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Free CE Inside! Improving Quality of Care Based on CMS Guidelines

Volume 10, Issue 3

Special Breast Cancer Awareness Issue!

IAD or Pressure Ulcer? Get It Right All the Buzz About Honey


Pink Glove Dance Video Competition Vote Now!


Ways to Reduce SSIs

CNAs Celebrate Their Pride, Page 14

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 to learn more!

ON THE COVER, More than 500 nursing aides gathered in Oklahoma City June 27 and 28 for the National Association of Health Care Assistants (NAHCA) 2012 National Conference to celebrate their pride, learn new skills and encourage each other.

Contents Editor Sue MacInnes, RD Clinical Editor Margaret Falconio-West, BSN, RN, 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 Rebecca McPherson, MSN, RN Joyce Norman, BSN, RN, CWOCN, DAPWCA

CE Article!


The Buzz Around Honey. 100% medical grade Manuka honey aids in wound care and healing.


Incontinence-Associated Dermatitis or Pressure Ulcer? A question that often plagues clinicians. Learn how to tell the difference.

Kim Kehoe, BSN, RN, CWOCN, DAPWCA Jackie Todd, MBA, BS, RN, CWCN, DAPWCA CA Patty Turner, BSN, RN, CWCN, CWS Wound Care Advisory Board Christine Baker, MSN, RN, CWOCN, APN Katherine A. Beam, DNP, RN, ACNS-BC Amparo Cano, MSN, CWON Jill Cox, PhD, RN, APN-C, CWOCN Sue Creehan, RN, CWOCN Donna Crossland, MSN, RN, CWOCN Barbara Delmore, PHD, RN, CWCN, AAPWCA Karen Keaney Gluckman, MSN, FNP-BC, APN, CWOCN Anita Prinz, RN, MSN, CWOCN, CFNC, COS-C Mary Ransbury, RN, BSN, PHN, CWON Denise Robinson, MPH, RN, CHWOCN


Medline Intern Helps Impoverished Children in India. Azza Cohen chronicles her experiences making a difference in the lives of India’s underserved children.


Pink Glove Dance Video Competition 2012. Vote for your favorite video October 12-26 at Winners announced November 2.

Diane Whitworth, RN, CWOCN About Medline Medline, headquartered in Mundelein, IL, manufactures and distributes more than 100,000 products to hospitals, extended care facilities, surgery centers, home care dealers and agencies and other markets. Medline has more than 800 dedicated sales representatives nationwide to support its broad product line and cost management services. ©2012 Medline Industries, Inc. The OR Connection is published by Medline Industries, Inc. One Medline Place, Mundelein, IL 60060. 1-800-MEDLINE.

Improving Quality of Care Based on CMS Guidelines 3

Contents Compliance

16 How Nursing Homes Can Cut Hospital Readmissions 19 Innovative Quality Assurance Tool Helps Nursing Home Achieve Citation-Free Survey

Page 62


10 Five Strategies to Reduce Surgical Site Infection 11 Case Study: Peri-operative Process Change to Reduce the Risk of Post-Operative Infection Following Orthopedic Procedures 41 Evidence for the Validity of the Medline Pressure Ulcer Prevention Program (mPUPP) 52 Celebrating Success in Pressure Ulcer Prevention Treatment

23 How to Measure Ankle Brachial Index 28 The Buzz Around Honey 36 Incontinence-Associated Dermatitis or Pressure Ulcer? 56 Making Strides in Continence Management Special Features

14 CNAs – Proud, Trusted and Valued: NAHCA’s 2012 National Conference Highlights 62 Ten Principles All Great Nurses Follow 66 Medline Intern Travels to India to Help Impoverished Children

Page 56

80 Pink Glove Dance Video Competition 2012 87 Cooking Pink Regular Features

9 Patient Safety News

90 Healthy Eating: White Bean Chicken Chili Caring for Yourself

70 Sleep More…Sleep Better

Page 70

84 FDA Approves First Breast Ultrasound Imaging System for Dense Breast Tissue

Forms & Tools

92 CMS FY 2014-2016 Measures for CMS Payment Determination 96 Marathon Skin Protectant Guidelines for Adults 97 Marathon Skin Protectant Guidelines for Neonates and Infants 98 Urinary Continence Assessment & Implementation Form

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Page 87

Contributing Writers Sara Coverstone, BSN, RN, CWOCN Sara Coverstone has worked with OSF Home Care Services in Peoria, Ill. for the past seven years. In her current role as WOCN Coordinator, she helps mentor other WOC nurses in the field and assists in overseeing the supply process. She enjoys helping patients in their homes through education and assisting in developing a plan of care utilizing advanced wound therapies. Sara received her bachelor of science in nursing degree from Indiana University and her WOCN training through Emory University. Sheila Guither, BSN, RN, CWOCN Sheila Guither has worked for the OSF Healthcare System since 1995. She is currently Manager of Practice Integration and WOCN Supervisor for OSF Home Care Services in Peoria, Ill. She oversees six certified WOCN nurses who work with the home care team and physicians to promote optimal wound outcomes. She received her bachelor of science in nursing degree from Mennonite College of Nursing and her WOCN training through Emory University. 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 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 Jackie Todd, MBA, BS, RN, CWCN, DAPWCA Jackie Todd is the Clinical Education Specialist for the Atlantic Division of Medline Industries, Inc. Jackie received her degree in nursing from Elizabethtown College in Elizabethtown, Kentucky and her degree in Healthcare Administration from Bryson University. Jackie has many years of experience in the acute care setting, serving as clinical coordinator of a wound care center in Kentucky. She developed protocols and procedures relating to wound care and has been extensively involved in continuous education program development. Daniel L. Young, PT, DPT Daniel L. Young is an assistant professor in the Department of Physical Therapy at the University of Nevada, Las Vegas. A few of his many research interests include factors affecting use of physical therapists for inpatient wound care, prevalence and incidence of nosocomial wounds in various acute care populations and factors related to the success of programs to address the nosocomial wounds. He received his Bachelor of Science degree in biology from Southern Utah University and he was awarded his doctor of physical therapy (DPT) degree from Creighton University.

Improving Quality of Care Based on CMS Guidelines 5

Healthy Skin Letter from the Editor


he last time I wrote the “letter from the editor,” I was in the thick of learning what it was like to be a “caregiver.” I will be honest with you … I have an incredible staff that writes, reviews and designs fantastic articles that resonate. They also “edit” my “letter from the editor,” but I unedited my last letter because I wanted you to know that what I experienced was real. I didn’t want what I wrote to sound too corporate. At that time I was caregiving for Doug, my husband of 30 years minus one week. Doug passed on May 22, 2012. I was there along with my youngest daughter. There were NO pressure ulcers, there were no reddened areas … we did a great job! Terry, our nurse aide, was a godsend. We worked together and I know we did more right than wrong as a team. Terry would give Doug a bed bath and I would take our dog, Gus, for a run. I had to do that to get out of the house and because I had made a promise that I would run the Chicago Marathon for our foundation, “Steps for Doug.” I’m 53, a terrible runner, but sometimes you just have to do something that is a stretch … because it gives you purpose and because it is not something inside your comfort zone. Maybe in the end being uncomfortable makes you feel better … like you did something and felt it. I’m only telling you this because many, many people feel as I do about making sure we do the best for those we love. NO regrets. When was the last time you stuck your neck out, got out of your comfort zone, and achieved something that made you proud. So many people tell me that they want to make a difference. Well, what’s stopping you? Look at the cover of this edition. It is not filled with WOCNs, VPs of nursing, chief nursing officers or directors of nursing. It is a representation of the “core” people who are on the front line, nursing aides. They are a part of our team. They are the people who have a direct influence on our patients and residents. They can make an experience great, or they can tell horror stories. They are who the families know and trust. How can we mentor them better? Can we separate ourselves from our profession just long enough to know the most important thing may not be whether we healed the sick but whether the “patient” experience was positive? I just had to say that. I tell my kids, you have to

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love each other. And, when I think of all the healthcare workers that interact with our patients, I think we should think of ourselves as a caring team and respect and work together with our teammates—Doctors, nurses, aides, therapists … everyone! You’ll want to check out this publication. There is something for everyone. New wound care dressings. Case studies of real experiences and what has worked. Strategies on how to send a patient from the hospital to an alternate care setting and making it work! Ways to reduce infections … sharing professionally … caring, from the inner workings of real people. We even included an article from a college intern, Azza, who worked at Medline this past summer. She went to India to be of service, because at such a young age she also had a yearning to make a difference. And then, I have to say … I love the breast cancer dancers … the thousands … no hundreds of thousands of people who are dancing around in pink gloves because they want to make a difference. The next time you think about making a difference, act on that thought. We circulate this publication to over 50,000 people. We have more than 300,000 people signed up on Medline University. Our articles are online. You are a part of a huge effort. Working together can change health care, make it more personal and feel a real reward for our efforts. Thanks for being on the team!!!

Sue MacInnes, RD Editor


The key to locking away exudate

• W  ound fluids—even heavy exudate­—are locked away to prevent maceration • N  on-adherent contact layer doesn’t stick—for greater patient comfort • F  ewer 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.

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

Join 300,000 other nurses for FREE CE courses at

Medline University

w 220 courses w 20 curriculum tracks w Interactive competencies w Flexible access: PC, iPhone, iPad w Free registration

Enroll for free at

Š2012 Medline Industries, Inc. Medline and Medline University are registered trademarks of Medline Industries, Inc.

Patient Safety News Study reveals link between tube feeding and pressure ulcer risk1

Possible connection between dental health and dementia4

A new study in the Archives of Internal Medicine reports that percutaneous endoscopic gastric (PEG) feeding tubes, long assumed to help bedridden dementia patients stave off or overcome pressure ulcers, may instead make the sores more likely to develop or not improve.

According to a study published in the August 2012 issue of the Journal of the American Geriatrics Society, there may be a relationship between poor dental health and dementia. A total of 5,468 seniors with an average age of 81 and no diagnosis of dementia were tracked for 18 years. Data was recorded regarding their dental habits including brushing, flossing, use of mouthwash and use of dentures. By the end of the study 21 percent of the study group had developed dementia.

The study, which involved thousands of nursing home patients, provides new information about the risks of feeding tube insertion in people with advanced cognitive impairment.

Men with poor chewing function due to lack of natural teeth had a 91 percent or higher risk of cognitive impairment. Women who did not brush their teeth daily had a 65 percent greater risk of dementia than women who brushed their teeth more than twice a day.

Among patients who did not start with an ulcer, 35.6 percent of those with a feeding tube ended up with at least one stage II ulcer, compared to only 19.8 percent of patients without a feeding tube. After statistical adjustment, the study found that the chance of getting an ulcer was 2.27 times higher for people with feeding tubes than for those without.

Men and women who showed the fewest signs of dementia had these dental health habits in common:

New CDC tools help nursing homes monitor and prevent HAIs2,3

To read the complete study, visit: http://onlinelibrary.wiley. com/doi/10.1111/j.1532-5415.2012.04064.x/abstract.

The Centers for Disease Control and Prevention (CDC) National Healthcare Safety Network (NHSN) has released a new tool for nursing homes and long-term care facilities to track healthcare-acquired infections (HAIs). Tracking these infections will help facilities identify problem areas and develop ways to prevent them. Infections that can be tracked include C. difficile, methicillin-resistant Staphylococcus aureus and urinary tract infections. The new tool also includes a component for facilities to track healthcare worker adherence to basic infection control procedures including hand hygiene and glove and gown use. To access or enroll visit LTC/index.html.

• Brushed their teeth several times per day • Had at least 16 natural teeth or wore dentures • Visited a dentist at least once a year

References 1. Feeding tubes may worsen pressure ulcer risk [press release]. Providence, RI: Brown University; May 14, 2012. Available at: 05/feeding. Accessed September 24, 2012. 2. LTC has new tools to monitor and prevent healthcare-acquired infections. Long-Term Living magazine website. September 18, 2012. Available at: 3. NHSN new capabilities for LTC, HCW flu vaccination, electronic submission of dialysis events. Infection Control Today magazine website. September 19, 2012. Available at: Accessed September 24, 2012. 4. Chew on this: dental health and senior dementia may be related. Long-Term Living magazine website. September 21, 2012. Available at: Accessed September 24, 2012.

Improving Quality of Care Based on CMS Guidelines 9

5 1

Strategies to Reduce Surgical Site Infection

Strict Asepsis When Changing Dressings Use sterile gloves, equipment, and sterile technique when changing dressings on any type of surgical incision and wash hands before and after dressing changes.1



Normothermia A threefold increase in the frequency of surgical site infections is reported in colorectal surgery patients who experience perioperative hypothermia (core body temperature less than 36°C [96.8°F]).2

Blood Glucose Control A 2010 study published in the Archives of Surgery found postoperative hyperglycemia to be the most important risk factor for surgical site infection in colorectal cancer and general surgery patients. Glucose levels higher than 110 mg/dL were associated with increasingly higher rates of post-surgical infection.3


Education Educate the patient and family regarding proper incision care and symptoms of surgical site infection.1

Decolonization 5 Nasal

Nasal decolonization of Staphylococcus aureus with Mupirocin ointment significantly reduces surgical site infections in patients who are nasal carriers.4

References 1. Gaudette V, ed. Clinical Care Improvement Strategies: Preventing Surgical Site Infections. Oakbrook Terrace, IL: Joint Commission on Accreditation of Healthcare Organizations; 2010. 2. Hart SR, Bordes B, Hart J, Corsino D, Harmon D. Unintended perioperative hypothermia. Ochsner Journal. 2011; 11(3): 259–270. Available at: http://www.ncbi.nlm. Accessed September 21, 2012.

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3. Postoperative high blood sugar associated with surgical site infection. Diabetes in Control website. Available at: Accessed September 21, 2012. 4. APIC Elimination Guide for the Prevention of Mediastinitis SSIs Following Cardiac Surgery, 2008. Available at: a994706c-8e6c-4807-b89a-6a7e6fb863dd/File/APIC-Mediastinitis-Elimination-Guide. pdf. Accessed September 21, 2012.


Peri-operative process change to reduce the risk of post-operative infection following orthopedic procedures Melissa Lingle, RN, CNOR

INTRODUCTION Of an estimated annual 500,000 hospital acquired infection events, from Centers for Disease Control and Prevention data, as many as 16% involved post-operative surgical site infections (SSI).1 Risk of post-operative surgical site infections following orthopedic surgery is increased for patients with body mass index (BMI) >25 and compounded for those with a co-morbidity of diabetes, both growing population segments. Post-operative infections involving multi-drug resistant organisms (i.e., MRSA) for “at risk” patients leads to increased morbidity-mortality, costly hospitalizations, corrective surgeries, long-term antibiotic therapy, extended recovery time, and delay in return to functional activities of daily living. Hip and knee arthroplasty procedures have a predicted occurrence rate of 1 to 2.4% and cost rom $60,000 to more than $100,000. The economic burden to U.S. hospitals from joint arthroplasty infections is projected to exceed $1.62 billion annually by 2020.2, 3, 4, 5, 6 The goal of this study was to assess the efficacy of interventions to reduce the risk of post-orthopedic procedure infections by using pre-operative chlorhexidine cleansing in tandem with postoperative silver-impregnated dressings.7, 8, 9


In 2011, an orthopedic surgical site infection reduction task force was created, responding to an unacceptably high rate of infection events. Preintervention orthopedic procedure data was collected for a seven-month period of 2011, including hip, knee, and shoulder arthroplasty surgeries, as well as laminectomy and discectomy procedures. Four hundred eighty eight (488) procedures were performed during the base line period with 18 infections identified — occurrence rate of 3.7%. Interventions were instituted in 2012 to reduce pre-operative resident and transient hopedic Procedure Totalsskin bacteria burden and post-operative incisional inoculation 498 of bacteria. Surgical sites were cleansed daily for three days with 2% chlorhexidine wipes prior to surgery and on the day of surgery. Surgical incisions 488 were then dressed for 10 days postoperatively with silver-impregnated, absorbent dressings*. The application of the wound dressings was initiated 2011 Procedures Procedures in the O.R. 2012 following incision closure and maintained during hospitalization.

Further wound coverage following discharge was accomplished with written instructions and replacement dressings sent with each patient. Data for the seven-month intervention period in 2012 were compiled to compare outcomes.

