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Improving Quality of Care Based on CMS Guidelines

Volume 6, Issue 3

Tom Daschle on Healthcare Reform The Scoop on

Support Surfaces FREE CE!

Create a Homelike Environment

Bacteria’s Secret Hiding Spots


Join the team!


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

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

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

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

Contact us at to learn more!

© 2009 Medline Industries, Inc. Healthy Skin is published by Medline Industries, Inc. One Medline Place, Mundelein, IL 60060. 1-800-MEDLINE.


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


Lorri Downs, RN, BSN, MS, CIC

Margaret Falconio-West BSN, RN, APN/CNS, 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

Survey Readiness


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

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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

Page 22

Special Features

6 Two Important Initiatives for Improving Quality of Care 39 Hotline Hot Topic: Support Surfaces

Page 26

Regular Features

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

Page 50

Forms & Tools

Page 66

Improving Quality of Care Based on CMS Guidelines 3

Healthy Skin

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 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

the time?

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.


Healthy Skin

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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:


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


Healthy Skin

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%

< 15%

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%

13.9% 26.6%

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!

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

Special Feature

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


Healthy Skin

“ 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

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




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 For more information on the speakers and event coverage, visit the Prevention Above All page at

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




Improving Quality of Care Based on CMS Guidelines 15

1-800-MEDLINE I Š2009 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

Kevin Yankowsky

Caroline Fife

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

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

Special Feature

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&#x20AC;&#x201C; Association for Professionals in Infection Control and Epidemiology, Inc. Please contact for reprint permission and update requests. Reprinted with permission.



































Hospital-specific public data FL

Statewide public data No public data


Voluntary reporting HI

No reporting

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.

System pending

Reprinted with permission from Hearst Newspapers. Hearst research by Olivia Andrzejczak. Graphic by Kyla Calvert. Template by Alberto Cuadra. Available at

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

20 Healthy Skin

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

Special Feature

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 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 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

Special Feature

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 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.

26 Healthy Skin

We encourage you to access the Center to Advance Palliative Care at 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 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.


Take the

Feels Like Homeâ&#x201E;˘


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 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. is an Internet-based site sponsored by the Center to Advance Palliative Care (CAPC) and provided for general educational and informational purposes only.

28 Healthy Skin

Š2009 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&#x20AC;&#x2122;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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©2008 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.


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

Our Challenge

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.

34 Healthy Skin

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

Post-Test Scores















Pressure Ulcer Treatment Costs Figure 2: Pressure Ulcer Costs % of total treatment cost

Cost per patient/case*

Nursing Time









Total Costs




*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



Nursing Time













Total Savings


*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 ©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:// Accessed August 28, 2009. 2. Viney C. Mobility Needs In: Nursing the Critically Ill. 1999. Harcourt Publishers Limited: Edinborough, Scotland. Available at: 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: 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

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 Accessed July 29, 2009.

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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 /NADMISSION ITISIMPORTANTFORTHEwound care specialist to assess the patientâ&#x20AC;&#x2122;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&#x20AC;&#x2122; notes for the first seven days of the patientâ&#x20AC;&#x2122;s hospitalization and asked me to read the Braden Score, the integumentary, neuromuscular section, turning/repositioning section of the flow sheet and the nursesâ&#x20AC;&#x2122; 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.

s $OCUMENTTHETYPEOFSUPPORTSURFACEthe patient is on or whenever a support system change is ordered.

s 4AKEACLEARPHOTOGRAPHOFTHEWOUNDaccording to your organizationâ&#x20AC;&#x2122;s guidelines. For me, that would mean using a measurement label and a black marking pen to clearly identify the patientâ&#x20AC;&#x2122;s name or initials, medical record number, date and location of the wound on the photo.


s ,ABELANDPLACETHEPREVENTIONPROTOCOL standing orders and, if a wound is present, the wound and skin care treatment standing orders. Complete the required sections and sign.

s .OTIFYTHEPHYSICIANREGARDINGTHESKIN wound condition. Based on your findings, document if the wound is healable or non-healable and document the interventions for prevention and treatment of the skin/wound.



s 2EMEMBERTHEPOWEROFWORDS0AY attention to â&#x20AC;&#x153;words not to use.â&#x20AC;?

The opposing counsel had me read my own charting for the times I had interacted with the patient and asked if the doctor had been informed consistently regarding the skin changes and wound management of the pressure ulcer. I was embarrassed with my own charting and lack of information charted. The photographs taken throughout her hospitalization were not labeled properly and were out of sequence. There were no follow-up notes to indicate the patient or family received education about pressure ulcer prevention or treatment. There also was no discharge note detailing the pressure ulcer other than the order to continue negative therapy.

After a few months, the case was settled out of court in favor of the patient. I hope by my sharing my own story of doing a deposition, you will gain from my pain!

IJJJJJJJJJJJJI Legal Issues in the Care of Pressure Ulcers: Key Concepts for Healthcare Providers

44 Healthy Skin


Are Your Physicians Making the Grade?

What to Do If This Happens

to You


Although finding out you are being sued can be shocking and upsetting, it is crucial to stay calm and take some simple steps to allow for the best possible results. • Notify your institution and malpractice carrier immediately for the name of your attorney (counsel). • DO NOT create notes on your own – separate and apart from a meeting with your lawyer. These notes could easily be discoverable in litigation. • Avoid the temptation to talk to anyone about the case until you have discussed it with your attorney. Your attorney will likely advise you to avoid talking to colleagues about the case; this is important advice. • Your attorneys or legal department are your resources, so ask them about terminology or procedures that are unfamiliar to you.

A recent survey graded physiciansʼ abilities to recognize, assess and document Stage III and IV pressure ulcers at a “D” level. Medlineʼs new Pressure Ulcer Prevention Program MD Education CD contains everything physicians need to brush up on their skills and comply with the new CMS Inpatient Prospective Payment System (IPPS).

“The new MD Education component of Medlineʼs Pressure Ulcer Prevention Program is critical for acute-care facilities to ensure that physicians understand their role in recognizing and accurately documenting POA pressure ulcers.”

Michael Raymond, MD, Associate Chief Medical Quality Officer, NorthShore University HealthSystem, Skokie Hospital, Skokie, IL

• As part of the litigation, you may be deposed. You can be deposed even if the case is not about you. If you face deposition, meet with your attorney first to go over the procedure and talk about the sorts of questions the other attorneys are expected to ask. • While not all litigation goes to court, sometimes you will find your self taking the witness stand. Talk to your legal representatives before testifying in court. It is important that you understand the procedures and can go over what you likely will be asked.

Contact your Medline sales representative for more details. You can also learn more about Medlineʼs Pressure Ulcer Prevention Programs for long-term care, acute care and perioperative services by visiting

Improving Quality of Care Based on CMS Guidelines 45

Treatment The Next Generation:

The Use of Basement Membrane and Extracellular Matrix-Containing Urinary Bladder Matrix* in the Treatment of Chronic Venous Ulcerations Up to 80 percent of leg ulcers are the result of chronic venous hypertension, most commonly caused by valvular incompetence.Various products have been proven to be effective for treatment under compression therapy, including extracellular matrix technology. Naturally derived, non-crosslinked extracellular matrix, such as those derived from Urinary Bladder Materials (UBM), are unique among scaffold technologies that fundamentally change healing through the deployment of significant biomolecules. These biomolecules have the capacity to engage cells involved in natural wound healing, including progenitor cells that differentiate to fully functional adult cells in sitespecific tissues. Specifically, preclinical research shows that the basement membrane component of the product described here allows increased activity from a wound healing perspective, as it contains multiple collagen types, proteoglycans, multiple growth factors, glycoproteins and anti-infective peptides.1,2 During the healing process, the Basement Membrane containing Wound Matrix* – the product studied in this case series – is known to be resorbed and replaced with new tissue where scar tissue normally would be expected. The experience at a busy wound center using this novel biomaterial are presented in a case study series on four patients with chronic venous ulcers with varying degrees of complexity.

Case 1

In the context of wound healing, of particular significance is the use of the Basement Membrane layer in the ECM material.* One of the best sources of an easily harvestable and reliable acellular Basement Membrane/ECM is the porcine urinary bladder material or UBM. A 58-year-old male with a past medical history significant for chronic venous insufficiency presented to the Wound Center with a large venous wound on the medial aspect of his right heel. Initially, he was treated with silver and collagen products and covered with four-layer compression

Case 2

A 41-year-old male presented to the Wound Center three months status post ORIF right tibial plateau fracture, ORIF right ankle fracture, and decompression of compartment syndrome, following a traumatic snowmobile accident. The patient’s past medical history is significant for chronic venous insufficiency as well as hypertension. The surgeons had attempted skin grafting on the wounds at the same time as the leg skin grafting with continued areas of non-healing. Upon initial evaluation, the

46 Healthy Skin

Joseph Gonzalez, DPM The Foot Wound Institute Capital Foot & Ankle Centers Okemos, Michigan

Introduction and Background Relatively recently, and in parallel with the understanding of the key role of ECM in wound healing, biomaterial science has evolved allowing the harvesting and processing of biological tissue into high quality biomaterials suitable for regular clinical use. For example, the acellular ECM isolated from the porcine bladder, or other similar materials isolated from the intestinal submucosa, are complex multicomponent biomaterials that have potential for making transformational changes in the practice of wound healing. The Wound Center is developing a protocol of using this UBM-derived Basement Membrane/ECM associated biomolecules to “fill” a tissue defect, hypothesizing that the complex interplay of the Basement Membrane components will provide the ability to recruit progenitor cells that may progress on to differentiate into a number of tissue types that fill the wound as nature intended. In this study we used the Basement Membrane/ECM material on a series of venous insufficiency-associated wounds that had resisted all efforts in healing. Each patient had significant co-morbidities and associated problems. The objective of the study was to note if the Basement Membrane/ECM material would change the dynamics of a wound that is stalled in a pernicious state of equilibrium with no healing observed using other advanced treatment methods.

dressings. After two months of weekly treatment and minimal healing, he was treated with the Basement Membrane/ECM Wound Matrix fixated in place with Steri-strips™ and covered with foam and a fourlayer compression dressing. The wound was debrided weekly. In the last two weeks of healing, the patient was treated with the Basement Membrane/ECM Wound Matrix and covered with a silver impregnated foam dressing under the compression wrap. The wound healed in seven weeks following the initiation of the Basement Membrane/ECM Wound Matrix

patient had significant venous edema in the right lower extremity with a large anterior ankle wound and a small venous wound laterally. Both were granular, with no signs of infection, yet remained open for three months. Therefore, Basement Membrane/ECM Wound Matrix was applied, fixated with Steri-strips™ and covered with oil emulsion and a four-layer compression wrap. The patient returned weekly for dressing changes and serial debridements, including a debulking of the hypergranular tis-

CASE STUDY sue laterally. Each week, a new piece of Basement Membrane/ECM was applied and four-layer compression was continued. The wounds were

Case 3

A 66-year-old female presented to the Wound Center 16 weeks status post ORIF of a right fibula fracture. The initial incision had yet to heal due to the patient’s chronic venous insufficiency. Her significant past medical history includes COPD and hypertension. Upon initial presentation the proximal one-third of her incision remained open with no exposed hardware. X-rays revealed adequate fixation across the fracture with a semitubular plate and screws. The fracture was well-healed and the screws

Case 4

completely healed after seven weeks; the patient was placed in a custommade knee-high compression stocking and discharged.

appeared to be intact with no sign of infection or loosening. Therefore, Basement Membrane/ECM Wound Matrix was applied, fixated with Steristrips™ and covered with oil emulsion and a four-layer compression wrap. The patient returned weekly for serial debridements and continued application of the Basement Membrane/ECM Wound Matrix and compression wrap. The wound healed in three weeks. She was placed in custom-made knee-high compression stockings and discharged.

An 87-year-old male presented to the Wound Center with a new venous ulceration at the lateral aspect of his left ankle. His past medical history included recurrent slow-healing, venous wounds as well hypertension. For the initial two months, he was treated for the ulceration with silver dressings, collagen and Apligraf® with minimal improvement. Two months following the application of Apligraf®, he was treated with the Basement

Membrane/ECM Wound Matrix and covered with oil emulsion and a twolayer compression wrap. The patient returned weekly for serial debridements and treatment with Basement Membrane/ECM Wound Matrix covered with compression wraps. Six weeks after the initial application of Basement Membrane/ECM Wound Matrix, the wound was completely healed.

Discussion of Results


A newly available Basement Membrane containing Extracellular Matrix (ECM) Wound Sheet* has properties that may augment the natural wound healing process, which is severely compromised in patients with complex co-morbidities. In addition to moist wound healing practices, it is possible that such complex biomaterials, which have proven ability to recruit wound healing cells, can make a real difference in disturbing the nonhealing equilibrium associated with chronic wounds. It is also possible that these technologies will be used in the healing of chronic wounds of the future, now that the concept of “active” wound healing is possible in a large measure. We believe that the remarkable healing that was demonstrated on four patients with non-healing venous insufficiency-associated wounds through the use of the Urinary Bladder Material with Basement Membrane/ECM components saved significant resources, pain and time. More research in this area is intended in future.

The use of Urinary Bladder Material derived Basement Membrane/ECM Wound Matrix is shown to be effective in the treatment of chronic venous ulcerations. 1. Brown B, Lindberg K, Reing J, Stolz DB, Badylak SF. The basement membrane component of biologic scaffolds derived from extracellular matrix. Tissue Eng. 2006;12(3):519-26. 2. Brennan EP, Reing J, Chew D, Myers-Irvin JM,Young EJ, Badylak SF. Antibacterial activity within degradation products of biological scaffolds composed of extracellular matrix. Tissue Eng. 2006;12(10):2949-55. * MatriStem® is a registered trademark of Acell Incorporated and distributed by Medline Industries Inc., Mundelein, IL. **Steri-strips™ is a registered trademark of 3M. ***Adaptic® is a registered trademark of Sandoz AG Corporation. * MatriStem® is a registered trademark of Acell Incorporated and distributed by Medline Industries Inc., Mundelein, IL. Steri-strips™ is a registered trademark of 3M. Apligraf® is ???? ©2009 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.

Improving Quality of Care Based on CMS Guidelines 47


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

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

©2009 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.

Special Feature

The gang’s all here and they’re ready to play. Methicillin-resistant staphylococcus aureus (MRSA), Vancomycin-resistant enterococcus (VRE), Escherichia coli (E. coli), Extended spectrum-lactamase (ESBL) and Clostridium difficile (C. diff) could be lurking in unsuspected places at your facility. How much do you know about these “bad bugs”? Hint: You can find some of the answers by reading the article on page 50. MRSA

C. diff

ESBL VRE E. coli

Choosing from the “bugs” shown above, indicate your answers below. 1______ In one study, 65 percent of nurses who cared for patients with this type of bacteria also contaminated their uniforms with it. 2______ Bleach is the only known cleaner proven to kill this “bad bug.” 3______ When this enzyme is produced, it can make microorganisms resistant to certain antibiotics. 4______ This is one of the many types of bacteria found in human and animal feces. Raw beef is sometimes infected with it, causing illness in humans. 5______ This type of “super bug” is found most often in hospitals.

49 Healthy Skin

Improving Quality of Care Based on CMS Guidelines 49

ANSWERS: 1-MRSA, 2-C.diff, 3-ESBL, 4-E. coli, 5-VRE

Your Act! MRSA, C. diff, other harmful bacteria lurk in unexpected places

Busy, overburdened healthcare facilities, ever-mutating strains of bacteria and spotty handwashing compliance – these are just a few of the reasons behind increasing rates of healthcare-acquired infection (HAI). But with multiple and varied contributing factors, it’s difficult to get a handle on this widespread, worldwide problem. According to the Centers for Disease Control and Prevention (CDC), HAIs account for an estimated 1.7 million infections and 99,000 deaths in U.S. hospitals each year.1 The so-called “bad bugs” behind many HAIs are so insidious, they can be found lurking practically anywhere within a healthcare facility. Several new studies show that healthcare professionals’ scrubs, lab coats and stethoscopes are carriers of deadly bacteria such as methicillin-resistant Staphylococcus aureus (MRSA) and Clostridium difficile (C. diff) that easily can be transmitted to patients.

50 Healthy Skin


Staphylococci and Enterococci were found to survive for days to months after drying on fabric.

