healthy skin magazine - volume 6; issue 2

Evonne FowlerEvolution toRevolution

Breaking NewsHealthcare Reform

Special SectionFREE CE!

Pressure Ulcer Prevention in Action

Pain

InfectionPreventionin LTC

Ease The

Join the team!

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

You, our readers, are on the front lines of everything thathappens in the healthcare industry – and we want to hearfrom you! Have you ever wished you could write an ar-ticle that would be published in a large-circulationmagazine? Nowʼs your chance. Healthy Skin is looking

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

HEALTHY SKIN

About MedlineMedline, headquartered in Mundelein, IL, manufactures and distributesmore 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 nationwideto support its broad product line and cost management services.

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

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

Contact us at [email protected] to learn more!

Improving Quality of Care Based on CMS Guidelines 3

Page 53

Page 44

Page 57

Page 20

Survey Readiness8 QIS Update

51 QAPI for Hospice

Prevention10 Pressure Ulcer Prevention News from Across the United States29 Best Practices for Blood Glucose Monitoring33 Education Strategies to Combat CAUTI35 Pressure Ulcer Prevention Program at Rest-Haven York38 Pressure Ulcer Prevention Program Statistics39 Product Spotlight: MARATHON Liquid Skin Protectant41 Education, Products that Work and Celebration

Treatment20 C. difficile: Facts and Interventions22 Case Study: Urinary Bladder Matrix Assistance with High Risk

Diabetic Limb Salvage25 Clinical Study of SilvaSorb Gel44 Reducing Total Pain at the End of Life49 The Pain-Relieving Touch of Reiki

Special Features12 NPUAP and EPUAP Draft New International Pressure

Ulcer Guidelines14 Evonne Fowler: Revolutionizing Wound Care with Passion

and Commitment53 Itʼs a Privilege: Caring for U.S. Veterans at Missouri

Veterans Home57 Point-of-Care Testing: Evolution or Revolution?65 ʻBee Stories: Linda Ellerbee Raises Awareness About

Breast Cancer

Regular Features5 Breaking News6 Two Important National Initiatives for Improving Quality of Care

Caring for Yourself60 Keep Your Job During Tough Times72 Healthy Eating: Bangers and Mash with Golden Onions

Forms & Tools74 Transdisciplinary Pain Flow Sheet76 Pain Assessment Cards78 Hospice Patient and Family Education: Control of Pain80 Pain Algorithm84 Taking Care of Type 2 Diabetes - English86 Taking Care of Type 2 Diabetes - Spanish

HEALTHY SKIN

EditorSue MacInnes, RD, LD

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

Managing EditorAlecia Cooper, RN, BS, MBA, CNOR

Contributing EditorAndy J. Mills, MBA

Clinical TeamLynne Brown, RN, BSN, MBAClay Collins, RN, BSN, CWOCN, CFCN,DAPWCACynthia A. Fleck, RN, BSN, CFCN, CWS,DAPWCA, MBA, FCCWSJanet L. Jones, RN, BSN, PHN, CWOCN,DAPWCAJoyce Norman, RN, BSN, CWOCN,DAPWCAElizabeth OʼConnell-Gifford, RN, BSN,CWOCN, DAPWCA, MBAAmin Setoodeh, BSN, RNJackie Todd, RN, BSN, CWCN, DAPWCA

Wound Care Advisory BoardLinda Woodward, BSN, RN, OCN, CWOCNLaurel Wiersema-Bryant, ANP, BCLynne Grant, MS, RN, CWOCNDiane Krasner, PhD, RN, CWCN, CWS,BCLNC, FAANEvonne Fowler, MSN, RN, CNS, CWONLinda Neiswender, BSN, RN, CPNLynne Whitney-Caglia, MSN, RN, CNS,CWOCNPatricia Coutts, RNDea J. Kent, MSN, RN, NP-C, CWOCNZemira M. Cerny, BS, RN, CWS

Improving Quality of Care Based on CMS Guidelines

Page 60

Special Insert1 CE Credit

FollowingPage 50

Dear Reader,

This year my husband and I both turned 50. We usedthis milestone as an excuse to celebrate by going on along weekend to Cancun. It was February, so leaving thebitter cold and snow in Chicago was not a problem. Itfelt so good to get away, and for the first time in a longtime, I actually sat still for a couple of minutes and let“work” related issues slip frommymind. I mean it is prettyhard to think about projects and deadlines when you aresitting on a pristine beach, soaking in the sun and gaz-ing at the bluest water you have ever seen. So there Iwas on the beach, my husband was reading Peoplemagazine and I was curled up with What We Can DoAbout the Health-Care Crisis by Sentator Tom Daschle.And, I was really happy.

I know what you are thinking … what in the worldprompted me to read about healthcare reform wile sittingon a beach? Couldn’t I find anything more interesting,like a good romance novel or the latest James Pattersonrelease? But no, I finally had a block of time where noone would bother me, and I wanted to read about theproposed future of health care and gain some insight intowhether we were on the right track with the programs,product innovations and research projects we had in theworks. There had been so many changes going on inour nation not only a change in administration in theWhite House, but also the unsettling issues with theeconomy. How was this affecting healthcare? Wouldthe direction we had been following also have tochange? I had my highlighter and my reading glassesand attacked the book enthusiastically.