RESULTS Of 498 orthopedic procedures performed to date in 2012, following the interventions, only three infection events were identified – an occurrence rate reduction from 3.7% to 0.6%. It is to be noted that the post-operative silver-impregnated absorbent dressing protocol was not used in one infection occurrences. By any estimate, the interventions instituted to reduce surgical site infections following orthopedic procedures have been successful. Unwanted negative outcomes for patients have been avoided, the overall quality of care improved, and significant cost savings realized.

CONCLUSION The results of our interventional study will continue to be monitored. Initial discussion of the results seen to-date are leading to strong consideration of applying the same peri-operative process and silverimpregnated dressing principles to additional surgical procedures. Our experience over seven months confirms the efficacy of these efforts, noted in prior clinical literature.

Orthopedic Surgical Site Infection Reduc


Orthopedic Procedure Totals 496 494 492 490 488 486 484





2011 Procedures

2012 Procedures

Orthopedic Surgical Site Infection Reduction 20

1. S  SI case data reporting confirmed 18 20 unacceptable post-operative surgical 15 site infection rate (SSI) – comparison of performance for 10 orthopedic procedures to National Healthcare Safety Network (NHSN) 5 data base. 2. C  reation of surgical site infection 2011 SSI reduction task force with physician champion to lead multi-discipline team covering full peri-operative process.

2012 SSI

3. R  eview and discussion of pertinent literature for “best case” practices to reduce/prevent post-op. SSI events.


15 10 5


0 2011 SSI

4. F  ollow the “Action Plan” to either improve or adopt as new processes.

2012 SSI

Improving Quality of Care Based on CMS Guidelines 11

SPECIAL THANKS ACTION PLAN 1. Mandatory education for all O.R. staff : a. Fundamentals of aseptic technique b. Followed by “technique of the week” reinforcement 2. Pre-operative: a. Educate patients on SSI prevention. b. Screening, via nasal swabs, for MRSA with treatment as needed. c. Provision of 2% chlorhexidine wipes for patients to scrub operative site (i.e., knee, hip, shoulder) daily for 3 days immediately prior to arrival at hospital for surgery. d. Scrub operative site with 2% chlorhexidine wipes in pre-op holding prior to transport to O.R. 3. Intraoperative: a. Emphasis on strict adherence to aseptic technique by all staff b. Application of silver-impregnated absorbent dressing to incision site immediately post-closure 4. Post-operative: a. The silver-impregnated dressing is used for 10 days; placed post-operatively and changed at day 3. The second dressing remains in place for 7 days. If there is excessive bleeding noted, the wound is examined and the dressing is changed immediately. b. Upon discharge, additional silver-impregnated dressing accompanies patient to home, to home with home-health nursing, or rehabilitation facility with written application instructions to care provider. Goal is to of maintaining incision coverage for total of 10 days. 5. NOTE: a. P  hysician order sets changed in accordance with required ordering processes to above 6. DATA COLLECTION for all orthopedic procedures including: a. Pre-op scrubbing of operative site with chlorhexidine wipes b. Emphasis on strict adherence to aseptic technique by all staff

Thank you to the perioperative clinical team at Mercy Medical Center in Canton, OH, that made this study possible. Michael D. London, M.D. Board Certified Orthopedic Surgery Vicki Merrick, RN, CASC Administrative Director, Surgical Services Melissa Lingle, RN, CNOR Clinical Manager, Surgical Services Richard G. Lyon, BA, MA, JD, RN, CIC Infection Control Coordinator Sue Passmore, RN, BSN, CPAN, CCRN Director PACU/SDU/P.E.A.T. Judith A. Melnyk, RN, MSN, CNOR, CSPDT Team Leader Orthopedics/Neuro/Podiatry O.R. Allison R. Goshay, BSN, BS,RN Nursing Director 2Main, 4Main, IV Team References 1. Mangram  AJ, et al. Guideline for prevention of surgical site infection, 1999. Hospital Infection Control Practices Advisory Committee. 2. P  erencevich EN et al. Health and Economic Impact of Surgical Site Infections Diagnosed After Hospital Discharge. Emerging Infectious Diseases, CDC, Volume 9, Number 2, Feb., 2003. 3. A  nderson DJ et al. Strategies to Prevent Surgical Site Infections in Acute Care Hospitals. Infection Control-Hospital Epidemiology 2008; 29:551-561 4. K  urtz SM et al. Economic Burden of Periprosthetic Joint Infection in the United States. J. Arthroplasty, May 2, 2012. 5. S  tudy Identifies Risk Factors for Complications after Spine Surgery Information release per American Academy of Orthopaedic Surgeons, July 15, 2011. 6. G  uide to the Elimination of Orthopedic Surgical Site Infections, 2010, Association for Professionals in Infection Control and Epidemiology 7. Z  yweil MG. Advance pre-operative Chlorhexidine reduces the incidence of surgical site infection in knee arthroplasty. Int. Orthop. 2011 Jull; 35 (7): 1001-6. 8. T  urner MS et al. Effect of silverimpregnated wound covers on neurosurgical infection rates. Poster presentation 2009 AANS Annual Meeting, San Diego, CA.

c. Post closure application of silver-impregnated absorbent dressing

9. W  orking Toward Zero, Hospitalassociated infections are not tolerated. AORN Specialty Assemblies, October, 2005.

d. Silver-impregnated dressings remain in place while in hospital

* Optifoam® AG+ Post-Op Strip. Optifoam is a registered trademark of Medline Industries, Inc.

e. After discharge, silver-impregnated dressing remains in place for a total of 10 days.

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Reducing turnover can transform your workforce into a proud and professional CareForce.

Introducing new CE courses and an exclusive partnership with the National Association of Health Care Assistants (NAHCA) Lori Porter, co-founder and CEO of the National Association of Health Care Assistants (NAHCA) is motivating, educating and leading frontline excellence for CNAs.


Job opportunities jump 20 percent for Nursing Aides

In newly released courses hosted by Medline, and through an exclusive partnership with NAHCA, Lori emphasizes the importance of the role of the CNA through her personal experience. She also explains how team building in the long term care setting can improve staff morale and job satisfaction among CNAs, reduce turnover and, hence dramatically improve patient care.

Free courses at Creating a “CareForce” in Long Term Care for Administators CE pending approval Creating a “CareForce” in Long Term Care for Nurses 1 CE*

According to the Bureau of Labor Statistics, employment of nursing aides, orderlies, and attendants is expected to grow by 20 percent from 2010 to 2020, faster than the average for all occupations. However, high turnover is a challenge that skilled nursing facilities have faced for decades.

Creating a “CareForce” in Long Term Care for CNAs CNA Course Log in to your Medline University account to access the course. If you don’t currently have an account, go to create one in less than a minute and view the course.

* Course is approved for continuing education by the Florida Board of Nursing and the California Board of Registered Nursing.

Improving Quality of Care Based on CMS Guidelines 13

CNAs –

Proud, Trusted and Valued NAHCA’s 2012 National Conference June 27-28 • Oklahoma City

Leadership coach Joe Coury, owner of Effective Strategies, shares tips and encouragement.

More than 500 nursing aides from 23 states attended the National Association of Health Care Assistants (NAHCA) 2012 National Conference June 27-28 in Oklahoma City, Okla. Some drove as far as 1,000 miles one way just to participate, and many held fundraisers to raise the money to pay for at least some of their costs. Participants learned new skills, heard from inspirational presenters, and supported each other in their common profession. Crystal Salsbery, from Heritage Nursing and Rehab Center in Cedar Rapids, Iowa, summed it up best when she said, “The conference has energy, it’s inspirational. I just feel like I’m going to take so much back with me to my facility. It’s like a fire I didn’t have before...”

Get ready for next year NAHCA’s 2013 National Conference Renaissance Hotel and Convention Center, Oklahoma City June 19-20, 2013. For further details: Visit Call 1-800-784-6049

14 Healthy Skin

NAHCA members get pumped for next year’s conference.

Conference participants cheer for fellow nursing aides’ accomplishments and commitment to their profession.

I was a little burnt out before I came here. Very, very burnt out. But this conference has made me feel very proud of who I am, and I can’t wait

to take this message home. We are in this together.

Sherry Hill Westbrook Healthcare, Waurika, OK

Improving Quality of Care Based on CMS Guidelines 15

How Nursing Homes Can



Readmissions By Howard Gleckman, September 12, 2012

Too many people make the dangerous roundtrip from hospital to nursing facility and back again. These transfers may increase risks of delirium, medication errors, falls, and infection. There is no doubt that some patients die as a result of these transfers. And, they cost payers—Medicare, Medicaid, and private insurance—hundreds of millions of dollars each year. The real tragedy: By some estimates as many as 60 percent of these rehospitalizations are preventable. Now, nursing facilities and their partner hospitals are taking steps to cut these readmissions. In researching a new article for the journal Health Progress, published by the Catholic Health Assn., I had the chance to visit and talk to some of the nation’s most creative senior service providers. And I learned about both the challenge of reducing hospital readmissions and some cutting-edge solutions.

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Some of these initiatives are being driven by new Medicare rules. Among them: On October 1, Medicare will begin cutting payments to hospitals where too many patients are readmitted within 30 days of discharge. While the initial penalties are relatively modest and for only three conditions—heart failure, pneumonia, and heart attacks—they will gradually stiffen. And the new rules seem to have changed the mindset of many hospital administrators. Increasingly, hospitals are improving discharges and keeping a close eye on patients after they leave. No longer do they abandon their patients once they roll out the front door. Many are putting transition programs in place—often using care managers, social workers, or nurses—to assist patients who are discharged to home. And slowly, they are beginning to work more closely with nursing facilities—both skilled nursing and long-stay nursing homes—to reduce readmissions.

Supplied by Medline Industries, Inc.

At the same time, the best nursing facilities are making big changes of their own. They include: • Increasing staff and improving training for nurses and aides to help them identify and treat situations that can lead to hospitalizations. At Wheaton-Franciscan Healthcare in Wisconsin, nursing facility aides are trained to identify warning signs in heart failure patients and how to communicate what they see to staff nurses. These steps often prevent a crisis before it occurs. • Working with primary care doctors to encourage them to allow the nursing facility to treat many acute episodes rather than ordering patients back to the hospital. • Asking patients, residents, and their families whether they want to be hospitalized. When Hebrew Senior Life asked patients at its post-acute care nursing facility in Boston what they wanted, it discovered many preferred to stay where they were. Now, the HSL system is expanding this program to residents of its long-stay nursing home.

Steps such as these are especially important since more patients are receiving post-acute and post-surgical care in skilled nursing facilities rather than in hospitals themselves. It is important to keep in mind that reducing hospitalizations is not the goal: The real aim is improving the quality of care for these patients, many of whom need both medical care and personal assistance. Sometimes, they should be hospitalized. But often, they can receive the best care by staying where they are. The medical and long-term care systems have a long way to go in their efforts to improve care for the frail elderly and others with severe chronic disease. But finally they are beginning to take some big steps down that road.

From the Forbes Contributor Network and not necessarily the opinion of Forbes Media LLC. From, September 12, 2012. ©2012 All rights reserved. Used by permission and protected by the Copyright Laws of the United States. The printing, copying, redistribution, or retransmission of this Content without express written permission is prohibited.

Improving Quality of Care Based on CMS Guidelines 17

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.



Š2012 Medline Industries, Inc. abaqis is a registered trademark of Providigm, LLC. Medline is a registered trademark of Medline Industries, Inc.

Innovative Quality Assurance Tool Helps Nursing Home Achieve Citation-Free Survey by Julie Bingman, RN

abaqis® quality assurance system helps facility go from 10 citations to zero in less than a year Our Healthcare Facility Bothell Health Care is an independent skilled nursing facility nestled on nine plus majestic acres of forestland in Bothell, Washington, about 20 miles north of Seattle. Bothell Health Care (BHC) is licensed for 99 beds and offers short and longterm skilled services. We work closely with the residents and their families to develop individualized care plans to meet their unique needs and goals. BHC offers skilled nursing, rehabilitation therapy, medical supervision and assistance with activities of daily living. The goal of our specialized rehab program is to help residents attain their maximum potential and restore the functional abilities and confidence necessary for independent living.

Bothell Health Care believes that getting good survey results is a reflection of their overall ability to provide excellent care to its residents, patients and their families.

Our Challenge In August 2010, my husband and I leased and took over management of BHC. The facility’s most recent state survey, prior to our taking control, was in 2009 when it was surveyed with the new Quality Indicator Survey (QIS). The results from that survey were only fair. That was not how we wanted our facility to perform. Our goal, was to achieve results better than the state average and, ultimately, to receive a deficiency-free report. We believe that getting good survey results is a reflection of our overall ability to provide excellent care to our residents, patients and their families. We believe we can accomplish our goal by running a facility where our residents, patients and their families can communicate openly about their care. When they can tell us what they like or don’t like, we can alter their individual plan of care based on their suggestions together with our staff’s input. The QIS is based on resident input. Compared to the traditional survey, the QIS is designed to be more consistent and less subjective with a resident-centered/customer service focus. It encourages providers of skilled nursing to survey residents and

family members about the care they are receiving. The emphasis is on customer satisfaction. The big question is how to best prepare for the QIS and to efficiently and effectively survey our residents within our continuous quality improvement (CQI) process. In January 2011, we had our first QIS as new managers. The results were less than impressive – 10 citations, including three G citations.

The Solution My previous position was at a facility that was piloting a new quality assurance system called abaqis®. After one year of using abaqis, that facility was cited for four deficiencies, all at the D level, and none in nursing. That result was outstanding based on their prior history. That experience convinced me, that we should implement abaqis in our facility. What I like about abaqis is that it gives us the ability to immediately identify problem areas through patient, family and staff interviews. It then provides a road map to fix those problems quickly. In short, it can prevent small concerns from becoming big ones and can even eliminate potential survey citations.

Improving Quality of Care Based on CMS Guidelines 19

Success stories I called my sales representative at Medline, the health care supply company that exclusively provides abaqis, to coordinate a training session with Providigm (the developers of abaqis), for my department heads. Initially, some members of our staff of 120, including nurses and CNAs, were not sold on abaqis. It wasn’t too long, however, before they too saw how it could help them provide better care. One of the things they liked best about abaqis was that it replicated the methods and procedures of a QIS. When it was time to have our first QIS after implementing abaqis, the staff, residents and families found the surveyors asking the same questions abaqis was asking. Everyone knew the answers immediately, had already resolved the issues, or knew how to get the answers. It decreased the anxiety level of the survey process.

The abaqis quality assurance system gives long-term care facilities the ability to immediately identify problem areas through patient, family and staff interviews and then provides a road map to fix those problems quickly and efficiently.

We also liked that abaqis was a web-based program that uses the same calculations, thresholds and analysis as the QIS to quickly highlight residents at risk. When the information from a resident interview is loaded in the program, abaqis immediately directs us to areas of concern – or triggers – that the specific issue can develop into. For instance, if a resident voices a concern about food quality, abaqis will point out the root of the problem. It highlights areas that this issue could impact, i.e., nutritional, weight loss or dietary system failure.

abaqis Ensures Objectivity abaqis is easy to implement, with the interview process taking no more than 10 minutes per resident or family member. One of the major benefits abaqis provides is helping us objectively look at the services that we provide through the eyes of our residents. For example, we have an activities program that we are very proud of. We thought our residents would feel the same way. However, the feedback from our residents and family members (as conveyed through the abaqis reports) told us that our communication concerning what is available through the activities program was inadequate. It appeared that some residents did not know what activities were offered or when. Upon learning that our communication was insufficient, we quickly enacted a comprehensive communications plan that included: 1) telling residents and family members upon admission about the program; 2) distributing daily flyers to all residents highlighting the day’s activities, and 3) reminding residents frequently about what activities are available and when. Since putting these initiatives into action, we have received significantly improved reviews on our activities program.

20 Healthy Skin

The ultimate testament to abaqis’ effectiveness was this past January when we had another QIS. BHC received a zero deficiency survey, further validating that abaqis is making a major impact on our CQI process, and, more importantly, helping us provide superior quality care. Our staff was very excited about the results, which gave them confidence that they were doing the right things to meet the needs of our patients and family members.

