Improving Quality of Care Based on CMS Guidelines
Volume 6, Issue 3
Tom Daschle on Healthcare Reform The Scoop on
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Bacteriaâ€™s Secret Hiding Spots
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Improving Quality of Care Based on CMS Guidelines
Editor Sue MacInnes, RD, LD
71 Making Sense of Changes to the LTC Surveyor Guidance
Clinical Editor Margaret Falconio-West, BSN, RN, APN/CNS, CWOCN, DAPWCA
33 A Systematic Approach to Pressure Ulcer Prevention Improves Patient Care, Reduces Costs 42 Legal Issues in the Care of Pressure Ulcers 50 Clean Up Your Act! 57 Tell Me Again Why This Resident Needs a Catheter? 66 Falls in Nursing Homes
Managing Editor Alecia Cooper, RN, BS, MBA, CNOR Senior Writer Carla Esser Lake Creative Director Mike Gotti Clinical Team
Clay Collins, RN, BSN, CWOCN, CFCN, DAPWCA
Lorri Downs, RN, BSN, MS, CIC
Margaret Falconio-West BSN, RN, APN/CNS, CWOCN, DAPWCA
Cynthia Fleck MBA, BSN, RN, APN/CNS, CWS, DNC, CFCN, DAPWCA, FCCWS
Kim Kehoe, BSN, RN, CWOCN, DAPWCA
Joyce Norman, RN, BSN, CWOCN, DAPWCA
Elizabeth O始Connell-Gifford, RN, BSN, CWOCN, DAPWCA, MBA Melissa Rossetta BSN, RN, CWCN
Jackie Todd, RN, BSN, CWCN, DAPWCA Wound Care Advisory Board Mary Brennan, RN, MBA, CWON Zemira M. Cerny, BS, RN, CWS
Patricia Coutts, RN
Cindy Felty MSN, RN, CNP, CWS
Evonne Fowler, RN, CNS, CWON Lynne Grant, MS, RN, CWOCN
Dea J. Kent, RN, MSN, NP-C, CWOCN
Diane Krasner, PhD, RN, CWCN, CWS, BCLNC, FAAN
Andrea McIntosh, RN, BSN, CWOCN, APN Linda Neiswender, RN, BSN, CPN Laurie Sparks, WOCN
Lynne Whitney-Caglia, RN, MSN, CNS, CWOCN Laurel Wiersema-Bryant, RN, ANP, BC
Deborah Zaricor, RN, CWOCN
26 What is Palliative Care? 31 Frequently Asked Questions: Palliative Care 46 Case Study: The Use of Basement Membrane and Extracellular Matrix-Containing Urinary Bladder Matrix 56 A Cost Effective Alternative to Urinary Catheterization 78 The Many Benefits of Correctly Sized Incontinence Briefs
8 14 19 20 22 81 82 84 49
The Quality Summit Highlights Prevention Above All Conference Highlights Public Reporting of Healthcare Errors and Infections What始s Happening in Healthcare Reform They Call it a Nursing Home for a Reason Creative Communication Techniques (English) Creative Communication Techniques (Spanish) FDA Issues Warnings for Diabetic Test Strips The Gang始s All Here and They始re Ready to Play
6 Two Important Initiatives for Improving Quality of Care 39 Hotline Hot Topic: Support Surfaces
90 How to Communicate More Effectively and Get More of What You Want 96 Losing Sleep Over Economic Worries? 99 Support Breast Cancer Awareness Caring for Yourself
102 Ten Absolutes: Simplify Daily Tasks and Create Positive Interactions (English) 104 Ten Absolutes: Simplify Daily Tasks and Create Positive Interactions (Spanish) 106 Incontinence Product Selection 107 FAQs: Catheter-Associated Urinary Tract Infection 109 How to Handrub? 110 Practice Hospital Bed Safety 115 Pressure Ulcer Pocket Reference Card
Forms & Tools
Improving Quality of Care Based on CMS Guidelines 3
Letter from the Editor
Dear Reader, It is with a sense of anticipation and genuine excitement that we launch this edition of Healthy Skin. Never in the history of this country has there been such an outpouring of debate and discussion on just how health care should be delivered, paid for and measured. Medline has been fortunate to have the opportunity on two different occasions, to bring together top healthcare executives, first from the long-term care industry, and then from the acute care industry, to discuss these issues. As a matter of fact, the first 18 pages of Healthy Skin are dedicated to these conferences, which were held in Washington, DC in July and August of this year. The meeting in July, The Quality Summit, brought together executives, both clinical and administrative, from long-term care facilities. We were grateful for the opportunity to host Dr. Keith Krein, chief medical officer of Kindred Healthcare; Dr. Andy Kramer, division head of healthcare policy and research at the University of Colorado; Mary Ousley, healthcare consultant and co-chair of AHCA Survey and Regulatory and Wayne Brannock, vice president of clinical affairs for Maryland Health Enterprises, just to name a few. The discussions, including a presentation by Senate Majority Leader Tom Daschle, centered around a continuous program of quality assurance. What are the obstacles? What has worked for these thought leaders to this point? How will the industry be molded in the future? How can long- term care better integrate with both hospitals and home care? And, how can we all, working together, provide the best care possible, to all patients all of the time? This was an open forum discussion, mixed with personal experiences, but centered on defining and offering a plan for executing quality care. The meeting in August, Prevention Above All, was geared toward chief medical officers and chief nursing officers from over 100 acute care hospitals from across the country. The emphasis of the conference was on prevention, specifically covering innovations in the reduction of catheter-associated urinary tract infections (CAUTI), hospital-acquired pressure ulcers and ways to improve hand hygiene practices. The audience was a powerhouse of talent, but just as dynamic were the
program presenters, which included Tom Daschle, Dr. Didier Pittet, from the World Health Organization (WHO); Dr. Trent Haywood, chief medical officer from VHA; Deborah Adler, known for educational healthcare product packaging design and Dr. Dale Bratzler, CEO of the national hospital QIO and representing the Surgical Care Improvement Project (SCIP) … and these are just a few of the speakers. We were also honored to host Dr. Harvey Fineberg, president of the Institute of Medicine, who discussed comparative effectiveness research and how it will impact the healthcare industry in the future. In this publication, we’ve given you a brief overview of what took place at these conferences, but I encourage you to also visit www.medline.com to hear for yourself the issues and potential solutions that are being discussed in both the long-term care and acute care arena. In August, we also announced our Discovery Grant Award winners, listed on page 15. Medline awarded over $700,000 in grant money to stimulate research that will lead to the development of new targeted interventions aimed at reducing medical risks and potential harm associated with hospital-acquired conditions, with a goal of effecting quality care in all settings. This initial grant program was so successful that Medline will be awarding a second round of grant funding. The next grant application period will be from November 1, 2009 through March 31, 2010.
How can we all, working together, provide the best care possible, to all patients all of
And that’s just the beginning of this magazine edition. You also will find an array of information on palliative care, falls prevention, diabetes care, pressure ulcers, CAUTI, our kick-off of our year-round breast cancer program, “Together we can save lives through early detection,” and much, much more. All the best to you, until we meet again,
Sue MacInnes, RD, LD Editor
Content Key Weʼve coded the articles and information in this magazine to indicate which national quality initiatives they pertain to. Throughout the publication, when you see these icons youʼll know immediately that the subject matter on that page relates to one or more of the following national initiatives: • QIO – Utilization and Quality Control Peer Review Organization • Advancing Excellence in Americaʼs Nursing Homes Weʼve tried to include content that clarifies the initiatives or give you ideas and tools for implementing their recommendations. For a summary of each of the above initiatives, see Pages 6 and 7.
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Two Important National Initiatives for Improving Quality of Care
Achieving better outcomes starts with an understanding of current quality of care initiatives. Hereʼs what you need to know about national projects and policies that are driving changes in nursing home and home health care.
QIO Utilization and Quality Control Peer Review Organization 9th Round Statement of Work
The QIO Statement of Work is based upon Part B of the Title XI of the Social Security Act. The Medicare-funded “Ninth Scope of Work” plan became effective August 1, 2008 and is a three-year work plan. Purpose: To carry out statutorily mandated review activities, such as: • Reviewing the quality of care provided to beneficiaries; • Reviewing beneficiary appeals of certain provider notices; • Reviewing potential anti-dumping cases; and • Implementing quality improvement activities as a result of case review activities. Goal: In the 9th SOW, the QIO Program has been redesigned with a framework for accountability and also in content. The content now consists of four themes with the goal to help providers, both in long-term care and acute-care facilities, prevent illness, decrease harm to patients and reduce waste in health care. Of note: QIOs will be required to help Medicare promote three overarching themes: adopt value-driven healthcare, support the adoption and use of health information technology and reduce health disparities in their communities. Under the direction of the Centers for Medicare & Medicaid Services (CMS), the QIO Program consists of a national network of 53 QIOs located in each of the 50 U.S. states, the District of Columbia, Puerto Rico and the Virgin Islands.
Quality Improvement Organization Program’s 9th Scope of Work Theme The official Executive Summaries for the 9th SOW Theme are available at: http://providers.ipro.org/index/9SOW_summaries
Advancing Excellence in America’s Nursing Homes
A coalition-based, two-year campaign initiated on September 26, 2006 to improve quality of life for nursing home residents and staff. The coalition has continued the campaign beyond its first-round end of August 25, 2008 for an additional 2 years (until September 26, 2010). Purpose: A coalition consisting of the Centers for Medicare & Medicaid Services (CMS), organizations representing providers, consumers and government that developed a grassroots campaign to build on and complement the work of existing quality initiatives including Nursing Home Quality Initiative (NHQI), Quality First and the culture change movement. Goal: To ensure that continuous quality improvement is comprehensive, sustainable and consumer-focused, the coalition has adopted goals that seek to improve clinical care, incorporate nursing home resident and family satisfaction surveys into continuing quality improvements and increase staff retention to allow for better, more consistent care for nursing home residents. Origin:
Participating providers will commit to focusing on at least three of the eight measurable goals, including at least one clinical goal and one operational process goal. Current participants may choose to continue with the same goals, add additional goals or change goals for the next two-year campaign. Advancing Excellence The coalition is meeting to consider the following additions for the next two-year campaign: 1. Improving immunizations as a clinical goal 2. Including target setting in all goals 3. Changes to the order in which the goals are presented
The 9th Scope of Work Content Themes Theme #4: Prevention Activities will focus on nine Tasks: 1. Recruiting participating practices 2. Identifying the pool of non-participating practices 3. Promoting care management processes for preventive services using EHRs 4. Completing assessments of care processes 5. Assisting with data submissions 6. Monitoring statewide rates (mammograms, CRC screens, influenza and pneumococcal immunizations) 7. Administering an assessment of care practices 8. Producing an Annual Report of statewide trends, showing baseline and rates 9. Submitting plans to optimize performance at 18 months
Theme #1: Beneficiary Protection Activities will focus on nine Tasks: 1. Case reviews 2. Quality improvement activities (QIAs) 3. Alternative dispute resolution (ADR) 4. Sanction activities 5. Physician acknowledgement monitoring 6. Collaboration with other CMS contractors 7. Promoting transparency through reporting 8. Quality data reporting 9. Communication (education and information) Theme #2: Patient Pathways/Care Transitions Activities will focus on three Tasks: 1. Community and provider selection and recruitment 2. Interventions 3. Monitoring
There will be two periods of evaluation under the 9th SOW. The first evaluation will focus on the QIO's work in three Theme areas (Care Transitions, Patient Safety and Prevention) and will occur at the end of 18 months. The second evaluation will examine the QIO's performance on Tasks within all Theme areas (Beneficiary Protection, Care Transitions, Patient Safety and Prevention). The second evaluation will take place at the end of the 28th month of the contract term and will be based on the most recent data available to CMS. The performance results of the evaluation at both time periods will be used to determine the performance on the overall contract.