Bacteria-laden stethoscopes

ability of isopropyl alcohol, bleach, benzalkonium chloride

Ill patients are obvious carriers of bacteria, and any sur-

swabs and soap and water, isopropyl alcohol was

face or piece of medical equipment is a potential vector

proven to be most effective to rid the stethoscopes of

for that bacteria. For example, bacterial contamination

S. aureus.4

of a stethoscope increases markedly after it is used to examine more than five patients without cleaning.2

The same study also addressed whether bacteria could

Several studies, however, suggest that many healthcare

be transferred to human skin from the stethoscope

professionals use bacteria-laden stethoscopes, poten-

diaphragm. Micrococcus luteus was inoculated onto a

tially transferring bacteria from patient to patient.

stethoscope diaphragm, and the study showed that it

A recent study at one tertiary care center suggests

the transfer of M. luteus to human skin made it likely that

roughly one third of stethoscopes carried by EMS

other bacteria could be transferred as well.

did transfer to human skin. The authors concluded that

professionals harbor MRSA. A microbiologic analysis of 50 stethoscopes provided by EMS professionals in an

Stethoscopes are an extension of the hand in clinical set-

emergency department revealed that 16 had MRSA

tings and should be cleaned with the same frequency;

colonization. Similarly, 16 of the EMS workers could not

that is, after contact with each patient. Cleaning a stetho-

remember the last time they cleaned their stethoscope.

scope takes little time and effort, requires no special

For those who did remember, the median time from the

equipment – and it could avoid a deadly infection.

last stethoscope cleaning was one to seven days. MRSA colonization rates fell considerably in the stetho-

Dirty scrubs

scopes that were cleaned more recently. 3

How about your scrubs? Some medical personnel wear

Another study cultured 99 stethoscopes on four medical

dering, meaning they could be starting their shift with C.

floors of a 600-bed hospital. All were positive for bacteria

diff, MRSA and who knows what other bacteria already

growth. Half of the stethoscopes were cleaned using

on their scrubs. A study conducted at the University of

the same uniform to work more than once before laun-

ethanol-based cleaner (hand-sanitizing gel) and the

Maryland revealed that 65 percent of medical personnel

other half were cleaned using isopropyl alcohol pads.

admitted to changing their lab coat less than once a

Cleaning with the ethanol gel and isopropyl alcohol pads

week; 15 percent changed once a month.5 Healthcare

significantly reduced the bacteria counts (by 92.8

workers often touch their own uniforms, potentially

percent and 92.5 percent, respectively).

transferring bacteria from the fabric to their patients.


Studies confirm that the more bacteria found on surA similar study at a large academic medical center took

faces touched often by doctors and nurses, the higher

cultures from 40 randomly selected clinicians’ stetho-

the risk for the bacteria to be carried to the patient and

scopes. Staphylococcus aureus was found on 38 per-

cause infection.5

cent of them. When comparing the bacteria-removing

Continued on Page 53

Improving Quality of Care Based on CMS Guidelines 51

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In one study, 65 percent of nurses who cared for

worn by health care workers, that becomes contami-

patients with MRSA contaminated their uniforms with

nated with blood or other potentially infectious body

MRSA.6 Staphylococci and Enterococci were found to

fluids, regardless of who owns the scrubs.”9

survive for days to months after drying on commonly used hospital fabrics, such as scrubs made from 100

The CDC supports home laundering of scrub uniforms

percent cotton or 60 percent cotton and 40 percent

in its Guideline for Isolation Precautions (2007), which

polyester, as shown in a study conducted by the

states, “In the home, textiles and laundry from patients

Shriners Hospital for Children and the Department of

with potentially transmissible infectious pathogens do

Surgery at the University of Cincinnati.6

Bleach is the only known cleaner proven to kill C. diff. Home laundering or professional laundering? Much debate centers around whether healthcare professionals should be allowed to launder their own scrubs at home. St. Mary’s Health Center in St. Louis, Mo., reduced infections after cesarean births by more than 50 percent by providing staff with hospital-laundered scrubs.5 Similarly, Monroe Hospital in Bloomington, Ind., which

not require special handling or separate laundering, and

has a near-zero rate of hospital-acquired infections,

may be washed with warm water and detergent.”10 Con-

requires all staff to wear hospital-laundered scrubs and

versely, the state health departments in Pennsylvania

bans them from wearing scrubs outside the hospital

and Massachusetts, among others, recommend that


patients infected with MRSA launder their clothing at home in hot water and laundry detergent. They also

On the other side of the debate, a 1997 state-of-the-art

suggest drying clothes in a hot dryer to help kill

report (SOAR) compiled by the Association for Profes-

the bacteria. 11,12

sionals in Infection Control and Epidemiology (APIC) states, “There is no scientific evidence to suggest that

The CDC’s laundering recommendation is based on the

home laundering versus institutional laundering poses

outcome of two small, limited studies. One of the stud-

any increased risk of infection transmission.” 9

ies examined the scrub clothing of 68 labor and delivery employees. The scrubs were laundered at home in

Yet the report also says, “OSHA holds employers

warm water and detergent and also dried in a clothes

responsible for laundering any clothing, including scrubs

dryer on the hot setting. The authors concluded that Continued on Page 55

Improving Quality of Care Based on CMS Guidelines 53

Antimicrobial Lab Coats

Your shield against bacteria. We have developed a cost-effective, safe and long-lasting textile solution. We call it the SilverTouch Lab Coat. Based on cutting-edge antimicrobial silver technology, SilverTouch fabric not only kills a broad spectrum of microbes, it also retains that efficacy over the life of the product. Day after day and wash after wash.

Safe, smart, SilverTouch.

To learn more about SilverTouch, contact your Medline representative or call 1-800-MEDLINE (633-5463)

Š2009 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.

54 Healthy Skin

home-laundered scrub clothing can be worn safely in labor and delivery units.


What about other areas of

a hospital?

scrubs, turn those dials to hot, and of course – keep washing your hands. Pass the word along to colleagues, and you may be surprised to see your facility’s HAI rates go down.

The other study tested the left front shoulders only of 30 home-laundered scrubs and 20 hospital-laundered scrubs. No pathogenic growth was found on either the home- or hospital-laundered fabrics.14 It could be argued, however, that the front shoulder of a scrub uniform is one of the least likely areas to be touched or contaminated.

Fewer bacteria = fewer HAIs When it comes to preventing HAIs, it’s better to be safe than sorry. If there’s even a small chance you could be transferring bacteria to patients, why not take a little extra time and a small amount of effort to clean up your act? Hand rub dispensers are conveniently located throughout most facilities, so go ahead and disinfect your stethoscope between patients. When you wash your

Change your habits for infection prevention • Keep isopropyl alcohol wipes or ethanol-based hand cleaner available and wipe down your stethoscope after each patient encounter. • Wear street clothes to work, and then change into clean scrubs every day. Keep an extra set on hand and change mid shift if your scrubs get visibly dirty or notably splattered with any substance possibly containing bacteria. Change back into street clothes before leaving the facility to avoid carrying bacteria into your car, public places and your home. If you wear a lab coat, keep a clean supply at your facility and change into a new one each day. • If your facility allows you to launder your own uniforms at home, be sure to use hot water (110 to 125 degrees F or 43.33 to 51.67 degrees C)7 with 50 to 150 parts per million of chlorine bleach.6 (Note: Bleach is the only known cleaner proven to kill C. diff.)15 Above all, drying laundered linen in a hot clothes dryer plays the most significant role in eliminating bacteria.6

References 1 Estimates of Healthcare-Associated Infections. Centers for Disease Control and Prevention Web site. Available at Accessed May 13, 2009. 2 Lecat P, Cropp E, McCord G, et al. Ethanol-based cleanser versus isopropyl alcohol to decontaminate stethoscopes. American Journal of Infection Control. 2009;37(3):241-243. 3 Merlin MA, Wong ML, Pryor PW, et al. Prevalence of methicillin-resistant Staphylococcus aureus on the stethoscopes of emergency medical services providers. Prehosp Emerg Care. 2009;13(1):71-74. 4 Marinella MA, Pierson C, Chenoweth C. The stethoscope. A potential source of nosocomial infection? Archives of Internal Medicine. 1997;157(7):786-790. 5 McCaughey, B. Hospital scrubs are a germy, deadly mess. The Wall Street Journal. January 8, 2009:A13. 6 LeTexier, R. Coming clean on home laundered scrubs. Infection Control Today Web site. Posted October 1, 2001. Available at Accessed May 11, 2009. 7 Recommended Practices for Surgical Attire in: 2008 Perioperative Standards and Recommended Practices. Association of PeriOperative Registered Nurses: Denver, CO. 8 Dix K. Apparel in the hospital: what to wear, where? Infection Control Today Web site. Posted March 1, 2005. Available at Accessed May 11, 2009. 9 Belkin NL. Use of scrubs and related apparel in health care facilities. American Journal of Infection Control. 1997;25(5):401-404. 10 Siegel JD, Rhinehart E, Jackson M, et al. Centers for Disease Control and Infection. 2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings. Available at Accessed May 11, 2009. 11 Recommendations on Children with Methicillin-Resistant Staphylococcus aureus (MRSA) in School Settings. Pennsylvania Department of Health Web site. Available at Accessed May 11, 2009. 12 Helpful Reminders About MRSA Infection. Massachusetts Department of Public Health Web site. Available at: Accessed May 11, 2009. 13 Kiehl E, Wallace R, Warren C. Tracking perinatal infection: is it safe to launder your scrubs at home? MCN Am J Matern Child Nurs. 1997;22(4):195-197. 14 Jurkovich P. Home- versus hospital-laundered scrubs: a pilot study. MCN Am J Matern Child Nurs. 2004;29(2):106-110. 15 Diarrhea-causing bacteria common in hospitals. Health News. Available at us_hospitals. Accessed May 13, 2009. 16 Denny D. Monroe Hospital’s low infection rates draw national interest. January 19, 2009. Bloomington Herald Times. Available at 17 Wenzel R, Edmond MB. The impact of hospital-acquired blood stream infections. Emerg Inf Dis. 2001;7(2):174-177.

Improving Quality of Care Based on CMS Guidelines 55


A cost-effective alternative to urinary catheterization ia Californ l a it p s Ho s e s a e r c De h it Use CAUTI w nence ti of Incon s Brief

Knowing catheter-related urinary tract infections (UTIs) are the most common of all hospital-acquired infections, Alan F. Rothfeld, MD, was looking for alternatives to catheterizing patients at Hollywood Presbyterian Medical Center (HPMC), a 434-bed hospital in Los Angeles. Rothfeld noted that new incontinence management products offer less costly and more effective alternatives to catheterization. Restore ultra-absorbent disposable briefs, manufactured by Medline, stay dry and hold significantly more urine per day. In order to document whether using disposable briefs in place of urinary catheters would decrease UTIs, Rothfeld led a sixmonth study, from January to October 2008, at HPMC’s ICU step-down units. The study observed the use of Restore briefs during two three-month periods in two separate units of the hospital with a total of 60 beds, averaging 83 percent occupancy.

50 Percent Reduction in UTIs

According to Rothfeld’s findings, catheters are needed in only about half the cases in which they are used. Before beginning the study, Rothfeld developed the following indications for the use of urinary catheters: 1. Written orders for hourly urinary output 2. Inability to void spontaneously (usually due to obstruction) 3. Active urinary tract infection with Stage 3 or 4 pressure ulcer If a patient had none of these indications, no catheter was requested. If a patient had a catheter already, a request to the physician for discontinuance was initiated. An anonymous questionnaire conducted at the end of the study revealed the disposable briefs were a welcome alternative among physicians and nurses. “In fact, no patient reported decreased comfort and most of the staff was supportive of this program, indicating it increased overall satisfaction among nursing personnel,” Rothfeld said.

There were five hospital-acquired UTIs during the three-month control period, indicating an infection rate of 3.2 per 1,000 catheter days. During the three-month intervention period, there were only two hospital-acquired UTIs, with an infection rate of 2.4 per 1,000 catheter days. Infections during the intervention period fell from an average of 1.06 per 1,000 patient days to 0.45. “The reduction in infections was mainly due to the decrease in catheter use rather than other changes in patient care,” Rothfeld explained, noting that catheter use during the intervention period fell from 330 to 190 per 1,000 patient days.

56 Healthy Skin

References Ditch the foleys, adopt diapers to address UTIs. Infection Control Today Web site. Posted March 10, 2009. Available at Accessed May 22, 2009. Rothfeld AF & Stickley A. A Program to Reduce Nosocomial Urinary Catheter Infections at an Acute Care Hospital [manuscript]. Hollywood Presbyterian Medical Center; 2009. Restore is a registered trademark of Medline Industries, Inc.


Tell Me Again Why This Resident Needs a Catheter? by Lorri Downs, RN, BSN, MS, CIC

Have you ever thought about or questioned if the catheter you were inserting was really necessary and clinically indicated? It has become critically important that we evaluate the need for urinary catheterization and no longer insert catheters for convenience or because that is what we always do. Whatâ&#x20AC;&#x2122;s more, did you know that requests from nurses to place a urinary catheter for nursing convenience are not uncommon?1 The 1997 APIC/SHEA position paper on urinary tract infections in long-term care identiďŹ es CAUTI as the most common infection in long-term care residents, with a bacteriuria prevalence without indwelling catheters of 25 to 50 percent for women and 15 to 40 percent for men. With this already elevated presence of bacteriuria, usage of indwelling urinary catheters can be expected to result in higher CAUTI rates with an associated risk of CAUTI-related bacteremia, unless appropriate prevention efforts are implemented.2 New guidelines and recommendations tell us that we should determine if there is an approved medical indication for catheterization. This means that we evaluate and reconsider the common practice of inserting indwelling catheters. This evaluation may change how we have always done things. The Centers for Medicare & Medicaid Services (CMS), as a result of the Medicare Modernization Act of 2003 and the Deficit Reduction Act of 2005, has identified CAUTI as a Continued on Page 59

Improving Quality of Care Based on CMS Guidelines 57


CAUTI Prevention: How Do You Rate? 1. At my facility, we practice timely removal of urinary catheters. a. Always b. Sometimes c. Never

4. At my facility, we keep track of how long catheters are kept in patients. a. Always b. Sometimes c. Never

2. I follow strict aseptic technique when inserting a catheter. a. Always b. Sometimes c. Never

5. Before placing a catheter, I assess whether the patient really needs it, and I document the assessment in the medical record. a. Always b. Sometimes c. Never

3. At my facility, we educate catheterized residents about urinary tract infections. a. Always b. Sometimes c. Never

What’s your score? a _____ x b _____ x c _____ x

5 3 0

= = =

_______ _______ _______

TOTAL _______ How do you rate? 25 Perfect score! Keep up the great work and educate others. 17 – 23 Great job. Read below for more helpful tips. 8 – 14 You’re doing OK. Read “Tell Me Again Why This Resident Needs a Catheter?” to find out more about CAUTI prevention AND earn a free CE! 0 – 5 Lots of opportunity to improve practices at your facility. Medline can help! Also review the strategies below.

We invite you to join the Race to ERASE CAUTI! With 100,000 nurses working together, we can do it!

CAUTI FACTS Evidence-Based Prevention Strategies • The MOST effective way to prevent CAUTI is to AVOID inappropriate catheterization.1 • Greater attention is REQUIRED to avoid inserting catheters in patients unnecessarily.2 • Limiting urinary catheter use and, when a catheter is indicated, minimizing the duration the catheter remains in place, are primary strategies for CAUTI prevention.3 • Alternatives to catheterization should be considered.3 • Documentation must include: indications for catheter insertion, date and time of catheter insertion, individual who inserted catheter, date and time of catheter removal.3 • Insertion using aseptic techniques and sterile equipment.4 • Handwashing is the FIRST and most important preventive measure.5 • Education must include appropriate indications for catheter placement and the possible alternatives to indwelling catheters.5 • Educating the patient can reduce readmissions6 and help to achieve higher patient satisfaction scores. • SHEA/IDSA guidelines advise against the routine use of silver-coated or antibacterial urinary catheters to prevent CAUTI.3, 4 References 1. Expert discusses strategies to prevent CAUTIs. Infection Control Today Web site. June 1, 2005. Available at Accessed July 10, 2009. 2. Catheter-related UTIs: a disconnect in preventive strategies. Physician’s Weekly. 25(6), February 11, 2008. 3. Lo E, Nicolle L, Classen D, Arias A, Podgorny K, Anderson DJ, et al. SHEA/IDSA practice recommendation: strategies to prevent catheter-associated urinary tract infections in acute care hospitals. Infect Control Hosp Epidemiol. 2008;29:S41–S50. 4. Gould CV, Umscheid CA, Agarwal RK, Kuntz G, Pegues DA, et al. Guideline for Prevention of Catheter-Associated Urinary Tract Infections 2008. Draft. Centers for Disease Control and Prevention. Available at Accessed July 10, 2009. 5. Gokula RM, Hickner JA, Smith MA. Inappropriate use of urinary catheters in elderly patients at a midwestern community teaching hospital. Am J Infect Control 2004;32:196-199. 6. Stokowski, LA. Preventing catheter-associated urinary tract infections. Medscape Nursing Perspectives. February 3, 2009. Available at Accessed July 6, 2009.