A couple months later I was interviewing the CEO of anearby hospital. As we were about to start the interview,and quite by coincidence, I noticed the same book byDaschle that I had read in Cancun, on his desk. I askedhim why he was reading it and he said because he alsowanted to see where things were going with health careand felt it would help him have greater insight into thefuture of his hospital.

It’s interesting. Everything I read about in this book, likean emphasis on information technology, aggressivelypromoting prevention, greater emphasis on treatingchronic conditions, concentrating our efforts more on thevalue of the care we are giving, etc. It is all happening. Ihave to tell you it felt better tackling these things with myeyes wide open. So, get involved, know the potentialproblems and start looking into how you can impact thefuture. (See the next page for more information onDaschle’s book.) There are so many creative ideas andstrategies out there and many of the best ones comefrom you and the people you are working with.

This edition of Healthy Skin continues to report updatesin the industry. But just as important as knowing the cur-rent events and trends is knowing how to apply strate-gies that actually work. You can read about real successstories, people and facilities that have tried new things,worked together and were able to report positive out-comes that changed the lives of their staff, their familiesand their patients.

And, for the first time we have decided to put one ofthose special people who contributed her life to thewound care profession and the improvement of patientcare, Evonne Fowler, on the cover of Healthy Skin. Wefelt it was only appropriate. Evonne was gracious enoughto allow us to interview her, so that we could share her re-markable story with all of you (pages xx-xx).

Thank you for all you do, everyday!

Sue MacInnes, RD, LDEditor

”

“So, get involved,know the potentialproblems and startlooking into howyou can impactthe future.

4 Healthy Skin

Content KeyWeʼve coded the articles and information in this magazine to indicate which national quality initiativesthey pertain to. Throughout the publication, when you see these icons youʼll know immediately thatthe 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 implement-ing their recommendations. For a summary of each of the above initiatives, see Pages 6 and 7.

Healthy Skin Letter from the Editor

The Quality SummitJuly 20-21, Washington DCOn July 20-21 in Washington, DC a conference ofdistinguished healthcare leaders in long-term care will be heldcalled The Quality Summit: Partnering to Improve Care inOur Nation’s Nursing Homes. Led by Andy Kramer, MD,Professor of Medicine, University of Colorado at Denver, andlead developer of the Quality Indicator Survey for CMS, theconference will address new approaches to quality assur-ance, as well as the use of health information technology forquality management.

Former Senator and architect of President Obama’s healthcareplan, Tom Daschle will discuss healthcare reform and itsimpact on the quality of care in nursing homes. The primarypurpose of the conference is to discuss ways in which thefederal and state governments and providers can worktogether to improve the quality of care given to the residentsof our nation’s nursing homes.

Critical: What We Can Do Aboutthe Health-Care Crisis, authoredby former Senator Tom Daschle, out-lines the healthcare reform strategiesthat are the foundation of PresidentObama’s healthcare plan. Evaluatingwhere previous attempts at nationalhealthcare coverage have succeededand where they have gone wrong,Daschle explains the complex social,economic, and medical issues

involved in reform and sets forth his vision for change. Thebook can be purchased at any leading retail bookstore oronline store.

Swine Flu - Residents Are at RiskThe CDC and WHO are currently developing recommenda-tions on control measures for this outbreak. Clinical presen-tation is similar to other strains of flu: fever, cough, sorethroat, myalgias, headache, chills and fatigue. Some patientsmay have nausea, vomiting, and diarrhea.

WHO Pandemic Levels• Phase 1: A virus in animals has caused no knowninfections in humans.

• Phase 2: An animal flu virus has caused infectionin humans.

• Phase 3: Sporadic cases or small clusters of diseaseoccur in humans. Human-to-human transmission, if any,is insufficient to cause community-level outbreaks.

• Phase 4: The risk for a pandemic is greatly increased butnot certain. The disease-causing virus is able to causecommunity-level outbreaks.

• Phase 5: Spread of disease between humans isoccurring in more than one country of one WHO region.

• Phase 6: Pandemic level. Community-leveloutbreaks are in at least one additional country in adifferent WHO region from phase 5.

Interim GuidanceDuration: Infected persons should be assumed to becontagious up to 7 days from illness onset and residentsshould be isolated when symptomatic.Testing - Preferred respiratory specimens: Collect assoon as possible after illness onset: nasopharyngealswab/aspirate or nasal wash/aspirate. If specimens cannotbe collected, a combined nasal swab with an oropharyngealswab is acceptable.Swabs - Ideally, swab specimens should be collectedusing swabs with a synthetic tip (e.g., polyester) and analuminum or plastic shaft.

Storing clinical specimens: All respiratory specimensshould be kept at 4°C until they can be placed at -70°C. If a-70°C freezer is not available, specimens should be kept at4°C, preferably no longer than 1 week.Shipping clinical specimens: Clinical specimens should beshipped on dry ice in appropriate packaging.