Theme #3: Patient Safety Activities will focus on six primary Topics: 1. Reducing rates of health care-associated methicillin-resistant Staphylococcus aureus (MRSA) infections 2. Reducing rates of pressure ulcers in nursing homes and hospitals 3. Reducing rates of physical restraints in nursing homes 4. Improving inpatient surgical safety and heart failure treatment in hospitals 5. Improving drug safety 6. Providing quality improvement technical assistance to nursing homes in need
Focus for the 9th Scope of Work – Move away from projects that are “siloed” in specific care settings – Focused activities for providers most in need – New emphasis on senior leadership (CEOs, BODs) involvement in facility quality improvement programs
Clinical and Operational/Process Goals Clinical Goals: Goal 1: Reducing high-risk pressure ulcers Goal 2: Reducing the use of daily physical restraints Goal 3: Improving pain management for longer-term nursing home residents Goal 4: Improving pain management for short-stay, post-acute nursing home residents
Goal < 10% < 5% < 4%
Actual 11% 3.9%
Operational/Process Goals: Goal 5: Establishing individual targets for improving quality Goal 6: Assessing resident and family satisfaction with quality of care Goal 7: Increasing staff retention Goal 8: Improving consistent assignment of nursing home staff so that residents receive care from the same caregivers
Goal > 90%
Actual 36.5% 22.5%
Trends in Goal Selection Each nursing home participating in Advancing Excellence selects a minimum of three goals (outlined above). The goals – and the percentage of participating nursing homes that have selected them – are listed below.
Goal 1: 70.8%
Goal 5: 32.1%
Goal 2: 45.4%
Goal 6: 62.7%
Goal 3: 54.3%
Goal 7: 41.3%
Goal 4: 39.4%
Goal 8: 31.3%
Participating nursing homes: 7,434 Percentage of participating nursing homes:* 47.3% Participating consumers: 2,224
Visit this Web site to view progress by state! www.nhqualitycampaign.org/star_index.aspx?controls=states_map
Average number of goals per nursing home: 3.8
*Based on the latest available count of Medicare/Medicaid nursing homes
Represents a 7.4% increase in participation since January 2008.
Improving Quality of Care Based on CMS Guidelines 7
The Quality Summit
Quality Summit Shares Center Stage with Healthcare Reform Debate
Nation’s Capital Site of Medline’s First Quality Summit for LTC Leaders
This summer, while Congress was hotly debating the merits of healthcare reform, another key meeting was taking place in our nation’s capital on improving health care in this country. Just down the block from the capitol building in Washington, DC, more than 100 thought leaders from skilled nursing facilities across the country gathered to discuss the changing healthcare policy landscape, industry trends and resident-centered quality assurance measures. Former Senate Majority Leader Tom Daschle, architect of the Obama administration’s healthcare reform efforts, delivered the keynote address at Medline’s inaugural Quality Summit: A New Era of Quality Assurance in Long-Term Care held July 19-21. Senator Daschle praised the content and opportune timing of the summit.
“The timing of this Medline conference simply could not be better,” he remarked. “We are in the heart of this special moment in 2009.” But he also expressed disappointment in how the reform initiative is addressing the issues in long-term care. There is “not sufficient awareness and recognition of the degree to which long-term care ﬁts into this picture,” Daschle said. “Greater emphasis on wellness, good chronic care management, reducing administrative costs and creating a strong technology infrastructure are also needed,” he added. Still, Daschle urged participants to lend their voices to the debate to help craft legislation addressing long-term care issues. He also emphasized the importance of quality initiatives to high value health care, outlining three goals he hoped reform would achieve: 1) increased access to health care, 2) cost reductions and 3) improved outcomes through quality initiatives. Continued on Page 10
“ How do we improve our resident and familycentered quality of care and prepare for QIS?
We use abaqis.” Sherri Dahle, RN, DNS Director of Nursing Central Healthcare LeCenter, MN
The new Quality Indicator Survey (QIS) for nursing homes
That gives you a unique advantage in preparing for your
is more resident-centered, with more information obtained
survey – and in meeting your resident’s needs.
from direct questioning of residents and families. In fact, 60 percent of facilities have had more deficiencies in QIS than in the prior traditional survey, often in regulatory areas such as quality of life that were not as fully investigated in
abaqis® is sold exclusively through Medline. Learn more by signing up for a free webinar demo at www.medline.com/abaqisdemo.
the traditional process. ®
abaqis is the only quality assessment and reporting system for nursing homes that is tied directly to the QIS, and its quality assessment modules reproduce the same forms, analysis and thresholds used by State Agency surveyors. Rich reporting capabilities on 30 care areas guide you to what surveyors will be targeting in your facility. ©2009 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc., abaqis is a registered trademark of Nursing Home Quality, LLC
The Quality Summit
Quality Efforts Critical as Acuity Moves Downstream In open panel discussions, nursing home medical directors, administrators and chief executives noted the importance of quality efforts in understanding the increasingly complex needs of the residents and patients being served by longterm care facilities. With the increasing popularity of home- and communitybased options, which allow seniors to “age-in-place” in less restrictive settings, a growing number of residents are “coming to the skilled nursing environment at a later point in their life expectancy and with more multi-morbid conditions,” explained conference panel member Keith Krein, MD, chief medical ofﬁcer at Kindred HealthCare’s Health Services Division based in Louisville, KY. Dr. Krein stressed the growing importance and connection between physician services and quality measures. With some patients seeking rehabilitation services, and others requiring chronic or custodial care —all in the same facility— ongoing quality assurance efforts can help identify the differences in the care needs because regulatory oversight hasn’t stayed in synch with this pivotal industry shift, he said. “Forty years ago, long-term care was mostly custodial in nature,” Dr. Krein said. “Acute care, rehabilitation and recovery took place in the hospital environment, as opposed to the nursing home. Today’s environment increasingly consists of patients requiring many distinct types of care all residing in one facility. Quality measures can improve services and control costs.”
Quality Assurance Tools Key to Excellent Customer Service As skilled nursing facilities compete for private-pay rehabilitation patients, panelists also spoke about the importance of improving the perception of the facility not only with state surveyors, but also with staff, residents, patients and family members shopping for rehabilitation or custodial care services. “Stop looking for revenue from the government. It’s not going to be there,” advised Barry Bortz, chief executive ofﬁcer of Carespring Health Management in Loveland, Ohio.
10 Healthy Skin
“Generate outside sources of revenue. To be successful at generating outside sources of revenue, you have to have good customer service and you have to have those [quality assurance] tools in place.” For its quality assurance program, Bortz said, Carespring utilizes abaqis, the only quality assessment and reporting system tied directly to the Quality Indicator Survey (QIS). The Centers for Medicare & Medicaid Services (CMS) plan to rollout QIS in all 50 states, and to date more than 13 states have begun implementation. abaqis, sold exclusively through Medline, is a Web-based system that enables nursing home providers to identify quality concerns and focus their improvement efforts using the same forms, analysis and thresholds used by the state surveyors in the QIS survey. But abaqis is also designed as an ongoing quality improvement system to help enhance customer satisfaction year-round.
Nancy Schwalm, Mary Ousley, Neil L. Pruitt Jr. and Keith Krein at Medline’s Quality Summit, July 19-21, in Washington, DC.
Panelist Wayne Brannock, vice president of clinical affairs for Maryland Health Enterprises in Ellicott City, MD, said using abaqis transformed the quality assurance process at his skilled nursing facility. Just like QIS, abaqis requires facilities to interview staff members, residents and their families about speciﬁc aspects of care. During Brannock’s first resident interview, the resident responded negatively to the QIS question regarding bedtime. Brannock calls the carefully worded question, “Is this acceptable to you?” the ﬁve magic words. After receiving the resident’s response, Brannock said, “That’s the day we changed QA in our company, because that’s the day that we started actually communicating to residents,” he recalled. “By asking them what they really want, we’re ﬁnding out what’s acceptable to them, and then we alter our service to improve their experience.”
Quality Assurance: Truly a Year-Round Initiative But the panelists pointed out that truly improving quality involves more than annual state survey preparations and offers greater rewards than just a successful survey. “Systematic quality improvement brings conﬁdence, and it brings trust,” said Mary Ousley, president of Ousley & Associates in Richmond, KY, and co-chair of the American Health Care Association Survey and Regulatory. “It brings conﬁdence in your staff—[conﬁdence] that they really know what they are doing and that they are part of making change, and it brings trust internally and externally to the organization from survey organizations and ﬁnance.” Ousley explained that incorporating quality measures into how a facility operates, versus addressing it only in response to state surveys, was key to ensuring better care for residents and ensuring that the facility continuously improves.
Improving Quality of Care Based on CMS Guidelines 11
The overwhelming message conveyed by all of the Quality Summit panelists was that for a nursing home to survive and thrive, it must focus quality assurance efforts in residentcentered quality care.
to culture change and what’s important to each individual, and obviously we need to embrace that and do more of it, because it’s only through asking those questions and understanding whether we are improving the services that are truly needed, will we improve as time goes on.”
“The whole customer satisfaction movement has come a long way in long-term care over the last 20 years, and particularly over the last ﬁve – and will be an increasingly important part of the milieu for years to come,” Krein explained. “It gets back to person-centered care, it gets back
When it Comes to Resident-Centered Quality of Care, One Size Does Not Fit All During the Quality Summit, a chief medical ofﬁcer from one skilled nursing facility raised the issue of how best to deﬁne quality and whether the term still applied to the latest QIS survey guidance by CMS and resident-centered care approaches. Summit speakers Keith Krein, Andrew Kramer, Mary Ousley and Carmen Shell shared their insights, each stressing the importance of individualized care and the evolution of the quality movement. Keith Krein, MD. Quality starts by recognizing the “heterogeneity of today’s nursing centers and the fact that we have many different types of individuals— young folks, middle-aged folks, elderly folks—coming through our doors with different desires, different needs and different discharge goals,” said Keith Krein, MD, chief medical ofﬁcer at Kindred Healthcare. Dr. Krein explained that two individuals with the same diagnosis may request different types of treatment, emphasizing the importance of taking those differences into consideration when formulating a treatment plan. Andrew Kramer, MD. “We need to work on the deﬁnition. The deﬁnition of quality as a standard set of practices that are forcefully applied in every case regardless of whether they apply or not is the wrong definition of quality,” said Andrew Kramer, MD, division head of health care policy and research at the University of Colorado. “You want to try to measure the variability in care that exists within an organization. Do you adapt and customize and tailor care to the needs of all the people, or do you do the same thing every time because that’s the
12 Healthy Skin
way it’s supposed to be? Because that ability to vary and tailor care is more about quality than applying that same structured approach regardless of the individual’s needs. We have managed over the years to deﬁne quality with rigidities that do not reﬂect quality.” Mary Ousley. “The totality of services that meet or exceed the expectations of the individual deﬁnes quality,” said Mary Ousley, president of Ousley & Associates, drawing on the deﬁnition crafted by the American Health Care Association and Bernie Dana, chair of AHCA/NCAL’s National Award Board of Overseers. Ousley stressed that maintenance and environmental services may be of greater importance to one resident, while nursing care and services rank highly for another. Only by taking the resident’s perception and desires into consideration can a facility truly achieve quality. Carmen Shell. Carmen Shell, vice president of clinical services at Morse Geriatric Center, also stressed the importance of understanding the speciﬁc goals and expectations of each resident while creating a workable deﬁnition of quality. “The mistake that we make is defining quality for others,” Shell explained. “We don’t ask the right questions. That’s one thing about QIS that is beginning to come full circle, and that is the right questions are being answered, but sometimes we don’t listen to the answers. The questions are being asked, and the questions are getting better and better, but what are the answers to those questions? And if we really want to effect change, what are we doing?”