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MAJOR BARRIERS TO CAUTI PREVENTION Too many indwelling urinary catheters are inserted

It has been estimated at up to 50 percent of the indwelling urinary catheters are unnecessarily placed.7 healthcare-associated infection (HAI) that can reasonably be prevented through the application of evidence-based practice. CMS reported in the 2008 Federal Register that in 2007 there were 12,185 CAUTIs, costing $44,043 per hospital stay. CAUTI is one of 10 hospital-acquired conditions (HACs) for which CMS will no longer provide reimbursement if it occurs during hospitalization.

Brand-new CAUTI prevention guidelines As a result of this data, leading industry experts, including the Association for Professionals in Infection Control and Epidemiology (APIC), the Society for Healthcare Epidemiology (SHEA), the Centers for Disease Control and Prevention (CDC), the Joint Commission and many others have joined together to outline strategies and guidelines to prevent catheter-associated urinary tract infections in acute care hospitals.5 The CDC’s Draft Guideline for Prevention of Catheter-Associated Urinary Tract Infections 2008 (released in June 2009) identifies new guidelines and recommendations to prevent CAUTI.6

Barriers to CAUTI prevention Three distinct barriers to the prevention of CAUTI become evident when analyzing the problem. In the long-term care environment the presence of a catheter predisposes the resident to symptomatic and asymptomatic bacteriuria. Now, compound this problem with the fact that many nurses do not routinely perform aseptic technique and may not be aware when contamination occurs. In fact, during most observations of nurses, we have seen inconsistent practice in setting up a sterile field and inserting indwelling catheters aseptically. It is perfectly clear that in many healthcare settings, three barriers to CAUTI prevention occur routinely – too many catheters are inserted, catheters stay in too long and contamination occurs upon insertion.

CAUTI reduction strategies To help you further realize the magnitude and role nurses play in preventing CAUTI, let’s look at some

additional statistics. Did you know that the hospital emergency department (ED) has the highest percentage of catheter placements?3 In the ED, documentation of the reason for catheter placement is poor, and a written physician order is frequently lacking. Without a physician order, physicians are unaware that the patient has a catheter.7 When physicians do not know that a catheter has been inserted, it is no wonder that an order for timely removal is lacking, and catheters stay in longer than medically necessary. Automatic stop orders and nurse-driven protocols, which allow nurses to remove catheters without a physician order when the patient no longer meets established criteria, can help with the timely removal of catheters.

Common catheter practices in healthcare settings Adding to the problem, inappropriately placed catheters are more often forgotten about.7 In 56 percent of hospitals there is no system to keep track of which patients have catheters, and 74 percent of hospitals do not keep track of how long the catheter is in place.8 Shocking as this may be, let’s see if any of these common situations occur at your facility. 1. Do you assess patients to determine if the standing order to insert an indwelling catheter is medically indicated? 2. When a patient comes to your facility with an indwelling urinary catheter or when you insert one, do you regularly evaluate the need to keep the catheter in place? 3. Do you date and time when the catheter was inserted? This critical step helps clinicians remove catheters in a timely manner. Nurses are positioned to significantly impact the reduction and elimination of catheter-associated urinary tract infections by removing catheters when patients do not meet the approved indications. Take a peek at Table 1, which lists when indwelling urinary catheters should and should not be used.

Improving Quality of Care Based on CMS Guidelines 59

What is a nurse to do? If your patient has no alternatives, and you must insert a urinary catheter, is there anything you can do to help prevent catheter-associated urinary tract infections? Absolutely!

CAUTI prevention methods a. Alternatives to urinary catheter use - Do not allow routine urinary catheter placement when certain criteria are not met. - Consider alternatives to indwelling urethral catheters, such as intermittent catheterization, condom catheters, briefs and absorbent underpads. b. Appropriate urinary catheter use - Use indwelling catheters only when medically necessary. - Do not use catheters for the management of incontinence. c. Aseptic insertion of urinary catheters - Use aseptic insertion technique with appropriate hand hygiene and gloves.

- Allow only trained healthcare providers to insert catheters. d. Proper urinary catheter maintenance - Properly secure catheters after insertion. - Maintain a sterile closed drainage system. - Maintain good hygiene at the catheter-urethral interface. - Maintain unobstructed urine flow. - Maintain drainage bag below level of bladder at all times. - Use portable ultrasound bladder scans to detect residual urine amounts. - Do not change indwelling catheters or urinary drainage bags at arbitrary fixed intervals. e. Timely removal - Remove catheters when no longer needed. - Document indication for urinary catheter on each day of use. - Use reminder systems to target opportunities to re move catheters.

Table 1. Appropriate Indications for Indwelling Urethral Catheter Use 2,6 Patient has acute urinary retention or obstruction Need for accurate measurements of urinary output in critically ill patients Perioperative use for selected surgical procedures: • Patients undergoing urologic surgery or other surgery on contiguous structures of the genitourinary tract • Anticipated prolonged duration of surgery (catheters inserted for this reason should be removed in PACU) • Patients anticipated to receive large-volume infusions or diuretics during surgery • Operative patients with urinary incontinence • Need for intraoperative monitoring of urinary output To assist in healing of open sacral or perineal wounds in incontinent patients Patient requires prolonged immobilization (e.g., potentially unstable thoracic or lumbar spine) To improve comfort for end of life care if needed Indwelling catheters should not be used: • As a substitute for nursing care of the patient or resident with incontinence • As a means of obtaining urine for culture or other diagnostic tests when the patient can voluntarily void • For prolonged postoperative duration without appropriate indications • Routinely for patients receiving epidural anesthesia/analgesia Note: These indications are based primarily on expert consensus.

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The above list was combined from recommendations in the CDC Guidelines and 2008 APIC CAUTI Elimination Guidelines.

Putting it all together to ERASE CAUTI Until recently, catheter-associated urinary tract infections have received little attention compared to many of the other types of HAIs. However, research and best practices for the prevention of CAUTI are readily available. Despite the link between urinary catheters and urinary tract infections in hospitals and other healthcare settings, a recent survey of U.S. hospital practices identified that no strategy is consistently or universally used in

MAJOR BARRIERS TO CAUTI PREVENTION Contamination occurs during insertion

Most nurses are aware of the importance of aseptic technique but it can take extra time. Heavier nursing workloads contribute to poor compliance with aseptic technique.3 U.S. hospitals to prevent these infections.2 Literature reports numerous organizations that have implemented successful strategies to reduce CAUTI. These organizations have utilized multidisciplinary teams to implement evidence-based changes in practice; have incorporated practice changes into the routine standard of care; and have performed ongoing or periodic review of progress to reinforce successful strategies.2

Develop a CAUTI prevention program for your facility If your organization does not have a CAUTI elimination program, or you are not getting the results you had hoped for, start by assessing whether an effective organizational program exists. Work with your infection preventionist and other key multidisciplinary stakeholders to develop your campaign. Questions to consider to help you get started with your own CAUTI prevention program:2 • Are there policies or guidelines that define criteria for insertion of a urinary catheter? • Has the organization established criteria for when a catheter should be discontinued? • Is there a process to identify inappropriate usage or duration of urinary catheters? • Is there a program or guidelines to identify and remove catheters that are no longer necessary? (e.g., physician reminders, automatic stop orders or nurse-driven protocols) • Are there policies or guidelines for use of a bladder scanner to detect urinary retention prior to insertion of a catheter? • Are there mechanisms to educate care providers about use and care of urinary catheters? • Overall Assessment: Is there an effective

Improving Quality of Care Based on CMS Guidelines 61



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Start the race to erase CAUTI by educating your residents and staff about CAUTI. Ensure all staff practice aseptic technique and remove catheters in a timely manner. Join the RACE to ERASE CAUTI! Talk about prevention, raise awareness, then implement solutions in your organization. References 1. Ribby KJ. Decreasing urinary tract infections through staff development, outcomes, and nursing process. J Nurs Care Qual. 2006; 21:272-276. 2. An APIC Guide to the Elimination of Catheter-Associated Urinary Tract Infections 2008 (CA-UTI) p. 5-6, 8-9, 22, 35 -41 The Association of Professionals in Infection Control and Epidemiology. 3. Stokowski, LA. Preventing catheter-associated urinary tract infections. Medscape Nursing Perspectives. February 3, 2009. Available at Accessed July 6, 2009. 4. Centers for Medicare & Medicaid Services. Proposed Changes to the Hospital IPPS and FY2009 rates; Available at Accessed July 24, 2009 5. Lo E, Nicolle L, Classen D, Arias A, Podgorny K, Anderson DJ, et al. SHEA/IDSA practice recommendation: strategies to prevent catheter-associated urinary tract infections in acute care hospitals. Infect Control Hosp Epidemiology. 2008; 29:S41â&#x20AC;&#x201C;S50. 6. The CDC Guideline for Prevention of Catheter-Associated Urinary Tract Infections 2008, Draft. 7. Saint S, Kaufman SR, Thompson M, Rogers MA, Chenoweth CE. A reminder reduces urinary catheterization in hospitalized patients. Jt Comm J Qual Patient Saf. 2005; 31(8):455-462. 8. Saint S, Kowalski CP, Kaufman SR, Hofer PH, Kauffman CA, Olmsted RN et al. Preventing hospitalâ&#x20AC;&#x201C;acquired urinary tract infection in the United States: a national study. Clinical Infectious Diseases. 2008; 46(2):243-250.

CE Questions

Tell Me Again Why This Resident Needs a Catheter? True or False (circle one) 1. CAUTI is the most common infection in long-term care residents. T F 2. The emergency department has the highest percentage of catheter placement. T F 3. Usage of indwelling urinary catheters can be expected to result in higher CAUTI rates. T F 4. Assistance in pressure ulcer healing for incontinent patients is an approved indication for urinary catheterization. T F 5. Allowing only trained healthcare providers to insert catheters is one method for preventing catheterassociated urinary tract infections (CAUTI). T F 6. A recent survey of U.S. hospital practices identified that no strategy is consistently or universally used to prevent CAUTI. T F 7. CAUTI is one of 10 hospital-acquired conditions for which the Centers for Medicare & Medicaid Services (CMS) will no longer provide reimbursement if it occurs during hospitalization. T F 8. Nurses rarely request to place a urinary catheter for nursing convenience. T F Multiple Choice 9. Which of the following is not an approved indication for urinary catheterization? a. To improve comfort during end-of-life care. b. Management of acute urinary retention and urinary obstruction. c. The patient requires prolonged immobilization. d. The patient is incontinent and requires two or three linen changes per shift. 10. Which of the following are techniques for proper urinary catheter maintenance? a. Properly secure catheters after insertion. b. Maintain unobstructed urine flow. c. Both a and b. d. Change indwelling catheters or urinary drainage bags at arbitrary fixed intervals.

11. CMS reported in the 2008 Federal Register that in 2007 there were ______CAUTIs. a. 800,000 b. 56,296 c. 1,877 d. 12,185 12. It has been estimated that up to ____ percent of indwelling urinary catheters are unnecessarily placed. a. 85 b. 10 c. 50 d. None of the above 13. Which of the following is a successful strategy implemented by healthcare organizations to reduce CAUTI? a. Redesign patient care areas b. Utilize multidisciplinary teams to put evidence-based changes in practice c. Serve cranberry juice to patients d. Deploy rapid response teams (RRTs) 14. Which of the following organizations did not participate in outlining strategies and guidelines to prevent CAUTI? a. American Medical Association (AMA) b. Centers for Disease Control and Prevention (CDC) c. Association for Professionals in Infection Control and Epidemiology (APIC) d. The Joint Commission 15. What percent of hospitals do not keep track of how long the catheter is in place? a. 25% b. 10% c. 36% d. 74%

Submit your answers at and receive 1 FREE CE credit

Improving Quality of Care Based on CMS Guidelines 63

Point and click to ERASE CAUTI The new ERASE CAUTI program combines design, education and awareness to tackle catheter-associated urinary tract infection – the number one hospital-acquired infection.1

Design The innovative one-layer tray design guides the clinician through the process of placing a catheter to ensure aseptic technique.

Education The acronym ERASE is easy to remember, reminding the clinician to:

Evaluate indications – Does the patient really require a catheter?

Read directions and tips – Follow evidence-based insertion techniques Aseptic techniques – Key design solutions support aseptic technique

Secure catheter – A properly secured catheter will reduce movement and urethral traction Educate the patient – Printed materials tell the patient how to reduce the likelihood of infection

Awareness Join the Race to ERASE CAUTI! The current state of health care demands that nurses play a leading role in identifying and implementing CAUTI risk reduction strategies. Help us reach our goal to introduce 100,000 nurses to the ERASE CAUTI system.

Ask your Medline representative about the new ERASE CAUTI Program or call 1-800-MEDLINE (633-5463).

Design Open up the innovative one-layer catheter tray and see the intuitive design for yourself.

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Education Click here for details on nursing education materials that promote evidence-based practice.

Awareness Visit this section to join 100,000 nurses in the Race to ERASE CAUTI.

Reference 1. Catheter-related UTIs: a disconnect in preventive strategies. Physicians Weekly. 25(6), February 11, 2008.


Each year, an average nursing home with 100 beds reports 100 to 200 falls.1 About 1,800 older adults living in nursing homes die each year from fall-related injuries.


in Nursing Homes

Those who experience nonfatal falls can suffer injuries, have difďŹ culty getting around and have a reduced quality of life.2

Continued on page XXX

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How big is the problem? • In 2003, 1.5 million people 65 and older lived in nursing homes.3 If current rates continue, by 2030 this number will rise to about 3 million.4 • About 5% of adults 65 and older live in nursing homes, but nursing home residents account for about 20% of deaths from falls in this age group.1 • Each year, a typical nursing home with 100 beds reports 100 to 200 falls. Many falls go unreported.1 • As many as 3 out of 4 nursing home residents fall each year.2 That’s twice the rate of falls for older adults living in the community. • Patients often fall more than once. The average is 2.6 falls per person per year.5 • About 35% of fall injuries occur among residents who cannot walk.6

How serious are these falls? • About 1,800 people living in nursing homes die each year from falls.7 • About 10% to 20% of nursing home falls cause serious injuries; 2% to 6% cause fractures.7 • Falls result in disability, functional decline and reduced quality of life. Fear of falling can cause further loss of function, depression, feelings of helplessness, and social isolation.2

Why do falls occur more often in nursing homes? Falling can be a sign of other health problems. People in nursing homes are generally more frail than older adults living in the community. They are generally older, have more chronic conditions, and have difficulty walking. They also tend to have problems with thinking or memory, to have difficulty with activities of daily living, and to need help getting around or taking care of themselves.8 All of these factors are linked to falling.9

What are the most common causes of nursing home falls? • Muscle weakness and walking or gait problems are the most common causes of falls among nursing home residents. These problems account for about 24% of the falls in nursing homes.2 • Environmental hazards in nursing homes cause 16% to 27% of falls among residents.7,2 Such hazards include wet floors, poor lighting, incorrect bed height, and improperly fitted or maintained wheelchairs.2,10

Each year, a typical nursing home with 100 beds reports 100 to 200 falls. Many falls go unreported.1

• Medications can increase the risk of falls and fall-related injuries. Drugs that affect the central nervous system, such as sedatives and anti-anxiety drugs, are of particular concern.11,12 • Other causes of falls include difficulty in moving from one place to another (for example, from the bed to a chair), poor foot care, poorly fitting shoes, and improper or incorrect use of walking aids.10,13

How can we prevent falls in nursing homes? Fall prevention takes a combination of medical treatment, rehabilitation, and environmental changes. The most effective interventions address multiple factors. Interventions include: • Assessing patients after a fall to identify and address risk factors and treat the underlying medical conditions.5 • Educating staff about fall risk factors and prevention strategies.10 • Reviewing prescribed medicines to assess their potential risks and benefits and to minimize use.14,15 • Making changes in the nursing home environment to make it easier for residents to move around safely. Such changes include putting in grab bars, adding raised toilet seats, lowering bed heights, and installing handrails in the hallways.10 • Providing patients with hip pads that may prevent a hip fracture if a fall occurs.16 • Using devices such as alarms that go off when patients try to get out of bed or move without help.2 Exercise programs can improve balance, strength, walking ability, and physical functioning among nursing home residents. However, it is unclear whether such programs can reduce falls.17,18

