Penn State Milton S. Hershey Medical Center, Hershey, PA

With the win, comes a $5,000 check from Medline, made payable to the Pennsylvania Breast Cancer Coalition.

Third Place The Carle Foundation, Urbana, IL

For placing third in the competition, Medline will contribute $2,000 to Carleâ&#x20AC;&#x2122;s breast cancer research charity of choice, the local office of the American Cancer Society in Champaign.

All of the Pink Glove Dance videos are available for viewing at www.pinkglovedance.com. Improving Quality of Care Based on CMS Guidelines 61

BEAT

the WinteR

BLUES

by Wolf J. Rinke, PhD, RD, CSP

According to data reported in the Wall Street Journal, one in four American adults who visits a primary-care physician suffers from a mental health problem.1 And I suspect that those findings may be even worse in the winter. So here is what you can do to beat the winter blues, and hopefully avoid more serious mental health issues.

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Improving Quality of Care Based on CMS Guidelines 63

1. Commit Random Acts of Kindness To do this right, you must do something for someone else without expecting anything in return. According to Professor Marti Seligman, known to many as the father of the Positive Psychology Movement, and author of Flourish: “We scientists have found that doing a kindness produces the single most reliable momentary increase in well-being of any exercise we have tested.” For example, get the family together and serve a meal at a shelter for the homeless, or visit your local nursing home and talk with an elderly person in need of companionship. According to Jonathan Haidt, Ph.D., assistant professor of psychology at the University of Virginia, when you do a good deed, you are helping not just the recipient, you are helping everybody. Haidt’s research demonstrates that people witnessing others performing good deeds also benefit. They experience an emotion called “elevation,” which is triggered if you see someone help

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others, show gratitude, behave honorably or act heroically. “Elevation makes people more open and loving toward others; it makes them feel better about humanity.”

you do while sitting on the throne? On second thought, let’s not go there. (I’m hoping that you are smiling.) Here is what I do that enables me to start every day with an attitude of gratitude.

2. Start Each Day with an Attitude of Gratitude No matter how badly things may be going for you, focus on what you have left, not what you have lost. (According to Seligman’s research this is the second most powerful thing you can do to improve your mental health.) One way to do this is to draw a line down the middle of a piece of paper. Label the left column “What’s gone,” and the right “What’s left.” Fill in both columns. Even though things may be tough, you will typically find much you can be thankful for. Now use your mental energy to develop an attitude of gratitude by focusing on all you have left. I start this process every morning shortly after I get up while I sit on the “throne.” Let me ask you what do

• First, I’m thankful that I’m married to Marcela my Superwoman. I’m often asked why I call her my Superwoman. One reason is that she is responsible for 85% of my success. Without her I would never have gotten to where I am today. You see, she was born with a positive gene and helped me transform myself from an eternal pessimist to an eternal optimist. Plus she has always loved me unconditionally, and she is a CPA, and my business partner who keeps me straight financially. • Typically the second thing I’m thankful for is the privilege of being a father to two wonderful daughters and the grandfather to Kylie age 5 (going on 9) and Aliana, age 2.

• Thirdly I’m grateful for the privilege of being able to impact you in a positive way. (You are reading this, aren’t you?) After all, there is nothing more gratifying than being in the business of helping other people, but you probably know that already— that’s why you do what you do. After getting your day started with an attitude of gratitude, you are going to face many negatives, starting with the news, which tells you all the things that are wrong in the world. The media’s operating slogan is “if it bleeds it leads.” The problem with this is that we are repeatedly exposed to this negative stuff, and we begin to believe that’s the way life is, forgetting that whatever gets reported in the media represents the exception. Otherwise it wouldn’t even be in the media. So do what I do. For the paper, electronic or hard-copy, skim the headlines—you can’t be out of touch. Read only those parts that are of specific interest to you. Skim the rest. For TV, avoid watching the local news, except perhaps the weather. Have you ever really listened to the local news? Over 85 percent has to do with bad stuff— shootings, killings, beatings, fires etc. So turn off the local news. Instead do what Superwoman and I do. Tape the national news—that way you don’t have to watch the commercials—and then watch it at a convenient time sometime in the evening, but not right before going to bed! To avoid programming your mind with negative stuff, watch a couple minutes of something light.