Mary Ousley on Quality Survey Says… Looking back on her decades of experience in long-term care, Mary Ousley believes the opportunity is before us today to take charge of quality. And her definition of quality involves far more than keeping track of QIs and QMs in notebooks, and then analyzing the data each month. She believes quality is best achieved by integrating a quality mindset into everything you do at your facility. “[Quality] is the way you run your business. It is embedded every single day. It is a philosophy of management that keeps your facility running,” Ousley said. “It is a business model that takes into consideration your business systems, your clinical systems, your human resources systems. And if you run it any other way, then you won’t really have a quality management system.”
To get a handle on the key issues facing our nation’s nursing homes, the more than 100 long-term care executives at the Quality Summit in Washington, DC were polled on the new QIS process and steps their facilities take to prepare for annual state surveys. Following are some of the poll questions and responses: What are the top three things that keep you up at night? 16% Patient/resident satisfaction 16% State survey 13% Documentation 13% Financial stability 11% Census 8% Lawsuits 8% Nursing shortage 6% Education & training 6% Turnover
“Quality management – exactly as it should work – is about moving an organization forward.”
Are your survey preparation activities aligned with your quality assurance initiatives? 80% Yes 20% No
After beginning her nursing career in acute care, Ousley reluctantly switched to long-term care when her husband asked her to serve as administrator for one of their familyowned nursing homes in Kentucky.
What do you do to prepare for the survey? 60% Mock survey 24% Chart review 16% Attempt to predict sample
She remembers one particular day at that facility when she established her personal mantra for long-term care. It was the day she met a resident named Hazel, whose colorful past included a position with Bob Hope’s public relations ﬁrm.
How far in advance of the annual state survey do you begin preparing for it? 43% More than 6 months 40% 3-6 months ahead 17% Less than 3 months ahead
“It was absolutely amazing to sit and talk with her,” Ousley said. “What I saw that day really set my path on quality. I no longer saw older people. I saw people. I learned about the value inside individuals and how we have to recognize and honor it in every single thing we do.” To achieve this, every team member must be onboard, according to Ousley, who often says the one position she would eliminate in long-term care if she could would be the quality assurance nurse. “The quality assurance nurse cannot assure quality. It has to be the team. It has to be the way we manage our facility every single day. It has to be the leadership we demonstrate,” Ousley said. “And the individual has to rest in the center of it – in our hearts – about what we do for quality.”
Have any of your buildings been through a QIS survey? 68% No 32% Yes Do you feel QIS will improve the quality of resident care? 46% Yes 18% No 36% I don’t know enough about it yet
Source: Medline Industries, Inc. poll of approximately 110 Quality Summit attendees. Data on file.
Improving Quality of Care Based on CMS Guidelines 13
TARGETED INTERVENTIONS • PRACTICAL SOLUTIONS
Prevention Above All Conference, Washington, DC, August 16-18, 2009 Chief nursing ofﬁcers, chief medical ofﬁcers, directors of nursing and other clinical executives from hospitals across the country gathered in Washington, DC, August 16-18, 2009, for Medline’s second annual Prevention Above All Conference. They learned new strategies for delivering cost-effective, high-quality health care in today’s uncertain economic climate, as well as evidencebased solutions for improving patient outcomes.
An impressive agenda Tying in all that is top-of-mind on Capitol Hill these days, former Senate Majority Leader Tom Daschle opened the conference by discussing the need for a stronger emphasis on primary care networks and an increased role for nurses in the prevention movement. Following Daschle was Institute of Medicine President Harvey Fineberg, who addressed the overwhelming beneﬁt of comparative effectiveness research. He also acknowledged, however, that “comparative effectiveness research alone will not ensure the adoption of valuable preventive care.”
Emphasis on patient safety Patient safety was a major focus, and world renowned experts shared the latest innovations and evidence-based practices in the prevention of catheter-associated urinary tract infections (CAUTI), hand hygiene and pressure ulcer prevention. CAUTI. Medline introduced its new evidence-based system to help prevent CAUTI. The ERASE CAUTI™ program combines product and packaging design, education and awareness to tackle catheter-associated urinary tract infection – a prevalent hospital-acquired infection. Hand hygiene. Internationally renowned professor and epidemiologist Didier Pittet of Switzerland shared the latest hand hygiene improvement strategies, including the new standard of care, alcohol-based hand rubs. Dr. Pittet is a member of the World Health Organization (WHO) World Alliance for Patient Safety and lead of the WHO’s First Global Patient Safety Challenge, “Clean Care Is Safe Care.” In addition, German epidemiologist Günter Kampf presented new discoveries and considerations in hand sanitizing techniques. He discussed the recommendation by the WHO that
14 Healthy Skin
hand sanitizers should contain 80% ethanol by volume for safe and effective hand decontamination. However, he noted that the United States currently recommends only 62% ethanol, far below the global standards defined by the WHO. Dr. Kampf works in the department of scientific affairs at Bode Chemie GmbH & Co. in Hamburg, Germany. He is the author of 119 scientiﬁc papers published in international infection control journals. Pressure ulcers. Pressure ulcer assessment and prevention remains a major area of concern. Wound care expert Elizabeth Ayello provided insight on CMS present-on-admission (POA) indicators as they relate to hospital administrators and clinicians. Also, two experts in wound care and healthcare law, Kevin Yankowski, J.D., partner at Fulbright & Jaworsky, LLP and Caroline Fife, MD, CWS, chief medical officer, Intellicure, Inc., addressed the legal implications of caring for patients with pressure ulcers, sharing ways healthcare professionals can protect themselves from litigation. Aspects of their presentation were based on their new white paper, “Legal Issues in the Care of Pressure Ulcer Patients: Key Concepts for Healthcare Providers.” SCIP. The Surgical Care Improvement Project continues to evolve, with two new measures debuting in October 2009. Highly regarded quality improvement specialist Dale Bratzler, medical director of the Hospital Interventions Quality Improvement Organization and SCIP, discussed patient safety in the context of SCIP and expanded on the upcoming new and revised SCIP measures.
Event highlights at medline.com/prevention-above-all For more information on the speakers and event coverage, visit the Prevention Above All page at www.medline.com/preventionabove-all.
Critical: What We Can Do About the Health-Care Crisis, authored by former Senator Tom Daschle, outlines the healthcare reform strategies that are the foundation of President Obama’s healthcare initiative. Evaluating where previous attempts at national healthcare coverage have succeeded, and where they have gone wrong, Daschle explains the complex social, economic and medical issues involved in reform and sets forth his vision for change. The book is available for purchase at leading retail bookstores and online outlets.
Special Feature interventions aimed at reducing medical risks and harms associated with hospital-acquired conditions (identiﬁed by the Centers for Medicare & Medicaid Services 2008 IPPS ﬁnal rule).
2009 Prevention Above All Discoveries Grants awarded Dr. Andrew Kramer, professor of medicine at the University of Colorado, and chair of the Prevention Above All (PAA) Discoveries Grant Review Committee, announced the names of the 2009 grant recipients.
All grant applications and proposals were independently reviewed and approved by healthcare professionals who served on the grant committee. Grant recipients will be paired with a research mentor/consultant to develop methods and guide the conduct of the study, ensuring that a rigorous research process is followed.
The objective of the PAA Discoveries Grant program is to stimulate research that will lead to the development of new targeted
Continued on Page 17
2009 Prevention Above All Discoveries Grant Recipients Congratulations to the following Prevention Above All Discoveries Grant recipients. Pilot Grants (funding up to $25,000 each)
Empirical Grants (funding up to $100,000 each)
Title: Surgical Time Out Assurance Program Institution: Carilion Clinic, Roanoke, Virginia Principal Investigator: Deb Copening Target: Surgical site infection and errors
Title: Cost Effectiveness of a Liquid Skin Protectant in the Prevention of Heel Pressure Ulcers Institution: New York Methodist Hospital, Brooklyn, New York Principal Investigator: Judy A LaJoie Target: Heel pressure ulcers
Title: Descriptive Study of OR Nursing Data Elements (Perioperative Clinical Processes, and Patient Outcomes) Institution: AORN (Association of PeriOperative Registered Nurses), Denver, CO Principal Investigator: AkkeNeel Talsma Target: Errors obtained in the perioperative area (OR processing errors and surgical patient complications) Title: Multi-institutional trial to test the validity of newly created HAI deﬁnitions and criteria designed especially for behavioral hospital and health care settings Institution: Acadia Hospital, Bangor, Maine Principal Investigator: Thomas Shandera Target: Healthcare-acquired infections Title: Pressure Ulcer Assessment Among Ethnically Diverse Patients Institution: Kaiser Permanente, San Jose Medical Center, San Jose, Calif. Principal Investigator: Katherine Ricossa Target: Pressure ulcers Title: Statewide Maine Infection Prevention Collaborative (MIPC) Institution: Eastern Maine HealthCare System, Brewer, Maine Principal Investigator: Erik Steele Target: Healthcare-acquired infections Title: Progressive Mobility Among Critically Ill and Critically Injured Patients: An Examination of Clinical Outcomes Prior to the Implementation of Standardized Guidelines Institution: East Tennessee State University College of Nursing, Johnson City, Tenn. Principal Investigator: Mona Baharestani Target: VAP, Pressure ulcers, falls, DVT, PE, catheter-associated urinary tract infections Title: Accelerating Pressure Ulcer Prevention Through Regional Collaboration – Partnership Grant Institution: The Hospital and HealthSystem Association of Pennsylvania/Health Care Improvement Foundation Pennsylvania Principal Investigator: Lynn Leighton and Kate Flynn Target: Pressure ulcers
Title: Pressure Ulcer Prevention via Early Detection and Documentation (both pediatric and adult) Institution: Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio Principal Investigator: Marty O. Vischer Target: Pressure ulcers Title: Perioperative Positioning Injuries Program Institution: Massachusetts General Hospital/Harvard Medical School Principal Investigator: Jesse M. Ehrenfeld Target: Perioperative positioning-related injuries Title: Family Centered Pressure Ulcer Prevention Program Institution: Grady Health System, Atlanta, Georgia Principal Investigator: Rhonda Scott Target: Pressure ulcers Title: Hand Hygiene Intervention Study Institution: Englewood Hospital and Medical Center, Englewood, New Jersey Principal Investigator: Maryelena Vargas Target: Hospital acquired infections Title: A Comprehensive Pressure Ulcer Prevention Program in a Multi-System Health Care Network Institution: St. Luke’s Hospital and Health Network, Bethlehem, Penn. Principal Investigator: Joanne Labiak Target: Pressure ulcers
TARGETED INTERVENTIONS • PRACTICAL SOLUTIONS
Improving Quality of Care Based on CMS Guidelines 15
1-800-MEDLINE I www.medline.com ÂŠ2009 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.