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Do physical restraints help prevent falls? • Routinely using restraints does not lower the risk of falls or fall injuries. They should not be used as a fall prevention strategy.19 • Restraints can actually increase the risk of fall-related injuries and deaths.2 • Limiting a patient’s freedom to move around leads to muscle weakness and reduces physical function.1 • Since federal regulations took effect in 1990, nursing homes have reduced the use of physical restraints.2 • Some nursing homes have reported an increase in falls since the regulations took effect, but most have seen a drop in fall-related injuries.9 Reprinted with permission from the Centers for Disease Control, National Center for Injury Prevention and Control, Division of Unintentional Injury Prevention References 1 Rubenstein LZ. Preventing falls in the nursing home. Journal of the American Medical Association 1997;278(7):595–6. 2 Rubenstein LZ, Josephson KR, Robbins AS. Falls in the nursing home. Annals of Internal Medicine 1994;121:442–51. 3 National Center for Health Statistics. Health, United States, 2005. With Chartbook on Trends in the Health of Americans. Hyattsville (MD): National Center for Health Statistics; 2005. 4 Sahyoun NR, Pratt LA, Lentzner H, Dey A, Robinson KN. The changing profile of nursing home residents: 1985–1997. Aging Trends; No. 4. Hyattsville (MD): National Center for Health Statistics; 2001. 5 Rubenstein LZ, Robbins AS, Josephson KR, Schulman BL, Osterweil D. The value of assessing falls in an elderly population. A randomized clinical trial. Annals of Internal Medicine 1990;113(4):308–16. 6 Thapa PB, Brockman KG, Gideon P, Fought RL, Ray WA. Injurious falls in nonambulatory nursing home residents: a comparative study of circumstances, incidence and risk factors. Journal of the American Geriatrics Society 1996;44:273–8. 7 Rubenstein LZ, Robbins AS, Schulman BL, Rosado J, Osterweil D, Josephson KR. Falls and instability in the elderly. Journal of the American Geriatrics Society 1988;36:266–78. 8 Bedsine RW, Rubenstein LZ, Snyder L, editors. Medical care of the nursing home resident. Philadelphia (PA): American College of Physicians; 1996. 9 Ejaz FK, Jones JA, Rose MS. Falls among nursing home residents: an examination of incident reports before and after restraint reduction programs. Journal of the American Geriatrics Society 1994;42(9):960–4. 10 Ray WA, Taylor JA, Meador KG, Thapa PB, Brown AK, Kajihara HK, et al. A randomized trial of consultation service to reduce falls in nursing homes. Journal of the American Medical Association 1997;278(7):557–62. 11 Mustard CA, Mayer T. Case-control study of exposure to medication and the risk of injurious falls requiring hospitalization among nursing home residents. American Journal of Epidemiology 1997;145:738–45. 12 Ray WA, Thapa PB, Gideon P. Benzodiazepenes and the risk of falls in nursing home residents. Journal of the American Geriatrics Society 2000;48(6):682–5. 13 Tinetti ME. Factors associated with serious injury during falls by ambulatory nursing home residents. Journal of the American Geriatrics Society 1987;35:644–8. 14 Cooper JW. Consultant pharmacist fall risk assessment and reduction within the nursing facility. Consulting Pharmacist 1997;12:1294–1304. 15 Cooper JW. Falls and fractures in nursing home residents receiving psychotropic drugs. International Journal of Geriatric Psychology 1994;9:975–80. 16 Kannus P, Parkkari J, Niem S, Pasanen M, Palvanen M, Jarvinen M, Vuori I. Prevention of hip fractures in elderly people with use of a hip protector. New England Journal of Medicine 2000;343(21):1506–13. 17 Nowalk MP, Prendergast JM, Bayles CM, D’Amico MJ, Colvin GC. A randomized trial of exercise programs among older individuals living in two long-term care facilities: the FallsFREE program. Journal of the American Geriatrics Society 2001;49:859–65. 18 Vu MQ, Weintraub N, Rubenstein LZ. Falls in the nursing home: are they preventable? Journal of the American Medical Directors Association 2005;6:S82–7.

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Costs of Falls Among Older Adults In 2000, the total direct cost of all fall injuries for people 65 and older exceeded $19 billion.1 The financial toll for older adult falls is expected to increase as the population ages, and may reach $54.9 billion by 2020 (adjusted to 2007 dollars).2

How big is the problem? • One in three adults 65 and older falls each year.3,4 • Of those who fall, 20% to 30% suffer moderate to severe injuries that make it hard for them to get around or live independently and increase their chances of early death.5 • Older adults are hospitalized for fall-related injuries five times more often than they are for injuries from other causes.5

How are costs calculated? The costs of fall-related injuries are often shown in terms of direct costs.

• Direct costs are what patients and insurance companies pay for treating fall-related injuries. These costs include fees for hospital and nursing home care, doctors and other professional services, rehabilitation, community-based services, use of medical equipment, prescription drugs, changes made to the home, and insurance processing.2

• Direct costs do not account for the long-term effects of these injuries such as disability, dependence on others, lost time from work and household duties, and reduced quality of life.

How costly are fall-related injuries among older adults? • In 2000, the total direct cost of all fall injuries for people 65 and older exceeded $19 billion: $0.2 billion for fatal falls, and $19 billion for nonfatal falls.1 • By 2020, the annual direct and indirect cost of fall injuries is expected to reach $54.9 billion (in 2007 dollars).2 • In a study of people age 72 and older, the average health care cost of a fall injury totaled $19,440, which included hospital, nursing home, emergency room, and home health care, but not doctors’ services.6

How do these costs break down? Age and sex

• The costs of fall injuries increase rapidly with age.1 • In 2000, the costs of both fatal and nonfatal falls were higher for women than for men.7 • Medical costs in 2000 for women, who comprised 58% of older adults, were two to three times higher than for men.1

• Fractures were both the most common and most costly type of nonfatal injuries. Just over one third of nonfatal injuries were fractures, but they accounted for 61% of costs—or $12 billion.1 • Hip fractures are the most frequent type of fall-related fractures. The cost of hospitalization for hip fracture averaged about $18,000 and accounted for 44% of direct medical costs for hip fractures.8 Reprinted with permission from the Centers for Disease Control, National Center for Injury Prevention and Control, Division of Unintentional Injury Prevention References 1 Stevens JA, Corso PS, Finkelstein EA, Miller TR. The costs of fatal and nonfatal falls among older adults. Injury Prevention 2006;12:290–5. 2 Englander F, Hodson TJ, Terregrossa RA. Economic dimensions of slip and fall injuries. Journal of Forensic Science 1996;41(5):733–46. 3 Hausdorff JM, Rios DA, Edelber HK. Gait variability and fall risk in community-living older adults: a 1-year prospective study. Archives of Physical Medicine and Rehabilitation 2001;82(8):1050–6. 4 Hornbrook MC, Stevens VJ, Wingfield DJ, Hollis JF, Greenlick MR, Ory MG. Preventing falls among community-dwelling older persons: results from a randomized trial. The Gerontologist 1994;34(1):16–23. 5 Alexander BH, Rivara FP, Wolf ME. The cost and frequency of hospitalization for fall-related injuries in older adults. American Journal of Public Health 1992;82(7):1020–3. 6 Rizzo JA, Friedkin R, Williams CS, Nabors J, Acampora D, Tinetti ME. Health care utilization and costs in a Medicare population by fall status. Medical Care 1998;36(8):1174–88. 7 Roudsari BS, Ebel BE, Corso PS, Molinari, NM, Koepsell TD. The acute medical care costs of fall-related injuries among the U.S. older adults. Injury, Int J Care Injured 2005;36:1316-22. 8 Barrett-Connor E. The economic and human costs of osteoporotic fracture. American Journal of Medicine 1995;98(suppl 2A):2A–3S to 2A–8S.

Type of injury and treatment setting

• In 2000, traumatic brain injuries (TBI) and injuries to the hips, legs, and feet were the most common and costly fatal fall injuries, and accounted for 78% of fatalities and 79% of costs.1 • Injuries to internal organs caused 28% of deaths and accounted for 29% of costs from fatal falls.1 • Hospitalizations accounted for nearly two thirds of the costs of nonfatal fall injuries, and emergency department treatment accounted for 20%.1 • On average, the hospitalization cost for a fall injury was $17,500.7

Improving Quality of Care Based on CMS Guidelines 69

Fall Prevention

Interventions to keep residents right side up.

Bath Safety Products Medline carries a wide variety of bath safety products, including grab bars, raised toilet seats and more. Our rugged steel grab bars are easy to grip and help reduce the risk of accidents. Raised toilet seats consist of a plastic, add-on seat cover that elevates a low toilet by six to seven inches to reduce According to the Centers for Disease Control and Prevention (CDC), fall prevention entails a combination of medical treatment, strain on both patients and assisting caregivers. rehabilitation and environmental changes. Pressure-Sensing Safety Alarms Some of the environmental interventions you can put into place When used properly, patient alarms can alert caregivers when include installing grab bars, adding raised toilet seats, providing a resident at risk for falls is on the move. Medlineâ&#x20AC;&#x2122;s patient alarms come packed with some of the most sought-after techpatients with hip pads that may prevent a hip fracture, and nological features, including auto-sensing without the need for using alarms that go off when patients try to get out of bed or an on/off switch, as well as nurse call system compatibility. move without help.1 All of these safety-enhancing products are available from Medline. Falls are a major concern in nursing homes. In fact, about 1,800 people living in nursing homes die each year from falls. About ten to 20 percent of nursing home falls cause serious injuries.1

This is just a small sampling of Medlineâ&#x20AC;&#x2122;s fall prevention products. For further information on these and more products and to receive a free on-site fall prevention preparedness assessment, contact your Medline representative or call 1-800-MEDLINE (1-800-633-5463).

Reference 1 Centers for Disease Control and Prevention. Falls in Nursing Homes. Available at: Accessed September 3, 2009.

Survey Readiness

Summary of CMS requirements for a homelike environment

Making Sense of Changes to the LTC Surveyor Guidance The Centers for Medicare & Medicaid Services (CMS) issued a new survey and certification letter June 12, 2009, that revises and clarifies requirements related to quality of life and environment.

The new guidelines enhance instructions to surveyors on how to evaluate compliance with areas such as resident choices about daily schedule, (including when to get up, go to bed, eat and bathe) visitation issues, homelike environment, food procurement and expand significantly on guidance related to lighting. The following is a summary of the new guidelines. Beginning June 18, 2009 surveys are being conducted with a sharpened focus on elements of quality of life. Because some of the changes require significant facility remodeling and capital expenditures, CMS realizes these modifications are not feasible immediately. CMS recommends that facilities view those changes as goals to strive toward.

Access and Visitation Rights - F172 Facilities must provide 24-hour access to non-relative visitors who are visiting with the consent of the resident. These other visitors are subject to “reasonable restrictions,” such as those imposed by the facility to protect the security of all the facility’s residents: • Keeping facility locked at night • Denying access or providing limited and supervised access to a visitor if that individual has been found to be abusing, exploiting or coercing a resident • Denying access to a visitor who has been found to have been committing criminal acts such as theft • Denying access to visitors who are inebriated and disruptive

Improving Quality of Care Based on CMS Guidelines 71

Married Couples, Roommates - F175 In the same way that married couples are allowed to share a room, all nursing home residents may choose to room with any other resident, male or female, provided that a room is available and the payment source is the same for each resident or private funding is available. Dignity - F241 • Encouraging and assisting residents to dress in their own clothes rather than hospital-type gowns. • Promoting resident dignity in dining, including the avoidance of: – Bibs instead of napkins (except by resident request) – Staff standing over residents while assisting them to eat – Staff interacting or conversing only with each other rather than residents, while assisting residents – Using labels to classify groups of residents (e.g., “feeders”) • Maintaining an environment free from signs posting confidential clinical or personal information about residents • Grooming residents in the way they wish to be groomed (e.g., removing facial hair, allowing residents to wear clothing styles of their choice) • Keeping residents sufficiently covered while in public areas (e.g., while en route to bathing areas) • Responding in a dignified manner to residents with cognitive impairments (i.e., refraining from challenging or disputing a resident’s intent, even if it is irrational). For example, if a resident with dementia says she needs to meet her children at the school bus, go ahead and walk outside with her, and then converse with her about her children until the behavior dissipates.

Self-Determination and Participation – F242 As already mentioned under this section, the resident has the right to: • choose activities, schedules and health care consistent with his or her interests • interact with members of the community both inside and outside the facility • make choices about aspects of his or her life in the facility that are significant to the resident Clarification has been added that the facility is responsible for actively seeking information from the resident regarding significant interests and preferences in order to provide necessary assistance to help residents fulfill their choices. Schedules: Residents have the right to have a choice over their schedules, consistent with their interests, assessments and plans of care. Types of “schedules” include those concerning daily waking, eating, bathing, healthcare appointments and the time for going to bed at night.

Individual Routines Improve Outcomes According to individuals who helped with the revisions to Tag F242, allowing residents to follow their own schedules and routines results in: • Residents sleeping better when they are allowed to wake and go to bed according to their own schedule; this also translates to a better mood • Better healing • Better appetite • Reduced agitation • Fewer falls • Fewer pressure ulcers • Better transitions from subacute care settings Source: “Creating Home: The New Quality of Life Revisions to LTC Surveyor Guidance” Webinar Series. June 10 & 11 and June 17 & 18, 2009. Presented by Pioneer Network, American Association of Homes and Services for the Aging (AAHSA) and American Health Care Association (AHCA).

Continued on Page 74

72 Healthy Skin

Control odors while you control costs

Silvertouch™ Antimicrobial Odor-Controlling Reusable Underpads Underpads can be a source of persistent odor caused by bacteria. Medline’s Silvertouch odor-controlling reusable underpads are designed to target and tame these odors. Silver technology kills odor-causing microbes Silvertouch underpads are treated with a unique, highly effective solution called SilverClear, which combines the power of silver ions with surface-active antimicrobial chemistry, delivering a fast kill rate across a broad spectrum of microbes. SilverTouch also controls odors by protecting the pad from the growth and multiplication of bacteria. No special laundering What’s more, there are no laundering restrictions, no need for special laundering additives and no changes to staff protocol required. Technology still effective wash after wash The technology remains effective for the life of the product – no matter how many times it gets laundered.

©2009 Medline Industries, Inc. Medline and Silvertouch are registered trademarks of Medline Industries, Inc.

Accommodation of Needs – F246 The facility is responsible for evaluating each resident’s unique needs and preferences and ensuring that the environment accommodates the resident to the extent reasonable and does not endanger the health or safety of individuals, including other residents. This includes adapting the resident’s bedroom and bathroom furniture and fixtures as necessary to ensure that the resident can (if able): • Open and close drawers and turn faucets on and off • See himself or herself in the mirror and have toiletry articles within reach at the sink • Open and close bedroom and bathroom doors and operate room lighting • Perform other desired tasks, such as turning a table lamp on and off or using the call bell Additional areas regarding accommodation of needs include providing: • Reasonably sufficient electric outlets to accommodate resident’s need to safely use his or her electronic personal items • Comfortable seating for residents in their bedroom • Adequate task lighting in resident’s bedroom to accommodate resident’s chosen activities • Accommodation of resident’s preference for the arrangement of furniture to the extent space allows, including facilitating resident choice about where to place his or her bed (with roommate’s consent) • Varying types and sizes of furniture in common areas to accommodate individual resident’s preferences and needs for seat height, depth, firmness and arms that assist in arising to a standing position • Staff interaction in a way that takes into account the resident’s physical limitations, assures communication and maintains respect, (e.g., getting down to eye level to speak with a resident who is sitting)

Syst em CM S M anualOper at ions at e Pub. 100-07 St tif ication Pr ovider Cer Tr ansmi ttal 48

Revisions to Ap SUBJECT: Car e Facilit ies”

pendix PP, “ Gu

Hea lth & Depar tmen t of es (DH HS) Human Ser vic

edi car e & Center s for M vices (C M S) M edi cai d Ser 2009 12, NE Date: JU

or idance to Sur vey

m s of L ong Ter

Guidance to Appendix PP, “ instruction revises language is unchanged. ANGES: Thi s tory CH ula reg OF the Y er, oved to Tag SUM M AR Tags, howev I. language is m several regulatory nd the regulatory Surveyors” f or Closet Space” is del eted a e vat Tag F255, “ Pri e 12, 2009 F461. DA TE* : Jun - EFFECT I VE TION DA TE: June 12, 2009 M AT ERI AL TA D EN SE VI EM RE PL IM NEW/ l number apply e and transmitta e revision dat previousl y published an d nges onl y: Th was cha al al nu teri ma ma tents, you wil l y. Any other Disclaimer for a ta ble of con ized ma teri al onl tents. ision contains to the red ital ic er, if th is rev ire table o f con wev ent Ho the d. not nge tion onl y, and remains un cha is ed inf orma /rev ated. ) new upd t the no receive manual ONS: (N/A if I NSTRUCTI Per Row. ) ) – ( Only One I N M ANUA L S ED GE ET L AN DE CH = D II. D, N = NEW, (R = RE VI SE TL E BS ECTION/TI Rights/Tag F172 ECTI ON/SU R/S TE AP d Vi sitation R/N/D CH (j)/Access an

Safe, Clean, Comfortable and Homelike Environment – F252 For the purpose of this requirement, “environment” refers to any area in the facility that is frequented by residents, including (but not limited to) the residents’ rooms, bathrooms, hallways, dining areas, lobby, outdoor patios, therapy areas and activity areas. A determination of “homelike” should include the resident’s opinion of the living environment. The intent of the word “homelike” is to provide an environment as close to that of a private home as possible. The concept of creating a home setting includes eliminating institutional odors and practices to the extent possible. The following practices also decrease the institutional character of the environment: • Eliminating overhead paging and canned music • Dining room meals served on regular dishes without trays • Storing medications securely in cabinets or resident rooms rather than using medication carts • Limiting the use of audible chair and bed alarms to avoid startling the resident • Using less institutional-looking furnishings • Eliminating large, centrally located nurses stations

Kind, Caring Staff

+ Knowing Me as an Individual = Quality Care Source: “Creating Home: The New Quality of Life Revisions to LTC Surveyor Guidance” Webinar Series. June 10 & 11 and June 17 & 18, 2009. Presented by Pioneer Network, American Association of Homes and Services for the Aging (AAHSA) and American Health Care Association (AHCA).