New Readmissions Tracker In addition to how abaqis can help us with our CQI process, we are excited about the new readmissions tracker offered by abaqis. The innovative system will allow us to develop trend analysis and track hospital rates of return. We can market that information to our community hospitals and demonstrate that we are being proactive about helping them reduce their readmission rates. Hospitals are penalized for readmissions based on specific diagnosis; therefore, they want to partner with long-term care facilities that are proactive in eliminating and/or reducing readmissions.  About the Author Julie Bingman is an owner of Bothell Health Care, as well as the executive director and a registered nurse. She has had a life of service in skilled nursing facilities, starting as an aide in high school, then, after earning her RN, working up through the system, first as a nurse, then as director of nursing, followed by positions as executive director, regional director and divisional director. As a divisional director, Julie had responsibility for as many as 34 skilled nursing facilities in the Northwest.

abaqis® is a registered trademark of Providigm.

Winner of National HCA Innovators Award

Camera not included.

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 • D  rive 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. ©2012 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

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

How to Measure Ankle Brachial Index

by Jackie Todd MBA, BS, RN, CWCN, DAPWCA

Ankle Brachial Index (ABI) is a screening tool for significant arterial flow problems to the extremities. It compares blood flow pressure in the lower leg to blood flow pressure in the upper arm. Its purpose is to help identify patients for whom compression therapy would be appropriate. Please note that ABI screening may not be accurate in patients with diabetes whose veins are calcified.

Improving Quality of Care Based on CMS Guidelines 23

ABI Measurement Steps Use the ABI Worksheet on page 26 to record your results.

1 Have the patient remove their shoes and socks and lie in the supine position for at least 10 minutes prior to obtaining blood pressure readings.

Posterior tibial pulse

2 Apply blood pressure cuff snugly to the upper arm with the lower edge of the cuff one inch above the antecubital space. An appropriately sized cuff for the arm will usually be appropriately sized for the ankle. In the event that arm and ankle sizes are markedly different, choose cuff sizes that are appropriate for each site.

3 Apply an adequate amount of Doppler gel to the antecubital area.

4 Turn the Doppler on and place the probe on the antecubital space at approximately a 60-degree angle to the skin surface. Move the probe around until the clearest arterial pulse is heard, and keep the probe in that position while taking the blood pressure.

5 Inflate the blood pressure cuff to approximately 20 mmHg above the numerical reading where the pulse sounds cease.

6 Deflate the cuff atarateof2mmHgpersecond until the first arterial pulse sound is heard. Once the number is determined, deflate the cuff completely and record this systolic pressure. Remove the gel from the patient’s skin.

7  Apply the same blood pressure cuff to the ankle on the same side of the body.

8 Palpate the area around the medial malleolus to find the posterior tibial arterial pulse.

24 Healthy Skin

Dorsalis pedis

Helpful 9 If the pulse is palpable, apply Doppler gel to the area. If there is no palpable pulse, apply the Doppler gel, turn on the Doppler device and use the probe to find the pulse. Move it around the general area until the clearest arterial sound is heard. Keep the probe in that position and take the blood pressure by inflating the cuff and following the procedure as before when obtaining the arm pressure readings. Record the reading.

10 Doppler device obtain the systolic reading for the pos-


 ollow the manufacturer’s F instructions specific to the Doppler probe you are using. Be sure to use enough gel.

terior tibial reading.

11 Repeat the process for other side of body—brachial, posterior tibial and dorsalis pedis.

 se a cuff size that is right U for both the arms and ankles of the patient.

12 To determine the ABI, divide the higher of the two ankle pressures by the higher of the two brachial pressures. If only one ankle pressure could be obtained, use that one.

Ankle Pressure = ABI Brachial Pressure

Be aware that patients with diabetes commonly have calcified vessels and abnormally high ABIs.

Interpretation of Findings The following is a guide to interpreting the results of the ABI. >1.4 Indicates noncompressible vessels > 1.0 Normal < 0.9 LEAD < 0.6 to 0.8 Borderline <0.5 Severe ischemia *Note: In instances where only one extremity can be accessed, use the available systolic ankle/brachial reading for calculating ABI. Source: Wound, Ostomy and Continence Nursing Society. Ankle Brachial Index: Best Practice for Clinicians

Be sure you’re centered on the pulse when you take the reading; if you are off to the side the reading will be low.

In a small percentage of patients, one of the ankle pressures will be undetectable. Use the detectable pressure for calculating the ABI.  on’t be discouraged if D measuring the ABI seems slow or clumsy at first. Like any procedure the ABI becomes easier to do with practice.

Improving Quality of Care Based on CMS Guidelines 25

ABI = Ankle brachial index DP = Dorsalis Pedis PT = posterior tibial

ABI Worksheet

Highest Left Ankle Pressure = ABI Highest Left Brachial Pressure

Highest Right Ankle Pressure = ABI Highest Right Brachial Pressure

Right Arm BRACHIAL Systolic

Left Arm BRACHIAL Systolic



Right Ankle Systolic Pressure

Left Ankle Systolic Pressure

DP mHg


DP mHg


PT mHg


PT mHg


Right ABI = Ratio of Higher of the Right Ankle pressures (DP OR PT) Higher Arm Pressure (right or left arm) Left ABI = Ratio of Higher of the Left Ankle pressures (DP OR PT) Higher Arm Pressure (right or left arm)

26 Healthy Skin

mmHg = mmHg

mmHg = mmHg



Contact Layer Wound Dressing

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.

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

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

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

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

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

Š2012 Medline Industries, Inc. Versatel is a trademark and Medline is a registered trademark of Medline Industries, Inc.



Around Honey By Sheila Guither, RN, BSN, CWOCN and Sara Coverstone RN, BSN, CWOCN

28 Healthy Skin

CE Article Visit 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.

T hroughout ages ,





C 0B 40







The ancient Egyptian medical text known as the Edwin Smith Papyrus mentioned honey as part of the “Three Healing Gestures:” washing the wound; applying a “plaster” made from honey, animal fat, and vegetable fiber; and bandaging the wound – not much different from the treatments used today. The ancient Assyrians, Chinese, Greeks and Romans also prescribed honey for wounds.1,2


Hippocrates used honey to clean sores and ulcers, and to soften hard ulcers on the lips.3

some sting of





care .

medieval times A Medieval European medical text mentions honey for the removal of scabs.3

Over time, however, medical texts stopped mentioning honey. At first, this might have been because honey was such a standard treatment for infected wounds that it was not worth mentioning.3 By the advent of antibiotics in the 1940s, honey had been relegated to a place of an “old-world” modality. Honey was comparatively undependable because it was not sterile – the first gamma irradiation device was built in the 1960s. But now, with the increasing development of complex synthetic molecules and technologies, there is a renewed interest in more natural products, and there’s quite a buzz around honey.

Improving Quality of Care Based on CMS Guidelines 29

Types of Medical Honey Medical-grade honey is not the kind you buy in the grocery store. To help reduce risks of introducing microorganisms into wounds, such as Clostridium botulinum, Medical-grade honey is sterilized.4 Gamma irradiation is one of the most common methods of sterilizing honey because it’s very effective and it doesn’t affect the honey’s antibacterial activity.4

Manuka Honey – Making a Beeline for the Wound Care Arena Produced from honeybees that gather nectar from the flowers of the New Zealand Manuka tree (Leptospermum scoparium), Manuka honey undoubtedly has a role in modern wound management, primarily in helping to lower the pH of a wound.5

F lowers of

Other types of honey that are currently being researched for medical use include types from Indonesia and Australia.

has a role in

Honey in Wound Healing


the M anuka tree produce honey that modern wound 5

Topical application of honey to burns and wounds has been found to be effective in controlling infection and producing a clean granulating bed.6

Physiology of Wound Healing Hemostasis

Inflammatory phase

The initial response to any tissue interruption, hemostasis stops any hemorrhaging from occurring by forming a clot. The function of this clot is to provide a preliminary cellular matrix where responding cells can migrate.

This is the body’s acute response to a wound following hemostasis. Typically the wounded area and its surrounding tissue may be warm, painful, red or swollen. This is normal for this phase and does not necessarily indicate an infection.

30 Healthy Skin

Proliferative phase

This phase involves the formation of new blood vessels and the beginning of granulation, where the surface of the wound appears red and bumpy. As cells migrate across the wound bed (epithelialization), the wound begins to shrink.

Maturation phase – also called remodeling phase

In this final phase of wound healing, collagen is deposited, providing stiffness to the skin structures and cells and giving the skin its tensile strength.

Encouraging the Movement of Wound Fluid

Acidic pH

The human body naturally wants to achieve balance. When honey is introduced into a wound, it creates an imbalance of too much sugar. The body then generates fluid movement towards the wound site to dilute the sugar.

Helps reduce the surface area of a wound Honey typically has a low pH of between 3 and 4.7 This acidity helps to lower the wound’s pH level, which has been shown to significantly reduce the surface area of a wound.5 In one study, wounds with an alkaline pH above 8.0 increased in size by up to 122%, while those with a pH of less than 7.8 reduced in size.5

• Creates a moist healing environment – The osmolarity of honey draws fluid out from tissues to create a moist healing environment.6 • Promotes debridement – Along the way, this fluid picks up dead tissue and bacteria (exudate), which helps to naturally debride the wound. • Stimulates tissue growth – As part of debridement, honey promotes the formation of clean, healthy granulation tissue and epithelialization.7 This stimulation of tissue growth may be due to the hydrogen peroxide in honey.

Delivering Hydrogen Peroxide to the Wound The action of an enzyme (glucose oxidase) that the bees add to nectar produces the hydrogen peroxide in honey.7 Honey effectively provides a slow-release delivery of hydrogen peroxide because the enzyme producing it becomes active only when honey is diluted through fluid drawn from deep tissues. It continues to produce hydrogen peroxide at a steady rate for at least 24 hours.7 Helping to provide needed oxygen The low levels of hydrogen peroxide in honey stimulate angiogenesis – the formation and development of blood vessels. This helps provide the oxygen needed for tissue regeneration. Helps with the development of connective tissue Hydrogen peroxide also stimulates the growth of fibroblasts cells, which contribute to the formation of connective tissue fibers.

Helps inhibit damaging wound byproducts8 • MMPs – Acidic pH levels help inhibit matrix metalloproteinases (MMPs). These enzymes come from the wound itself as well as bacteria end-products and are damaging to a wound’s extracellular matrix (ECM) because they cleave proteins. • Ammonia – Ammonia is produced by the enzyme urease as well as by bacteria. It is toxic to wound tissue and also favors an alkaline rather than an acidic environment.

Antibacterial Effects Manuka honey, derived from the Manuka tree (Leptospermum scoparium) of New Zealand, is well-known for its pronounced antibacterial activity. In addition to hydrogen peroxide, Manuka honey also contains methylglyoxal, which provides antibacterial activity in concentrations of around 150 mg/kg.9

T he low p H level of honey helps lower a wound ’ s p H level , which significantly reduces the surface area of the wound .


Too much hydrogen peroxide can give rise to oxygen radicals, which can cause cellular and protein damage in tissue. Honey, however, contains antioxidants that help protect wound tissues from oxygen radicals.7

Improving Quality of Care Based on CMS Guidelines 31

T he antibacterial agents in honey are active against nearly all bacteria , including common resistant strains found today .

Photograph of right upper thigh. Taken just prior to initiation of manuka honey gel. There is significant slough present and no granulation.

Photograph taken approximately one month after beginning manuka honey gel. You can visualize the progress with more granulation and less slough.

Photograph taken approximately three months after beginning manuka honey gel. The wound size has decreased significantly.


Helps eliminate the most problematic bacteria The antibacterial agents in honey are active against nearly all bacteria, including common resistant strains found today.1 The University of Waikato in New Zealand found that 18 strains of methicillin-resistant Staphylococcus aureus (MRSA), and seven strains of vancomycin-sensitive Enterococcus faecalis were sensitive to Manuka and pasture honey (Cooper et al, 2002). All of these organisms came from infected wounds, and represent the most intractable categories of bacteria for clinicians dealing with wound infections.10 In vitro studies have shown honey to completely inhibit the major wound-infecting species of bacteria and a collection of strains of MRSA, Staphylococcus aureus, and Pseudomonas.7 In vivo studies include reports of infections being no longer present in wounds in 3-6 days, 7 days, and 7-10 days.7 Recent testing of Egyptian â&#x20AC;&#x153;wound salveâ&#x20AC;? revealed that it is strongly bacteriocidal against Escherichia coli and coliform bacteria.1 Works even when diluted The antibacterial activity of honey is not solely a result of its viscosity as many have presumed. Studies have shown honey to have an antibacterial effect even when diluted by wound fluid.1

Additional Benefits of Honey Photograph taken less than five months after beginning manuka honey gel. Complete closure noted.

Less Scarring When compared to silver sulphadiazine-impregnated gauze in the treatment of fresh, partial-thickness burns, honey was shown to produce an early subsidence of acute inflammatory changes, a lower incidence of hypertrophic scarring, and postburn contraction.7

Continued on page 34

32 Healthy Skin


Sterile Wound Dressings

The sweet solution for wound care 100% medical grade honey helps promote debridement, moist healing environment, reduced 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. 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.

TheraHoney™ Gel

For more details on the uses for TheraHoney or to arrange a trial, call your Medline representative or 1-800-MEDLINE.

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

TheraHoney™ Gauze

Frequently Asked Questions Q. Should honey be avoided if the patient has a known allergy to honey? A. Yes, though there have been no cases of allergic reactions to medical-grade honey reported to the FDA to date. Q. Can honey wound care products be used on diabetic patients? A. Diabetic patients can use honey wound care products. Normal monitoring of blood glucose levels should continue.

Controls Odor The antibacterial action in honey helps control odors.7 Ammonia, amines and sulfur compounds cause the malodor in wounds. These compounds are produced when infecting bacteria metabolize amino acids from proteins in the wound’s serum and necrotic tissue. With honey, the infecting bacteria metabolize glucose instead of the amino acids, which produces lactic acid instead of malodorous compounds.7

Reduces Pain By reducing inflammation and edema, honey helps reduce pain and provides a soothing effect when applied to wounds.7

Improves Circulation Applying honey decreases skin elasticity and may increase tissue oxygenation. The anti-inflammatory action reduces pressure in the interstitial fluid and allows for improved circulation.7

Here to Stay After a time of neglect, honey appears to be making a comeback, and the clinical community is recognizing the benefits of honey. As the concentrated juice from plants, honey naturally contains many nutrients and herbal chemicals that are helpful in the care of wounds. Honey is finally earning its rightful place as a viable option for safe and effective wound care.

34 Healthy Skin

References: 1. T  readwell T. Honey’s Healing History. [ITAL] Wounds. September 4, 2008. Available at: Accessed August 17, 2012. 2. Z  umla A, Lulat A. Honey – a remedy rediscovered. Journal of the Royal Society of Medicine. 1989;82:384-385. Available at: articles/PMC1292197/pdf/jrsocmed00148-0008.pdf. Accessed August 17, 2012. 3. M  olan PC. Debridement of wounds with honey. Journal of Wound Technology. 2009;5:12-17 4. M  icrobiological quality control for medical grade honey. Activon Medical Manuka Honey website. Available at: microbiological_quality.php. Accessed August 20, 2012. 5. Gethin GT, Cowman S, Conroy RM. The impact of Manuka honey dressings on the surface pH of chronic wounds. International Wound Journal. 2008;5(2):185-194. 6. B  enhanifia MB, Boukraa L, Hammoudi SM, Sulaiman SA, Manivannon L. Recent Patents on Topical Application of Honey in Wound and Burn Management. Recent Patents on Inflamation & Allergy Drug discovery. 2011;5:81-86. 7. M  olan PC. The role of honey in the management of wounds. Journal of Wound Care. 1999;8(8):415-418. 8. G  ethin G. The significance of surface pH in chronic wounds. Wound Healing Science. 2007;3(3):52-56. Available at: content_124.pdf. Accessed August 21, 2012. 9. A  trott J, Henle T. Methylglyoxal in Manuka Honey – Correlation with Antibacterial Properties. Czech J. Food Sci. 2009;27:S163-S165. 10. H  oney: A modern wound management product. Activon Medical Manuka Honey website. Available at: Accessed August 17, 2012.


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 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.