3. Master the PIN Technique The PIN technique is a powerful way to reframe your perceptions and turn negatives into positives. Here is how it works. When you are confronted with anyone or anything that would cause you to react negatively, PIN it. For example, your daughter brings home a new boyfriend with rings in all the wrong places. Or your team member says: “Boss, you know how morale has gone down the tube, let’s close up shop and go on a cruise for a week.” Instead of NIPing “weird” ideas, focus your mental energy first on: P—the positive. Ask yourself what’s positive about your daughter’s boyfriend—for example, he may be courteous, or at least she has a boyfriend. After you’ve done that in your mind’s eye, evaluate the:

I—the interesting or innovative. Ask what could be interesting or innovative about closing the office for a week and going on a cruise, such as “She seems interested in helping making things better.” And once you’ve evaluated that, and only after you’ve exhausted all the P’s and I’s, then ask yourself, what is the down side, the: N—the negative. Because in life nothing ever goes one way, there is Ying and Yang, health and sickness, life and death, high real estate market and low real estate market, strong economy and weak economy...and if you want to beat blues then you must evaluate both the upside and downside of everything. However, if you NIP ideas in the bud, it’s like closing the proverbial shade which prevents you from seeing all the positive stuff that is all around you.

Improving Quality of Care Based on CMS Guidelines 65

When someone asks you

4. Take Advantage of Every “Moment of Truth” When people meet for the first time they typically greet you with, “How are you?” Let me ask you, do they really want to know? Of course not! It’s just a figure of speech. In fact, 97% of the people you meet don’t care how you’re doing, and the other 3% are just glad that you are worse off than they are. However, how you respond to that rhetorical question will determine your attitude, because your response will program your subconscious. And your subconscious can’t tell right from wrong. It’s like working on your word processor with the spell checker turned off. It doesn’t ever say: “Hey, what’s that word? I’ve never seen that before.” Instead, it accepts everything as if it were reality. And your subconscious works just like that. It simply can’t tell right from wrong, fiction from fact or reality from imagination. To take advantage of this phenomenon you want to get in the habit of programming your subconscious with positive messages so it can work for you, instead of against you. Here is how: When someone asks you how you’re doing, consider that your moment of truth and answer with what I refer to as a minimum response. It’s a five-letter word that starts with a G and ends with a T. What’s the word?

66 Healthy Skin I www.medline.com

how you’re doing, consider that your moment of truth and answer with what I refer to as a minimum response. It’s a five-letter word that starts with a G and ends with a T. What’s the word? The word is GRRREAT!

The word is GRRREAT! The trick is you’ve got to say it as if you really mean it, even if you don’t quite feel that way. At this point you might be saying: “What if I don’t feel great; but I say I’m great? That is telling a lie, or at least a fib.” No you’re not. You’re just telling the truth in advance. If you don’t feel great, and you respond over and over again with GRRREAT, your subconscious says, “Hey what do I know, maybe she is doing great!” And before you know it, your subconscious has created a more positive reality for you. By the way, this is such a powerful technique that it single handedly can beat the winter blues in your family or organization forever. You see, this positive stuff is contagious, and spreads like a “virus.” Except this virus, according to research conducted by Seligman, cranks up your immune system and has the potential to keep you, and everyone around you, healthy. It can even help you heal faster and live longer. © 2012 Wolf J. Rinke Reference 1. How Doctors Try to Spot Depression. Wall Street Journal. December 7, 2010. Available at: http://online.wsj.com/article/SB10001424052748 703471904576003520708615998.html. Accessed October 18, 2012.

OPTILOCK

™

The key to locking away exudate

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

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

http://goo.gl/fmftS

Nutrition Information Servings: 12 Fat: 4.5 g Fiber: 1.2 g Sodium: 77 mg Calories: 161

Fudgy Low Fat Brownies Everyone who visits Medline’s corporate headquarters in Mundelein, IL, is greeted with a warm smile from receptionist Lenore Czyznik. In this issue, she shares her recipe for tasty, gooey brownies that are lower in fat and calories. Enjoy! Directions

Adjust oven rack to middle position and heat oven to 350 degrees F. Fold two 12-inch pieces of foil lengthwise. Fit one sheet into an 8-inch square baking dish, pushing foil into corners and up sides of pan. (Overhang will help in removal of brownies after baking.) Repeat with second sheet of foil, placing it in the pan perpendicular to the first sheet. Spray foil with cooking spray. Whisk flour, cocoa, baking powder and salt together in a mixing bowl. Melt bittersweet chocolate and butter together in large bowl over a pan of simmering water until smooth.