A complete copy of the surveyor guidance summarized in this article is located at: CMS Manual System Pub. 100-07, Provider Certification. Transmittal 48. June 12, 2009. Revisions to Appendix PP, “Guidance to Surveyors of Long Term Care Facilities.” Continued on Page 76

Bringing You Closer to Home™

Medline Healthcare Furnishings Even though your residents might have a new address, it’s important that they still feel like they’re at home. Let Medline show you all the ways we can make your facility a more welcoming, comfortable place to live. We’ve been supplying quality healthcare products for more than 40 years and we know what you need and want. With that in mind, we’ve developed versatile furnishing collections with the quality and durability you need and the stylish look and feel that you love. We offer great furnishings for your: • Lounge • Living rooms • Reception area

Visit to explore all of our furnishing options. While you’re there, don’t forget to try our Living Spaces Virtual Designer, a handy online tool that can help you create your own resident rooms – free of charge! Of course, our Interiors Specialists are waiting to help you as well.

• Dining room • Resident rooms

©2009 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.

Quick Ways to Adapt Your Facility to Residents’ Needs Widespread change to your facility to accommodate new surveyor guidelines can take time, effort and money. But small changes can begin right away for little cost. Here are some ways to begin taking smaller steps toward change. First, be sure to tour your entire facility, taking a good look at all areas used by residents. Next, take a group of residents around, and get their input. Note light levels at different times of the day, glare levels from sunshine coming through windows and from shiny floors. Think about ease-of-use for residents with low vision and limited hand dexterity. Ask residents about difficulties they may have (i.e., opening doors, seeing where they are going, using a faucet). The following are simple changes that can be made in specific areas of your facility. Bedrooms

• Install extra brackets in closets to make closet rods moveable to accommodate both the resident standing and the resident in a wheelchair • Replace standard drawer handles with easy-to-use ones • Add grippers to door knobs or switch to long handle knobs • Replace standard table lamp switches with easy-to-use ones • Add night lights along the path to the bathroom Bathrooms

• Use flip-up grab bars • Select easy-to-use faucet handles • Tilt down sink mirrors to accommodate residents using wheelchairs • Add storage space near sinks Hallways

• Use contrasting color for baseboard or wall so residents can distinguish where the floor ends and the wall begins • Stop using shiny floor wax • Determine if it is time to replace pictures and decorations in hallways to enhance visual interest

Common areas

• Ask tall and short residents to sit on and get up from furniture. Is it time to do some furniture replacement? • Consider different seat heights for people of different sizes • Would a “get up” pole or trapeze help? Dining areas

• Can residents using wheelchairs get the arms of their chair under the dining table? • Stop using trays; provide table service using china and glassware • Use oversized linen napkins or heavy paper napkins instead of adult bibs Household kitchens within facility

• Install cabinet and drawer hardware that is large and easy to use • Install an adjusting system for kitchen cabinets Notice Before Room or Roommate Change

• Being sensitive that a move or change of roommate can be traumatic for some residents • Notifying residents of changes in advance to help ease the transition • Allowing time for residents to grieve the loss of their previous room or roommate

Source: Schoeneman K & Bowman C. Quick fixes for the environment. Pioneer Network Conference, 2008. Available at /Data/Documents/Quick_Fixes_for_the_Environment.pdf. Accessed August 31, 2009.

76 Healthy Skin

Adequate and Comfortable Lighting – F256 Lighting is important, as residents often have issues with eyesight. As people age, the eyes usually change, requiring more light. Adequate lighting design includes these features: • Sufficient lighting with minimal glare • Even light levels in common areas and hallways • Use of daylight as much as possible • Elimination of glare caused by high-gloss flooring, waxes and uncovered windows • Task lighting for reading and other activities requiring concentration • Night lights to help residents find their way to the bathroom at night • Dimmer switches or the use of pen lights to allow nurses to care for residents at night without disturbing roommates • Floor and baseboard to be in contrasting colors to enable residents with impaired vision to determine the horizontal plane of the floor • Use of contrasting colors for bathroom walls and toilets so residents with impaired vision can distinguish the toilet fixture from the wall. • Use of dishes that contrast with the table or tablecloth to help residents with impaired vision see their food. Sanitary Conditions – F371 • Clarification: Food procurement requirements are not intended to restrict resident choice. All residents have the right to accept food brought to the facility by any visitor(s) for any resident.

Interiors by Medline

Living Spaces Room Makeover Contest Enter to win a FREE resident room makeover! First Place Winner: Receives free remodel of a semi-private resident room with a value of $4,000. Second Place Winner: Receives a free remodel excluding the furniture in the room with a value of $500.

Resident Rooms – F461 • Allowable window sill height shall not exceed 36 inches • Resident’s clothing to be kept separate from the clothing of roommate(s) • Closet space to be arranged so the resident can reach hanging clothing and items on closet shelves • The term “closet space” is not necessarily limited to a space installed into the wall. Compliance may be attained through the use of storage furniture such as clothing wardrobes. Out-of-season items may be stored outside the resident’s room.

How to Enter Send us a picture of your resident room most in need of a makeover. Include a paragraph explaining what it will mean to you to win the competition. Send your paragraph and picture to or mail to Interiors Division, Medline Industries, Inc. One Medline Place, Mundelein, IL 60060. Entries must be received by December 31, 2009. For more information on Medline Interiors and to try our Virtual Room Designer free of charge, visit Contest Details A panel of judges will choose the winners based on the picture and the response describing what it would mean to win the competition. No purchase is necessary. Medline will take before and after pictures of the makeovers at each winner’s facility. We will require the consent of the winners to take the photos and use the name of the facility for marketing purposes.

Improving Quality of Care Based on CMS Guidelines 77

The Many Benefits of Correctly Sized

Incontinence Briefs

by Claire Sweeney, BS, MSN, RN

Today’s adult incontinence products come in many forms and sizes to meet individual needs. They are helpful in promoting healthy skin and maintaining the overall health of individuals who are incontinent. The most frequently used products are briefs and protective underwear (pull-ups). The level of incontinence, gender, fit and use are all factors in product selection. Sizing is important for correct fit, leakage control and to help prevent skin damage.

Improper sizing can lead to problems Frail skin can be damaged in a number of ways by an inappropriately fitted brief. A brief that is too small can lead to friction and pinching, which can result in skin damage. Briefs that are too large can cause even more problems. Products that are oversized create

78 Healthy Skin

increased pressure over the entire groin and delicate perineal area when the wearer is “wrapped” in excess layers of product. Ill-fitting garments do not fit snugly and are not able to quickly wick away moisture from urine, which can cause skin maceration. Skin maceration in turn can lead to further damage and potential infection.

Bigger ≠ better A myth that compounds the sizing problem is that bigger is “better” or “easier to apply.” Larger products do not hold more urine or feces. And the risk of damage to skin from an improperly fitted garment far outweighs the ease of applying an oversized product. Larger sized products are often packed with fewer pieces per package, taking up more storage space than smaller products. They are


also more expensive. Incontinence products can represent up to one third of a facility’s budget, so correct selection and sizing can have a huge impact on an institution’s bottom line, as well as the care of its residents.

The importance of a properly fitted brief1 • Proper fit can help prevent leakage, which in turn, protects the skin. • An overly large brief may be exposing more skin surface area than necessary to urine and fecal material, which poses a risk to the skin. • Improperly fitting briefs require more frequent changing, which can be expensive and time-consuming. • A properly fitting brief is more comfortable for the wearer. • Those who wear briefs are apt to be less sensitive about the touchy issue of “diapers” if the garment is somewhat discreet under clothing.

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



Weight Hip measurement Waist measurement

Adult brief Small: Green backing


(51cm – 81cm)

Medium: White backing

32"– 42"

(81cm – 107cm)

Regular: Purple backing

40"– 50"

(102cm – 127cm)

Who’s in charge of incontinence care?

Large: Blue backing


(122cm – 147cm)

Incontinence care program responsibilities are often divided among several departments in a facility. Oftentimes nurses assess, central supply and /or environmental services orders (and sometimes delivers) supplies, and nursing assistants and caregivers actually apply the products.

X-Large: Beige backing

59"– 66"

(150cm – 168cm)

XX-Large: Green backing 60"– 69"

(152cm – 175cm)

All departments need to work as a team to ensure the correct product is available and used for a resident when necessary. It might be more convenient to order only large and extra large products due to ease of ordering and storage limitations, however, this practice will not meet the Centers for Medicare & Medicaid Services (CMS) guidelines that call for the provision of “individualized interventions.” People come in all shapes and sizes, and appropriate sizing of product promotes dignity, self-esteem, healthier skin, and cost-effectiveness.

Bariatric: Beige backing

65"– 90" (165cm – 229cm)

Knit pants Medium/Large: Blue/Brown waistband

20"– 60"

(51cm – 152cm)

X-Large: Green waistband

45"– 70"

(114cm – 178cm)

XX-Large: Purple waistband

50"– 75"

(127cm – 191cm)

Disposable mesh pants


Three Easy Steps for Better Sizing

Step 1: Measure across the front of the body; from hip bone to hip bone and over the abdomen. Or measure from thigh to thigh, if that area appears to be larger. Step 2: Double the measurement from Step 1 and add two inches. Step 3: Match the final measurement with the manufacturer’s size chart.


28"– 40"

(72cm – 102cm)


30"– 45"

(76cm – 114cm)


32"– 48"

(81cm – 122cm)


38"– 58"

(97cm – 147cm)

Need additional help with sizing? Ask your Medline representative to arrange for a nurse to visit your facility for hands-on instruction.

About the Author Reference 1. Managing incontinence. In Pressure Ulcer Prevention Program - Nurse. Mundelein, Ill.: Medline Industries; 2008.

Claire Sweeney, BS, MSN, RN, has 22 years of nursing experience, primarily in geriatric settings, assisted living and long term care and her main areas of interest include infection control and pressure ulcer management.

Improving Quality of Care Based on CMS Guidelines 79

Just one touch...

Comfort-Aire™ Disposable Briefs One touch and you know Comfort-Aire disposable briefs are unique. Velvety soft side panels allow airflow for enhanced comfort and skin care. The comfortable outer cover helps prevent skin irritation.

For more information about Comfort-Aire, contact your Medline representative or call us at 1-800-MEDLINE. Extra-wide, skin-safe refastenable tape tabs

Breathable side panels

One look and you can see the advantages. The wider hook tape tabs make it easier to grasp and won’t stick to skin or gloves, and the compressed packaging is easier to handle. One try and you’ll understand. Comfort-Aire’s enhanced, super-

Enhanced, super-absorbent core

absorbent core keeps skin dry, which helps to keep it healthy.

Comfort-Aire. The right choice for ultimate patient comfort and protection.

Soft cloth-like outer cover

Special Feature

Creative Communication Techniques Take the stress out of relating to people with Alzheimer’s by Jo Huey

The following tool, “Ten Absolutes,” was developed while providing direct care for persons with Alzheimer’s disease. It was designed to give care providers a way to positively interact, focusing on the completion of personal care and important health issues such as nutrition and hydration. “Ten Absolutes” is equally useful in providing the tools for relaxed interaction with a person with Alzheimer’s or a related disorder. If you find yourself on the “Absolutely Never” side, don’t despair. Simply move to the right side of the list and things will improve. For a more detailed version of this tool, turn to page 102.

TEN ABSOLUTES Absolutely Never!!!!!!!


1. Argue


2. Reason


3. Shame


4. Lecture


5. Say “Remember”


6. Say “I Told You”


7. Say “You Can’t”

Do What They Can

8. Command/Demand


9. Condescend


10. Force


©Huey 1996

About the author

Jo Huey is a world-renowned specialist in helping family caregivers work through the maze of emotions and skills needed to assist an Alzheimer’s patient. She is also author of two books: Alzheimer’s Disease: Help and Hope and Don’t Leave Momma Home with the Dog. To learn more, visit

Improving Quality of Care Based on CMS Guidelines 81

Técnicas de Comunicación Elimine el estrés de su relación con personas con Alzheimer por Jo Huey

La siguiente herramienta, “Diez Absolutos” fue desarrollada mientras se proporcionaba cuidado directo a personas con la enfermedad de Alzheimer. Fue diseñada originalmente para dar a los proveedores de cuidados de salud una forma de interactuar positivamente, centrándose en completar tareas de cuidado personal y salud importantes, tales como nutrición e hidratación. “Diez Absolutos” es igualmente útil para proporcionar las herramientas para una interacción relajada con una persona con enfermedad de Alzheimer u otra parecida. Si se encuentra usted en el lado del “Absolutamente Nunca”, no desespere. Simplemente pase al lado derecho de la lista y las cosas mejorarán. Para una versión más detallada de esta herramienta, vaya a la página 104.

DIEZ ABSOLUTOS Absolutamente Nunca!!!!!!!

En vez de ello

1. Discuta

Esté de acuerdo

2. Razone


3. Avergüence


4. Sermonee


5. Diga “Recuerda”


6. Diga “Te lo dije”


7. Diga “No puedes”

Haga lo que ellos pueden

8. Ordene/Demande


9. Sea condescendiente


10. Fuerce


©Huey 1996

Sobre la Autora

Jo Huey es una especialista de renombre mundial en ayudar a cuidadores de familia a abrirse paso entre el laberinto de emociones y habilidades necesarios para ayudar a un paciente con Alzheimer. También es autora de dos libros: Enfermedad de Alzheimer: Ayuda y Esperanza y No Dejes a Mamá en Casa con el Perro. Para más información, visite

82 Healthy Skin

How 4 square inches of Puracol Plus changed chronic wound care. Forever.

Look closely. It’s not a bandage. It’s Puracol Plus MicroScaffold , made entirely of pure native collagen. ™

Chronic wounds tend not to heal when unbalanced levels of elastase and MMPs (inflammatory enzymes) destroy the body’s own collagen and growth factors.1 But apply Puracol Plus and help restore nature’s balance.

This is Puracol Plus MicroScaffold as seen through an electron microscope. Its open, cellular structure allows easy fibroblast migration.2 The high strength of the MicroScaffold2 also assists in establishing a fresh wound bed.

1. Schultz GS, Mast BA. Molecular analysis of the environment of healing and chronic wounds: Cytokines, proteases, and growth factors. Wounds. 1998;10 (6 Suppl): 1F-9F. 2. Data on file.

In vitro studies show that Puracol Plus has the ability to reduce the levels of elastase and MMPs from surrounding fluid.2

Each Puracol package, like every other Medline wound care package, is a 2-Minute Course in Advanced Wound Care.

Special Report Elevated blood glucose readings are possible with some types On August 13, 2009, the FDA issued a notiďŹ cation alerting healthcare professionals about the possibility of falsely elevated blood glucose results in patients who are receiving therapeutic products containing certain non-glucose sugars. The false readings occur when the tested blood reacts to diabetic test strips containing GDH-PQQ (glucose dehydrogenase pyrroloquinoline quinone). Continued on Page 86

84 Healthy Skin

OptiumEZ Blood Glucose Monitoring provides


accurate & reliable


Medline’s OptiumEZ monitor, manufactured by Abbott Diabetes Care, minimizes the variables that can affect glucose readings with its patented TrueMeasure® Technology. TrueMeasure Technology screens out common medications that may interfere with the accuracy of blood glucose results. Individual foil wrapping ensures that the test strips are not compromised by humidity, dust or dirt. Advanced Technology Made Simple™ for the Post Acute Care Professional. • No coding required • Simple two-step testing • Results in five seconds • Small blood sample size – 0.6 µl • Easy-to-read display with backlight • Simple 3-button navigation • Test starts only when enough blood is applied– designed to minimize errors, repeat tests and wasted test strips

©2009 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc. TrueMeasure is a registered trademark and Advanced Technology Made Simple is a trademark of the Abbott Group of Companies.

For more information, please contact your Medline sales representative or call 1-800-MEDLINE.