IncontinenceAssociated Dermatitis or

Pressure Ulcer? When wiping and cleaning become a reportable event

36 Healthy Skin

Although incontinence-associated dermatitis (IAD) and pressure ulcers are clinically and pathologically different conditions, differentiating them from each other remains a major challenge for clinicians.1 And yet accurate identification is even more critical now that development of pressure ulcers affects Medicare reimbursement. 46.4% urinary

46.4% urinary

29.5% fecal

25.6% urinary

Incontinence prevalence among Incontinence nursing home residents prevalence 1

sample size: among nursing 279,191 nursing home residents1 home residents sample size: 279,191 nursing home residents

& fecal 29.5% 25.6% fecal

urinary & fecal

In a sample of 279,191 nursing home residents, the prevalence of urinary incontinence was 46.4 percent, fecal incontinence was 29.5 percent and a combination of urinary and fecal incontinence was 25.6 percent.2 In other words, a significant number of nursing home residents have the potential for developing IAD.

One study measured the prevalence of IAD and perineal skin injury in three acute care facilities in the United States and reported that among patients with incontinence, 33 33% IAD & pressure percent had a pressure ulcer, 27 percent had perineal ulcer IAD and 18 percent had fungal infections. 33% IAD & pressureskin injury Recent literature suggests that many wounds 18% incontinent ulcer among perineal fungal patients at acute skin injury classified as stage I and II pressure ulcers may infection care facilties3 be attributable to IAD and not pressure. Also, 27% 18% among incontinent sample size: fungalIAD patients at acutethe presence of moisture-associated skin 3 acute care facilities infection care facilties3 damage may increase pressure ulcer risk.3 27% IAD sample size: 3 acute care facilities

Improving ImprovingQuality QualityofofCare CareBased Basedon onCMS CMSGuidelines Guidelines37 37

References 1. Doughty D, Junkin J, Kurz P, et al. Incontinence-associated dermatitis: consensus statements, evidence-based guidelines for prevention and treatment, and current challenges. Journal of Wound, Ostomy, and Continence Nursing. 2012; 39(3):303-315. 2. Nix D, Ermer-Seltun J. A review of perineal skin care protocols and skin barrier product use. Ostomy Wound Management. 2004; 50(12):59-67.

Unlike pressure ulcers, areas of the skin affected by IAD have more irregular, diffuse margins in the locations exposed to urine and feces.

IAD has been defined as a “form of moisture-associated skin damage ... associated with changes in the skin’s moisture barrier function, erythema (redness), rash or vesiculation (blistering), and adverse symptoms such as pain or itching.”3 It involves inflammation of the skin in the genitals, buttocks or upper thighs associated with either ongoing or recent urinary and/or fecal incontinence.3 Unlike pressure ulcers, areas of the skin affected by IAD have more irregular, diffuse margins in the locations exposed to urine and feces. Another difference between IAD and pressure ulcers is that IAD will not cause a fullthickness skin injury (unless complicated by infection).4 In addition, whereas incontinence-associated dermatitis consists of lesions that develop from the top down, first presenting as reddened intact skin, and then progressing to blistering and loss of epidermal tissue; pressure ulcers develop from the bottom up, developing inside deep tissue and progressing toward the surface of the skin.1

38 Healthy Skin

3. Long MA, Reed LA, Dunning K, Ying J. Incontinence-associated dermatitis in a long-term acute care facility. Journal of Wound, Ostomy, and Continence Nursing. 2012; 39(3):318-327. 4. Junkin J, Selekof JL. Beyond “diaper rash”: incontinence-associated dermatitis: does it have you seeing red? Nursing. 2008; 38(11): 56hn1-56hn10. 5. Kehoe K. Strategies and interventions for prevention and management of incontinence-associated dermatitis. Medline University website. Available at: Accessed September 25, 2012.

Methods for preventing incontinenceassociated dermatitis (IAD)   1 Identify and treat the cause of incontinence. Until incontinence is resolved, the skin must be consistently cared for and protected from excess moisture and bacteria.4  2 After determining that IAD is present or that the patient is at risk for IAD, regularly check the skin. Watch for skin color or integrity changes each time care is provided (i.e, when turning the patient or cleansing the skin).4  3 For someone who’s incontinent, gently cleanse the skin with a product that is pH-balanced (4.5 - 5.5 pH of normal skin).

Accurate Classification of IAD Lesions and Pressure Ulcers Many patients who are at risk for IAD are also at risk for pressure ulcers, and many of these patients have both conditions. Here are some ways to tell the difference between the two.5 Pressure ulcer



Non-blanchable erythema of intact skin (stage I)

Blanchable erythema of intact skin response

Underlying factors

Inflammatory response to ischemic damage of subdermal tissues over a bony prominence

Inflammatory response to urine or feces exposure confined to the epidermis or dermis


Over bony prominences: coccyx, sacrum, ischium. Also under tubes and other devices

Perineum, buttocks, inner thighs, groin, lower abdominal folds and any areas exposed to urine and feces


Absent to severe

Mild to severe


Pink, red, yellow, tan, gray, green, brown, black

Pink or red


Sometimes (stage II)


Additional characteristics

Intact discoloration, partial thickness, full thickness

Rash, denudement, erosion, maceration

 4 Regular cleansing is crucial to avoid the growth of high levels of Staphylococcus aureus or Candida albicans, which contribute to the development and severity of IAD.  5 To avoid friction, donâ&#x20AC;&#x2122;t scrub while cleansing. Use pHbalanced cleansers; not harsh soaps. Pre-moistened wipes are also available.  6 Use emollients and skin agents that soften and soothe but that donâ&#x20AC;&#x2122;t add excess water to the skin. Incontinent patients already have overhydrated skin that is possibly damaged from exposure to urine or feces (liquid stool is especially damaging to the skin) and possibly sweat. Avoid products with strong concentrations of humectants such as urea, glycerin, alpha hydroxyl acids, and lactic acid, which retain water in the skin.1, 4

 7 Apply a protectant to the skin (for example, dimethicone, liquid clear film barrier, or zinc oxide) to prevent injury from future episodes of incontinence. Applying protectants may also assist in preventing other skin injuries such as pressure ulcers and skin tears.1, 4  8 Provide proper positioning by developing an individualized turning program for high-risk patients with limited mobility.  Although many efforts are being made to reduce pressure ulcer rates, bedside practice in the area of incontinence care has been slow to change despite the growing body of knowledge that IAD prevention is an effective way to reduce pressure ulcer incidence.4

Improving Quality of Care Based on CMS Guidelines 39

Wipe Out

Skin Breakdown

Aloetouch Cleansing Wipes ®

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

Aloetouch wipes are available in three types:

• A  loetouch Protect – 3.2% Dimethicone skin protectant which leaves a breathable barrier on the skin with every wipe.

• A  loetouch Select – pH balanced, hypoallergenic wipes that moisturize with aloe as they cleanse the skin.

• A  loetouch – There’s value in these full-sized, economical wipes, providing aloe-enriched cleansing.

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.

Contact your Medline sales rep or call 1-800-MEDLINE to discover how Aloetouch cleansing wipes can help treat and prevent IAD at your facility.

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

Evidence for the Validity of the Medline Pressure Ulcer Prevention Program (mPUPP) by Daniel L Young, Debashish Chakravarthy, Kiarash Mirkia

ABSTRACT Introduction: Pressure ulcers (PrU) develop on 1 million people every year and the costs for treating this problem approach $11 billion. While not all PrUs can be prevented, most can be and Medicare has begun to deny payment for PrUs that develop in hospitals. A pressure ulcer prevention program has been developed and the researchers sought to evaluate the impact of the program. Methods: The program was based on previously published evidence that clinician involvement, patient, family, and caregiver education, and good skin care are important components of a successful prevention program. All facilities participating in the program, for which pre and post program PrU incidence data were available, were included in the study. Pre-program PrU incidence data were collected from 99 facilities and compared to post-program PrU incidence data. Results: The mean pre-program PrU incidence was 6.18 (range 38 to 0) and the mean post program incidence was 2.82 (range 24 to 0), yielding an average improvement for the entire sample of 3.36 (range -8 to 34), a 54% improvement. This difference was statistically significant, t (98) = 6.349, p<.001. No statistical differences between PrU rates or changes in facilities of different types or sizes were observed. Conclusions: The program demonstrated validity by reducing PrU incidence in facilities of different types. Whether this improvement is different from other pressure ulcer reduction programs is not known.

Daniel L Young, PT, DPT, Corresponding author, Assistant Professor, Department of Physical Therapy, School of Allied Health Sciences, University of Nevada, Las Vegas, 4505 S. Maryland Parkway Box 453029, Las Vegas, NV 891543029. Phone: 702-895-2704, Fax: 702-895-4770, email: Debashish Chakravarthy, PhD, Medline Industries, Inc., Mundelein,Illinois. Kiarash Mirkia, MD, FACS, Sunrise Hospital, Las Vegas, NV. Medline Industries, Inc provided financial support for this study and the writing of the manuscript

Improving Quality of Care Based on CMS Guidelines 41

Pressure Ulcers (PrU) have long been a problem for individuals and institutions caring for people with disability, illness, or advanced age. Recent information indicates that more than 1 million people develop a PrU every year and that the cost of care for these wounds exceeds $11 billion.1-4 The magnitude of the problem has attracted the attention of the largest payer for the care of these people, Medicare. With enforcement of the Deficit Reduction Act (DRA) of 2005 beginning October 1, 2008, hospitals can no longer collect the additional payment for PrUs acquired in the hospital.5 The new Patient Protection and Affordable Care Act signed into law March 23, 2010 stipulates that Medicaid will not pay for stage III or IV PrU if they are hospital acquired.6 This means that unless a PrU is documented as being present when the patient is admitted, the hospital will care for the new wound without payment from patients insured by either Medicare or Medicaid.

facility PrU reduction program with a specific component for heel ulcers, like other programs, combined caregiver education, pressure reduction equipment, skin care products, and focused documentation to reduce its incidence.14 In addition to the elderly and heel ulcers, young injured war veterans have been studied for their PrU risk and incidence reduction program components.15 An increasing level of consensus in the literature demonstrates that clinician led efforts, education, and evidence based practice for risk assessment and prevention are more successful in terms of patient outcomes.16-18 The NDNQI (established by the American Nurses Association (ANA) in 1998) has established an effective training program for nurses on pressure ulcers to combat poor knowledge among staff nurses regarding PrU identification, staging, and prevention.19 A connection between PrU risk (as seen with a drop in Braden score) and the implementation of the Registered Nurses Intervention Checklist interventions has also been shown.20 In addition, involvement of hospital management may improve outcomes in pressure ulcer reduction programs.21 Despite all of the effort and attention, Jankowski highlights that deficiencies exist in: â&#x20AC;&#x153;lack of physician involvement; limited involvement of unlicensed nursing staff; lack of plan for communicating at-risk status; and limited quality improvement evaluations of bedside practices.â&#x20AC;?22 This clearly indicates that more work needs to be done in the area of PrU reduction.

Implementation of a comprehensive pressure ulcer prevention program can lead to significant reductions in PrU incidence.

With this change in reimbursement policy, and the published knowledge that the cost of PrU prevention is more cost effective than standard care,7 facilities are looking for effective ways to reduce PrU incidence. Several examples from the published literature highlight these efforts and their findings or effectiveness. Sharkey et. al., describe a program implemented in long term care facilities to reduce PrU incidence. The program focuses on using certified nursing assistant observations through electronic documentation to generate reports that could be used to drive interventions and highlight at risk patients.8,9 An earlier version of this program was described the year before.10 A hospital group in Minnesota implemented a program involving education of providers and patients, point-of-care resources, and nutrition assessment.11 A Seattle hospital improved its system for monitoring PrU incidence, implemented monthly multidisciplinary reviews on hospital acquired PrUs, and applied an algorithm to determine whether the PrUs were avoidable.12 PrU prevention efforts for specific populations or vulnerable areas of the body have been given special attention in the literature. In the acute orthopedic patient population, efforts included a simple foam wedge after getting input from stakeholders and had positive results in heel ulcer elimination.13 A long term care

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While not all PrUs are avoidable,23 implementation of a comprehensive pressure ulcer prevention program can lead to significant reductions in PrU incidence. In addition, changes to existing PrU reduction programs can improve their effectiveness and specific skin care products may contribute to this improvement.24 This growing need for improved prevention of facility acquired PrU and the growing evidence of comprehensive program success has led to the development of a program by Medline Industries, Inc., Medline Pressure Ulcer Prevention Program (mPUPP). This paper will describe the mPUPP and provide evidence for the validity of the program to effect PrU reduction among participating facilities.

Users click here to choose the Pressure Ulcer Prevention Program. Medline University offers several other clinical programs as well.

Figure 1. Screenshot of the Medline University homepage for the Pressure Ulcer Prevention Program

Program participants can show their knowledge with hands-on virtual competency.

Users choose from an array of course materials on pressure ulcers.

Improving Quality of Care Based on CMS Guidelines 43

MEDLINE PRESSURE ULCER PREVENTION PROGRAM The mPUPP program is organized and administered by a program team. This team includes three groups of people. Two program administrators report to executive level company leaders. These administrators are responsible for program development and oversight. They track program participants, oversee marketing materials, and coordinate the efforts of others working to administer the program. The second group in the program team is the program service representatives. They are responsible for data collection and follow up with participating facilities on a quarterly basis to review progress and provide support. These individuals work with local representatives, the third group, who identify facilities that may benefit from mPUPP and ensure they have the support they need. The mPUPP team contacts each facility at the initiation of the program to provide orientation and explanation of all aspects of the program. During this contact, usually via phone call, they also collect baseline data on the PrU incidence in these facilities. Currently, the program is expanding its online resources for facilities to access interactive quarterly reports. These reports will allow the facility to view progress, track improvements, and quantify savings that come from PrU reductions. The second piece of the program is education for caregivers who work for the facility and for families. All participating facilities have access to an education resource at www. (MedlineU). MedlineU is a web-based suite of interactive educational material. Figure 1 shows the home page for material specific to the mPUPP while Figure 2 shows how the educational courses related to PrU are presented. MedlineU combines foundational information about integument anatomy and physiology, PrU development and healing with evidence based guidelines on risk assessment and treatment interventions. Figure 3 is a screen shot of one of the interactive course modules on PrU risk assessment. Assessment pieces are also available to allow individuals and facilities track and measure the change in knowledge realized through use of the individual modules. Figure 4 illustrates an assessment page on

which the learner can respond to a specific question. Family education materials can be provided by clinicians to families to support the prevention efforts of the facility or to guide families as they take their loved ones home. Beginning in the summer of 2012 these materials will also be available through MedlineU. The third aspect to the program is the product component. An advanced line of skin care products for cleaning, moisturizing and barrier protection, as well as pads and briefs for incontinence management have been made an integral part of the mPUPP program.* These products support other caregiver interventions like positioning, mobility training, attention to the choice of support surfaces, and scheduled voiding. These products have been designed to ensure integument integrity by maintaining appropriate moisture balance through bathing and cleansing and episodes of incontinence. Clinical representatives involved with these products have extensive knowledge of the material science and clinical benefits of these products, and are trained on the evidence base associated with the clinical use of these products in various settings. Clinicians involved in PUPP can also help facilities select product lines that synergistically support the educational components of mPUPP. Even with the evidence supporting the components of the mPUPP, clear and objective analysis of the program was desired to validate the impact on PrU reduction. With IRB approval, deidentified data on all mPUPP program facilities for which preprogram and post-program PrU incidence data were available were provided to the researchers for further analysis. Thus, the researchers were unaware of facility names and locations. Interim data provided for a snapshot analysis resulting in a sample of 99 facilities further broken down into 55 hospitals and 44 nursing homes. The mean number of beds for the sample was 166 and the median was 120. All facilities had fully implemented the educational components of the program and any product use changes prior to data

The extensive line of competitive skin care products available with the custom mPUPP may be one of the major reasons why this program has been remarkably successful.

44 Healthy Skin

Figure 2. Screenshot of the Medline University pressure ulcer prevention course list (not all courses are visible)

In addition to pressure ulcer prevention, courses are available on a wide variety of clinical topics.

Improving Quality of Care Based on CMS Guidelines 45

Figure 3. Screenshot of a Medline University interactive course on pressure ulcer risk assessment

Users maneuver through this virtual patient room. As questions appear at the top of the screen, users click on the object that answers the question.