Yankowsky and Fife on Preventive Legal Care With the implementation of new CMS reimbursement guidelines in October 2008, hospitals have been stepping up efforts to prevent facility-acquired pressure ulcers. Attorney Kevin Yankowsky, who represents healthcare facilities and clinicians, urged Prevention Above All conference participants to implement preventive legal measures as well. “In this environment, you’re not looking at pressure ulcer prevention systematically unless you are also taking some time to look at how you can prevent legal risks and liabilities that arise from unavoidable pressure ulcers,” Yankowsky said. Yankowsky and co-presenter Caroline Fife, MD, are members of the International Expert Wound Care Advisory Panel that recently released the white paper “Legal Issues in the Care of Pressure Ulcer Patients: Key Concepts for Healthcare Providers.” (For an excerpt from the paper, turn to page 42) Yankowsky, a partner with Fulbright & Jaworsky, LLP, in Houston, Texas, stressed that healthcare litigation is about how much money can be made, not about righting bad care. Now that financial rewards have been limited by widespread tort reform in many areas of health care, Yankowsky said attorneys are increasingly taking cases that fall into the category of elder abuse. Elder abuse is an area that is an exception under many states’ tort reform legislation, and it still produces monetary awards in the millions of dollars. “As avenues to make big money are diminished in other tort areas,” Yankowsky said, “you are going to see more and more interest in litigation over pressure ulcers.”
Show Me the Money Pressure Ulcer Litigation: Civil Liability Awards Adams v. Valencia Health Care Center (Calif. 2008): Death from sepsis caused by decubitus ulcers: $2 million compensatory damage award Brown v. Menorah Home & Hospital (New York 2007): Medical malpractice: negligent treatment of decubitus ulcers: $1.25 million compensatory damage award Myers v. National Healthcare Corp. (Tenn. 2007): Wrongful death/medical malpractice: death from decubitus ulcers: $4.1 million compensatory damage award: $28.6 million punitive damage award
He added that facilities and clinicians who provide excellent care are at risk for litigation because plaintiff attorneys look for (and often ﬁnd) weaknesses in documentation and facility policies that give the appearance of abuse or neglect. The following is an excerpt Yankowsky shared from a recent advertisement for legal services in Texas: “Developing a bed sore is a clear sign of elder abuse. Bedsores are a sign of negligence.” This statement gives the public the impression that if an elderly individual develops a pressure ulcer, the reason is abuse and neglect, whereas healthcare professionals know otherwise. Pressure ulcers can develop even under the best of circumstances – and in spite of excellent care.
“Despite tort reform, and in some cases because of it – with an aging population and as an unintended consequence of a lot of these federal reimbursement regulations – the frequency and severity of your risk from legal consequences is here. It’s going to stay, and it’s likely to go up.” - Kevin Yankowsky Co-presenter Dr. Caroline Fife, a physician with experience treating patients with pressure ulcers, pointed out how the widely known and accepted pressure ulcer staging system, which labels pressure ulcers in Stages from I through IV, can give attorneys and their clients the false idea that pressure ulcers worsen along a continuum, with the assumption that their progression could have been stopped along the way. Fife, an associate professor of medicine at the University of Texas in Houston, explained how pressure ulcers develop from the inside out. Although there usually is extensive tissue damage deep within the layers of skin from the very beginning, the ﬁrst appearance of a pressure ulcer often looks like a bruise, known as a Stage I pressure ulcer. As time progresses, the true result of the injury deep within the tissue becomes visually apparent, and the pressure ulcer is labeled a Stage III or Stage IV. Logically and intuitively, it would seem that what began as a minor bruise developed into a severe, deep, oozing pressure ulcer, when in fact, a severe injury was there underneath the skin all the time. It just takes time to show itself visually.
Improving Quality of Care Based on CMS Guidelines 17
Yankowsky and Fife on Preventive Legal Care “The numeric nature of the [pressure ulcer] staging system creates the impression that the ulceration is worsening, implying negligent care, when, instead, the injury is evolving along a predictable path,” Fife said.
Medline’s Pressure Ulcer Prevention Program Update! The results are in the numbers. Be a part of our national benchmark scorecard to measure your progress and reduce facility-acquired pressure ulcers.
How to protect yourself and your facility Yankowsky outlined ways to remove opportunities for litigation through careful practices regarding the development of policies and procedures and patient chart documentation. He advised creating policies that are guidelines rather than hard and fast rules, in order to allow clinicians to exercise their professional judgment. “Policies and procedures must be drafted not only with an eye toward improving care, but also with careful consideration of their potential use by adversaries in future litigation,” Yankowsky advised. Concerning documentation, Yankowsky said the patient’s chart is the ﬁrst thing a plaintiff’s lawyer looks at when researching a case. He advised evaluating your documentation system with an eye toward both how it will be used for patient care needs now and how it will look to litigation adversaries years in the future. To learn more about preventive legal care, request a copy of the white paper, “Legal issues in the Care of Pressure Ulcer Patients: Key Concepts for Healthcare Providers” at www.medline.com/whitepaper/white-paper-registration.asp.
Hospitals currently enrolled
Nursing homes currently enrolled
Average test scores Nursing Assistant Registered Nurse
Pre-test 76% 77%
Post-test 92% 96%
Pressure Ulcers Average Facility-acquired Incidence Before implementing 6 pressure ulcers (16%) Medline PUP program After implementing Medline PUP program
3 pressure ulcers (3%)
Source: Data on ﬁle. Medline Industries, Inc.
Medline presents a powerful and comprehensive solution to six of the most common hospital-acquired conditions (HACs). The six conditions targeted by Prevention Above All and their complementary Medline product and program solutions are: 1. Operating Room and Surgical Errors Gold Standard Safety Program 2. Hospital-Acquired Infections Hand Hygiene Compliance Program Preventing HACs is one of the most important issues in health care today. Simply put, the CMS reimbursement changes that took effect last October 1 mean healthcare professionals must eliminate HACs and improve patient safety — or risk losing Medicare reimbursement dollars. The good news is that almost all HACs are preventable, and with Medline’s Prevention Above All, you will have the knowledge and products to prevent six of the most common HACs. The program’s multi-layered approach provides you with targeted evidence-based interventions that will not only save lives but also improve your bottom line.
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3. Pressure Ulcers Pressure Ulcer Prevention program 4. Harm Avoidance and Patient Satisfaction Educational Packaging 5. Objects Retained After Surgery RF Surgical® Detection System 6. Catheter-Associated Urinary Tract Infection (CAUTI) ERASE CAUTI™ Foley Catheter Management System
Public Reporting of Healthcare Errors and Infections WA VT MT
No HAI reporting required FL
HAI reporting required
Mandatory HAI Reporting in Long-Term Care Only four states currently require long-term care facilities to report the incidence of healthcareacquired infections (HAIs). The states are Oregon, California, Pennsylvania and Florida, as shown on the map above.
Copyright 2008 â€“ Association for Professionals in Infection Control and Epidemiology, Inc. Please contact firstname.lastname@example.org for reprint permission and update requests. Reprinted with permission.
SC MS TX
Hospital-specific public data FL
Statewide public data No public data
Voluntary reporting HI
State Reporting of Adverse Events With no national mandatory event reporting system in place, the United States is blanketed by a patchwork of state reporting systems collecting a variety of data in different ways. The amount of information available to the public also differs from state to state.
Reprinted with permission from Hearst Newspapers. Hearst research by Olivia Andrzejczak. Graphic by Kyla Calvert. Template by Alberto Cuadra. Available at http://www.chron.com/deadbymistake/hospitals.
Improving Quality of Care Based on CMS Guidelines 19
What’s Happening in Healthcare Reform
Patient-centered research Therefore, the healthcare research conducted under this initiative will be patient-centered and apply to the “real world” in order to help patients, clinicians and other decision makers assess the relative beneﬁts and harms of strategies to prevent, diagnose, treat, manage or monitor health conditions.1 In addition, the research should consider and include a variety of patient populations (e.g., people with disabilities and chronic illnesses, and different racial and ethnic backgrounds) for the program to be effective.2
Federal Coordinating Council for Comparative Effectiveness Research
Comparative Effectiveness Research:
What It Is and How It Can Help You and Your Patients Legislators in the Senate and House have been busy this year preparing and debating their versions of a healthcare reform bill. Perhaps one of the bills, or a hybrid, will be passed by the end of 2009. In the interim, the launch of a new federally funded healthcare program on comparative effectiveness research is well underway. The American Recovery and Reinvestment Act of 2009 allocated $1.1 billion to the U.S. Department of Health and Human Services (HHS) for this initiative. What is comparative effectiveness? The Institute of Medicine (IOM) deﬁnes it as “the extent to which a speciﬁc intervention, procedure, regimen or service does what it is intended to do under real world circumstances.”1 As HHS describes it, comparative effectiveness research provides information on the relative strengths and weaknesses of various medical interventions, including drugs, devices and procedures.2
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The ﬁrst step in the comparative effectiveness initiative was to appoint a management council in March 2009. The Federal Coordinating Council for Comparative Effectiveness Research (the Council) is composed of 15 distinguished leaders from key government healthcare-related agencies, including the Veterans Health Administration (VHA), Centers for Disease Control and Prevention (CDC), Centers for Medicare & Medicaid Services (CMS) and the HHS, among others.2 The Council’s purpose is to coordinate comparative effectiveness research and related health services research across the federal government with the intent of reducing duplication and encouraging the complementary use of resources.1
Goals of Comparative Effectiveness Research (CER) • Reduce healthcare costs2 • Build public interest2 • Improve patient care2 • Encourage development and use of clinical registries and data networks1 • Increase consistency of treatment provided in different geographic regions1 • Greater ability to tailor interventions to treat patients’ speciﬁc needs1 • Care based on evidence and best practices1
The Council will oversee the $1.1 billion in funding, of which $300 million is allocated to the Agency for Healthcare Research and Quality (AHRQ), $400 million to the National Institutes of Health (NIH) and $400 million to the Ofﬁce of the Secretary.1
High-Priority Topics for Federally Funded Comparative Effectiveness Research3 The American Recovery and Reinvestment Act of 2009 called on the Institute of Medicine to recommend a list of priority topics to be the initial focus of a new national investment in comparative effectiveness research. The complete list contains 100 topics, prioritized into four groups of 25 each. The following is a sampling of topics that relate to healthcare professional who care for older adults. They are listed in order from highest to lowest priority, as indicated by the Institute of Medicine: • Compare the effectiveness of the different treatments for hearing loss in children and adults, especially individuals with diverse cultural, language, medical and developmental backgrounds.
• Compare the long-term effectiveness of weight-bearing exercise and biphosphonates in preventing hip and vertebral fractures in older women with osteopenia and/or osteoporosis. • Compare the effectiveness of diverse models of transition support services for adults with complex health care needs (e.g., the elderly, homeless, mentally challenged) after hospital discharge. • Compare the effectiveness of different residential settings (e.g., home care, nursing home, group home) in caring for elderly patients with functional impairments.
References 1. U.S. Department of Health and Human Services. Federal Coordinating Council for Comparative Effectiveness Research: Report to the President and Congress, June 30, 2009. Available at http://www.hhs.gov/recovery/programs/cer/cerannualrpt.pdf. Accessed August 3, 2009. 2. Zigmond, J. Healthy choices: industry wonders how $1.1 billion for comparativeeffectiveness research will be applied. Modern Healthcare. March 30, 2009: 6-7,16. 3. Institute of Medicine. 100 Initial Priority Topics for Comparative Effectiveness Research. Available at http://www.iom.edu/?id=71032. Accessed August 3, 2009.