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

68 Healthy Skin I www.medline.com

Ingredients ¾ cup all-purpose flour 1/3 cup Dutch processed cocoa powder ½ teaspoon baking powder ¼ teaspoon salt 2 ounces bittersweet chocolate, chopped 2 tablespoons unsalted butter 2 tablespoons low fat sour cream 1 tablespoon chocolate syrup 2 teaspoons vanilla extract 1 large egg plus 1 large egg white 1 cup sugar

Cool chocolate and butter mixture 2 to 3 minutes, then whisk in sour cream, chocolate syrup, vanilla, egg, egg white and sugar. Using rubber spatula, fold dry ingredients into chocolate mixture until combined. Pour batter into pan, spread into corners, and level surface with the spatula. Bake 20 to 25 minutes until slightly puffed and a toothpick in the center comes out with a few sticky crumbs attached. For a truly fudgy consistency, do not overbake. If the toothpick emerges with no crumbs, the brownies will be cakey.

Remove brownies from pan using foil handles. Cut into two-inch squares and serve. To keep brownies moist, do not cut until ready to serve. Brownies can be wrapped in plastic and refrigerated up to three days.

Forms & Tools

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

Infection Prevention Environmental Checklist Observation Form……………………………….……70 Infection Prevention and You in Long-Term Care………………………………82 Infection Prevention and You at the Hospital………………………...…………83 CMS Measures Hospital-Acquired Conditions (HAC) in Acute Inpatient Prospective Payment System (IPPS) Hospitals ……………………………………………………...…72 Medical Device Safety Making Medical Devices Safer at Home………………………………………...78

Improving Quality of Care Based on CMS Guidelines

Forms & Tools

Environmental Checklist

EXAMPLE: Environmental Checklist Observation Form For Daily and Terminal Cleaning – Room Observations Observe two daily cleanings per week and one terminal cleaning per month. Report your results in the cells highlighted in yellow.

Check the type of cleaning: Routine: Terminal:

Date: Patient Name: Medical Record Number: Unit: Room Number:

Instruction At start, perform hand hygiene Put on PPE Needed supplies/equipment

Component

Yes

Not Applicable

Door knobs Light switches Windowsills Spot clean walls with disinfectant cloth Medical equipment (e.g., IV controls) High-touch surfaces: Bed rails and Call button Phone Damp dust/clean: Overbed table and drawer TV & stand Bathroom door knob Bathroom: Tub/shower Disinfect w/ hypochlorite-based Bathroom handrails disinfectant Sink including faucet Call button Toilet (lever/flush, horizontal surface/seat Clean floor: Dust mop tile/wet mop tile Bed frame Matress covers For terminal cleaning, damp dust: Pillows Blood pressure cuffs, as per hospital policy Remove unused linen and other such items EXIT ROOM AFTER CLEANING IS COMPLETE: Remove trash, mops, soiled curtains, discard wipes/cloths, etc. Dispose of gloves, gown, wash hands RE-STOCK ROOM with SUPPLIES and EQUIPMENT as needed: Hand sanitizer/ hand soap After Daily Cleaning Paper towels (Replace as needed) Replace trash liner Remake bed with clean linen After TERMINAL CLEANING, Replace as needed: Pillows, mattresses, gowns/gloves not needed; it’s a pillowcovers, mattress covers clean room Replace curtains as needed OTHER: Change mop heads after each room Remove PPE before walking in hallway Perform hand hygiene

Source: Evaluation and Research on Antimicrobial Stewardship’s Effect on Clostridium difficile (ERASE C. difficile) Project, Agency for Healthcare Research and Quality (AHRQ). Available at: http://www.ahrq.gov/qual/cdifftoolkit/cdifftoolkit.pdf. 70 Healthy Skin I www.medline.com

The same warming, no waste.