Figure 4. Screenshot of a Medline University pressure ulcer prevention assessment question

46 Healthy Skin

collection. PrU incidence values represent the number of PrUs present in the facility for one month. The PrU values came from the most recent full month prior to program implementation and the most recent full month prior to the call to collect the PrU numbers. All programs self counted and reported these PrU numbers. Comparisons were then made among facilities of different types (skilled care and hospital) using the pre and post PrU incidence data.

Figure 6. Pre Program Pressure Ulcers

RESULTS For all facilities combined, the mean pre-program PrU incidence was 6.18 (range 38 to 0) and the mean postprogram incidence was 2.82 (range 24 to 0), yielding an average improvement for the entire sample of 3.36 (range -8 to 34), which is more than a 54% improvement (see Figure 5). A paired samples t-test comparing the pre (mean = 6.18, SD = 6.88) to post (mean = 2.82, SD = 4.10) PrU incidence indicated a statistically significant difference between the means, t(98) = 6.349, p<.001.

Figure 7. Post Program Pressure Ulcers

Comparisons between nursing homes and hospitals revealed no differences. Specifically, no difference was found between the pre-program PrU incidence for nursing homes (mean = 5.84, SD = 5.25) and hospitals (mean = 6.45, SD = 7.98), F(1,97)=.193, p=.661 (Figure 6); no difference between postprogram PrU incidence for nursing homes (mean = 3.05, SD = 3.84) and hospitals (mean = 2.64, SD = 4.33), F(1,97)=.241, p=.624 (Figure 7); and finally no difference between the change in PrU incidence for nursing homes (mean = 2.80, SD = 4.26) and hospitals (mean = 3.82, SD = 5.96), F(1,97)=.919, p=.340 (Figure 8).

Figure 5. Graphs represent 54% improvement after implementing Medlineâ&#x20AC;&#x2122;s Pressure Ulcer Prevention Program

Figure 8. Change in Pressure Ulcers

Continued on page 49

Improving Quality of Care Based on CMS Guidelines 47

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.

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

This study provides compelling evidence that significant pressure ulcer reductions can be facilitated by Medline’s Pressure Ulcer Prevention Program.

The results of this study indicate that the mPUPP can produce significant reductions in PrU rates for both hospitals and nursing homes. While the mean change was larger for hospitals, the statistical analysis did not indicate that this difference was greater than chance alone could have produced. The nonsignificant results of the comparisons between the hospitals and nursing homes provide evidence for the validity of this study as well as the ability of the program to succeed in different settings. If the pre or post program PrU numbers had been significantly different, any comparisons involving both hospitals and nursing homes together would affect the impact of the other. Because no difference was observed, the data can be confidently analyzed in the aggregate. It also supports the value of the individualized approach to program implementation, as the same overall mPUPP can be just as effective for hospitals and nursing homes. Several aspects of the mPUPP have good support in the literature. Clinician-focused education is one component of several other successful PrU reduction programs.8,9,11-14,16-19 In mPUPP, clinician education is provided through MedlineU and adds the ability for facilities and clinicians to quantify their knowledge and learning. Specific attention to skin care and even specific products can help in PrU prevention.24 The extensive line of competitive skin care products available with the custom mPUPP may be one of the major reasons why this program has been remarkably successful. Similar to other studies in the field this work had some limitations. The PrU data for each facility were self reported and bias might have influenced the reporting. However, this collection method was consistent across facilities and is used by regulatory agencies for quality monitoring. This study evaluated 99 facilities using mPUPP, but did not compare these to facilities using any other PrU reduction activities or programs and such comparison would strengthen the analysis. In addition, over 700 facilities today are at some stage of mPUPP implementation. Some were just learning

about the program, some were still working to get all clinical staff through the MedlineU education modules and complete the assessments there, and others had not been participating long enough to have 30 days of post program PrU incidence data. Furthermore not all of these facilities could be included in this study because they had not provided information about their PrU incidence before or after and they may have results quite different than what has been found in our sample.

CONCLUSIONS The mPUPP is effective in reducing PrU incidence in participating hospitals. This effect may be the result of a combination of program features such as individualized assessment of facility needs, caregiver education, and the use of specific skin and wound care products. Further work is needed to quantify the impact of these individual program elements and to make comparison between this and other PrU reduction programs. Despite these unanswered questions this study provides compelling evidence that significant PrU reductions can be facilitated by mPUPP.* The core consumable or disposable products involved in the mPUPP program are the Remedy® skin care line and the Ultrasorbs® brand of pads and briefs. References 1. Cuddigan J, Berlowitz D, Ayello E. Pressure ulcers in america: Prevalence, incidence, and implications for the future. an executive summary of the national pressure ulcer advisory panel monograph. Adv Skin Wound Care. 2001;14(4):208215. Accessed 2/2/2011. 2. Kuhn BA, Coulter SJ. Balancing the pressure ulcer cost and quality equation. Nurs Econ. 1992;10(5):353-359. Accessed 12/30/2010. 3. Whittington KT, Briones R. National prevalence and incidence study: 6-year sequential acute care data Adv Skin Wound Care. 2004;17(9):490-494. 4. Reddy M, Gill SS,Rochon PA. Preventing pressure ulcers: A systematic review. JAMA. 2006;296(8):974-984. 5. Overview hospital-acquired conditions (present on admission indicator). http:// Accessed 2/2/2011. 6. Medicaid program; payment adjustment for provider-... [fed regist. 2011] -PubMed result Accessed 7/13/2011, 2011.

Improving Quality of Care Based on CMS Guidelines 49

7. Padula WV, Mishra MK, Makic MB, Sullivan PW. Improving the quality of pressure ulcer care with prevention: A cost-effectiveness analysis Med Care. 2011;49(4):385-392.

16. Young J, Ernsting M, Kehoe A, Holmes K. Results of a clinician-led evidence-based task force initiative relating to pressure ulcer risk assessment and prevention J Wound Ostomy Continence Nurs. 2010;37(5):495-503.

8. On-time quality improvement for long-term care: Download information http://www. Accessed 7/13/2011.

17. van Gaal BG, Schoonhoven L, Hulscher ME, et al. The design of the SAFE or SORRY? study: A cluster randomised trial on the development and testing of an evidence based inpatient safety program for the prevention of adverse events BMC Health Serv Res. 2009;9:58.

9. Sharkey S, Hudak S, Horn SD, Spector W. Leveraging certified nursing assistant documentation and knowledge to improve clinical decision making: The on-time quality improvement program to prevent pressure ulcers Adv Skin Wound Care. 2011;24(4):182-8; quiz 188-90. 10. Horn SD, Sharkey SS, Hudak S, Gassaway J, James R, Spector W. Pressure ulcer prevention in long term-care facilities: A pilot study implementing standardized nurse aide documentation and feedback reports Adv Skin Wound Care. 2010;23(3):120-131. 11. Sendelbach S, Zink M, Peterson J. Decreasing pressure ulcers across a healthcare system: Moving beneath the tip of the iceberg. J Nurs. Adm. 2011;41(2):84-89. 12. Z  aratkiewicz S, Whitney JD, Lowe JR, Taylor S, O’Donnell F, Minton-Foltz P. Development and implementation of a hospital-acquired pressure ulcer incidence tracking system and algorithm J Healthc Qual. 2010;32(6):44-51. 13. Campbell KE, Woodbury MG, Houghton PE. Implementation of best practice in the prevention of heel pressure ulcers in the acute orthopedic population. Int Wound J. 2010;7(1):28-40 14. Lyman V. Successful heel pressure ulcer prevention program in a long-term care setting. J Wound Ostomy Continence Nurs. 2009;36(6):616-621. 15.  Crumbley DR, Kane MA. Development of an evidence-based pressure ulcer program at the national naval medical center: Nurses’ role in risk factor assessment, prevention, and intervention among young service members returning from OIF/OEF Nurs Clin North Am. 2010;45(2):153-168.

18. Blankenship JS, Denby AS. Empowering UAP to champion pressure ulcer prevention Nursing. 2010;40(8):12-13. 19. Bergquist-Beringer S, Davidson J, Agosto C, et al. Evaluation of the national database of nursing quality indicators (NDNQI) training program on pressure ulcers J Contin Educ Nurs. 2009;40(6):252-8. 20. Magnan MA, Maklebust J. Braden scale risk assessments and pressure ulcer prevention planning: What’s the connection? J Wound Ostomy Continence Nurs. 2009;36(6):622-634. 21.  Bales I, Padwojski A. Reaching for the moon: Achieving zero pressure ulcer prevalence J Wound Care. 2009;18(4):137-144. 22. Jankowski IM, Nadzam DM. Identifying gaps, barriers, and solutions in implementing pressure ulcer prevention programs Jt Comm J Qual Patient Saf. 2011;37(6):253-264. 23. National Pressure Ulcer Advisory Panel (NPUAP). Not all pressure ulcers are avoidable. http://npuap. org/A_UA%20Press%20Release.pdf. Accessed 7/13/2011. 24. Shannon RJ, Coombs M, Chakravarthy D. Reducing hospital-acquired pressure ulcers with a silicone-based dermal nourishing emollient-associated skincare regimen. Adv Skin Wound Care. 2009;22(10):461-467. JACPT. Volume 3, Number 2. 2012. Reprinted with permission.

A Better Position for Learning Learn anytime, anywhere A new Medline University course “Proper Perioperative Positioning to Prevent Patient Injuries” Now with an interactive virtual simulation! Makes online learning more real.

50 Healthy Skin

Get started at

Gentle Enough for Skin of All Ages. Medline Remedy. The Remedies for Sensitive Skin • Hydrating Cleansers, gentle, phospholipid-based and sulfate-free; available as a spray, foam or gel • Hydraguard, a 24% silicone cream that is highly moisture repellent and smooths gently on fragile skin

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.

• Nourishing Skin Cream, a blend of emollients including safflower oleosomes, all-natural oils, plant extracts • Z-Guard Protectant Paste, formulated with pure white petrolatum and zinc oxide and without potential irritants • Antifungal Clear Ointment, with 2% miconazole nitrate in a clear petrolatum base amended with soothing botanicals. (Not for use on scalp, nails or on children under 2 years of age.)

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Ask for a sample. Start with a trial. Change for the better.

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

Celebrating Success

in Pressure Ulcer Prevention DeKalb Medical Center, Decatur, GA Fran Perren, RN, BSW, CWOCN, director of wound care services at DeKalb Medical Center, won the VHA Most Improved Clinical Leadership Award in October 2009 for a series of initiatives that lowered pressure ulcers at her hospital from 2008-2009.

2. Audit and data collection tools. Fran developed a series of tools to perform monthly audits of patients with wounds, those with catheters and those at risk for pressure ulcers and to collect data regarding skin breakdown, skin assessments, turning and other skin-related care. Quarterly prevalence and incidence studies are also performed.

Keys to success 1. Quarterly skin and wound care competency fair. All patient care professionals are required to attend once a year. The fair consists of stations covering each of the following issues related to pressure ulcers: • Heel care • Positioning • Transfer • Specialty beds • Incontinence • Risk assessment • Documentation • Staging and POA sticker application • Product utilization

52 Healthy Skin

3. “No Briefs in Bed” campaign. Patients with incontinence who are unable to get to the toilet lie on an ultra absorbent disposable underpad rather than wearing a disposable brief. This practice allows the skin to breathe, making it less susceptible to moisture damage.

Results A decrease in pressure ulcers from 15 percent to 1.74 percent from March 2008 to March 2009. The hospital continues to have a low prevalence of pressure ulcers today.

1017 Places You’re Less Likely to Get a Pressure Ulcer Get results with

Medline’s Pressure Ulcer Prevention Program (PUPP) • Average reduction in facility-acquired pressure ulcers: 72.6% • Average annual savings: $215,190

If you are interested in:

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

How does PUPP work?

Reducing the incidence of pressure ulcers at your facility

Learning more about Medline’s Pressure Ulcer Prevention Program

With a compelling combination of products and education: 1. Medline’s strategic product bundle, including skin care and incontinence products 2. Medline’s free educational program for nurses and nursing assistants, including 4 CE credits for nurses plus online, interactive competencies

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

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

Pillow-Like Design Provides comfort and protection

Unique straps Multiple strapping options dependent upon the patient’s needs

Color-coded tags For quick size identification

Open heel design For pressure offloading and easy clinical checks

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.

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.

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

Foot Drop Strapping For enhanced foot drop protection. Pressure, friction and shear are reduced within the area.

Criss-Cross Strapping Firmly isolates the foot while floating the heel. Pressure, friction and shear are reduced within the area.

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Making Strides in Continence Management Pleasant Valley Nursing Center in Derry, NH, has been implementing several new initiatives over the past

at Pleasant Valley Nursing Center, Derry, NH

Melissa Jean, LPN, infection control and wound care nurse, said the continence management program at Pleasant Valley seeks to “restore each resident to the most normal bladder and bowel functioning possible.”

year in order to provide more patientcentered care, particularly in the areas of bathing, dining and continence management. To provide a more

When deciding on a name for the program, the committee did not want to use the words “continence” or “incontinence” in order to respect the dignity of the residents when meetings were called over the intercom. They decided on the word “aquatics.”

home-like atmosphere, patients live in “neighborhoods” throughout the facility and are referred to as “neighbors.”

56 Healthy Skin

The mission statement of the Aquatics Program states that “as a committee of various professionals, we will provide the best care while maintaining each neighbor’s dignity and quality of life through a series of assessments and development of an individualized plan of care.” An average of 75% improvement in continence functioning has been documented in residents who participate in the Aquatics Program.

The Aquatics Program is led by Melissa and the facilityâ&#x20AC;&#x2122;s director of nursing. Members include the facility administrator, unit managers and lead nursing assistants, the facility medical director, a representative from staff development, a restorative aide, the facilityâ&#x20AC;&#x2122;s MDS coordinator and a staff member responsible for supplies. Aquatics Program committee members set a goal to have all neighbors assessed for continence with implemented plans of care in place within one year. Incorporating requirements from MDS 3.0, the assessment and treatment process follows a flowchart provided in Medlineâ&#x20AC;&#x2122;s Continence Management Program. The goal is to help each neighbor reach his or her maximum potential for continence. For example, one neighbor might begin the aquatics program having to wear disposable briefs all day and night. By retraining him to urinate in the toilet at the times he would usually urinate in his brief, this neighbor might transition to only having to wear briefs at night.

An average of 75% improvement in continence functioning has been documented in residents who participate in the Aquatics Program

The committee began by choosing three neighbors from each floor who were cognitively able to participate. Those who were found to be incontinent became candidates for bowel and bladder retraining over a four-week period:

Week 1 • Nursing assistants observe and document neighbors’ bowel and bladder patterns to establish a baseline. • Nurses complete a medication review and document environmental risks, historical factors and any history of urinary tract infections.

Week 2 • Staff brings each participant to the toilet one hour before their usual times documented during Week 1. • Progress and any changes are noted.

Week 3 • New scheduling for toileting is noted from data gathered during Week 2. • Toileting begins 2 hours before newly established times.

Week 4 • Staff identifies candidates who would benefit from bladder therapy (e.g., Kegel exercises) • Review of neighbor’s need for change of incontinence products and sizing • Review need for neighbor to continue to be monitored or discontinue the Aquatics Program if greatest potential and all goals have been met.

58 Healthy Skin

Melissa emphasized that having access to a wide range of sizes and types of incontinence products has been invaluable in developing individualized care for the neighbors at Pleasant Valley. Being able to fit bariatric patients into specially sized bariatric products instead of size XL, which just doesn’t provide the proper fit, has made a big difference in the quality of life for many residents. To learn more about the Aquatics Program at Pleasant Valley Nursing Center, contact Melissa Jean at For details on Medline’s Continence Management Program, contact your Medline representative or call 1-800-MEDLINE (1-800-633-5463).

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

Replaces Compass Box F315

• CNA workbook • R  eproducible 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.

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

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

Make the change to

FitRight. TM

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

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

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

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

The all-new FitRight brief helps accelerate your culture of patient-centered care. • Designed with individual in mind • More high-tech features for high performance • Discreet, comfortable, garment-like fit and feel • 4D core with odor protection for dryness and dignity

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

10 Principles

All Great

Nurses Follow by Sue Heacock


10 9

Be true to your patients. Do you remember why you originally chose the profession of nursing? To help people. Be true to this goal and remind yourself everyday that you are there to provide the best patient care possible. This means not coming to work sick or calling off at the last minute. This means providing all care to the patients you are responsible for. There is no excuse for skipping care you may feel is non¬essential and don’t want to provide because you are tired or understaffed and need to rest. Be true to your patients at all times.