• Compare the effectiveness of primary prevention methods, such as exercise and balance training, versus clinical treatments in preventing falls in older adults at varying degrees of risk. • Compare the effectiveness of various screening, prophylaxis and treatment interventions in eradicating methicillin resistant Staphylococcus aureus (MRSA) in communities, institutions and hospitals. • Compare the effectiveness and costs of alternative detection and management strategies for dementia in community-dwelling individuals and their caregivers. • Compare the effectiveness of pharmacologic and non-pharmacologic treatments in managing behavioral disorders in people with Alzheimer’s disease and other dementias in home and institutional settings.
Improving Quality of Care Based on CMS Guidelines 21
They Call it
22 Healthy Skin
Brush aside those stereotypes — long-term care lets families ﬂourish and loved ones enjoy life
a Nursing Home For a Reason by Janice Gohm Webster, PhD
I remember a television advertisement not too long ago for an Alzheimer’s drug that has a middle-aged woman narrating about her fear that she would have had to put her father into a nursing home if it weren’t for this medication that has allowed him to continue living with her and her family. It was a warm-hearted ad that ended with the family having dinner together and laughing. The main message of the ad was that this medication works, but the not-so-subtle underlying message is that we need to do all we can to make sure that our aged parents do not have to live in the dreaded world known as “the nursing home.” If we are truly loving children, the message goes, we will do all we can to make sure our parents avoid such a hellish existence.
My mother was widowed at 74 and continued to live an incredibly active life for the next nine years or so. But then she lost her ability to drive. And her friends lost their ability to drive, or, in some cases, they passed away. She then lost her ability to walk unaided and began to experience urinary incontinence. Finally, she was diagnosed with early stage Alzheimer’s. Her world, always so rich with outings, friendship, travel, and interest in a wide variety of activities, became smaller and smaller. It happened quickly and seemingly all at once. She was left with just two regular activities: a weekly trip to the “beauty shop” where she would get her hair done and a weekly trip to mass.
Though the ad is effective, I became bothered by the message that nursing homes are, without question, negative places in which to live. I am bothered by this because I know it isn’t true: My 88-year-old mother has been living in a nursing home for two-anda-half years, and her time there has not only been “not negative,” it has been extremely positive. In fact, it has served to bring her back to us, her three children and two grandchildren.
One of my two brothers lived with her in the house where we grew up, but it became clear about three years ago that she needed more assistance than he was able to give. My husband and I teach English at a small college in Vermont and we, along with our two teenaged children, sincerely offered to have my mom move in with us. She’d always loved visiting us several times a year since we moved here in 1989, ﬁrst with my dad and then, after he passed away in 1994, on her own. But to our offer she Continued on Page 25
Improving Quality of Care Based on CMS Guidelines 23
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She moved into the nursing home in the summer of 2005 and almost immediately we knew it was the right choice.
replied, “Well, I love all of you with all my heart, but honey, what would I do there?” And although she wasn’t “doing” much in Michigan anymore, she did have a point. Although her world had grown small, it was still a world with which she was familiar, in a town where she’d lived her entire life. She wanted that familiarity and the comfort it provided her. So there we were. She couldn’t live alone, and she needed more help than my brothers and I could give her. So, after many lengthy conversations with each other and with my mom, we all made the decision that a nursing home was the appropriate choice. But even knowing this, we made the decision with some reluctance because we, like so many others, had the impression that a nursing home was less than one step away from the funeral parlor. And my mom had lived in our family home for 45 years, so leaving was emotional. But nonetheless, we knew it was the place my mom needed to be. And thankfully, she knew it as well. She moved into the nursing home in the summer of 2005, and almost immediately we knew it was the right choice. Three years later, I can honestly say that this home has not only provided a place for my mother to live, it has also provided a place for her to thrive. For the year or so before moving out of our family home, I would talk to my mom (we talk on the phone daily) and she would have very little to say. “What did you do today Mom?”
dinners that are always a treat, the regular concerts given by people from throughout the community and, of course, the regular visits from family and friends, and Mom has a richer life than we would have imagined possible before she moved there.
In addition to talking with Mom every day, I am able to visit every couple of months, and though she is conﬁned to a wheelchair, she is, in so many ways, the active mom she’s always been.
And some of the best news is that Mom’s Alzheimer’s remains incipient—most likely at least in part due to her re-engagement in so many activities lost to her in the last couple of years she lived at home. In addition to talking with Mom every day, I am able to visit every couple of months, and though she is conﬁned to a wheelchair, she is, in so many ways, the active mom she’s always been. She’s even able to leave the home for dinner out and overnights at my brother’s home where my family and I stay when we come to town. But, as much as she loves getting out and about—just as she always has—she is never reluctant to return, and that is both a huge relief and a real comfort to my brothers, my husband, my children, and myself.
“Oh, not much. Watched some TV. Took a nap. Ate a bit.” I would often cry after hanging up—feeling helpless and wanting to help. My mother, always a great conversationalist and easy laugher, now had little to say, was easily distracted, and seldom laughed. Now, I look so forward to talking with her every day because I know she’ll have a lot to say. And once again, every conversation is punctuated with laughter. She not only has three social meals a day with friends she’s made since moving in, she also has daily mass, she continues to get her hair done weekly at a shop right at the home, she participates in the daily reading/discussion of the local newspaper, she has physical therapy, and she plays various games provided on an almost daily basis. Add to this the monthly birthday parties—replete with cake and ice cream and various party favors—in honor of all of the residents celebrating birthdays that month, the monthly “wine and dine”
Because of the kindness of the nurses, aides, administrators, and volunteers, and because of relationships with other residents, the nursing home has really become her home. And, because she is in great spirits and better health than we ever could have dreamed of three years ago, I am so thankful that we didn’t let the stereotype of a “nursing home” keep our family from providing Mom with the best care possible. Making this choice has resulted in these years of her life being not just tolerable, but truly happy. How’s that for an advertisement? About the Author
Janice Gohm Webster, PhD, is an English professor at Champlain College, Burlington, Vermont. For further information, phone (802) 893-7622 or email email@example.com. Reprinted with permission from Long Term Living magazine
Improving Quality of Care Based on CMS Guidelines 25
What is Palliative Care? Palliative care (pronounced pal-lee-uh-tiv) is the medical specialty focused on relief of the pain, stress and other debilitating symptoms of serious illness.
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We encourage you to access the Center to Advance Palliative Care at www.getpalliativecare.org/home where you will find much more in-depth information, resources, videos and tools to help you understand and discuss palliative care.
Palliative care is not dependent on prognosis and can be delivered at the same time as treatment that is meant to cure. The goal is to relieve suffering and provide the best possible quality of life for patients and residents and their families. To date, there have been few resources to assist caregivers in learning about and explaining palliative care. Healthy Skin would like to introduce you to an excellent, Internet-based resource from the Center to Advance Palliative Care (CAPC). This article contains excerpts from the Get Palliative Care Web site. Let’s look at what they have to offer.
Different from hospice Palliative care is NOT the same as hospice care. Palliative care may be provided at any time during a person`s illness, even from the time of diagnosis. And, it may be given at the same time as curative treatment. Hospice care always provides palliative care. However, it is focused on terminally ill patients – people who no longer seek treatments to cure them and who are expected to live for about six months or less.
Provided by a team
Ensures quality of life Palliative care is not a one-size-ﬁts-all approach. Patients have a range of diseases and respond differently to treatment options. A key beneﬁt of palliative care is that it customizes treatment to meet the individual needs of each patient. Palliative care relieves symptoms such as pain, shortness of breath, fatigue, constipation, nausea, loss of appetite and difﬁculty sleeping. It helps patients gain the strength to carry on with daily life. It improves their ability to tolerate medical treatments. And it helps them better understand their choices for care. Overall, palliative care offers patients the best possible quality of life during their illness. Palliative care beneﬁts both patients and their families. Along with symptom management, communication and support for the family are the main goals. The team helps patients and families make medical decisions and choose treatments that are in line with their goals.
Usually a team of experts, including palliative care doctors, nurses and social workers, provides this type of care. Chaplains, massage therapists, pharmacists, nutritionists and others might also be part of the team. Typically, you get non-hospice palliative care in the hospital through a palliative care program. Working in partnership with your primary doctor, the palliative care team provides: • Expert treatment of pain and other symptoms • Close, clear communication • Help navigating the healthcare system • Guidance with difﬁcult and complex treatment choices • Detailed practical information and assistance • Emotional and spiritual support for you and your family
How to get pallative care There is a three step process provided by the Center to Advance Pallative Care to access pallative care. Step 1 recommends talking with the doctor. Most of the time, you have to ask a doctor for a palliative care referral to get palliative care services. Whether you are in the hospital or at home, a palliative care team can help you. They provide a list of some tips to help you talk to the doctor.
Improving Quality of Care Based on CMS Guidelines 27
Step 2 is The Palliative Care Provider Directory of Hospitals, which is a resource to help you locate a hospital in your area that provides a palliative care program. The directory is based upon palliative care programs listed in the American Hospital Association (AHA) Annual Survey. If you are looking for non-hospital-based palliative care, you are directed to go to www.caringinfo.org. Caring Connections, a program of the National Hospice and Palliative Care Organization (NHPCO). It is a national consumer and community engagement initiative to improve care at the end of life, supported by a grant from the Robert Wood Johnson Foundation. Step 3 involves meeting with a palliative care team. At this step you will find a list of questions that should be addressed during the team meeting to help the patient, resident and/or family determine if palliative care is appropriate for them.
Feels Like Homeâ„˘
Is palliative care right for you? There is an online survey with only four questions that can be completed by the patient, resident or family member to determine if palliative care is appropriate based upon individualized responses. In addition to the survey, there are direct links to many resources such as advance directives, cancer societies and other specialty organizations, ďŹ nancial assistance and many, many other resources. They include many personal stories, educational articles, facts and videos that can help everyone involved in the decision making process obtain the data needed to make the best decision.
om o R
er! v o ke a M
See for yourself what a difference Feels Like Home textiles will make in your facility. Choose any room in your facility and we will come in with the linen samples for a Feels Like Home room makeover. Schedule your FLH makeover today! To learn more about the Feels Like Home line, please call 1-800-MEDLINE, visit www.medline.com or speak to your Medline sales representative
We have also included a list of frequently asked questions that you can use to learn more about palliative care yourself and when discussing palliative care with your residents and patients.
Summing it up The Center to Advance Palliative Care (CAPC) provides healthcare professionals with the tools, training and technical assistance necessary to start and sustain successful palliative care programs in hospitals and other healthcare settings. CAPC is a national organization dedicated to increasing the availability of quality palliative care services for people facing serious illness. Direction and technical assistance are provided by Mount Sinai School of Medicine. Reprinted with permission from the Center to Advance Palliative Care. www.getpalliativecare.org. Getpallativecare.org is an Internet-based site sponsored by the Center to Advance Palliative Care (CAPC) and provided for general educational and informational purposes only.
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ÂŠ2009 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.
Some Methods Are Better Than Others for Getting The Job Done
Use the right tool for the job. Sure, it’s possible to cut your lawn using scissors, but it’s not the best tool for the job. Using the right tools help you get the job done more effectively and efficiently. That’s why you should consider Skintegrity® Wound Cleanser for cleaning wounds or TenderWet® for cleansing and debriding wounds. A gentle, yet thorough cleansing Skintegrity Wound Cleanser facilitates the removal of debris and proteinaceous material from the wound using a non-cytotoxic formula. And, it’s within the recommended guidelines for proper wound irrigation pressure.