GDH-PQQ glucose monitoring measures a patient’s blood glucose value using methodology that cannot distinguish between glucose and other sugars. Certain non-glucose sugars, including maltose, xylose and galactose, are found in certain drug and biologic formulations, or can result from the metabolism of a drug or therapeutic product. The concern is that if a healthcare professional treats a patient with insulin based on a falsely elevated glucose reading, inappropriate dosing and administration of insulin could result and potentially cause hypoglycemia, coma or death.1 Recommendations1 • Avoid using GDH-PQQ glucose test strips in healthcare facilities. If your facility currently uses GDH-PQQ glucose test strips, NEVER use them on patients who are receiving interfering products or from whom or about whom you cannot obtain information regarding concomitant medication use, e.g., patients who are unresponsive or cannot adequately communicate. Interfering products containing non-glucose sugars include: – Extraneal (icodextrin) peritoneal dialysis solution – Some Immunoglobulins: Octagam 5%, Gamimune N 5%, WinRho SDF Liquid, Vaccinia Immune Globulin Intravenous(Human), and HepaGamB – Orencia (abatacept) – Adept adhesion reduction solution (4% icodextrin) – BEXXAR radioimmunotherapy agent – Any product containing, or metabolized into maltose, galactose or xylose. Use ONLY laboratory-based glucose assays on these patients.

86 Healthy Skin

• Determine whether patients are receiving interfering products on admission and periodically during their stay at your facility. • Educate staff and patients about the potential for falsely elevated glucose results in the presence of certain non-glucose sugars when using GDH-PQQ glucose test strips. • Consider using drug interaction alerts in computer order entry systems, patient profiles and charts to alert staff to the potential for falsely elevated glucose results. • Periodically verify glucose meter results with laboratorybased glucose assays if you are using GDH-PQQ test strips in patients who are not receiving interfering products. The FDA’s recommendation is to avoid using GDH-PQQ glucose test strips The following products on the market use the reagent GDH-PQQ:1 • Roche® Accu-Chek® Comfort Curve strips that are used on The Inform®, Complete®, Advantage® and Voicemate™ meters • The Accu-Chek Aviva, Compact, Go and Active test strips Abbott® FreeStyle Flash, Freedom and Lite meters* • HDI True Test strips that work on the True Result and True2go meters. Test strips currently on the market may be distributed under multiple trade names. In addition, manufacturers of GDH-PQQ test strips currently on the market may subsequently change

to non-GDH-PQQ methodology. Therefore, healthcare providers (and patients) should refer to device labeling or consult with test strip manufacturers to confirm the type of methodology used. * In late August 2009 Abbott submitted 510(k) applications to the FDA for new FreeStyle and FreeStyle Lite test strips, which will use GDH-FAD chemistry designed to minimize interference from common non-glucose sugars. Abbott’s current Optium system provides you with choices that can help you manage the individual needs of your patients with diabetes.2

References 1. U.S. Food and Drug Administration. FDA Public Health Notification: Potentially Fatal Errors with GDH-PQQ* Glucose Monitoring Technology. Available at: http://www.fda. gov/MedicalDevices/Safety/AlertsandNotices/PublicHealthNotifications/ucm 176992.htm. Accessed September 9, 2009. 2. Abbott Diabetes Care. Letter to healthcare providers, September 1, 2009.

Perioperative Pressure Ulcer Education. More important than ever before

“I have seen an increase in the number of legal issues linking facility-acquired pressure ulcers to post-surgical patients. A pressure ulcer program for the OR is more critical than ever.” Diane Krasner, PhD, RN, CWCN, CWS, BCLNC, FAAN Medlineʼs Pressure Ulcer Prevention Program now has a component designed specifically for the perioperative services. The easy-to-use interactive CD addresses the following: • Hospital-acquired conditions • CMS reimbursement changes • Best practices for pressure ulcer prevention • Perioperative assessment tools • Critical patient and equipment risk factors

Contact your Medline sales representative for more details. You can also learn more about Medlineʼs Pressure Ulcer Prevention Programs for long-term care, acute care and perioperative services by visiting

Improving Quality of Care Based on CMS Guidelines 87

Think green with environmentally conscious products for all areas of your facility. These Medline products are either: Recycled, recyclable, biodegradable or made from easily renewable materials Reduced in size to take up less space when shipped, saving fuel and reducing carbon monoxide emissions Free from environmentally harmful chemicals or pollutants Reusable, to reduce waste in landďŹ lls Water-conserving Minimally packaged

Environmentally conscious Medline products Apparel Enviro ISO gown Reusable surgical gowns Reusable ISO gowns Reusable briefs and underpads Scrubs Diagnostic Equipment Blood pressure cuffs (reusable) Sphygmomanometers Stethoscopes Thermometers Environmental Services Disinfectant products Eco floor mats Eco floor mops General cleaners Hard surface germicidals Microfiber cleaning cloths Microfiber mops Pillows Recycling sorting containers Reusable hamper bags Super-concentrated detergents and lubricants Touchless sensor faucets and flushers Tile, grout and bathroom cleaner/deodorizer Toilet paper, facial tissue and hand towels Trash liners Upholstery cleaner Urinals

Food Service Biodegradable paper cups Recyclable plastic cups and straws Patient utensils Infection Control Advanced Bowie Dick test Bio-zolve pre-soak instrument spray Sterilization containers Latex-Free Surgical Products Aneroids Anesthesia breathing bags Anesthesia circuits Anesthesia masks Anti-fog solution Band bags and equipment covers Bone wax Disposable safety scalpels Electrosurgical disposables (tips, ground pads, pencils and tip cleaner) Esmark bandages Insufflation tubing and needles Light handle covers Sharps safety products (magnetic drapes, transfer trays, scalpel holders) Skin markers Stockinettes Suture boots Thermoform molded trays Tube holders (amnio hook, umbilical cord clamp, umbilical cord clamp cutter) Vessel loops

©2009 Medline Industries, inc. Medline is a registered trademark of Medline Industries, Inc.

Miscellaneous Connecting tubes Drain bags Eco-friendly foam positioners Med-Pack Oxygen concentrator Peak flow units Reusable nebulizer cups Safesorb Silver Foley catheters Suction catheters More Ways to Go Green • Make it a habit to turn off the lights when leaving any room for 15 minutes or more. • Think before you print. Could this document be read or stored online instead? • Make it a policy to purchase supplies made from recycled materials. • Bring your own mug instead of using paper cups at work. • Brighten up your workplace with live plants, which absorb indoor pollution. Source: The Sierra Club,

Ask your Medline rep for details on ordering these products.

1-800-MEDLINE (1-800-633-5463)

By Wolf J. Rinke, PhD, RD, CSP

1. Reality Test

Do you have problems with communication in your facility and at home? Whenever I ask that question of my audiences virtually all hands go up. Why? Because we are all terrible communicators. Here are 12 specific strategies that will help you communicate more effectively and get more of what you want.

Most of us assume words have meaning. They do not! The fact is all of us speak a different “language” because we all have different values, beliefs and life experiences that impact how we interpret everything. For example, what does the word “fast” mean to you? If you’ve been dieting, it probably means “to not eat.” If you are an amateur photographer, you might be thinking of the speed of film. If you do a lot of laundry, you might be thinking of how stable a color is. If you like to race, you might think of the speed of a vehicle. And the list goes on.

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Caring for Yourself

How to Communicate More Effectively and Get More of What You Want

To get around this, do a reality test, especially when a shared understanding is critical. Here are several examples. When your spouse tells you how much you irritate him, summarize your conversation: “Sweetheart, let me just make sure that you and I are on the same page. What I heard you say was . . .” At the end of a complicated instruction to one of your patients: “Now Miss Eager, we went over a lot of technical information. To make sure you will be able to follow my instructions, please repeat what you heard me say.”

2. Get Really Good at Asking Questions As an executive coach, I’ve learned the benefits of asking questions. Here is what questions can do: • Put you in control of the conversation. Questions elicit an almost Pavlovian response in the listener to find an answer. • Establish rapport. Questions demonstrate interest, which causes others to like you. And people who like you are more likely to comply with your wishes and requests. • Build trust. Eliciting ideas from others causes them to feel that you care about them, which helps build trust.

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I see this all the time in my coaching practice. A manager tells me, “My boss does not care about me.” I ask, “How do you know?” “Well, he never tells me anything.” I ask, “How do you mean?” “Well, most of the time I find out stuff through the grapevine instead of from my boss.” I ask, “Have you ever asked him to keep you in the loop?” “No, but you know, that is a very good idea. I should really do that.”

• Achieve deeper understanding. When you ask questions, you will help the other party focus on what you want them to focus on. • Provide for greater buy-in, higher motivation and compliance. Questions allow individuals to come up with their “solution,” and invariably their level of commitment will increase.

My consistent advice is deceptively simply but extremely powerful: If in doubt, check it out.

4. Utilize Adult Language According to Eric Berne and Thomas Harris, of the transactional analysis (TA) fame, all of us utilize three different internal “recordings” that represent our “ego states”: child, parent and adult.

3. Avoid Fundamental Attribution Errors Someone is late for an appointment, and we perceive that they don’t care or they are sloppy, when in fact they may have had an accident. In psychology this is referred to as making a fundamental attribution error. I refer to it as “we are very good at running our own movies,” meaning that we attach all kinds of meanings to behavior we observe that has nothing whatsoever to do with the person’s actions.

The child ego state refers to the behavior pattern, thoughts and feelings we learned as children. They include helplessness, blaming and emotional expressions such as “I can’t help it,” “Don’t blame me,” “It’s your fault,” etc. Nonverbal cues of the child ego state include whining, whistling, laughing, teasing, expressing dejection, pouting, nail biting, moving restlessly and looking rebellious, nervous or sad.

I see this all the time in my coaching practice. A manager tells me, “My boss does not care about me.” I ask, “How do you know?” “Well, he never tells me anything.” I ask, “How do you mean?” “Well, most of the time I find out stuff through the grapevine instead of from my boss.” I ask, “Have you ever asked him to keep you in the loop?” “No, but you know, that is a very good idea. I should really do that.”

Our parent ego state was developed by observing parents and other authority figures. When we are in a parent role we tend to be very judgmental, critical, controlling, comforting or nurturing, and use such phrases as “You can’t do that,” “You have to,” “Always,” “Never,” etc. Nonverbal cues include finger pointing, looking at your watch while communicating, finger tapping, pressing lips tight, grinding teeth, checking up on others, scowling, sneering, patronizing or expressing sympathy. The third internal recording is that of the adult. An adult is a fact finder, information seeker, analyzer and logical problem

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It is better to remain quiet and be thought a fool than to speak and remove all doubt,” — Anonymous

solver. When you use your adult recording, you ask why? what? when? where? who? how? and say such things as “I made a mistake,” “I changed my mind,” “I don’t know,” “I don’t understand,” “It’s my opinion,” “Let me check on that,” and “What can we learn from this?” When you are in this ego state, you tend to be clear, calm and non-judgmental. Your nonverbal expressions include straight but relaxed posture, comfortable eye contact and a friendly face that says, “I’m interested in what you have to say. I’m alert, thoughtful and attentive.” Communication effectiveness is dramatically enhanced when you express yourself in an adult ego state, especially when both you and the other party are playing the same recording. Since it is difficult to change other people, I strongly urge you to get in the driver’s seat of your transactions by using adult language whenever you are communicating. If you would like more help with this, read my How to Maximize Professional Potential CPE program available from

5. Accept 111 Percent Responsibility for the Entire Communication Process Most of us are experts at playing the blame game. Have you noticed that when there is a breakdown in communication, it’s almost always the fault of someone or something else, but seldom the person who is making the excuses! To make this point, ask someone who arrives late for a meeting, “Would you have been on time if $1,000 were riding on it?” The typical answer is “Of course!” To achieve dramatic improvements in your communication effectiveness, I strongly recommend that you buy 111 percent into the following axiom: If it is to be, it is up to me. (This one works for all aspects of your life, so do try this at home.)

6. Listen Actively Even though it’s been said by the prolific author Anonymous, “It is better to remain quiet and be thought a fool than to speak and remove all doubt,” most of us are very good at removing all doubt. One reason is that most of us are very good at “talking and telling” instead of “listening and learning.” To become an active listener, remind yourself that there must be a reason that we were born with only one mouth and two ears. The better you get at listening, the more you’ll find out what the other party really wants. Once you know that, you are communicating from a position of strength. Your husband says: “For our next vacation I want to go to Phoenix.” Unfortunately you are tired of Phoenix. Instead of telling him why Phoenix is a bad idea, ask questions to find out what he really wants. “Please tell me what you would like to do in Phoenix?” He might say, “I want to play golf where the air is warm and dry.” Now you can put your thinking caps on to identify lots of places that will meet both of your needs. Here are several related strategies: • When someone asks a question, keep your mouth shut until the other person has finished speaking. Do this even though you know the answer when the other person begins to speak. Remember, when the mouth is engaged, the ears are out of gear. • Show the person speaking that you are listening actively by totally focusing all of your mental energy on what the other person is saying, not only with her words but also her body. You can achieve that by making strong eye contact, leaning slightly forward and using your body language to acknowledge the message and the messenger.

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• Listen to the “music” as well as the words. In order to really understand what’s being communicated, it’s important that you hear more than the words, which you can achieve by tuning into the mood, atmosphere and emotional tone that put the words into context. • Demonstrate empathy by getting inside the other person’s thoughts and feelings. This can be expressed by saying “I see,” “I understand,” “I follow you,” “I’m with you,” and so on. • Take off your mask and be yourself. This engenders trust, and trust is essential to effective communication. • Before ending your communication, summarize and do a reality test, as previously discussed.

7. Express Yourself in Positive Terms When we speak, we can say things negatively or positively. For example, you can say, “I don’t have an answer for that,” or “I can answer that the next time we get together.” Which do you think is easier to understand? Research has demonstrated that positively worded statements are one-third easier to comprehend than their negative counterparts. The reason is that human beings are unable to move away from the reverse of an idea. Instead, we move toward that which we visualize in our minds. Don’t believe it? Let me ask you not to think of a green snake. What did you just think of? A green snake, right? You see, none of us can move away from the reverse of an idea. Take advantage of this phenomenon by expressing yourself in positive terms.

8. Master the PIN Technique The PIN technique is a powerful way to reframe your perceptions and turn the negatives into positives. Here is how it works. When you are confronted with anyone or anything that

To turbo-charge your communication effectiveness, pretend that all people you communicate with have printed across their forehead a big bold sign that reads


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would cause you to react negatively, PIN it. For example, your team member says, “Boss, you know how morale has gone down the tube? Let’s close the hospital and go on a cruise.” Instead of NIPing anything “weird,” focus your mental energy first on the: P - Positive. Ask yourself what could be positive about your employee’s suggestion: “Well at least she seems interested in making things better.” After you’ve done that in your mind’s eye, next evaluate the … I - Interesting or Innovative. Ask what could be interesting or innovative about your team member’s suggestion. “Maybe there is a need for more celebration around here.” Once you’ve evaluated that, and only after you’ve exhausted all the Ps and Is, then ask yourself: “What is the downside, or the…” N - Negative. Because in communication, just like in life, nothing ever goes one way, there is yin and yang, health and sickness, life and death, high stock market and low stock market and the list goes on. PINing it will enable you to evaluate both the upside and downside of every conversation. However, if you NIP comments, ideas or suggestions in the bud, it’s like closing the proverbial shade, which prevents you from seeing opportunities.

9. Convey Integrity at All Times People prefer to deal with communicators they can trust, rather than those they have to second-guess. The fact is that without trust, relationships die and your ability to communicate is severely compromised. So be sure to be congruent, which means that your body language, vocal patterns and pitch support what you’re saying. And the way to achieve that is to “tell it like it is,” even though it shows that you are not omnipotent. Also be aware of self-defeating phrases some

results with far less resistance. (For other powerful techniques read my Win-Win Negotiation CPE program, available at people use habitually without being aware of their implications. For example, avoid saying, “Let me be absolutely honest with you.” If you say that to me, I’m thinking: “What are you normally?”

10. Strive For Win-Win When you are communicating be on the lookout for things that will be beneficial to the other party. For example, if you are talking with a team member, instead of saying “You have to yada, yada, yada,” use: “How can I help you with . . .?” When you are talking to patients, instead of saying, “According to hospital policy you have to . . .,” use, “What options can we think of that will . . .” This attitude shows that you are interested in helping the other person get what he wants, which in turn will make him more receptive to helping you get what you want.

12. Make Them Glad They Communicated with You To turbo-charge your communication effectiveness, pretend that all people you communicate with have printed across their forehead a big bold sign that reads MAKE ME FEEL IMPORTANT! This phrase will remind you to always focus on their needs first, because once they get the feeling you want to help them, most people will do whatever they can to reciprocate, which in the long run will help you get more of what you want.