Be true to your profession. Represent the nursing profession well, both on the job and in the community. Being a nurse volunteer and join local organizations to help in your neighborhood. Keep current on your education requirements and job functions.

8 62 Healthy Skin

Be true to your peers. “Dumping” work on your peers or calling off late is not being true to your peers. You expect an honest day of work from them, and they should count on the same from you. Treat your peers with respect and professionalism.


Be true to yourself. Nurses, know your limitations. You also need to know it really is fine to say no. If you find yourself stressed out, do something about it, and donâ&#x20AC;&#x2122;t lose yourself in the process of helping others.

6 5

When in doubt, ask. Great nurses are not afraid to admit they are confused or not sure of something. Great nurses, for the protection of their patients, are always willing to ask questions and get clarification.

Great nurses laugh at themselves. Nurses are able to see the nursing humor in everyday events and are not afraid to acknowledge their shortcomings!


Take time for family and friends. Great nurses understand the importance of a work/life balance. This includes ample time for your family and friends. It does not help to work overtime for months at a time to save money for the dream vacation and then spend the entire time you are on vacation in bed with mono!

Continued on page 65

Improving Quality of Care Based on CMS Guidelines 63

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

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3 4

You will receive personal assistance from your dedicated greensmart Program Manager.

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Š2012 Medline Industries, Inc. greensmart is a trademark and Medline is a registered trademark of Medline Industries, Inc.


When tired, great nurses will not pick up those extra shifts. This goes along with being true to yourself. Great nurses know their limitations and don’t take on extra hours if they aren’t comfortable with it for the safety of their patients and their own personal health.

2 1

Great nurses are proud leaders and mentors. Please don’t eat our young! Be a leader to the new nurses or the inexperienced nurses on your floor. Teach them and help them to excel. Both the profession and your organization will benefit immensely when you share your talent in this way.

Be true. Poor ethics are my pet peeve. Great nurses uphold honesty all the time. Be honest in everything you do. You are human and when you make an error, admit it. Integrity, once lost, is almost impossible to get back.

About the author: Sue Heacock, RN, MBA, COHNS, is a Certified Occupational Health Nurse Specialist and author of the recently published book, Inspiring the Inspirational: Words of Hope From Nurses to Nurses. She has worked in a variety of areas of nursing including pediatrics and research.

Improving Quality of Care Based on CMS Guidelines 65

Part 1

Medline Intern Travels to India to Help Impoverished Children

By Azza Cohen

Editor’s note: Medline summer intern and Princeton University student Alexandra (Azza) Cohen, 19, 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.

On a typical day I would awaken to a hypnotic combination of Sanskrit chants, splashing water and ringing bells of early morning sun worship. I pulled back my lime green mosquito net and carefully replaced it. Chai bubbled in a small pot on a single burner; I shared a steaming cup with my host mother even though the temperature outside was often over 100 degrees F. I meet some friends for yoga, and then begin my bike journey to Guria, the NGO where I volunteered. I wind between motorcycles, goats, vegetable carts, rickshaws and people pointing at my helmet. (Yes, I wore a helmet, and yes, I was the only one who ever did.) I see an occasional car, but it is most inconvenient to get stuck behind a herd of water buffalo crossing the street. I’m sweaty. It’s hot. I’ve already finished the liter of water I brought with me, so I stop at my favorite coconut stand on the side of the road. Ramadevi selects a large fruit from her pile, hacks it open with a small machete, and hands me a flimsy straw. I sip gratefully; I need these electrolytes to avoid heat stroke. I arrive at the Guria office. Ajeet (the founder of Guria) sweeps the floor and I join him. He believes in no hierarchy. Everyone is equal,

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and everyone does every sort of work from sweeping to teaching to cooking. When the office is clean, I work on compiling poverty statistics, searching to prove a correlation between human trafficking and poverty.

How Guria makes a difference Guria is a grassroots organization dedicated to fighting human trafficking and forced prostitution in Varanasi and beyond. Through brothel rescues, legal intervention, education and empowerment programs, Guria has rescued all minors in Shivdaspur, the red light area of Varanasi, a huge step forward in the fight to end this modern form of slavery. The shelter, which is run via funding from inspired individuals and funding agencies, both local and global, serves as a haven for these kids. A “non-formal education” is provided: meditation, art therapy, dance, and computer and beauty classes. Guria hopes through teaching vocational skills and outlets for creative expression to raise the kids with compassion they’ve never known, and help them escape the cycle. It is hoped that the learning of these skills empower the girls to find an honorable and safe living instead of perpetuating the cycle of prostitution.

Dr. Singh treats a g irl’s ear infection from uns terile pier cing.

Guria hopes through teaching vocational skills and outlets for creative expression to raise the kids with compassion they’ve never known, and help them escape the cycle.

Ajeet’s Blackberry flashes. A group of global health students are in Varanasi and want to tour the Guria center. I call Sanjay, my favorite rickshaw driver, to pick them up and meet me in Shivdaspur (the red light area). I trust him because my host father has known him for years. Most rickshaw drivers refuse to go to Shivdaspur because they’ll gain a sinister reputation, or they’ll drop you off and leave by dusk. I refill my water bottle; I’ll need it for the second bike journey. This time I wrap my dupatta (scarf) around my face—partly to block the pollution, mostly to hide my face. Sunglasses too. If I’m lucky, I’ll make it in 30 minutes and beat the student group. I don’t want them to arrive before me and have to wait around in Shivdaspur, even in daylight. I biked the route to Shivdaspur a thousand times; I was always horrified at the litter lining the street, the growling dogs and the barefoot kids. None of it matters once you’re inside. I lock my bike to a pole inside the Guria gates, and as soon as they hear, the kids come running. “Azza madam! Madam ji, namaste!” I soon have too many hugs to count, and heave up the stairs with children attached to my arms and legs to the meditation room.

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Improving Quality of Care Based on CMS Guidelines 67

We begin by singing “Isi Dharti Ki Kassam,” meaning “the promise of this earth”—a song about living responsibly. The kids sit in a giant circle as we distribute clay to groups of four. Teaching teamwork is important, because living in Shivdaspur means learning violence. The kids must decide how to divide the clay to make their idea come alive. One group makes a clay family living with a TV, a garden and two parents. This is a family unit none of the children have experienced.

Medical care, while easily accessible to the middle class was rarely available to these children Home for them is a deteriorating, crowded one-room section of a busy brothel without electricity or running water. That same room is where the Guria kids are forced to watch their mothers with their clients, simply because going outside the brothel is more dangerous than staying in. The Guria kids face unimaginable obstacles each day—from feeding their many siblings, to being kicked out of classrooms because of their caste, to finding a pencil and paper to finish their homework, to surviving beatings and finding clean drinking water. I pull out five of the older girls for computer class. By now, they’ve mastered the art of turning on the computer and beginning their typing practice. I trust them, and leave the girls on the computers to administer first aid to some other students. Ear piercings, culturally of value to Indian girls, would often turn septic because 13-year-olds pierce their own ears with unsterile safety pins. Danger lurks along the main drag of Shivdaspur; exposed power lines, rusting brothel gates, typhoid-ridden water pumps and rabid dogs all pose serious health threats to the unsupervised children walking miles to and from school every day. Medical care, while easily accessible to the middle class was rarely available to these children, both from lack of funds, as well as the neglect that is associated with belonging to a lower caste.

Making basic first aid available While in India, I contacted Medline for a donation of first aid supplies for Guria. Once the supplies finally arrived at Guria, after an extended time in India’s version of customs, medical care became possible. Painful infections were treated successfully with SilvaSorb Gel. Dog bites were carefully cleaned with ReadyBath wipes, potentially saving the kids from rabies. Medline thermometers helped diagnose typhoid, slowing the spread of the disease. Medline gloves were distributed and used to educate HIV positive patients about the importance of cleaning

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up their contaminated blood. Curad first-aid kits are now with every Guria staff member, so they are prepared the next time they rescue an abused girl from a brothel, or bring her back to her home village. And kid-friendly cartoon Curad bandages covered minor scrapes and burns, as well as making the kids smile. Medline’s donation marks the first access to medical supplies for the citizens of Shivdaspur, and more importantly, sends the message that someone beyond the brothel walls is out there, caring enough to send these critical supplies. With a Curad ® first-aid kit in hand, I head upstairs to help the youngest kids. Sahima’s nose is infected from the stump of wood her mother used to pierce it; Aftab’s foot sports a deep gash from stepping barefoot on broken glass; Aishani’s tight braids can’t hide an open sore behind her ear. The others gaze, fascinated, as I open the little green box. First, I use Sterilium® rub on my hands (there’s no soap to be found). I pour water from my water bottle (the water in the pump outside is arguably worse than the infection itself) and gently clean off the dirt from my three patients. They squeeze each others’ hands while I dab some Silvasorb® gel and cover it with a brightly cartooned Curad® kids’ bandage. I warn them not to touch it, but I can tell it’s hard for them to listen because these bandages are just so interesting (they’ve likely never seen one before). Checking back at the computers, I catch Chhoti using Excel instead of Word. She explains that she finished her typing level and wanted to practice math. I forgive her—I’m more proud that she figured out Excel on her own – faster than I ever did. After a quick game of kabaddi, Indian tag, the kids are tired and head for lunch (it might be the only meal they’ll eat today). The older girls arrange everyone in straight lines and pass out plates so the younger ones eat first. Before they start, each child waits until everyone has food on their plate, and they fold their hands together in meditation. Thank you to the sky, thank you to the sun, thank you to the Earth for this food I will eat… They are so thankful for all the little things. And me, I’m grateful for memories like these.

Stay tuned for Part II in the next issue as Azza describes her experiences with the Indian healthcare system when she contracted typhoid – not once, but twice. To learn more about Guria and Azza’s experience in India, email her at or visit her blog

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.

To Prevent Transmission of Infections in Healthcare

Medline Safety Syringes also feature: • Low dead space design to reduce medication waste and expense

Injection Safety is Every Provider’s Responsibility

• Easy-to-read bold markings • Insulin and tuberculin versions

©2012 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: Accessed March 16, 2012.

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Want to achieve peak performance and lose weight?

Sleep more ... sleep better Wolf J. Rinke, PhD, RD, CSP

Improving Quality of Care Based on CMS Guidelines 71

Researchers tell us that most of us do not get enough sleep. According to one estimate, 10 to 15 percent of Americans are suffering from chronic, long-term sleep deprivation, mostly insomnia and nightmares. The National Sleep Foundation maintains that Americans sleep almost two fewer hours a night than 40 years ago, with the average person sleeping far less than seven hours per night. Your reply—“so what, I’m doing just fine.” It may seem that way; however, research is telling us that to achieve peak performance, your body requires seven to nine hours. (That’s for most adults. Children, pregnant woman and older adults need more sleep.) Consistently sleeping less than seven to nine hours results in lower productivity, more accidents and higher levels of stress. For example, recent research at the University of Pennsylvania found that people who slept less than six hours a night had serious lapses in attention. Cognitive performance deficits included a reduced ability to pay attention and to react in a timely manner during such tasks as driving. Other deficits included the reduced ability to multi-task, to think quickly and to avoid making mistakes. Those lapses got worse as the week progressed. Getting six hours of sleep per night for two weeks was equivalent to staying up for 24 hours straight. Yet these subjects were not aware of how severely sleep deprived they actually were, putting themselves at even greater risk of harm. Plus a lack of sleep may also result in weight gain. (Yes, you read correctly!) New scientific evidence presented recently at a meeting of sleep researchers in Boston, found that sleep deprivation increases activity in areas of the brain that seek out pleasure— including that provided by high-calorie junk food. To make matters worse, sleepiness also seemed to dampen activity in other brain regions that usually serve to inhibit this type of craving. These latest findings, which are based on studies

using functional magnetic resonance imaging (fMRI), appear to affirm previous studies that established a link between sleep deprivation and obesity. And it’s not only the number of hours of sleep, it’s also the quality of your sleep. For example, during times of high stress, such as the period after 9/11, some people slept less well while others had sleep disturbing nightmares, or were unable to sleep at all. (The National Sleep Foundation found that over 75 percent of the people they surveyed after 9/11 experienced at least one sleep disorder several times a week.) Again, researchers have found that high levels of stress tend to disrupt the second half of a night’s sleep. And once you wake up at two or three in the morning, it’s difficult to fall back into a restful sleep. Inadequate amounts of restful, rejuvenating sleep will, according to the National Sleep Foundation, have a negative effect on your emotions, mood, memory, concentration and even your ability to make high quality decisions. Repeat that pattern several nights a week, and you will likely experience more severe effects such as feeling short-tempered, anxious or upset. It may even lead to depression. According to Timothy Roehrs, director of the Henry Ford Hospital of Sleep Disorders and Research Center in Detroit and the National Sleep Foundation, here are eight strategies that will enable you to get more quality ZZZZZZs Continued on page 74

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


Strategies to get more zzzzzz’s


Maintain a Regular Sleep Schedule To get the most from your sleep, go to bed and get up at approximately the same time, every day. Also, if you have insomnia, you may want to avoid napping. If you do feel you need a nap, take a powernap of no more than about 20 minutes. Although this is good advice, Superwoman (that’s my wife and business partner of over 40 years) and I allow ourselves the luxury of a short power nap on Saturday and sleeping in on Sundays. And why not? Some of the research evidence suggests that we are able to “store” some sleep.


Wind Down Be sure to create a wind-down phase before going to sleep. Stuff that really works well is reading, especially if it is a boring book, listening to soft music, meditating, cuddling with your partner, soaking in a warm bath or listening to music. What works like magic for us is television. Although I’m not a proponent of TV, I do advocate it as a tool for getting sleepy. When I’m at home, we typically read till about 9 pm. We tape the national news and our favorite shows—that way we can skip the commercials— and watch our favorite shows until we are ready to go to bed at about 11 pm. Then we read in bed until we get drowsy (usually about 15 minutes) and with any degree of luck, we have another restful night. Avoid exercising (see #8 below) arguing, scary movies or books, and TV news—especially the local news— right before going to sleep.

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Get Out the “Blankie” Make your bed into a comfort zone, such as warm down blankets in the winter, fuzzy pajamas and your favorite pillow. Anything that gives you comfort, even your childhood “blankie.” (Hey, who’s going to know?) And while I’m thinking of it, don’t use your bed for anything else except the two S’s: sleep and sex.


Create a “Quiet” Zone Make sure your bedroom is as comfortable, calm, dark and quiet as you can make it. Install heavy curtains, shades, or double pane windows. If all else fails, get yourself a dark mask and a set of the gel type earplugs. Mack’s ( work best for us. You may also want to try a soothing CD with very quiet mood music or the sound of a burbling brook.


Invest in a High-Quality Large Mattress Think about it. You spend a third of your life in bed. Marcela and I spent over 20 years of our married life on a full size mattress—not even a queen size. That just does not make any sense! (Hey who said I don’t do stupid stuff?) Now we sleep on a very spacious, soft, quality king size mattress. Because Marcela has been suffering with back problems, we tried a wide variety of mattresses, even one that was so hard they called it “Granite.” (I’m not making this up.) And what we finally found, after we wasted a lot of money, is that a soft, cushiony, spacious mattress works best for us. Continued on page 76

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 PerfecTemp is custom-fit to your table configuration. Ask Medline for a free quote.


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


Eat as Early as Possible Avoid eating before going to bed. In fact, eat your main meal as early as possible in the day. It will help with your weight-control, and enable you to sleep better at night. Also be sure to avoid high fat snacks, caffeine, nicotine and alcohol late in the day (after 7 pm).


Exercise Participate in a regular aerobic exercise program at least five days a week. Since it stimulates your metabolic rate, avoid this type of exercise three hours before going to bed.