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

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

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

PerfecTemp™

OR Patient Warming System

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

http://goo.gl/fmftS

Forms & Tools

Hospital-Acquired Conditions

DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Medicare & Medicaid Services

Hospital-Acquired Conditions (HAC) in Acute Inpatient Prospective Payment System (IPPS) Hospitals FACT SHEET Hospital-Acquired Conditions Section 5001(c) of the DRA required the Secretary to identify, by October 1, 2007, at least two conditions that: 1. Are high cost or high volume or both, 2. Result in the assignment of a case to an MS-DRG that has a higher payment when present as a secondary diagnosis, and 3. Could reasonably have been prevented through the application of evidence-based guidelines.

Hospital-Acquired Conditions (HAC) and Present on Admission (POA) Indicator Reporting Overview The Deficit Reduction Act of 2005 (DRA) requires a quality adjustment in Medicare Severity Diagnosis Related Group (MS-DRG) payments for certain hospital-acquired conditions. CMS has titled the provision â&#x20AC;&#x153;Hospital-Acquired Conditions and Present on Admission Indicator Reportingâ&#x20AC;? (HAC & POA).

ICN 901045 October 2012

72 Healthy Skin I www.medline.com

For discharges occurring on or after October 1, 2008, Inpatient Prospective Payment System (IPPS) hospitals do not receive the higher payment for cases when one of the selected conditions is acquired during hospitalization (i.e., was not present on admission). The case is paid as though the secondary diagnosis is not present.

Medline Safety Syringes

Protect yourself and patients from needlestick injuries Safety features so you won’t get stuck A staggering 74 percent of nurses report being stuck by a contaminated needle,1 which can lead to infection with Hepatitis B and C, HIV, and other dangerous bloodborne pathogens. Avoid needlesticks with Medline Safety Syringes. After injection, slide the safety shield forward and simply twist clockwise. Once you hear a click, the needle is fully protected and the syringe is ready for safe and proper disposal. Medline Safety Syringes also feature:

To Prevent Transmission of Infections in Healthcare

Injection Safety is Every Provider’s Responsibility

• Low dead space design to reduce medication waste and expense • Easy-to-read bold markings • Insulin and tuberculin versions http://goo.gl/Z1YIz ©2013 Medline Industries Inc. Medline is a registered trademark of Medline Industries, Inc.

Reference 1. American Nurses Association. 2008 Study of Nurses’ Views on Workplace Safety and Needlestick Injuries. Available at: http://nursingworld.org/MainMenuCategories/WorkplaceSafety/SafeNeedles/2008-Study/2008InviroStudy.pdf. Accessed March 16, 2012.

“

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

Visit www.medlineuniversity.com for 24 nursing home administrator courses. Topics include: • QIS • Diabetes • Infection Control • Pressure Ulcer Prevention • Spend Management • Wound and Skin Care

Access courses on your computer, iPhone or iPad.

Follow us Be the first to know when we add new courses and content. REGISTER WITH MEDLINE UNIVERSITY TODAY http://www.medlineuniversity.com

Hospital-Acquired Conditions

In August 2012, CMS published the Inpatient Prospective Payment System (IPPS) Fiscal Year (FY) 2013 Final Rule. The Final Rule discusses the addition of two new HACs, one of which is a new Surgical Site Infection Following Cardiac Implantable Electronic Device (CIED) and the other is Iatrogenic Pneumothorax with Venous Catheterization. Two additional ICD-9-CM codes are added to the Vascular Catheter-Associated Infection HAC Category. A complete list of the HAC categories and their corresponding complication or comorbidity (CC) or major complication or comorbidity (MCC) codes finalized for FY 2013 is found in Table 1.

Forms & Tools

Affected Hospitals

The Hospital-Acquired Conditions payment provision applies only to IPPS hospitals. At this time, the following hospitals are EXEMPT from the HAC payment provision: ❖ Critical Access Hospitals (CAHs),

❖ Long-Term Care Hospitals (LTCHs), ❖ Maryland Waiver Hospitals, ❖ Cancer Hospitals, Children’s Inpatient Facilities, ❖ Rural Health Clinics, ❖ Federally Qualified Health Centers (FQHCs), ❖ Religious Non-Medical Health Care Institutions, ❖ Inpatient Psychiatric Hospitals, ❖ Inpatient Rehabilitation Facilities (IRFs), and ❖ Veterans Administration/Department of Defense Hospitals.