11. Always Strive to Make the Other Person Right—Never Wrong Whatever you do, avoid arguing. People who argue will lose the “battle” because it causes the other person to become defensive. So what’s a better approach? Make the other person right. My Superwoman and I have taken this to another level. Anytime we find ourselves getting into conflict, one of us will raise his/her hand with all five fingers extended, which stands for: “You are right about that.” (One finger for each word.) So you don’t sound like a parakeet, use other phrases that make the other person right, such as: “That is a very interesting idea;” “I’ve never thought of it that way;” “This seems very important to you,” etc. So make it a habit to agree with people and you will find that you will get much better

Dr. Wolf J. Rinke, RD, CSP is a keynote speaker, seminar leader, management consultant, executive coach and editor of the free electronic newsletters Make It a Winning Life and The Winning Manager. To subscribe go to He is the author of numerous books, CDs and DVDs including Winning Management: 6 Fail-Safe Strategies for Building High-Performance Organizations and Don’t Oil the Squeaky Wheel and 19 Other Contrarian Ways to Improve Your Leadership Effectiveness available at His company also produces a wide variety of quality pre-approved continuing professional education (CPE) self-study courses including his latest The Power of Communication: How to Increase Your Personal and Professional Effectiveness on which this article was based. It is available at Reach him at

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Losing Sleep Over Economic Worries? You’re Not Alone

More Americans are losing sleep because of financial worries. Declining home values, dwindling savings and fear of layoffs are forcing more people to seek help for insomnia and a host of other sleep disorders.1 Nearly 30 percent of Americans say they lose sleep at least a few nights a week, according to a national “Sleep in America” poll conducted by the National Sleep Foundation.1 Sleep specialists say the survey results mirror patient concerns in their medical practices lately. “We’ve been seeing this clinically for months, a very sharp increase in insomnia due to stress,” said Joseph Ojile, CEO and founder of Clayton Sleep Institute in St. Louis.2 Losing sleep goes deeper than just feeling tired. People who slept poorly were also almost twice as likely to eat

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high-sugar and high-carbohydrate foods, and they smoked or used tobacco more often than better sleepers.2 And we’re more tired than ever. The average adult needs seven hours and 24 minutes of sleep, but most report getting just six hours and 40 minutes on a typical weekday, according to the poll. One in five surveyed said they get fewer than six hours of sleep on average. The number of Americans who report they get the recommended eight hours has declined since 2001.2 Lack of sleep can have devastating health consequences. A 1999 study at the University of Chicago showed that restricting sleep to just four hours per night for a week left healthy young adults with the glucose and insulin readings of diabetics.1

Caring for Yourself

Tips to Help You Get Your


If you’re having trouble sleeping lately, here are some ways to help get your inner clock back on track.3 • Go to bed and get up at about the same time every day, even on the weekends. Sticking to a schedule helps

• Start a relaxing bedtime routine. Do the same things each night to tell your body it's time to wind down. This

reinforce your body’s sleep-wake cycle.

may include taking a warm bath or shower, reading a

• Don’t eat or drink large amounts before bedtime.

book, or listening to soothing music.

Eat a light dinner at least two hours before sleeping.

• Go to bed when you’re tired and turn out the lights.

• Avoid nicotine, caffeine and alcohol in the evening.

If you don’t fall asleep within 15 to 20 minutes, get up and

These are stimulants that can keep you awake. Avoid caffeine

do something else. Go back to bed when you’re tired. Don’t

for eight hours before your planned bedtime. And although

agonize over falling asleep. The stress will only prevent sleep.

often believed to be a sedative, alcohol actually

• Check with your doctor before taking any sleep

disrupts sleep.

medications. He or she can make sure the pills won’t

• Exercise regularly. Regular physical activity, especially aerobic exercise, can help you fall asleep faster and make your sleep more restful. However, for some people, exercising right before bed may make getting to sleep more difficult.

interact with your other medications or with an existing medical condition. Your doctor can also help you determine the best dosage. • Nearly everyone has occasional sleepless nights.

• Make your bedroom cool, dark, quiet and comfortable.

But if you have trouble sleeping on a regular or frequent basis,

Adjust the lighting, temperature, humidity and noise level

see your doctor. You could have a sleep disorder, such

to your preferences. Use blackout curtains, eye covers,

as obstructive sleep apnea or restless legs syndrome.

earplugs, extra blankets, a fan or white-noise generator, a humidifier or other devices to create an environment that suits your needs. • Sleep primarily at night. Daytime naps may steal hours from nighttime slumber. • Children and pets are often disruptive, so you may need to set limits on how often they sleep in bed with you.

References 1. Layton MJ. More people are seeking help for insomnia and sleep disorders. The Ledger. March 29, 2009; p. N25. Available at: Accessed August 17, 2009. 2. Marcus MB. Economy doing a number on people’s sleep. USA Today. March 1, 2009. Available at: N.htm. Accessed August 17, 2009. 3. Mayo Clinic. 10 tips for better sleep. Available at health/sleep/HQ01387. Accessed August 17, 2009.

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For more information on Medline’s exam gloves, please contact your Medline sales representative or call 1-800-MEDLINE.

Caring for Yourself


Breast Cancer

Awareness Month

October 2009


Medline Breast Cancer Awareness Campaign Celebrates Five Years

“Together We Can Save Lives”

Five years ago, Medline began a mission to promote breast cancer awareness beyond the standard 31 days of public awareness each October. We launched a year-round breast cancer campaign called “Together We Can Save Lives Through Early Detection,” which supports breast cancer education and early detection. Since the launch of the campaign, Medline has donated more than $450,000 to the National Breast Cancer Foundation (NBCF). For more information on the NBCF, visit

In partnership with NBCF, Medline has helped fund grants to hospitals and other healthcare organizations that offer free mammograms to women in need. Through this partnership, Medline continues its mission to give back to customers and their communities, help promote the early detection of breast cancer and ultimately save lives. We hope this campaign will help spread the word – early detection and mammograms save lives!

The Web page contains background on the breast cancer campaign, AORN breakfast forum special event details with photo galleries and keynote speaker bios. Visit today at

New Breast Cancer Awareness Web Page Medline has just launched a new Web page dedicated to breast cancer awareness and the “Together We Can Save Lives” campaign. Raising breast cancer awareness among nurses is one of our key goals, as it is the leading cause of death for women ages 40-55. The average age of a nurse is 46.

Pink Ribbon Products Medline Industries, Inc. also promotes breast cancer awareness by displaying the pink ribbon logo on products. By purchasing a pink ribbon product from Medline, you are helping to support Medline’s $100,000 annual contribution to the NBCF. Some of the products include pink exam gloves, the pink ribbon rollator, pink ribbon bouffant caps and breast cancer awareness scrubs and other apparel. Ask your Medline rep for details or visit

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Breast Self-Examination 1. In the Shower Fingers flat – move gently over every part of each breast.

Breast Cancer

Facts • Each year, more than 211,000 American women learn they have breast cancer. • The chance of a woman having invasive breast cancer sometime during her life is about 1 in 8. The chance of dying from breast cancer is about 1 in 35. • About 192,370 estimated cases of breast cancer for women and about 1,910 estimated cases of breast cancer for men will be diagnosed in 2009. Of these, 40,170 cases for women and 440 cases for men will result in death. • Nearly 90 percent of women diagnosed with breast cancer will survive their disease at least five years. • The chance of getting breast cancer goes up as a woman gets older. Most cases occur in women over 60. • Women 40 and older should have a mammogram every one to two years. Mammograms are the most effective way to detect breast cancer. • Breast cancer death rates are falling, probably as a result of early detection and improved treatment.

Use your right hand to examine left breast, left hand to examine right breast. Check for any lump, hard knot or thickening. Carefully observe any changes in your breast. 2. Before a Mirror Inspect your breasts with your arms raised high overhead. Next, place your arms at your sides. Look for any changes in contour of each breast; a swelling, a dimpling of skin, or changes in the nipple. Then rest palms on hips and press firmly to flex your chest muscles. Left and right breasts will not match exactly. Few women’s breasts do match. 3. Lying Down Place pillow under right shoulder, right arm behind your head. With fingers of left hand flat, press right breast gently in small circular motions, moving vertically or in a circular pattern covering the entire breast. Use light, medium and firm pressure. Squeeze nipple, check for discharge and lumps. Repeat these steps on your left breast. Recommendations for Routine Mammography Screening Age 40: A baseline mammogram as a standard for future comparison 40-49: a mammogram every one or two years, depending on previous findings 50 and older: a mammogram every year

References American Cancer Society, National Cancer Institute,

Compliments of Medline’s “Together We Can Save Lives Through Early Detection” campaign. To learn more go to


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The following pages contain practical tools for implementing patient-focused care practices at your facility. Positive Interactions English ............................................................102 Spanish ............................................................104 Prevention Incontinence Product Selection........................106 CAUTI FAQs ....................................................107 How to Handrub? ............................................109 Safety Practice Hospital Bed Safety ............................110 Pressure Ulcer Pocket Reference Card ....................................115

Improving Quality of Care Based on CMS Guidelines 101

Forms & Tools

Positive Interactions

Ten Absolutes: Simplify Daily Tasks and Create Positive Interactions Absolutely Never!

Do This Instead!

1. Argue “You know your mother has been dead for years. You cannot wait for her to eat dinner” “You have lived in this house for 25 years, you are home”

Agree “I haven’t seen your mother today. If I see her, I will tell her you are looking for her. While we are waiting, let’s have a bite to eat. I want to go home, too. While we are waiting, let’s have a bite to eat.”

2. Reason “You did not take a bath today, and you need to take a bath because we have an appointment with the doctor. Then we are going to go to lunch with Jane, and then we are going to get you a new pair of shoes, and why are you walking off when I am talking to you? We have to go in here and get your bath and we have to hurry.”

Divert “Please come in here with me. Oh, I know you aren’t going to take a bath. Let me help with that shoe. Oh, I know you aren’t going to take a bath. Just slide this off over your arm. Oh, I know you aren’t going to take a bath. How does this water feel? It seems warm enough. Oh, I know you aren’t going to take a bath. Just step right in here.”

3. Shame “How can you accuse John of stealing after all he has done for us?”

Distract “John is here to help us find your wallet. Let’s have a cup of coffee and get started.”

4. Lecture “You have got to go back to bed and get some sleep. You have been up half the night and why on earth did you empty these drawers? Who is supposed to clean up this mess? I suppose tomorrow you will want to sleep all day and we won’t be able to go to Carol’s house and help with the children. I am just too tired to deal with this, so you have to get in bed and go to sleep right now. We can’t continue like this. No one can live this way. We both have got to get some sleep.”

Reassure “I can’t sleep either. Let’s go to the bathroom. I need something to drink.” (Offer a drink.) “Try to lie down again.” (Pat the bed.) “No? How about some cookies and milk?” “Try to lie down again.” (Sit beside bed and pat the bed.) “Doesn’t that feel good?” (Stay until settled or asleep. Rub their hand, forehead or arm.)

5. Say “Remember” “Do you remember who this is?” “What did you have for lunch today?” “Did Mary visit today?” “When did Jeanne come to visit?”

Reminisce “Hi, Tom. This is Sarah. She is visiting me from Elmhurst Elementary PTA. I had the nicest lunch today. Mary is such a pleasant person and she visits often. I hoped I would get here before Jeanne’s visit.”

6. Say “I told you” “I just told you that we are not going to the bank today. It is Sunday, and the bank is closed. How many times do I have to tell you we are not going to the bank. It is Sunday.”

Repeat/Regroup “Wouldn’t you know it is too late for church, and we have to go to the bank tomorrow. Since it is Sunday, let’s have fried chicken. Yes, we will go to the bank when it opens tomorrow.”


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© Huey 1996

Positive Interactions

Forms & Tools

Absolutely Never!

Do This Instead!

7. Say “You can’t” “You can’t wear two shirts. You can’t pick that up with your hands. You can’t eat that like that. You can’t put your sweater on your legs. You can’t put your shoe on your shoe. You can’t go outside; it’s raining. You can’t keep putting things in the wrong place. You can’t go home; you are home.”

Do What They Can “Try this one. It looks nice. See how this spoon works. Isn’t this fun?” Try this one. Try it over here. We need to find the umbrella. This looks nice here. I want to go home, too.”

8. Command/Demand “You have got to change your clothes. Sit down right here and stop walking around. This doesn’t belong to you. Now give it back. Why would you take those when we didn’t pay for them? You have to leave your clothes on; we’re in a public restroom. We are in a hurry. You need to do this right now.

Ask/Model “This is pretty. Do you want to try it on? Sit with me a minute.” (Pat the chair.) “This is nice. May I see it? Do you want to buy those? See if you will be warmer with this. How about going here?”

9. Condescend “Did you have any problem with him today? Be sure he takes his medicine; he spit it out this morning. I hope you don’t have trouble today. It took me 20 minutes just to get him into the car. He has been looking for his mother all morning.”

Encourage/Praise “I’m sure you were your sweet, wonderful self today. Dad will help you with his medication today; it has been hard to swallow. We are having a challenging day today, and Dad will help you a lot. He is especially interested in his mother today.”

10. Force “Now you are going to take a bath because you haven’t had one for two weeks. These nice people are here to help us. Give that to me right now; it’s not yours. If you don’t give it back, we will have to take it from you. You may not go into this room. You must come out of this room right now.”

Reinforce “I know you already took a bath. Come right in here. I know you don’t want a bath. Let’s take off this shoe. I know you don’t want to take a bath. This lady is helping out, and it is OK. That is really pretty. May I see it? Do you like this? Would you like to have it? Isn’t this a nice room; would you like to have a cup of coffee?”

© Huey 1996 From: Alzheimer’s Disease: Hope and Help by Jo Huey Reprinted with permission.

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Formas y Herramientas

Interacciones Positivas

Diez Absolutos: Simplifique las Tareas Diarias y Cree Interacciones Positivas Absolutamente Nunca

¡Haga Esto!

1. Discuta "Tú sabes que tu madre ha estado muerta por años. No puedes esperarla para cenar" "Has vivido en esta casa 25 años, estás en casa"

Esté de acuerdo "No he visto a tu madre hoy. Si la veo , le diré que la estás buscando. Mientras esperamos, comamos algo. Yo también quiero ir a casa. Mientras esperamos, comamos algo."

2. Razone "No te bañaste hoy, y necesitas bañarte porque tenemos una cita con el doctor. Luego vamos a almorzar con Jane, y luego vamos a comprarte un nuevo par de zapatos, y ¿por qué te alejas cuando te estoy hablando? Tenemos que entrar y bañarte, y tenemos que darnos prisa."

Desvíe "Por favor entra aquí conmigo. Oh, Sé que no te vas a bañar. Déjame ayudarte con ese zapato. Oh, sé que no te vas a bañar. Desliza esto por tu brazo. Oh, sé que no te vas a bañar. ¿Cómo se siente esta agua? Parece lo suficientemente tibia. Oh, sé que no te vas a bañar. Pisa justo aquí."

3. Avergüence "¿Cómo puedes acusar a John de robar después de todo lo que ha hecho por nosotros?"

Distraiga "John está aquí para ayudarnos a encontrar tu billetera. Tomemos un café y empecemos."

4. Sermonee "Tienes que volver a la cama y dormir un poco. Has estado despierto la mitad de la noche y ¿por qué vaciaste estos cajones? ¿Quién crees que va a limpiar este lío? Supongo que mañana querrás dormir todo el día y no podremos ir a la casa de Carol y ayudar con los niños. Simplemente estoy demasiado cansada para ocuparme de esto, así que tienes que ir a la cama y dormirte ahora. No podemos seguir así. Nadie puede vivir así. Ambos tenemos que dormir un poco."

Tranquilice "Yo tampoco puedo dormir. Vamos al baño. Necesito algo de beber." (Ofrezca algo de beber.) "Trata de recostarte de nuevo." (Palmadas en la cama.) "¿No? ¿Qué te parece unas galletas y leche?" "Trata de recostarte otra vez." (Siéntese al lado de la cama y dé palmaditas en ésta) "¿No se siente rico?" (Quédese hasta que esté tranquilo o dormido. Frote su mano, frente o brazo.)

5. Diga "Recuerdas" "¿Recuerdas quién es esta persona?" ¿Qué almorzaste hoy?" "¿Te visitó Mary hoy?" "¿Cuándo vino Jeanne de visita?"

Rememore "Hola, Tom. Esta es Sarah. Ella me está visitando de la Asociación de Padres de Familia de Elmhurst. Tuvimos un almuerzo muy agradable hoy. Mary es una persona muy agradable y nos visita con frecuencia. Yo esperaba llegar aquí antes de la visita de Jeanne."

6. Diga “Te lo dije” "Te acabo de decir que no vamos a ir al banco hoy. Es domingo, y el banco está cerrado. ¿Cuántas veces tengo que decirte que no vamos a ir al banco? Hoy es domingo."

Repita/Reagrupe "No sabes que es demasiado tarde para ir a la iglesia, y tenemos que ir al banco mañana. Dado que es domingo, comamos pollo frito. Sí, iremos al banco cuando abra mañana."


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Interacciones Positivas

Absolutely Never!

Formas y Herramientas

Do This Instead!

7. Diga "No Puedes" "No puedes usar dos camisas. No puedes recoger eso con tus manos. No puedes comer así. No puedes poner tu abrigo en tus piernas. No puedes poner tu zapato en tu zapato. No puedes salir, está lloviendo. No puedes seguir poniendo cosas en el lugar equivocado. No te puedes ir a casa, estás en casa".