A continuous rinsing effect TenderWet debrides necrotic wounds by attracting the large molecule proteins found in dead tissue and bacteria. At the same time, TenderWet cleans by releasing Ringer’s solution into the wound. This creates a rinsing effect that lasts for 24 hours, requiring less dressing changes compared to wet-to-dry. Two great options Skintegrity Wound Cleanser and TenderWet offer very effective options for cleansing and debriding wounds. “TenderWet is an excellent choice for debriding wounds, especially compared with wet-to-dry dressings. In our experience with TenderWet, wounds debride quickly and nursing visits are greatly reduced.” Connie Parsons, BS, RN, CWCN, CWS
SKINTEGRITY WOUND CLEANSER & TENDERWET Better options for cleansing and debriding wounds
FAQs 1. How do I know if palliative care is right for me? It may be right for you if you suffer from pain and other symptoms due to a serious illness. A coordinated clinical team can provide care to meet your needs and wishes and your family's during your illness. Serious illnesses include but are not limited to cancer, cardiac disease, respiratory disease, kidney failure, Alzheimerâ€™s, AIDS, Amyotrophic Lateral Sclerosis (ALS) and multiple sclerosis. Palliative care can be used at any stage of illness, not just advanced stages. 2. Who else, besides the patient, can benefit from palliative care? Everyone involved! Patients as well as family caregivers are the special focus of palliative care. Your doctors and nurses benefit, too, because they know they are meeting their patients' needs by providing care that reduces suffering and improves quality of life.
Frequently Asked Questions
Palliative Care 30 Healthy Skin
3. Does my insurance pay for palliative care? Most insurance plans cover all or part of the palliative care treatment you receive in the hospital, as with other hospital and medical services. This is also true of Medicare and Medicaid. Drugs and medical supplies and equipment may also be covered. If costs concern you, a social worker or ďŹ nancial consultant from the palliative care team can help you with payment options. 4. Where do people get palliative care? Palliative care can be offered in a number of places. These include hospitals, long-term care facilities, hospices or at home. 5. Can I get palliative care if I am at home? Yes. After symptoms and pain have been managed and are under control, you and your doctor can discuss outpatient palliative care.
6. What does palliative care involve? • Pain and symptom control: Your palliative care team will identify your sources of pain and discomfort. These may include problems with breathing, fatigue, depression, insomnia, or bowel or bladder. Then the team will provide treatments that can offer relief. These might include medication, along with massage therapy or relaxation techniques. • Communication and coordination: Palliative care teams are extremely good communicators. They put great emphasis on communication between you, your family and your doctors in order to ensure that your needs are fully met. These include establishing goals for your care, aid in decision-making and seamless coordination of care. • Emotional support: Palliative care focuses on the entire person, not just his or her illness. The team members caring for you will address any social, psychological, emotional or spiritual needs you may have. • Family/caregiver support: Caregivers bear a great deal of stress too, so the palliative care team supports them as well. This focused attention helps ease some of the strain and can help you with your decision-making. 6. What can I expect from palliative care? You can expect a comfortable and supportive atmosphere that reduces anxiety and stress. Your specialized plan of care is reviewed each day by the palliative care team and discussed with you to make sure your needs and wishes are being met. You can expect relief from symptoms such as pain, shortness of breath, fatigue, constipation, nausea, loss of appetite and difﬁculty sleeping. Palliative care addresses the whole person. It helps you carry on with your daily life. It improves your ability to go through medical treatments. And it helps you better understand your condition and your choices for medical care. In short, you can expect the best possible quality of life.
7. Does treatment meant to cure me stop when palliative care begins? No. You can get palliative care at any stage of illness, no matter what your diagnosis or prognosis. 8. Who provides palliative care? Usually a team of experts, including palliative care doctors, nurses and social workers, provides this type of care. Chaplains, massage therapists, pharmacists, nutritionists and others might also be part of the team. Generally, each hospital has its own type of team. 9. What role does my doctor play? The hallmark of palliative care is a team approach to patient care. Your primary doctor will continue to direct your care and play an active part in your treatment. The palliative care team provides support for and works in partnership with your primary doctor. 10. What is hospice care? Hospice care is for a patient who has a terminal diagnosis and is usually no longer seeking curative treatment. It focuses on relieving symptoms and supporting patients who are expected to live for months, not years. Hospice care is provided in the home, in a residential setting or in the hospital. 11. Is palliative care the same as hospice care? No. Hospice care provides palliative care for those approaching the last stages of life. Palliative care is appropriate for anyone, at any point of a serious illness. It can be provided at the same time as treatment that is meant to prolong your life. 12. How do I start getting palliative care? Ask for it! Start by talking with your doctor or nurse. Tell your family, friends and caregivers that you want palliative care. Then ask your doctor for a referral.
Improving Quality of Care Based on CMS Guidelines 31
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To learn more about Ultrasorbs® AP and Medline's Pressure Ulcer Prevention Program, contact your Medline representative, call 1-800-MEDLINE or visit us at www.medline.com/incocare
©2008 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.
A SYSTEMATIC APPROACH TO PRESSURE ULCER PREVENTION IMPROVES PATIENT CARE, REDUCES COSTS By Zemira M. Cerny, BS, RN, CWS Our Hospital:
Hospital: Chesapeake Regional Medical Center
Chesapeake Regional Medical Center, Chesapeake, VA, was founded in 1976 with the goal of providing the highest quality health care available to meet the needs of southeastern Virginia and northeastern North Carolina. The hospital established several affiliates over the years, and in 1998 they all combined under the same name, Chesapeake Regional Medical Center. The Medical Center includes: • A 310-bed inpatient facility • A 24-hour emergency room • Rehabilitation services • Two intensive care units – one is neurological, one is medical • Sleep Center • Lifestyle Center • Obstetrics • Center for Wound Care and Hyperbaric Medicine
Location: Chesapeake, VA
The hospital is a local, independent, community-focused organization offering area residents what they want: high-quality health care delivered by people who openly display their concern and compassion.
Challenge: Develop a systematic program to reduce prevalence level of hospital-acquired pressure ulcers
Size: 311-bed inpatient facility
Results: Conducted 90-day program trial in ICU2. Reduced ICU2’s pressure ulcer incidence from 57.1 percent to 0 percent. Overall, the facility’s pressure ulcer incidence went from 16.2% in July 2008 to 2.5% in May 2009. Estimated cost savings for the hospital were $1,079,500 in nursing time, pharmaceuticals and supplies.
When I joined the hospital in April 2008 as the facility’s Wound Care Coordinator, I learned we had an increasing level of hospital-acquired pressure ulcers. Pressure ulcers (sometimes referred to as “bed sores”) affect millions of people each year. A pressure ulcer is an injury to the skin that is caused by pressure. Sitting or lying in one position without moving puts pressure on the skin and slows down blood flow. When blood flow slows down, skin and tissue can die and result in a pressure ulcer. When pressure ulcers occur, they often can be painful, debilitating and potentially cause serious health issues. They also can add to a patient’s length of stay in the hospital. The cost savings from preventing pressure ulcers and eliminating additional treatment is very significant for both the hospital and our patients. According to the Centers for Medicare & Medicaid Services (CMS), the average cost per patient per hospital stay for a pressure ulcer as a secondary diagnosis is $43,180, including nursing time, medication and supplies. (See figure 2 on page 36.)
Improving Quality of Care Based on CMS Guidelines 33
In the spring of 2008, our hospital’s ICU2 unit had a pressure ulcer incidence level of 57.1 percent (incidence is the rate of new pressure ulcers in a given time period) with 25 hospital-acquired pressure ulcers. This number was significantly higher than the national benchmark of 3.3 percent. This was the result of inconsistent skin assessments as well as documentation, and a general lack of focus about the value of preventative skin care. Our program had focused on treating pressure ulcers after they had already developed rather than preventing them. The staff had products available, but education was limited regarding efficient use of these products. Ointments and cleansers were used, but provided no protective barrier to prevent pressure ulcer formation. The skincare procedure also did not include moisturizers, a key step to an effective skincare program. We also had very few pressure-relieving devices such as heel supports and cushions to help minimize pressure to vulnerable body parts. Use of reusable incontinence pads amplified the problem by keeping moisture close to the patients’ skin for extended periods of time. Although the high prevalence of pressure ulcers in our facility was cause for great concern, the issue took on more immediacy with the impending reimbursement changes. Beginning in October 2008, the Centers for Medicare & Medicaid Services (CMS) no longer reimbursed healthcare facilities at the higher payment rate for the costs associated with hospitalacquired pressure ulcers. With an at-risk population (elderly patients who are thin and have diabetes or vascular disease) of over 50 percent, our staff and senior administration realized the immediate
need to reevaluate the current pressure ulcer program and create a new, preventionoriented system. Beginning in May 2008, an interdisciplinary wound team and a wound care advisory panel was developed to create new protocols and procedures aimed at reducing pressure ulcer prevalence. The team consisted of physicians, nurses, dieticians and a physical therapist. The panel’s first initiative was to create an innovative program called the “Wound Warriors.” The Wound Warriors were the wound care team’s first line of defense on each unit. These individuals are nurses selected based on their interest in wound care. They receive additional education about the proper assessment and documentation involved in the prevention of pressure ulcers. Each team member dedicates two shifts per month to review audits and ensure that the correct procedures are being followed. They are also involved in wound rounds with the interdisciplinary wound team. Even with the creation of the Wound Warriors and their focus on pressure ulcers, a systematic, staff-wide approach to pressure ulcer prevention, including standardization and quality products, was still lacking.
The Solution In May 2008 we were introduced to Medline’s Pressure Ulcer Prevention Program (PUP) through a webinar presented by the company. The program, we learned, includes intensive staff education, skincare products and hands-on implementation by Medline staff aimed at reducing pressure ulcer incidence levels in healthcare facilities.
The program is based on sound wound care principles backed by excellent teaching materials. The one potential hurdle was that, on paper, the program would increase our supply budget with the introduction of some new, but necessary products. To overcome this initial challenge, Medline guaranteed that at the end of the trial period, if our facility did not reduce our incidence of facilityacquired pressure ulcers, they would reimburse us the cost of the products we used during the trial period. Moreover, knowing the severity and immediacy of the pressure ulcer situation at Chesapeake, the vice president of nursing was fully behind the program to do whatever we could to lower our rates.
Implementation We began the program in September 2008 with a 90-day trial in our ICU2 unit, whose total patient census is 14. As mentioned earlier, but worth repeating, the unit had a pressure ulcer incidence level of 57.1% percent with 25 hospitalacquired pressure ulcers – a disturbingly high level of pressure ulcers. The trial was spearheaded by the unit manager and involved the Medline wound care specialists, the Wound Warrior and the charge nurse. In all, there were about 45 ICU2 staff members participating in the program – 37 licensed nurses and eight nursing assistants (CNAs). The program started with an educational poster displayed in the staff lounge to bring awareness to the program. Prior to implementation, a pre-test was administered to our nurses and nursing Medline headquarters based in Mundelein, Ill.