Visit the HAC & POA web page at http://www.cms.gov/HospitalAcqCond on the CMS website.

Improving Quality of Care Based on CMS Guidelines

Forms & Tools

Hospital-Acquired Conditions

Table 1: HACs and Codes HAC

CC/MCC (ICD-9-CM Codes)

Foreign Object Retained After Surgery

998.4 (CC) 998.7 (CC)

Air Embolism

999.1 (MCC)

Blood Incompatibility

999.60 (CC) 999.61 (CC) 999.62 (CC) 999.63 (CC) 999.69 (CC)

Pressure Ulcer Stages III & IV

707.23 (MCC) 707.24 (MCC)

Falls and Trauma: ❖ Fracture

Codes within these ranges on the CC/MCC list: 800 - 829 830 - 839 850 - 854 925 - 929 940 - 949 991 - 994

❖ ❖ ❖ ❖ ❖

Dislocation Intracranial Injury Crushing Injury Burn Other Injuries

Catheter-Associated Urinary Tract Infection (UTI)

996.64 (CC) Also excludes the following from acting as a CC/MCC: 112.2 (CC) 590.10 (CC) 590.11 (MCC) 590.2 (MCC) 590.3 (CC) 590.80 (CC) 590.81 (CC) 595.0 (CC) 597.0 (CC) 599.0 (CC)

Vascular Catheter-Associated Infection Manifestations of Poor Glycemic Control: ❖ Diabetic Ketoacidosis ❖ Nonketotic Hyperosmolar Coma ❖ Hypoglycemic Coma ❖ Secondary Diabetes with Ketoacidosis ❖ Secondary Diabetes with Hyperosmolarity Surgical Site Infection, Mediastinitis, following Coronary Artery Bypass Graft (CABG)

999.31 (CC) 999.32 (CC) 999.33 (CC) 250.10-250.13 (MCC) 250.20-250.23 (MCC) 251.0 (CC) 249.10-249.11 (MCC) 249.20-249.21 (MCC) 519.2 (MCC) And one of the following procedure codes: 36.10-36.19

Visit the HAC & POA web page at http://www.cms.gov/HospitalAcqCond on the CMS website.

76 Healthy Skin I www.medline.com

Forms & Tools

Hospital-Acquired Conditions Table 1: HACs and Codes (continued)

CC/MCC (ICD-9-CM Codes)

HAC Surgical Site Infection Following Certain Orthopedic Procedures: ❖ Spine ❖ Neck ❖ Shoulder ❖ Elbow Surgical Site Infection Following Bariatric Surgery for Obesity: ❖ Laparoscopic Gastric Bypass ❖ Gastroenterostomy ❖ Laparoscopic Gastric Restrictive Surgery

996.67 (CC) 998.59 (CC) And one of the following procedure codes: 81.01-81.08, 81.23-81.24, 81.31-81.38, 81.83, or 81.85 Principal Diagnosis: 278.01 539.01 (CC) 539.81 (CC) 998.59 (CC) And one of the following procedure codes: 44.38, 44.39, or 44.95

Surgical Site Infection Following Cardiac Implantable Electronic Device (CIED)

996.61 (CC) 998.59 (CC) And one of the following procedure codes: 00.50,00.51,00.52,00.53,00.54, 37.80,37.81,37.82, 37.83,37.85, 37.86, 37.87, 37.94, 37.96,37.98, 37.74, 37.75, 37.76, 37.77, 37.79, 37.89

Deep Vein Thrombosis and Pulmonary Embolism Following Certain Orthopedic Procedures: ❖ Total Knee Replacement ❖ Hip Replacement

415.11 (MCC) 415.13 (MCC) 415.19 (MCC) 453.40-453.42 (CC) And one of the following procedure codes: 00.85-00.87, 81.51-81.52, or 81.54

Iatrogenic Pneumothorax with Venous Catheterization

512.1 (CC) And the following procedure code: 38.93

NOTE: As specified by statute, CMS may revise the list of conditions from time to time, as long as the list contains at least two conditions. For More Information

The HAC & POA web page at http://www.cms.gov/HospitalAcqCond provides further information, including links to the law, regulations, change requests (CRs), and educational resources including presentations, Medicare Learning Network® (MLN) articles, and fact sheets.