Don’t Fight It If you find yourself unable to sleep for about 30 minutes, don’t fight it. Get up, get yourself a warm glass of milk (yes, it actually works), watch a boring TV program or read something that will calm you down. (That’s how I catch up on all my professional journals. They work like magic.) If all of this does not help you achieve restful sleep, you may have an underlying medical problem such as clinical depression, apnea or narcolepsy, and it’s time to see your doctor. © 2012 Wolf J. Rinke

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

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


ing Quality of

PGD 2012 Pink Glove Dance II Video Competition

Vote for your favorite video at Voting ends: October 26 Winners announced: November 2 Winners Receive a Donation to Their Favorite Breast Cancer Charity* • First Place: $10,000 • Second Place: $5,000 • Third Place: $2,000 *Subject to review and approval by Medline Industries, Inc

Complete contest details are available at

Some of last yearâ&#x20AC;&#x2122;s PGD Video contestants!

Gwinnett Medical Center, Duluth, GA

Lexington Medical Center, West Columbia, SC

Highland Hospital, Rochester, NY

San Juan Medical Foundation, Farmington, NM

Victoria Hospital, Prince Albert, SK, Canada

Pink Glove Dance




by Jay Sean

by Cascada

“Evacuate the Dance Floor”

“Part of Me”

by Katy Perry

“Let Yourself Go”

by Emily

“You Won’t

I am very honored that Medline and Providence St. Vincent Hospital used my song “Down” to promote and support Breast Cancer Awareness. Jay Sean

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2012! “This One’s For THe girls”

by Martina McBride

The 2012 Pink Glove Dance Video Competition is in full swing. New songs, new artists and new social media bring the competition to the next level. Vote for your favorite video at before the October 26 deadline. This year, the competition embraces old favorites like “Down” by Jay Sean (the song in the original Pink Glove Dance) and “You Won’t Dance Alone” by The Best Day Ever (the song in Pink Glove Dance: The Sequel). New tunes include “Part of Me” by Katy Perry, “Evacuate the Dance Floor” by Cascada, “This One’s for the Girls” by Martina McBride, and “Let Yourself Go” by Emily. Medline is grateful to these artists with heart who are supporting the cause and providing great dance beats.

Dance Alone”

by The Best Day Ever

The thanks are going both ways. “It’s very cool,” said Tonya Puerto, of Capitol Records, who is excited about Katy Perry’s music being used for the second year in a row. Singer Jay Sean said, “I am very honored that Medline and Providence St. Vincent Hospital used my song “Down” to promote and support Breast Cancer Awareness. I like that such a fun and light hearted approach was taken to create awareness for a serious disease that can be cured if caught early. The positive response and reaction that the ‘Pink Gloves’ video has received has been incredible, and coming from a medical background myself, I hope that we are able to keep a spotlight on this illness until we reach a cure!”

Improving Quality of Care Based on CMS Guidelines 81

The Pink Glove D ance co great wa mpetitio y f or Lexin n was a show th g ton Med e world ical Cen our hosp commitm ter to ital and ent to th our stea e treatm dfast ent of b reast ca ncer. Lexington 2011 First Medical C Place Pink enter Glove D ance Winn


Emily Rosenberg, of Highland Park, Ill. and a sophomore at Berklee College of Music in Boston, donated the rights to use her song the Pink Glove Dance. When asked why, she responded, “I’m so thrilled to be involved in the Pink Glove Dance. These videos bring such joy and laughter to the people who deserve it most. Breast cancer affects so many people — both the patients and their loved ones. The more awareness we can raise the better, and we might as well do it in such a fun way! I’m ecstatic that my music will be used for something that makes people so happy. That’s the goal of making music: to improve lives. That’s the dream, and I’m so grateful that the Pink Glove Dance is helping make it come true.” Lexington Medical Center, the facility that won the 2011 Pink Glove Dance Competition, loved dancing pink last year. “The Pink Glove Dance was a wonderful experience for Lexington Medical Center,” said Jennifer Wilson, Lexington Medical Center public relations manager. “We are so grateful to the people from around our community, country and the world who viewed our Pink Glove Dance video and voted for us. To date, our video has received more than 150,000 You Tube views. The Pink Glove Dance competition was a great way for Lexington Medical Center to show the world our hospital and our steadfast commitment to the treatment of breast cancer, a disease that affects 1 in 8 women in her lifetime.”

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What started as a crazy fun way to raise awareness about early detection of breast cancer has become an international dancing phenomenon, including 21,000 total Pink Glove Dancers, 13,608,658 (and counting!) views of the original Pink Glove Dance, and more than one million page views of To get the message out there as much as possible, Pink Glove Dance this year has enhanced its presence on the web through new social media including Facebook, Twitter, Pinterest, Tumblr and Flickr. These social media sites are more important than ever, and not only get the Pink Glove Dance out there, but are a great resource for competition participants to spread the word as well. Medline hopes to keep spreading smiles and awareness by promoting the Pink Glove Dance as much as possible. Medline corporate headquarters hosted a Pink Glove Day this year on

the launch date of the competition, when Medline employees enthusiastically donned their best pink clothes, sipped pink lemonade and tweeted pink to get the word out. How did last year’s winner do it? Wilson reflected, “Lexington Medical Center believes that one of the elements that made our video a winner was the fact that it showcased hundreds of our employees, emphasizing the commitment of a large number of people to battling breast cancer. Importantly, the video also used the lyrics from the Katy Perry song “Firework” to help tell a story.” The Pink Glove Dance reflects Medline’s commitment to saving lives through raising awareness and funds for early detection of breast cancer. Medline has donated more than $1 million to date to the National Breast Cancer Foundation to fund free mammograms from the proceeds of pink gloves and other Generation Pink™ products.

Breast Cancer Awareness Activities Schedule a mammogram and remind a friend to do the same. Join a breast cancer walk in your local area. Cook pink! (See page 87). Wear pink gloves and other pink attire. Sign up for Medline’s Daily Dance inspirational emails at

Improving Quality of Care Based on CMS Guidelines 83

FDA approves first breast ultrasound imaging system for dense breast tissue Device designed to help health care providers detect smaller tumors On September 18 the U.S. Food and Drug Administration approved the first ultrasound device for use in combination with a standard mammography in women with dense breast tissue who have a negative mammogram and no symptoms of breast cancer.

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Breast cancer is the second leading cause of cancer-related death among women. This year an estimated 226,870 women will be diagnosed with breast cancer, and 39,510 will die from the disease. The National Cancer Institute estimates that about 40 percent of women undergoing screening mammography have dense breasts. These women have an increased risk of breast cancer, with detection usually at a more advanced and difficult to treat stage. Dense breasts have a high amount of connective and glandular tissue (fibroglandular tissue) compared with lessdense breasts, which have a high amount of fatty tissue. A physician determines if a woman has dense breast tissue with a mammography exam. Mammography is a low-dose X-ray imaging method of the breast. However, mammograms of dense breasts can be difficult to interpret. Fibroglandular breast tissue and tumors both appear as solid white areas on mammograms. As a result, dense breast tissue may obscure smaller tumors, potentially delaying detection of breast cancer. Ultrasound imaging has been shown to be capable of detecting small masses in dense breasts. During an ultrasound exam, a device called a transducer directs highfrequency sounds waves at the portion of the body being examined. Software analyzes the differences in how the sound waves are reflected off different tissues and back to the transducer to create an image a physician can review for abnormalities.

The specially shaped transducer of the somo-v Automated Breast Ultrasound System (ABUS) can automatically scan the entire breast in about one minute to produce several images for review. As part of the approval process, the FDA reviewed results from a clinical study in which board-certified radiologists were asked to review mammograms alone or in conjunction with somo-v ABUS images for 200 women with dense breasts and negative mammograms. Biopsies were performed on masses detected with the somo-v ABUS to determine if they were cancer. The results show a statistically significant increase in breast cancer detection when ABUS images were reviewed in conjunction with mammograms, as compared to mammograms alone. “A physician may recommend additional screening using ultrasound, for women with dense breast tissue and a negative

mammogram,” said Alberto Gutierrez, Ph.D., director of the Office of In Vitro Diagnostic Device Evaluation and Safety at FDA’s Center for Devices and Radiological Health. “The somo-v ABUS is a safe and effective breast ultrasound tool when such screening is recommended.” The somo-v ABUS is approved for use in women who have not had previous clinical breast intervention, such as a surgery or biopsy, since this might alter the appearance of breast tissue in an ultrasound image. As part of the approval, FDA has required that the manufacturer provide thorough training for physicians and technologists using the ABUS device, and that the manufacturer provide each facility with a manual clearly defining system tests required for initial, periodic, and yearly quality control measures. The somo-v ABUS is marketed by Sunnyvale, Calif.-based U-Systems Inc.

Dense breast tissue may obscure smaller tumors, potentially delaying detection of breast cancer.

Source: Newsroom/PressAnnouncements/ucm319867.htm

Improving Quality of Care Based on CMS Guidelines 85


Get your mammogram.


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

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Improving Quality of Care Based on CMS Guidelines 86

Breast Cancer Awareness

C o o k i n g

Pink The foods you choose every day are one of the most important

factors in protecting you against cancer. Most Americans eat a diet that is far too high in meat and calories. Even more

important is what the average diet lacks: a variety of vegetables, fruits, beans and other plant-based foods. Plant-based foods give your body not only the nutrients it needs for good health, but an arsenal of compounds (phytochemicals) that help protect against naturally-occurring cancer risks you face every day.

Healthy Pink Foods

 Beets  Raspberries  Cranberries  Salmon

 Cherries  Red peppers  Watermelon  Shrimp

 Strawberries  Pink grapefruit  Red potatoes  Red beans

Improving Quality of Care Based on CMS Guidelines 87


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Whatâ&#x20AC;&#x2122;s in it for you?

Blueberries are high in soluble fiber. They are an excellent source of vitamins C and Kâ&#x20AC;&#x201D;all for about 80 calories per cup. In addition, blueberries contain a family of plant compounds called anthocyanides, which are potent antioxidants and may play a role in reducing risk of chronic diseases such as cancer.

88 Healthy Skin

For more healthy and delicious recipes, check out:

The New American Plate: Recipes for a Healthy Weight and a Healthy Life Delicious food. Healthy food. Theyâ&#x20AC;&#x2122;re one in the sameâ&#x20AC;&#x201D;especially when the recipes are developed by the American Institute for Cancer Research (AICR) cookbook team. AICR is proud to announce the publication of its treasure-trove of 200 recipes, which ravish the palate while helping you manage your weight and reduce the risk of disease. The cookbook is available at and Barnes & Noble. Source: American Institute for Cancer Research

Strawberries provide a hearty dose of vitamin C, and their vibrant color is a sign that they are rich in cancerfighting phytochemicals. In addition, strawberries are a source of ellagic acid, which has shown promising anticancer properties in laboratory studies.

Improving Quality of Care Based on CMS Guidelines 89

Healthy Eating

Nutrition Information Servings: 8 Fat: 11.6 g Fiber: 27.8 g Calories: 1040 Sodium: 514

White Bean Chicken Chili In Beach Park, Illinois, the leaves on the trees are starting to change from green to bright red and orange. As the sun sets – a little earlier than a few weeks ago – Maria Biddle turns on her kitchen light, and soon the sounds of laughter and conversation fill the room. “I love to cook with my husband and parents. They also share a love for cooking and we make a pretty good team in the kitchen.” Maria, who has been with Medline since 2007, recently returned to work after taking maternity leave and plans to make homemade baby food for her new baby boy. But they’re not making baby food this evening; they’re making the recipe that won first prize in Medline’s 2011 Chili Cook-Off: Maria’s White Bean Chicken Chili. “I feel like chili is just such a good hearty soup that is so comforting, especially during the fall on a cool evening.” The recipe is based on her father-in-law’s chili recipe with some alterations and different spices. The chili’s chunky chicken makes for a pleasant change from the usual ground beef, and might have been the reason it won first place.

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

90 Healthy Skin


Ingredients 2 tbsp olive oil 2 cup of chopped celery 1 yellow, orange and red bell pepper chopped 1 large white onion chopped 4 cloves garlic minced 2 tbsp chili powder 3 tbsp cumin 3 tbsp paprika 1 tsp cayenne pepper 1 tsp thyme 2 tsp oregano ½ tsp ground cloves 1 tsp of salt A pinch of black pepper 4 cans (14.5 oz. each) of diced tomatoes 1 can of tomatoes with green chilies 8 cans (9.75 oz. each) of cooked chicken or about 5 lbs of cooked chicken in chunks 2 tbsp of chicken bouillon 1 3-lb jar of northern beans (rinsed – you don’t need the liquid) Directions In a big pot add the oil and sauté the celery, bell peppers, onion and garlic on medium heat. Stir constantly to make sure they cook and not burn. Once the vegetables have been cooked, start stirring in the spices (chili powder, cumin, paprika, cayenne pepper, thyme, oregano, clove, salt and black pepper). Once the spices have been added, start adding the cans of tomatoes with all the liquid. Add the chicken with the broth included and add the chicken bouillon. Add the beans and stir chili constantly. Let it come to a boil and then simmer for a half hour.

Forms & Tools

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

CMS Measures CMS FY 2014-2016 Measures for CMS Payment Determination...................92 Skin & Wound Care Marathon Skin Protectant Guidelines for Adults................................................96 Marathon Skin Protectant Guidelines for Neonates and Infants......................97 Continence Care Urinary Continence Assessment & Implementation Form................................98

Improving Quality of Care Based on CMS Guidelines 91

Forms & Tools

CMS Measures

Premier healthcare alliance CMS FY 2014-2016 measures for CMS payment determination: Hospital IQR, hospital-acquired conditions, IPPS-exempt cancer hospitals quality reporting, VBP program quality measures and long term care hospitals quality reporting.

Hospital IQR Program Measures for FYs 2014, 2015 and 2016 2014



AMI-2 Aspirin prescribed at discharge




AMI-7a Fibrinolytic (thrombolytic) agent received within 30 minutes of hospital arrival




AMI-8a Timing of Receipt of Primary Percutaneous Coronary Intervention (PCI)




AMI-10 Statin Prescribed at Discharge




Acute Myocardial Infarction (AMI) Measures

Heart Failure (HF) Measures HF-1 Discharge instructions




HF-2 Evaluation of left ventricular systolic function




HF-3 Angiotensin Converting Enzyme Inhibitor (ACE-I) or Angiotensin II Receptor Blocker (ARB) for L ventricular systolic dysfunction




Stroke (STK) Measure Set STK-1 VTE prophylaxis



STK-2 Antithrombotic therapy for ischemic stroke



STK-3 Anticoagulation therapy for Afib/flutter



STK-4 Thrombolytic therapy for acute ischemic stroke



STK-5 Antithrombotic therapy by the end of hospital day 2



STK-6 Discharged on Statin



STK-8 Stroke education



STK-10 Assessed for rehabilitation services



VTE-1 VTE prophylaxis



VTE-2 ICU VTE prophylaxis



VTE-3 VTE patients with anticoagulation overlap therapy



VTE-4 VTE patients receiving un-fractionated Heparin with doses/labs monitored by protocol



VTE-5 VTE discharge instructions



VTE-6 Incidence of potentially preventable VTE



Venous Thromboembolism (VTE) Measure Set

Pneumonia (PN) Measures PN-3b Blood culture performed before first antibiotic received in hospital




PN-6 Appropriate initial antibiotic selection




SCIP INF-1 Prophylactic antibiotic received within 1 hour prior to surgical incision




SCIP-INF-2: Prophylactic antibiotic selection for surgical patients




SCIP-INF 3 Prophylactic antibiotics discontinued within 24 hours after surgery end time (48 hours for cardiac surgery)




SCIP-INF-4: Cardiac surgery patients with controlled 6AM postoperative serum glucose




SCIP窶的NF-9: Postoperative urinary catheter removal on postoperative day 1 or 2 with day of surgery being day zero




SCIP-INF-10: Surgery patients with perioperative temperature management




SCIP-Cardiovascular-2: Surgery Patients on a Beta Blocker prior to arrival who received a Beta Blocker during the periop period




Surgical Care Improvement Project (SCIP) Measures

92 Healthy Skin


Forms & Tools

CMS Measures Hospital IQR Program Measures for FYs 2014, 2015 and 2016




SCIP-VTE-1: Surgery patients with Venous thromboembolism (VTE) prophylaxis ordered



SCIP-VTE-2: Surgery patients who received appropriate VTE prophylaxis within 24 hours pre/post surgery




AMI 30-day mortality rate




Heart Failure 30-day mortality rate




Pneumonia 30-day mortality rate






AMI 30-Day Risk Standardized Readmission




Heart Failure 30-Day Risk Standardized Readmission




Pneumonia 30-Day Risk Standardized Readmission




Mortality Measures (Medicare Patients)