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books covered CMS policy, risk factors, assessment, skin care, turning, incontinence care, nutrition and documentation. As a further incentive, everyone who successfully completes the course and achieves at least an 80 percent on the post-test will be presented with a reward pin to display on their uniform and a certificate of completion.
assistants to assess their baseline level of treating pressure ulcers. A post-test was then given about four to six weeks later to reassess the staff’s knowledge. The goal of the program is to pass the test with a score of 90 percent or higher. The Medline representatives implemented an incentive program with small awards to encourage staff members to review the materials and complete the tests within the specified time frame. This system worked well, and all nursing staff in ICU2 completed their tests on time. The staff’s initial test scores were actually pretty high – the average CNA score was 85 percent and the nurse’s was 83 percent. (See figure 1 on back page.)
Medline also supplied and reviewed the education and training materials with our staff. The unit manager received a comprehensive training manual including a CMS presentation, workbooks, instructor’s guide, forms and tools and pre- and post-tests. The nursing assistant’s workbook included basic information covering skin care, patient turning, incontinence care and nutrition. The nurse’s work-
The Medline representatives worked closely with our staff on the education aspect of the program by reviewing the format outlined in the workbooks. But the staff really took it upon themselves to learn the material through self-training. Medline conducted intensive inservicing on the products with our staff – covering their benefits and how and when to use them. Product education was a crucial step in the success of the program. The main products utilized in the program are: • Remedy advanced skin care system, Medline’s exclusive line of skin care products. The comprehensive program includes cleanser foams, barrier ointments, and skin repair creams (moisturizers). The staff also likes the products’ scent and feel, which further motivates them to use the products and follow the protocols. • Ultrasorbs Dry Pads, a superabsorbent underpad that wicks moisture away from the skin for increased dignity and better skin care. We also are using more pressure relief devices for highly vulnerable areas such as heels and elbows. These devices, when used properly in conjunction with the products cited above, help prevent
pressure ulcers in high-risk patients. The program also offers adult briefs and low air loss mattresses, but we have not employed those products as of yet.
The Results By the middle of October 2008 – about six weeks into the trial – ICU2’s pressure ulcer incidence was reduced to 23.1 percent, a reduction of more than half from where we started. At the end of the trial, ICU2’s incidence rate was down to 0 percent. This was in the beginning of January. A few weeks later, they were still at 0 percent with February’s facility-wide prevalence study. The facility’s incidence rate was 7.5 percent. As of May 13, 2009, the facility’s rate was down to 2.5 percent, which is below the national benchmark of 3.3 percent. What this means in real numbers is that at the end of the trial we had virtually no facility-acquired pressure ulcers, compared to the 25 we had at the beginning of the trial. This trend has continued as we report incidence levels well below the national average. The staff’s post-test scores also reflect these outstanding results. Both the CNA and nurse’s scores averaged 98 percent! Moreover, whatever little resistance we did have from our staff to this new system has completely disappeared and has been replaced by enthusiasm and a great amount of self-satisfaction for doing an excellent job. To have your staff believe in the benefits of the program and see their efforts result in improved patient care are essential to the long-term success of this or any patient care initiative. Most importantly, senior administration and materials management have fully
Improving Quality of Care Based on CMS Guidelines 35
bought into the program. By showing them how preventing pressure ulcers saved $1,079,500, they understood the full value of the program. (See figure 3 below.) This savings was determined by multiplying 25 – the number of pressure ulcers acquired in the ICU2 – by the average cost of a pressure ulcer – $43,180, as calculated by CMS. The savings numbers combined with implications of the the new CMS inpatient prospective payment system (IPPS) that no longer reimburses facilities at the higher payment rate for hospitalacquired pressure ulcers, presented an overwhelming case to administration to implement the program permanently in the ICU2 and to roll it out facility-wide.
Future Initiatives The success of the 90-day trial period has shown us that a systematic approach to pressure ulcer prevention can eliminate facility-acquired pressure ulcers. As a result of this success, we are now in the early stages of implementing the program facility-wide and hope to have it in all our nursing units by the end of June 2009. In order for complete house-wide prevention, we are anxiously awaiting the Medline emergency room pressure ulcer prevention program. In addition, in the summer of 2009, we will be seriously assessing Medline’s new pressure ulcer prevention module for the operating room. The operating room is a high-risk environment for pressure ulcers – according to AORN, the incidence of pressure ulcers occurring as a result of surgery may be as high as 66 percent. This perioperative module includes risk assessment and prevention methods to help prevent facility-acquired pressure ulcers in our surgical patient population.
Pressure Ulcer Prevention Education Data Figure 1: Chesapeake Regional Medical Center Pre-Test Scores
Pressure Ulcer Treatment Costs Figure 2: Pressure Ulcer Costs % of total treatment cost
Cost per patient/case*
*Centers for Medicare & Medicaid Services. Medicare Program; Changes to the Hospital Inpatient Prospective Payment Systems and Fiscal Year 2008 Rates; Final Rule. Federal Register. 2007;72(162):47130-48175
Pressure Ulcer Prevention Program Savings Figure 3: Chesapeake Regional Medical Center Savings Pre-Program
*Based on reducing the incidence of pressure ulcers from 25 prior to the implementation of the program to zero post-program.
ABOUT THE AUTHOR Zemira M. Cerny, BS, RN, CWS is the Wound Care Coordinator at Chesapeake Regional Medical Center in Chesapeake, VA. Zemira has 10 years specializing in wound care and is a Certified Wound Specialist through the American Academy of Wound Management. Zemira’s role is to oversee wound care in the outpatient and inpatient areas, whereby allowing for continuity of care across the health care settings. Currently, she is managing a staff of ten certified Hyperbaric and Wound Care Clinicians.
This paper was approved by the Wound Care Advisory Panel and Nurse Manager, the staff of ICU 2, Elaine Grifﬁths, VP of Nursing, Angela McPike, VP of Marketing, and Michelle Laisure, Corporate Compliance Ofﬁcer. ©2009 Chesapeake Hospital Authority. Medline is a registered trademark of Medline Industries, Inc.
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Join the program to reduce pressure ulcers. We’ve Made Pressure Ulcer Prevention Easy
Pressure Ulcer Prevention Program
Systematic efforts at education, heightened awareness, and specific interventions by interdisciplinary healthcare teams have demonstrated that a high incidence of pressure ulcers can be reduced.1
The Pressure Ulcer Prevention Program from Medline will help you in your efforts to reduce pressure ulcers in your facility.
The main challenges to having an effective pressure ulcer prevention program are: lack of resources; lack of staff education; behavioral challenges; and lack of patient and family education.2 Medline’s comprehensive Pressure Ulcer Prevention Program offers solutions to these challenges.
This has been a great learning experience for our staff and for our facility as a whole. I am thankful Medline had this program and that we were able to access it. I can’t imagine recreating this wheel!”
The program includes: • Education for RNs, LPNs, CNAs and MDs • Teaching materials for you to help train your staff • Practical tools to help reduce the incidence of pressure ulcers • Innovative products supported by evidence-based information that results in better patient care References 1 Holmes A, Edelstein T. Envisioning a world without pressure ulcers. ECPN. 2007;122(8):24-29. 2 CMS Roundtable, Omni Hotel, Chicago, Ill. March 10, 2008.
To join the ﬁght against pressure ulcers and for more information on the Pressure Ulcer Prevention Program, please contact your Medline sales representative or call 1-800-MEDLINE.
Katrina “Kitty” Strowbridge, RN Quality Improvement Coordinator St. Luke Community Healthcare Network Ronan, Montana
www.medline.com ©2009 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.
Under Pressure? Alternating-pressure, low-air-loss therapy mattresses are a critical component in your battle to help prevent pressure ulcers. Medline® Supra DPS mattresses are affordable, state-of-the-art and virtually maintenance free. They feature a digital pump and advanced technology. The innovative specialty air support surface features: • Alternating pressure/low air loss/static float/auto firm/seat inflation • Choice of four alternating pressure cycle times • Upgraded low-friction, anti-shear stretch cover • Stays inflated during power outages • Cell-on-cell mattress design prevents “bottoming out” • Quick connector allows for easy setup and keeps mattress inflated during transport • 400 lb. weight capacity The Supra DPS is also available with 4” raised edges to help reduce the risk of patient falls and entrapment. This unique design utilizes raised air bolsters that are integrated into the mattress to enhance patient safety and comfort.
For more information on alternating-pressure, low-air-loss therapy mattresses, contact your Medline sales representative or call 1-800-MEDLINE.
©2009 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.
Hotline Hot Topic Support Surfaces by Jackie Todd, RN, CWCN, DAPWCA
Every day clinicians turn to Medline’s Wound Care Hotline in search of solutions for their patients’ and residents’ wound and skin care needs. Some questions are simple; some are more complex, but at the end of the day the fact remains that the callers need guidance to ﬁnd the right solution, and the clinical education specialists at Medline are there to answer their calls. A recent caller asked about support surfaces, which play a multi-faceted role in making a difference in the quality of care patients receive. ate support surface, you must become familiar with the following terms: • Capillary closing pressure • Internal cushion pressure • Interface pressure These terms may sound confusing, but think about an item you Minimizing the risk for pressure ulcers already know, such as a tire. The surface of the tire, where the Many patients are considered to be at high-risk for pressure rubber meets the road, is the interface pressure, the air inside ulcer development due to their injuries, disease processes the tire corresponds to the internal cushion pressure, and if there and/or the presence of risk factors such as malnutrition and happened to be a cat in the road, and you accidentally rode immobility Although many factors are involved, the primary over its tail, there would be capillary cause of pressure ulcers is sustained closing pressure in the tail. “Pressure causes compression of the cutaneous and Many factors go into appropriately choosing a support surface. Developing product selection guidelines speciﬁc to a particular facility and based on patient characteristics may reduce excessive and inappropriate use of specialty support surfaces.1
subcutaneous tissue between a bony prominence and a surface. When external pressure is greater than capillary blood-ﬂow pressure, diminished and impaired blood ﬂow leads to the death of the tissues.1
pressure ulcers,” and the only variable you have complete control of is the support surface.
“Pressure causes pressure ulcers,” and the only variable you have complete control of is the support surface. Therefore, it is important to understand the performance characteristics delivered by various support surfaces. Each redistributes pressure in a different way and to a different degree. Let’s start with how to evaluate a support surface’s ability to redistribute pressure.
Pressure redistribution It would be nice if we had a tool that could predict when tissue is in danger of dying from pressure. Unfortunately, there are no tissue viability measurement tools currently available. So, to help make an informed decision when selecting the most appropri-
Now, if that same cat were not on the road, but on a soft marsh when the tire rode over its tail, the tail would sink into the soft surface and be protected from the pressure of the tire.
You can use the same theory when thinking of a support surface for your patient or resident. This would equate to the “immersion” property of the surface, which is the ability to let the patient’s body sink into the surface. Along with the envelopment that occurs around the patient’s body as he is immersed into the surface, the redistribution of weight is maximized across the surface. This, in turn, minimizes pressure over any given point and reduces the risk of capillary closure and subsequent tissue death that results in pressure ulcer formation. Another key component to remember is that a small amount of pressure (even while sitting or lying on a surface that provides
Improving Quality of Care Based on CMS Guidelines 39
Hotline Hot Topic maximum pressure redistribution) over a long period of time can do as much damage at the capillary level as a large amount of pressure over a short period of time. What does all of this mean? It means that no surface is a magic potion or silver bullet. Regardless of the support surface used, patients/residents still need to be turned a minimum of every two hours or more frequently if tissue tolerance requires it. Tissue tolerance is the skin’s ability to resist injury due to pressure. Capillary closing pressure for every person is as individual as a ﬁngerprint. So everyone’s skin can tolerate different amounts of pressure for different lengths of time before injury takes place. Capillary closing pressure is the measurement of pressure on capillaries (in mmHg) that will cause their collapse or closure. Capillary closing pressure is the only measurement that has real value because it reﬂects intracapillary pressure in the tissues themselves, not surface pressures outside the body. Capillary closing pressure can only be measured by invasive techniques and has been found to be around 32 mmHg2 but will be different for each patient. The pressure can range from as low as 12 to as high as 40 mmHg.3 This information supports the individualization of turning schedules to prevent skin breakdown.