Official CMS Information for Medicare Fee-For-Service Providers

The International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) is published by the United States Government. A CD-ROM, which may be purchased through the Government Printing Office, is the only official Federal government version of the ICD-9-CM. ICD-9-CM is an official Health Insurance Portability and Accountability Act standard. This fact sheet was current at the time it was published or uploaded onto the web. Medicare policy changes frequently so links to the source documents have been provided within the document for your reference. This fact sheet was prepared as a service to the public and is not intended to grant rights or impose obligations. This fact sheet may contain references or links to statutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of either the written law or regulations. We encourage readers to review the specific statutes, regulations, and other interpretive materials for a full and accurate statement of their contents. The Medicare Learning Network (MLN)®, a registered trademark of CMS, is the brand name for official CMS educational products and information for Medicare Fee-For-Service providers. For additional information, visit MLN’s web page at http://www.cms.gov/MLNGenInfo on the CMS website.

Visit the HAC & POA web page at http://www.cms.gov/HospitalAcqCond on the CMS website.

Improving Quality of Care Based on CMS Guidelines

Forms & Tools

Safe Medical Devices

Consumer Health Information www.fda.gov/consumer

Making Medical Devices Safer at Home

atients and consumers are using medical devices more often at home—not just in health care facilities. Many medical devices are now portable, and this feature enables patients to live active lives outside of the confines of the hospital room or treatment center. “(Home use) devices once were designed only to keep you alive. Now they’re designed to keep you as independent as possible,” according to Mary Brady, MSN, RN, a senior policy analyst at FDA’s Center for Devices and Radiological Health (CDRH). However, the Food and Dr ug Administration (FDA) has long been concerned that consumers may sometimes be literally left to their own devices—depending upon medical devices they might not know how to operate and for which they might not understand the safety risks. There have been serious, and even fatal, problems reported to FDA associated with medical devices used at home. For example, a woman with kidney failure got cat hair in her dialysis tubing, resulting in peritonitis, a life-threatening abdominal infection. And a child died when his mother didn’t hear an alarm on his ventilator signaling that the tubing had become disconnected. FDA is working on ways to help consumers safely operate and maintain home use devices, which include blood glucose monitors, infusion

pumps (a device that delivers fluids, including nutrients and medications, into a patient’s body) and respirators. These efforts include issuing a draft guidance document for manufacturers on the design and testing of devices intended for home use, and the development of clearer instructions for use.

Understanding the Instructions Using a medical device at home is not as simple as it might sound. Brady explains that the device might not come with the written instructions that inform a home user how to operate it safely and how to know if it’s not working properly. Even if the device comes with instructions, the language used in the instructions might be too technical.

1 / FDA Consumer Health Information / U.S. Food and Drug Administration

78 Healthy Skin I www.medline.com

“If you can’t understand the directions,” said Brady, “it’s hard to be independent.” While more medical devices are being specifically designed for home use, some devices used at home weren’t originally designed for use by the average person. “Devices are often designed for the health care professional to use in a clinical setting such as a medical office or a hospital,” says Brady. Also, home use devices designed to be used in medical facilities—not homes—might be adversely affected by things found in a home environment, such as pet hair, well water or temperature variations. Other challenges include the user’s and the caregiver’s physical and emotional health. People taking mediD ECEMBER 2012

Don’t Catheterize. Visualize. ™

BioCon - 700 Ultrasound helps minimize unnecessary catheterization Bladder scanners accurately assess bladder volumes, and many urinary catheterizations can be avoided.3 Research has shown that 80 percent of urinary tract infections acquired at healthcare facilities are associated with an indwelling urethral catheter.1 This type of infection is known as CAUTI, or catheter-associated urinary tract infection. Avoiding unnecessary catheter use is a primary strategy for preventing CAUTI, and clinical guidelines recommend the consideration of alternatives to catheterization.2

1. Lo E, Nicolle L, Classen D, Arias A, Podgorny K, Anderson DJ, et al. SHEA/IDSA practice recommendation: strategies to prevent catheter-associated urinary tract infections in acute care hospitals. Infect Control Hosp Epidemiol. 2008;29:S41-S50. 2. Stokowski, LA. Preventing catheter-associated urinary tract infections. Medscape Nursing Perspectives. February 3, 2009. 3. Stevens E. Bladder ultrasound: avoiding unnecessary catheterizations. Med/Surg Nursing. 2005; 14(4):249-253.