Patientsâ&#x20AC;&#x2122; Experience of Care Measures HCAHPS survey

1 Expanded

Readmission Measures (Medicare Patients)

30-Day Risk Standardized Readmission following Total Hip/Total Knee Arthroplasty



Hospital-Wide All Cause Unplanned Readmission



AHRQ Patient Safety Indicators (PSIs), Inpatient Quality Indicators (IQIs) and Composite Measures PSI 06: Iatrogenic pneumothorax, adult



PSI 11: Post Operative Respiratory Failure



PSI 12: Post Operative PE or DVT



PSI 14: Postoperative wound dehiscence



PSI 15: Accidental puncture or laceration



IQI 11: Abdominal aortic aneurysm (AAA) mortality rate (with or without volume)



IQI 19: Hip fracture mortality rate



Complication/patient safety for selected indicators (composite)


Mortality for selected medical conditions (composite)


PSI 04 Death among surgical inpatients with serious, treatable complications




Participation in a Systematic Database for Cardiac Surgery




Participation in a Systematic Clinical Database Registry for Stroke Care




Participation in a Systematic Clinical Database Registry for Nursing Sensitive Care




Participation in a Systematic Clinical Database Registry for General Surgery





X Removed

Structural Measures

Safe Surgery Checklist Use


Healthcare-Associated Infections Measures Central Line Associated Bloodstream Infection (CLABSI)




Surgical Site Infection




Catheter-Associated Urinary Tract Infection (CAUTI)




MRSA Bacteremia



Clostridium Difficile (C.Diff)



Healthcare Personnel Influenza Vaccination





Surgical Complications Hip/Knee Complication: Hospital-Level Risk Standardized Complication Rate following Elective Primary Total Hip Arthroplasty

Improving Quality of Care Based on CMS Guidelines 93 8-31-12

Forms & Tools

CMS Measures

Hospital Acquired Condition (HAC) Measures 2014



Foreign Object Retained After Surgery



Air Embolism



Blood Incompatibility



Pressure Ulcer Stages III & IV



Falls and Trauma (Includes: Fracture, Dislocation, Intracranial Injury, Crushing Injury, Burn, Electric Shock)



Vascular Catheter-Associated Infection



Catheter-Associated Urinary Tract Infection (UTI)



Manifestations of Poor Glycemic Control



Emergency Department (ED) Throughput Measures ED-1 Median time from ED arrival to departure from the emergency room for patients admitted to the hospital




ED-2 â&#x20AC;&#x201C; Median time from admit decision to time of departure from the ED for ED patients admitted to the inpatient status




Immunization for Influenza




Immunization for Pneumonia










Cost Efficiency Medicare Spending per Beneficiary Perinatal Care Elective delivery < 39 completed weeks gestation 1

HCAHPS expanded to include one 3-item care transition set and two new About You items on mental health status and admission through the ED.

PPS-Exempt Cancer Hospital Quality Reporting Program Five measures are included in the new cancer hospital quality reporting program for FY 2014. These include two outcome measures, CAUTI and CLABSI that are already part of the Hospital IQR other quality reporting programs. (Note: CLABSI and CAUTI apply to both ICU and non-ICU in PPS-exempt cancer hospitals) and three process of care measures that were developed by the American College of Surgeons/Commission on Cancer accreditation program. PPS-Exempt Cancer Hospital Quality Reporting Program Measures 2014 Outcome measures


NHSN CLABSI outcome measure (NQF #0139) (Note: applies to both ICU


NHSN CAUTI outcome measure (NQF #0138)


Process measures


Adjuvant chemotherapy is considered or administered with 4 months (120 days) of surgery to patients < 80 with


AJCC T1c (lymph node positive) colon cancer (NQF #0223) Combination chemotherapy is considered or administered within 4 months (120 days) of diagnosis to women < 70 with AJCC T1c or Sta X or III hormone receptor negative breast cancer. (NQF #0559) Adjuvant hormonal therapy (NQF #0220) (Tamoxifen or third generation aromatase inhibitor is considered or administered within


1 year of diagnosis to women > 18 with AJCC T1cN0M0, or Stage II or III hormone receptor positive breast cancer.)

94 Healthy Skin


CMS Measures

Forms & Tools

VBP Program Quality Measures for FYs 2014 and 2015 Measure ID

Measure Description





Process of Care Measures AMI-7a

Fibrinolytic Therapy Received Within 30 Minutes of Hospital Arrival


Primary PCI Received Within 90 Minutes of Hospital Arrival




Discharge Instructions




Blood Cultures Performed in the Emergency Department Prior to Initial Antibiotic Received in Hospital




Initial Antibiotic Selection for CAP in Immunocompetent Patient




Prophylactic Antibiotic Received Within One Hour Prior to












Surgery Patients on a Beta Blocker Prior to Arrival That Received a Beta Blocker During the Perioperative X



Surgery Patients with Recommended Venous Thromboembolism Prophylaxis Ordered





Communication with Nurses



Communication with Doctors



Responsiveness of Hospital Staff



Pain Management



Communication About Medicines



Cleanliness and Quietness of Hospital Environment



Discharge Information



Overall Rating of Hospital



Surgical Incision SCIP-Inf-2

Prophylactic Antibiotic Selection for Surgical Patients


Prophylactic Antibiotics Discontinued Within 24 Hours After Surgery End Time


Cardiac Surgery Patients with Controlled 6AM Postoperative Serum Glucose


Postoperative Urinary Catheter Removal on Post Operative Day 1 or 2


Surgery Patients Who Received Appropriate Venous Thromboembolism Prophylaxis Within 24 Hours Pri Surgery to 24 Hours After Surgery

Patient Experience of Care Measures Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS)

Outcome Measures MORT-30-AMI

Acute Myocardial Infarction (AMI) 30-Day Mortality Rate




Heart Failure (HF) 30-Day Mortality Rate




Pneumonia (PN) 30-Day Mortality Rate




Complication/patient safety for selected indicators (composite)



Central Line-Associated Blood Stream Infection


Medicare spending per beneficiary


Efficiency Measures MSPB-1

Improving Quality of Care Based on CMS Guidelines 95

96 Healthy Skin

•Helps protect skin that is exposed to shear and friction from bedding, clothing, or any material that would rub against the skin. •Helps protect skin from moisture such as urine, feces, digestive enzymes, and wound drainage. •Helps protect the skin from adhesive trauma. 

•Do NOT apply directly to the wound bed or to deep puncture wounds. •Do NOT apply to second or third degree burns. •Do NOT apply to infected areas. 

•Clean and dry the skin thoroughly before applying Marathon making sure that all traces of moisturizers, lotions, lotion soaps y g y pp y g g , , p or lanolin are   removed from the application site.   •Holding the applicator upright, firmly squeeze between the finger and thumb to crush the sealed inner tube.  •Turn the applicator upside down and wait for 5 seconds while the Marathon soaks through the sponge tip.  •Slowly and gently spread a thin even coat of Marathon that extends about 2.5 cm beyond the affected area.  •Ensure that Marathon has dried completely before covering with clothes, tapes, dressings or incontinence products. 

Excess Marathon Liquid Skin Protectant can be removed before it dries by wiping with a clean tissue. Once it has dried, unwanted Marathon can be  softened with petrolatum jelly and removed. It will naturally wear off within 3 days as the skin cells slough away. 

Contraindications for Use

Instructions for Use


Periwound Skin

Indications for Use

Fragile or Damaged Skin

Marathon Liquid Skin Protectant is a non‐cytotoxic cyanoacrylate based, rapid drying, liquid barrier film. It is applied as a liquid and dries, within a  minute, adhering to the contours of the skin to form a transparent flexible film. Marathon will wear off, naturally, as the skin cells slough away.  Reapplication is up to every 3 days and as needed.    

Peristomal Skin

Product Description

Under Medical Devices Including Feeding Tubes

Skin Tears

Skin Condition Type

Skin Condition Photos


Forms & Tools Marathon Guidelines for Adults

•Helps protect skin that is exposed to shear and friction from bedding, clothing, or any material that would rub against the skin. •Helps protect skin from moisture such as urine, feces, digestive enzymes, and wound drainage. •Helps protect the skin from adhesive trauma. 

•Do NOT apply directly to the wound bed or to deep puncture wounds. •Do NOT apply to second or third degree burns. •Do NOT apply to infected areas. 

•Clean and dry the skin thoroughly before applying Marathon making sure that all traces of moisturizers, lotions, lotion soaps y g y pp y g g , , p or lanolin are   removed from the application site.  •Holding the applicator upright, firmly squeeze between the finger and thumb to crush the sealed inner tube.  •Turn the applicator upside down and wait for 5 seconds while the Marathon soaks through the sponge tip.  •Slowly and gently spread a thin even coat of Marathon that extends about 2.5 cm beyond the affected area.  •Ensure that Marathon has dried completely before covering with clothes, tapes, dressings or incontinence products. 

Excess Marathon Liquid Skin Protectant can be removed before it dries by wiping with a clean tissue. Once it has dried, unwanted Marathon can be  softened with petrolatum jelly and removed. It will naturally wear off within 3 days as the skin cells slough away. 

Contraindications for Use

Instructions for Use


Periwound Skin

Indications for Use

Damaged Skin

Marathon Liquid Skin Protectant is a non‐cytotoxic cyanoacrylate based, rapid drying, liquid barrier film. It is applied as a liquid and dries, within a  minute, adhering to the contours of the skin to form a transparent flexible film. Marathon will wear off, naturally, as the skin cells slough away.  Reapplication is up to every 3 days and as needed.    

Peristomal Skin

Product Description

Under Medical Devices Including Feeding Tubes

Fragile Skin

Skin Condition Type

Skin Condition Photos

MARATHON SKIN PROTECTANT GUIDELINES FOR NEONATES AND INFANTS Marathon Guidelines for Neonates and Infants Forms & Tools

Improving Quality of Care Based on CMS Guidelines 97

Forms & Tools

Urinary Continence

Continence Management Program: Forms


ASSESSMENT & IMPLEMENTATION FORM Resident __________________________________________________________________ Room #_____________________ Assessed by _________________________________________ Date ______________ Date of last MDS ______________ Current Product Information: Size ______ Type ___________ Frequency of Leakage: ________ times/week

 None

Diagnosis ______________________________________________________________________________________________ Medications ____________________________________________________________________________________________


Is the incontinence related to something other than urinary tract, such as inability to undo a zipper? . . . . . . . . . . . . . . . . . . . . . . . . . . N Does the resident have a postvoid residual greater than 200 cc? . . . . . . N Does the resident take stool softeners, antipsychotic, anticholergenic, narcotic analgesics, or other drugs that may affect continence? . . . . N


Resident is continent . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Do you leak when you cough, sneeze, exercise, laugh? . . . . . . . . . . . . . Do you need to rush suddenly to toilet? . . . . . . . . . . . . . . . . . . . . . . . . . Do you urinate more than 7 times/day or 2 times/night? . . . . . . . . . . . . Do you have a weak stream of urine? . . . . . . . . . . . . . . . . . . . . . . . . . . . Do you have frequent dribbling? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Do you have burning or blood in urine? . . . . . . . . . . . . . . . . . . . . . . . . .


1. Determine Type of Incontinence N N N N N N N


 proceed to section 2  stress  urge  urge  overflow  overflow  transient


 functional  overflow


 further evaluation may be necessary

Female Is there presence of pelvic prolapse or other abnormal finding? . . . . . . . N Is the vaginal wall reddened and/or thin? . . . . . . . . . . . . . . . . . . . . . . . . N Is there abnormal discharge? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . N


 stress  transient  transient

Male Is the foreskin abnormal (difficult to draw back, reddened)? . . . . . . . . . . . N Is there drainage from the penis? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . N Is the urethral meatus obstructed? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . N


 transient  transient  overflow

Select (circle) the type of incontinence that most fits the resident based on answers above: Urge Sudden urge, large amounts, can’t get to toilet in time

Stress Leakage when coughing, standing up, sneezing

Mixed Combination of urge and stress symptoms

Overflow Weak stream, dribbling, incomplete voiding

Functional Unable to get to toilet without assistance (mobility)

Transient Temporary or recent onset, variety of causes

2. Determine Resident’s Voiding Pattern Every resident should have a completed voiding diary upon admission and with significant changes in condition. Voiding diary scheduled (date) ________________________ Did the resident have a pattern? _______

Date completed _______________________


For pattern, see voiding diary.

3. Evaluate for Behavioral Program What is the MDS coding for item B0800 (Ability to understand others)? If 0, 1

If 2, 3

Consider MDS coding on G0110, 1-I (self performance/toileting)

Scheduled Voiding

If 0, 1, 2

If 3, 4

Bladder Rehabilitation or Pelvic Floor Rehab

Prompted Voiding

Residents with the following conditions could still benefit from participating in a prompted or scheduled voiding program: • Those who cannot feel “urge” to urinate • Agitated or disoriented residents • Bedridden residents or those with mobility limitations

Based on above, the resident may be a candidate for _______________________________________________________________________________ Resident is not a candidate for a bladder program due to: Use of appliances No bowel or bladder pattern Other ______________________ ©2011 Medline Industries Inc.

98 Healthy Skin


Continence Management Program: Forms

Forms & Tools

Urinary Continence

4. Determine Appropriate Absorbent Product Minimum Data Set (MDS) Version 3.0 — Section H 0300 & 0400, Bladder and Bowel





Always Continent

Occasionally Incontinent

Frequently Incontinent

H0300 & H0400

Bladder—less than 7 episodes of incontinence

Bladder—7+ episodes, at least 1 episode of continence

Bladder—No episodes of continent voiding

Bowel—1 episode of incontinence

Bowel—2+ episodes, at least 1 continent bowel movement

Bowel—No episodes of continent voiding

Ambulatory Weight-bearing

Always Incontinent


Heavy Liner

Bladder Control Pad: (females without bowel incontinence episodes) Liner

Nonambulatory Contracted Chronic diarrhea Combative Low air loss mattress

Protective Underwear

Adult Brief Ultrasorbs Dry Pad (on a low air loss mattress)

Daytime selection: _____________________________________

Adult Brief Heavy/Overnight Brief Ultrasorbs Dry Pad (on a low air loss mattress)

Overnight protection: __________________________________

5. Determine Sizing of Absorbent Product Determine and document the size by selecting the larger of the hip or waist measurement, or use sizing matrix reference based on gender/weight. Gender: M F

Weight ___________________

Hip measurement ________

Waist measurement ________



20" – 34"

Medium/Large: White backing

27" – 47"

Large/X-Large: Blue backing

39" – 59"

Small: Green backing

20" – 31"

Medium: White backing

32" – 42"

Regular: Purple backing

40" – 50"


Large: Blue backing

48" – 58"

Med/Large: Blue/Brown thread at waist

20" – 60"

X-Large: Beige backing

59" – 66"

X-Large: Green thread at waist

45" – 70"

XX-Large: Green backing

60" – 69"

XX-Large: Purple thread at waist

50" – 75"

Bariatric: Beige or Green backing

65" – 94"

XXX-Large: Red thread at waist

65" – 85"

5. Catheterization Catheter — Type ____________________________________ Size: ____________________________ Medical Justifications Urinary retention that cannot be treated medically or surgically, related to: - Post void residual volume over 200 ml - Persistent overflow incontinence - Inability to manage retention/incontinence - Symptomatic infections with intermittent catheterization - Renal dysfunction • Contamination of stage III or IV pressure ulcers with urine which impeded healing. • Terminal illness/severe impairments – which makes positing/changing uncomfortable or associated with intractable pain.


© Medline Industries Inc. ©2011

Improving Quality of Care Based on CMS Guidelines 99

PGD 2012 Pink Glove Dance II Video Competition

Vote for your favorite video at Voting ends: October 26 Winners announced: November 2 Winners Receive a Donation to Their Favorite Breast Cancer Charity* • First Place: $10,000 • Second Place: $5,000 • Third Place: $2,000 *Subject to review and approval by Medline Industries, Inc

Complete contest details are available at

©2012 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc. MKT1221151 / LIT806R / 25M / JBK 5

Healthy Skin Volume 10 Issue 3  

Medline's Healthy Skin Magazine, Volume 10, Issue 3 - FREE C...