How to choose the right support surface Specialty support surfaces are frequently rented, and those fees can dramatically add to yearly expenditures for treatment of pressure ulcers, depending on the sophistication of the technology used. That’s why capital purchases of surfaces have become a more appealing choice. Plus, having the right surface readily available means quicker intervention, which results in better outcomes. So how do you choose the right support surface for your patient or resident? This is not a “one size ﬁts all” world, and one product cannot meet the needs of everyone. When selecting a support surface, it is best to begin by determining the depth of tissue destruction and/ or by determining the patient’s level of risk. You’ll also want to review the support surface features that can reduce or eliminate shear, friction, moisture and other factors that contribute to pressure ulcer development.
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In addition to keeping these contributing factors in mind, as well as whether the patient already has existing pressure ulcers and their anatomical locations, we also must consider pain control when we decide which support surface the patient requires. Whether a prevention or treatment surface is needed and chosen, the need for pain control must be included in the choice criteria. Turning and repositioning, as well as pressure redistribution, are key components in pain control for immobile patients. Comfort and the ability to rest are very important pieces in the healing process as well, so choosing the surface that meets all these needs is imperative to positive outcomes. The right support surface dramatically contributes to the prevention and treatment of pressure ulcers. Combining good skin care, adequate nutrition, appropriate interventions for all contributing factors and co-morbid conditions makes attaining positive outcomes a more realizable goal. Positive outcomes result from “managing the whole patient, not just the hole in the patient” and getting positive outcomes shows the high quality of care given, which results in improved quality of life. References 1. Warren JB, Yoder LH, Young-McCaughan S. Development of a decision tree for support surfaces: a tool for nursing. MedSurg Nursing. 1999; 8(4):239-245, 248. Available at http:// ﬁndarticles.com/p/articles/mi_m0FSS/is_4_8/ai_n18608862. Accessed August 28, 2009. 2. Viney C. Mobility Needs In: Nursing the Critically Ill. 1999. Harcourt Publishers Limited: Edinborough, Scotland. Available at: http://books.google.com/books?id=kEe9tvW5kSs C&pg=PA288&lpg=PA288&dq=Capillary+closing+pressure+has+been+found+to+be+ around+32+mmHg&source=bl&ots=5b-jyYQAw8&sig=spSd2AATO3jF1YtczogkAQvv P24&hl=en&ei=cxWhSob-K4u_lAfBpo2TDQ&sa=X&oi=book_result&ct=result& resnum=1#v=onepage&q=Capillary%20closing%20pressure%20has %20been%20 found%20to%20be%20around%2032%20mmHg&f=false. Accessed September 4, 2009. 3. Le KM, Madsen BL, Barth PW, Ksander GA, Angell JB, Vistnes LM. An in-depth look at pressure sores using monolithic silicone pressure sensors. Plastic & Reconstructive Surgery 1984; 74(6):745-754.
About the author
Jackie Todd RN, CWCN, DAPWCA is the Clinical Education Specialist for the Atlantic Region of Medline Industries. She is a member of the Wound Ostomy and Continence Nurses Society; a Diplomat in the American Professional Wound Care Association; and a member of the Association for the Advancement of Wound Care. Jackie is a Corporate Advisory Council member of the National Pressure Ulcer Advisory Panel, serving on both the Support Surface Standards Initiative and the Deep Tissue Injury Task Force, and Public Policy Committee. She has served as a Corporate Advisory Council member to the European Pressure Ulcer Advisory Panel, a corporate liaison to board members of the Japanese Pressure Ulcer Society and the Australian Wound Management Association.
Bringing it home to you More than 1 million Americans receive home health care services every year.1 Just as every patient is unique, so is
For your free cost-savings analysis, contact your sales representative or call 1-800-678-7852.
every home health care agency. That’s why Medline HomeCare is proud to offer innovative solutions for every segment of your business, designed to fit your specific needs. We provide: • Supply management • Clinical support • Increased productivity • Back office connectivity • Documented cost savings To learn more about Medline HomeCare, call us at 1-800-678-7852. Reference 1 The Centers for Disease Control and Prevention. Home Health Care Patients: Data from the 2000 National Home and Hospice Care Survey. Available at: www.cdc.gov/nchs/pressroom/04facts/patients.htm. Accessed April 12, 2008.
©2009 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.
Legal Issues in the Care of Pressure Ulcer Patients The International Expert Wound Care Advisory Panel released a 23-page white paper in June 2009 identifying key concepts to help healthcare professionals with preventative legal care practices taking into consideration the current pressure ulcer regulatory and legal environment. The paper is titled “Legal Issues in the Care of Pressure Ulcer Patients: Key Concepts for Healthcare Providers.” Lawsuits over pressure ulcers are increasingly common in both acute and long-term settings with judgments as high as $312 million in a single case.1 Quoting from the paper itself, “Like some pressure ulcers, litigation over pressure ulcers may be unavoidable. For this reason, knowing how to react when it occurs is no less important than knowing how to minimize the risk of pressure ulcer lawsuits themselves.”2 Read the excerpt on the next page from “Legal Issues in the Care of Pressure Ulcer Patients: Key Concepts for Healthcare Providers” for a nurse’s personal account of what happened after she was handed a subpoena to report for a deposition. For more information and to request a copy of the entire white paper, visit Medline’s Web site at www.medline.com/whitepaper/white-paperregistration.asp.
References 1. Voss AC, Bender SA, Ferguson ML, et al. Long-term care liability for pressure ulcers. J Am Geriatric Soc. 2005;53:1587-1592. 2. Ayello EA, Capitulo KL, Fife CE, Fowler E, Krasner DL, Mulder G, et al. Legal is sues in the care of pressure ulcer patients: key concepts for healthcare providers. White paper. June 2009. 3. Aronovitch SA. Intraoperatively acquired pressure ulcers: are there common risk factors? Ostomy Wound Management. 2007;53(2):57-69. Available at http://www.o-wm.com/article/6776. Accessed July 29, 2009.
42 Healthy Skin
IJJJJJJJJJJJJI Deposed: A Personal Perspective By Evonne Fowler, MSN, RN, CWOCN The unthinkable happened to me. In my 46 years of nursing, I have always felt that I was a patient advocate. In fact, I have told many a patient, “If I were you, I would want me to take care of you.” I was shocked when I opened the door one evening and was handed a subpoena to report for a deposition. One of the patients I had cared for a few years ago had brought a lawsuit against the hospital and I was implicated as one of the wound care specialists who had rendered service. I was devastated. I have always done my best to keep patients in my charge clean, dry, comfortable and safe. So how did this happen and what does it mean for me? What would happen next? I remembered the patient quite well. She was a very complex and difficult patient. Here’s what my review of her medical record revealed. She was a 54-year-old morbidly obese (425 lbs.) female who was admitted to the Emergency Department after three days of being febrile, unable to eat, experiencing liquid stools and being lethargic. The paramedics had been called to the home earlier, but she had refused to be taken to the hospital. Later that night, her daughter was able to persuade her to go to the Emergency Department. Her admitting diagnosis was right leg cellulitis. She had a history of multiple co-morbidities including venous disease, diabetes, morbid obesity, hypertension, chronic anemia, chronic kidney disease, asthma, and of non-adherent behavior. She had called the membership services over 100 times during her years of coverage, reporting various incidents regarding her care. A few hours after admission, she was taken to the operating room, where she had a soft tissue incision and fasciotomy for compartment syndrome of the right leg. On post-op admission to the intensive care unit, her initial skin assessment was clear
of bruising or wounds. She developed sepsis, had an altered mental status with bouts of confusion, uncooperative behavior, lethargy, difficulty awakening and agitation; she was verbally abusive to the staff. Her hospitalization was fraught with complications, including pneumonia with subsequent need for intubation. Her behavior became combative. She pulled out the nasogastric tube and intravenous lines and had to be placed in restraints. Eight days after admission, two pressure ulcers (Stage I and Stage II) were noted in the sacral area. As per our protocol, photographs were taken. On post op day 12, the orthopedic surgeon requested a wound care consultation for recommendations regarding the management of the open fasciotomy incision. During the skin assessment, the wound care nurse documented a 9 x 20 centimeter unstageable pressure ulcer on the sacral area, 75% black, 20% yellow, 5% red. The patient was on the bariatric air support surface. The post-op leg wound continued to heal; however, the sacral pressure ulcer needed multiple surgical debridements. At the base of the pressure ulcer, an abscessed area was found. Once the sacral area was clean, a negative pressure wound therapy closure device was applied over the wound. Upon discharge, she spent an additional six months in a skilled nursing facility for pressure ulcer management. Eventually, she returned home with a small open wound. Her lower leg cellulitis had extended into an eight-month saga due to the complication from the hospital-acquired pressure ulcer. Now what? I was a fact witness (required to help relate the specific facts of this one case) rather than expert witness (who is usually called in to offer an opinion). The hospital’s attorney represented me for the deposition. I was called by the defense and counseled not to give any opinions.
IJJJJJJJJJJJJI Legal Issues in the Care of Pressure Ulcers: Key Concepts for Healthcare Providers
Improving Quality of Care Based on CMS Guidelines 43 21
IJJJJJJJJJJJJI My attorney sent a file box filled with medical records for me to review. I was frustrated as I reviewed these records. Notes were handwritten, difficult to read and fragmented with different disciplines writing in various sections. Very few notes were made in the comment section of the nursing notes. Flow sheets were not completed. It was challenging to determine if the patient actually had been turned, cleansed and repositioned consistently. Although the patient was incontinent of stool, there were very few episodes of incontinence noted. Even though I remembered that she was placed on a special mattress for pressure redistribution, I was unable to determine this fact from the chart, despite the fact that a special bed was ordered on day eight.
Lessons Learned Some of the common complaints registered against nurses in a lawsuit are failure to follow a standard of care, failure to communicate, failure to assess and monitor appropriately, failure to report significant findings, failure to act as a patient advocate and failure to document. That certainly applies in this case. Documentation is essential! Here are the main lessons I learned from this experience:
s /N ADMISSION IT IS IMPORTANT FOR THE wound care specialist to assess the patientâ€™s skin and wound and write a detailed, initial, focused assessment. If a wound is present on admission, document the wound profile.
The Deposition The attorney for the plaintiff handed me the nursesâ€™ notes for the first seven days of the patientâ€™s hospitalization and asked me to read the Braden Score, the integumentary, neuromuscular section, turning/repositioning section of the flow sheet and the nursesâ€™ comment section. There was very little charted in any of the sections. The Braden Score showed the patient to be at high risk for pressure ulcer development. I was unable to find a plan of care in any of the files. Although the hospital had just implemented a new pressure ulcer program, none of the new forms or the pressure ulcer trending were filled out. The attorney had me go through the chart looking for documentation of instances of patient non-adherence. I was stunned at the lack of documentation by both physicians and nurses about her behavior, the skin and the pressure ulcer throughout her hospitalization.