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

NO CATHETER SIMPLIFIED TO SAVE TIME IS THE BESTYOU CATHETER

ERASE CAUTI ERASE CAUTI

速

www.erasecauti.com

Safe Medical Devices

Forms & Tools

Consumer Health Information www.fda.gov/consumer

Usability is a critical factor in the design of medical devices. It refers to the extent to which people can use their medical device safely and effectively to accomplish specific tasks. cations that affect their alertness or memory might have trouble using or taking care of their devices. Similarly, the emotional impact of caring for a loved one might influence the caregiver’s ability to use complex, highmaintenance devices. Usability is a critical factor in the design of medical devices. It refers to the extent to which people can use their medical device safely and effectively to accomplish specific tasks. The ECRI Institute (formerly the Emergency Care Research Institute), an organization that evaluates medical products and processes, has found that poor usability is among the top 10 health technology hazards of 2012. Examples include users having difficulty with the start/stop button on an infusion pump or the inability to hear different types of alarms in other rooms in a house.

Working on Providing Resources

device makers to consider factors such as the user’s likely physical condition, emotional issues like anxiety, necessary training, and the home environment that might have children and pets. This document also addresses the development of userfriendly instructions, including how to handle the device in an emergency. • Designing Visual Learning Guides, using mostly pictures. The first two guides will be produced over the next two years, and will focus on containers for the disposal of sharps, (needles, syringes, and lancets) and patient lifts (used to move disabled or injured people). • Exploring the feasibility of making device labeling available on the Internet. The agency has also created a list of recommended practices regarding the use of patient lifts. These devices are increasingly used in the home to transfer patients from one place to another, such as from bed to bath. These recommendations are designed to reduce risks associated with the use of these devices, such as falls.

In April 2010, the FDA launched the Medical Devices Home Use Initiative. The agency has been working since then to develop information and resources for manufacturers, health care professionals, patients (home care recipients), consumers and caregivers. These efforts include:

Tips for Consumers

• Issuing a draft guidance document for manufacturers that describes factors to consider when designing, testing, and developing home use devices, focusing on the realities of how people use their devices at home. FDA is asking

• Know how your device works; keep instructions close by. • Understand and properly respond to device alarms. • Have a back-up plan and supplies in the event of an emergency. • Keep emergency numbers available and update them as needed.

2 / FDA Consumer Health Information / U.S. Food and Drug Administration

• Educate your family and caregivers about your device. • Frequently ask your doctor and home health care team to review your condition and recommend any changes related to your equipment. • Report serious events to the device supplier and to FDA’s MedWatch (http://www.fda.gov/ Safety/MedWatch/HowToReport/ ucm053074.htm).

For More Information • Home Healthcare Medical Devices: A Checklist (http:// www.fda.gov/MedicalDevices/ ProductsandMedicalProcedures/ HomeHealthandConsumer/ ucm070217.htm) • Additional Resources on Home Use Devices (http:// www.fda.gov/MedicalDevices/ ProductsandMedicalProcedures/ HomeHealthandConsumer/ HomeUseDevices/ucm204907.htm)

Find this and other Consumer Updates at www.fda.gov/ ForConsumers/ConsumerUpdates Sign up for free e-mail subscriptions at www.fda.gov/ consumer/consumerenews.html

D ECEMBER 2012

Improving Quality of Care Based on CMS Guidelines 81

Forms & Tools

Patient Handout Infection Prevention in Long-Term Care

82 Healthy Skin I www.medline.com

Patient Handout Infection Prevention in Long-Term Care

Forms & Tools

Improving Quality of Care Based on CMS Guidelines

TheraHoney™

Sterile Wound Dressings

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

TheraHoney™ Gel

The high sugar levels (87%) in TheraHoney result in osmotic pressure that helps promote autolytic debridement of necrotic tissue, lowers the pH of the wound, provides a moist wound healing environment and rapidly reduces wound odor. For more details on the uses for TheraHoney or to arrange a trial, call your Medline representative or 1-800-MEDLINE (633-5463).

TheraHoney™ Gauze

http://goo.gl/HgjRJ

MKT1324544 / LIT336 / 30M / JBK 5