Haga lo que Puedan "Pruébate esto. Se ve bien. Ve cómo funciona esta cuchara. No es divertido?" Prueba ésta. Pruébalo aquí Necesitamos encontrar el paraguas. Esto se ve bien aquí. Yo también quiero ir a casa."

8. Ordene/Demande "Tienes que cambiarte de ropa. Siéntate aquí y deja de dar vueltas. Esto no te pertenece. Ahora devuélvelo. ¿Por qué tomaste esto cuando no lo pagamos? Tienes que dejarte la ropa puesta, estamos en un baño público. Estamos apura dos. Necesitas hacer esto de inmediato.

Pregunte/Modele "Esto es bonito. ¿Te lo quieres probar? Siéntate conmigo un minuto." (Toque la silla.) "Esto está bien. ¿Puedo verlo? ¿Quieres comprarlos? Ve si estás más abrigado con esto. ¿Qué tal si vamos aquí?"

9. Sea condescendiente "¿Tuviste algún problema con él hoy? Asegúrate que tome su medicina; la escupió esta mañana. Espero que no tengas problemas hoy. Me tomó 20 minutos simplemente meterlo en el auto. Ha estado buscando a su madre toda la mañana".

Estimule/Alabe "Estoy seguro que fuiste muy dulce y maravilloso hoy. Papá te ayudará con su medicina hoy, ha sido difícil de tragar. Estamos teniendo un día difícil hoy, y Papá te ayudará un montón. Está especialmente interesado en su madre hoy".

10. Fuerce "Ahora vas a bañarte porque no te has bañado en dos semanas. Esta buena gente está aquí para ayudarnos. Dame eso de inmediato, no es tuyo. Si no lo devuelves, te lo tendré que quitar. No puedes entrar en esta habitación. Debes salir de esta habitación de inmediato".

Refuerce "Sé que ya te bañaste. Ven aquí. Sé que no quieres bañarte. Quitemos este zapato. Sé que no quieres bañarte- Esta dama está ayudando, y está bien. Esto es muy bonito. ¿Puedo verlo? ¿Te gusta esto? ¿Te gustaría tenerlo? Qué habitación tan bonita. ¿Te gustaría una taza de café?" © Huey 1996 De: Enfermedad de Alzheimer: Esperanza y Ayuda, por Jo Huey. Reimpreso con permiso.

Improving Quality of Care Based on CMS Guidelines 105

Incontinence Product Selection

Forms & Tools

Incontinence Product Selection Light Slight volume of urine less than half a cup or 100cc



Protective Underwear

• Stress incontinence • Can walk with or without assistance • Urinary incontinence Female

Moderate Moderate volume of urine up to one cup or 250cc


Protective Underwear

Protective Belted Undergarments



Protective Underwear


Protective Underwear High Capacity

• Stress, urge, mix or transient incontinence • Can walk with or without assistance • Dementia

Heavy Moderate volume of urine up to two cups or 500cc • Urge, overflow or bowel incontinence • Bedridden • Difficulty walking or standing

Heavy Plus Moderate volume of urine more than two cups or 500cc in 4 hours


• Overflow or bowel Incontinence • Contracted, bedridden • Difficulty walking or standing • Loose stool Ultrasorbs® AP DryPad


Healthy Skin

Ultrasorbs® DryPad



Forms & Tools







Improving Quality of Care Based on CMS Guidelines 107

Sterillium® Comfort Gel®

Your hands will love you even more. Also available: Sterillium Rub for surgical hand antisepsis

Do more with less

Sterillium Comfort Gel delivers greater efficacy than other alcohol-based hand antiseptics* by virtue of its ethyl alcohol concentration, and it does more for your infection control efforts by using up to 50 percent less volume per application.* Independent in vitro testing demonstrated that Sterillium Comfort Gel achieves reductions of ≥ 5 log10 (≥ 99.999 percent) on a broad range of nosocomial pathogens.*

Add comfort for compliance

Sterillium Comfort Gel’s incredible bactericidal effect doesn’t matter if the product isn’t being used! You’ll want to reach for Sterillium Comfort Gel again and again because it includes a balanced blend of moisturizing emollients that leverages technology shared with BODE Chemie by its parent company Beiersdorf AG, makers of well-known skincare products NIVEA® and Eucerin®. The result is a product proven to increase skin hydration by 14 percent in just two weeks.*

Increased efficacy. Incredible comfort. Improved compliance. Sterillium Comfort Gel.

©2009 Medline Industries, Inc. Medline® is a registered trademark of Medline Industries, Inc. Sterillium® is a registered trademark of BODE Chemie GmbH. NIVEA and Eucerin are registered trademarks of Beiersdorf AG. Sterillium® Comfort Gel® is a registered trademark of Bode Chemie GmbH.

*Data on file

Available in three packaging styles to suit any need, including a touchless dispensing option.

Contact your Medline representative or call 1-800-MEDLINE


Forms & Tools

How to Handrub? RUB HANDS FOR HAND HYGIENE! WASH HANDS WHEN VISIBLY SOILED Duration of the entire procedure: 20-30 seconds




Apply a palmful of the product in a cupped hand, covering all surfaces;



Right palm over left dorsum with interlaced fingers and vice versa;



Palm to palm with fingers interlaced;


Rotational rubbing of left thumb clasped in right palm and vice versa;

Rub hands palm to palm;

Backs of fingers to opposing palms with fingers interlocked;


Rotational rubbing, backwards and forwards with clasped fingers of right hand in left palm and vice versa;

Once dry, your hands are safe.

All reasonable precautions have been taken by the World Health Organization to verify the information contained in this document. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World Health Organization be liable for damages arising from its use. WHO acknowledges the H么pitaux Universitaires de Gen猫ve (HUG), in particular the members of the Infection Control Programme, for their active participation in developing this material.

May 2009

Improving Quality of Care Based on CMS Guidelines 109

Forms & Tools

Practice Hospital Bed Safety

Consumer Health Information

Practice Hospital Bed Safety “H

ospital beds are found in nearly all patient care settings or environments,” says Joan Ferlo Todd, RN, a senior nurse-consultant at the Food and Drug Administration’s (FDA) Center for Devices and Radiological Health (CDRH). “They are used not only in hospitals, but also in outpatient care centers, longterm care facilities, and in private homes.”

CDRH reports that about 2.5 million hospital beds are in use in the United States. The center regulates these beds as medical devices. “Many of today’s hospital bed models are quite complex. Patients and health care professionals should understand how to use them properly, and manufacturers must provide adequate instructions for use,” says Todd, who works in CDRH’s Office of Surveillance and Biometrics.

Hospital Bed Entrapment Zones An FDA guidance characterizes the head, neck, and chest as key body parts at risk of entrapment, and identifies seven potential “zones of entrapment” where special care is required: 1. within the rail 2. under the rail, between the rail supports or next to a single rail support 3. between the rail and the mattress 4. between the rail, at the ends of the rail

Beware of Entrapment The main risk is entrapment, which occurs when a patient is caught in spaces in or around the bed rail, mattress, or bed frame. Entrapped individuals can become strangled.

5. between split bed rails 6. between the end of the rail and the side edge of the head or foot board 7. between the head or foot board and the mattress end

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


Healthy Skin

JUNE 2009

Continued on Page 112

Rest Assured Caregivers appreciate the ability to maneuver Medline’s Alterra 1232 hi-low bed no matter the height. Staff aren’t forced to use the lowest or highest setting to move the bed. Risk managers value the built-in battery back-up system that comes with each Alterra 1232 bed for no additional cost. This feature keeps the bed functioning in a power outage. Residents love the comfort and style of the Alterra 1232 hi-low bed by Medline. Additional features: • Optimal hi-low range of 26” to 7.25” • Built-in motor stop keeps the bed from applying more pressure in the event that something gets caught in the head or foot section • Interest-free payment plan of 3, 6 or 12 months


Alterra 1232

MAX height of

LOW height of


Custom head/footboards and staff control also available

To learn more about the Alterra 1232 hi-low bed, contact your Medline representative or call 1-800-MEDLINE.

Forms & Tools

Practice Hospital Bed Safety

Consumer Health Information

It is important to view the hospital bed as a system. Not all mattresses or bed rails are suitable with any given bed frame. “Patient entrapment is uncommon,” says Todd, “but when it occurs, it’s often fatal.” Between 1985 and 2009, FDA received reports of 803 incidents of patients caught, trapped, entangled, or strangled in hospital beds. The reports included 480 deaths, 138 nonfatal injuries, and 185 cases where staff intervened to prevent an injury. Most of the affected patients were frail, elderly, or confused. “Not all patients are at risk for entrapment, and not all hospital beds pose an entrapment risk,” says Todd. “But health care facilities, as well as patient caregivers, are urged to take a careful look at hospital beds. They need to determine if there are large openings that present an entrapment risk, and to take steps to minimize this risk.” Any type of rail or grab bar attached to a bed, as well as the fit of the bed mattress, should be assessed for entrapment risks, she adds. “It is important to view the hospital bed as a system,” she says. “Not all mattresses or bed rails are suitable with any given bed frame.”

Guidance FDA regulates hospital beds through post-market activities such as analyzing reports of product problems and adverse events, says Todd. “Although the agency does not regulate the design of the beds, it offers safety guidance to industry.” FDA is a member of the Hospital Bed Safety Workgroup (HBSW), a partnership among the medical bed industry, national health care organi-

FDA and the HBSW, have improved patient safety. “Manufacturers have redesigned their bed frames and their side rails to reduce the risk of entrapment.”

Entrapment Zones

OJO Images

zations, patient advocacy groups, and federal agencies. In 2006, FDA with collaboration from HBSW issued “Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment,” recommendations for manufacturers of new hospital beds and for facilities with existing beds, including hospitals, nursing homes, and private homes. “The guidance may also be used by health care facilities,” says Jay A. Rachlin, director of CDRH’s Division of Health Communication in the Office of Communication, Education, and Radiation Programs. “It offers useful information for health care facility staff.” Rachlin says the guidance, along with other educational products from

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


Healthy Skin

The guidance characterizes the head, neck, and chest as key body parts at risk of entrapment. It also identifies these seven potential “zones of entrapment” in hospital beds: 1. within the rail 2. under the rail, between the rail supports or next to a single rail support 3. between the rail and the mattress 4. between the rail, at the ends of the rail 5. between split bed rails 6. between the end of the rail and the side edge of the head or foot board 7. between the head or foot board and the mattress end Rachlin says that proper fitting rails can be useful. However, health care professionals and patients need to assess whether rails are necessary in each instance. “In addition to entrapment, there are other potential hazards associated with bed rail use, including serious injuries from falls when patients climb over rails, and having patients feel isolated or unnecessarily restricted,” he says.

Fire Prevention Fire is a rare safety risk associated with motorized hospital beds. “Fires are due mostly to a lack of maintenance,” says Todd. “There are electriJUNE 2009

Practice Hospital Bed Safety

Forms & Tools

Consumer Health Information

Some hospital beds used at home may require patient or caregiver training. cal shorts due to frayed or strained wires, motors overheat, or dust or other materials from the hospital fall into the motor casing.â&#x20AC;? She suggests these steps to cut the risk of fire incidents: s)NSPECTTHEBEDSPOWERCORDFOR damage. s$ONTCONNECTTHEBEDSPOWER cord to an extension cord or to a multiple-outlet strip. s)NSPECTTHEmOORBENEATHTHEBED for buildup of dust and lint, which could clog the motor. s)NSPECTTHEBEDCONTROLPANEL covering for signs of damage where liquids could leak in. s#HECKEQUIPMENTFORSIGNSOF overheating or physical damage. s+EEPLINENSANDCLOTHESAWAY from power sources.

Home Use Todd says there have been very few reports of safety incidents with hospital beds used in private residences. â&#x20AC;&#x153;This may represent underreporting by consumers,â&#x20AC;? she says. â&#x20AC;&#x153;The reporting system for these incidents is set up for health care facilities, but consumers and home patients can still report medical device incidents to FDA through its MedWatch program.â&#x20AC;? She adds that hospital beds used at patientsâ&#x20AC;&#x2122; homes are usually prescribed devices. â&#x20AC;&#x153;Theyâ&#x20AC;&#x2122;re not required to be prescribed, but the beds are usually very expensive to rent or buy, and most patients get them for home through health plans.â&#x20AC;? It is important to ask that the bed meet the guidelines in the FDA guidance to reduce the risk of entrapment. Some hospital beds used at home may require patient or caregiver training,

Todd says. â&#x20AC;&#x153;It depends on the complexity of the bed.â&#x20AC;?

â&#x20AC;&#x153;These beds may have features such as height-adjustment mechanisms or adjustable positions for the back and Safety Tips knee, or be fitted with snap-on rails. CDRH offers the following safety tips But theyâ&#x20AC;&#x2122;re not regulated by FDA.â&#x20AC;? She says that such beds fall under for home use of hospital beds: s# HECK THE MOTORS ESPECIALLY FOR the jurisdiction of the U.S. Consumer Product Safety Commission. â&#x20AC;&#x153;If these dust and debris. s%NSURETHATEACHCOMPONENTÂ&#x2C6;THE beds are used with any type of rail, bed frame, mattress, rails, and any consumers should adhere to the same ADDED ACCESSORIESÂ&#x2C6;PROPERLY FITS safety recommendations in place for together. Make sure the mattress is hospital beds.â&#x20AC;? the correct size for the bed frame so unsafe gaps are not present. If you see an opening let a health This article appears on FDAâ&#x20AC;&#x2122;s care professional know or call the Consumer Update page (www.fda. gov/ForConsumers/ConsumerUpdates/ manufacturer. s7 HEN IN DOUBT CONSULT THE BED default.htm) which features the latest frame manufacturer to determine on all FDA-regulated products. if a component or accessory is comFor More Information patible with your bed frame. s5SERAILSCAUTIOUSLY0ATIENTSSHOULD Hospital Bed Safety not try to climb around or over the ProductsandMedicalProcedures/ rails to get out of bed. MedicalToolsandSupplies/ What is a Hospital Bed? HospitalBeds/default.htm Todd says that there is no standard definition for hospital beds, a fact Preventing hospital bed fires that consumers shopping for such a bed need to be aware of. Safety/AlertsandNotices/ â&#x20AC;&#x153;A bed becomes a hospital bed PublicHealthNotifications/ when it meets the requirements for ucm062151.htm being a medical device,â&#x20AC;? she says. CDRH defines a medical device as Safety Brochure: Bed Rails in â&#x20AC;&#x153;an instrument, apparatus, imple- Hospitals, Nursing Homes, and ment, machine, contrivance, implant, Home Health Care in vitro reagent, or other similar arti- cle that is intended for use in the diag- MedicalDevices/ nosis of disease or other conditions, ProductsandMedicalProcedures/ or in the cure, mitigation, treatment MedicalToolsandSupplies/ or prevention of disease.â&#x20AC;? HospitalBeds/ucm125857.pdf â&#x20AC;&#x153;There are beds sold in retail stores that donâ&#x20AC;&#x2122;t meet the definition of med- MedWatch, for reporting adverse ical devices under the law, but which events may have some of the characteris- tics of a hospital bed,â&#x20AC;? says Todd. default.htm

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

JUNE 2009

Improving Quality of Care Based on CMS Guidelines 113

Š2009 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.

Pressure Ulcer Pocket Reference

Forms & Tools

PRESSURE ULCER POCKET REFERENCE CARD Pressure Ulcer Staging A pressure ulcer is a localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction. These stages should only be used for pressure ulcers.

SUSPECTED Deep Tissue Injury (DTI) Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. STAGE I Intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area. STAGE II Partial-thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister. STAGE III Full-thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. STAGE IV Full-thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling.

UNSTAGEABLE Full-thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. ŠNPUAP 2007 Adapted from National Pressure Ulcer Advisory Panelâ&#x20AC;&#x2122;s Pressure Ulcer Staging Classification.

Improving Quality of Care Based on CMS Guidelines 115

Check out

All-new look and upgraded content! Easier navigation to find what you need â&#x20AC;&#x201C; faster. Interactive courses & competencies Continuing education courses are still available, and now you can earn all credits for FREE! In addition, we are adding online competencies. Courses and competencies are more interactive with more graphics, sound and animation to make learning more fun. Facility-specific features Now each facility has the option of creating a group account on Medline University. This will

help you and your facility view and keep track of all completed courses. And for facilities participating in the Pressure Ulcer Prevention and Hand Hygiene programs, all materials, pre- and post-tests are now conveniently located online at Visit the redesigned today, and let us know what you think!

Š2009 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.


Healthy Skin Volume 6 Issue 3  

Medline's Healthy Skin Magazine, Volume 6, Issue 3 - FREE CE: Tell Me Again Why This Resident Needs A Catheter?

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