6 Healthy Skin

Two Important National Initiativesfor Improving Quality of Care

Achieving better outcomes starts with an understanding of current qualityof care initiatives. Hereʼs what you need to know about national projects and

policies that are driving changes in nursing home and home health care.

Origin: The QIO Statement of Work is based upon Part B of the Title XI of the Social Security Act. The Medicare-funded “NinthScope 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. Thecontent 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 nationalnetwork 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 ThemeThe official Executive Summaries for the 9th SOW Theme are available at:http://providers.ipro.org/index/9SOW_summaries

Origin: A coalition-based, two-year campaign initiated on September 26, 2006 to improve quality of life for nursing homeresidents and staff. The coalition has continued the campaign beyond its first-round end of August 25, 2008 for anadditional 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 existingquality 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 coalitionhas adopted goals that seek to improve clinical care, incorporate nursing home resident and family satisfactionsurveys into continuing quality improvements and increase staff retention to allow for better, more consistentcare for nursing home residents.

Participating providers will commit to focusing on at least three of the eight measurable goals, including at least one clinical goal andone operational process goal. Current participants may choose to continue with the same goals, add additional goals or change goalsfor the next two-year campaign.

Advancing ExcellenceThe coalition is meeting to consider the following additions for the next two-year campaign:

1. Improving immunizations as a clinical goal2. Including target setting in all goals3. Changes to the order in which the goals are presented

QIO Utilization and Quality Control Peer Review Organization9th Round Statement of Work1

Advancing Excellence in America’s Nursing Homes2

Trends in Goal SelectionEach 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: 70.6% Goal 5: 32%

Goal 2: 45.0% Goal 6: 62.7%

Goal 3: 54.2% Goal 7: 41.1%

Goal 4: 39.3% Goal 8: 31.3%

Visit this Web site to view progress by state!www.nhqualitycampaign.org/star_index.aspx?controls=states_map*Based on the latest available count of Medicare/Medicaid nursing homes


Theme #1: Beneficiary Protection Activities will focus onnine Tasks:1. Case reviews2. Quality improvement activities (QIAs)3. Alternative dispute resolution (ADR)4. Sanction activities5. Physician acknowledgement monitoring6. Collaboration with other CMS contractors7. Promoting transparency through reporting8. Quality data reporting9. Communication (education and information)

Theme #2: Patient Pathways/Care Transitions Activitieswill focus on three Tasks:1. Community and provider selection and recruitment2. Interventions3. Monitoring

Theme #3: Patient Safety Activities will focus on sixprimary Topics:1. Reducing rates of health care-associated methicillin-resistant

Staphylococcus aureus (MRSA) infections2. Reducing rates of pressure ulcers in nursing homes and hospitals3. Reducing rates of physical restraints in nursing homes4. Improving inpatient surgical safety and heart failure treatment

in hospitals5. Improving drug safety6. Providing quality improvement technical assistance to nursing

homes in need

Theme #4: Prevention Activities will focus on nine Tasks:1. Recruiting participating practices2. Identifying the pool of non-participating practices3. Promoting care management processes for preventive services

using EHRs4. Completing assessments of care processes5. Assisting with data submissions6. Monitoring statewide rates (mammograms, CRC screens, influenza

and pneumococcal immunizations)7. Administering an assessment of care practices8. Producing an Annual Report of statewide trends, showing baseline

and rates9. Submitting plans to optimize performance at 18 months

There will be two periods of evaluation under the 9th SOW. The firstevaluation will focus on the QIO's work in three Theme areas (CareTransitions, Patient Safety and Prevention) and will occur at the endof 18 months. The second evaluation will examine the QIO's perform-ance on Tasks within all Theme areas (Beneficiary Protection, CareTransitions, Patient Safety and Prevention). The second evaluation willtake place at the end of the 28th month of the contract term and will bebased on the most recent data available to CMS. The performanceresults of the evaluation at both time periods will be used to determinethe performance on the overall contract.

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

The 9th Scope of Work Content Themes

Clinical Goals: Goal ActualGoal 1: Reducing high-risk pressure ulcers < 10% 11.4%Goal 2: Reducing the use of daily < 5% 4.3%

physical restraintsGoal 3: Improving pain management for < 4% 3.9%

longer-term nursing home residentsGoal 4: Improving pain management for < 15% 20.4%

short-stay, post-acute nursinghome residents

Operational/Process Goals: Goal ActualGoal 5: Establishing individual targets for > 90% 36.4%

improving qualityGoal 6: Assessing resident and family 21.5%

satisfaction with quality of careGoal 7: Increasing staff retention 12.9%Goal 8: Improving consistent assignment 25.4%

of nursing home staff so thatresidents receive care from thesame caregivers

Clinical and Operational/Process Goals

Participating nursing homes: 7,366Percentage of participating nursing homes:* 46.8%Participating consumers: 2,186

Represents a 7.4% increase inparticipation since January 2008.

Average number of goals pernursing home: 3.8

QIS

New training approach for small statesThe Centers for Medicare & Medicaid Services (CMS) havebegun a new training approach for surveyors in small statesso that the entire state can transition to QIS over a shortperiod of time. The approach was conducted in WestVirginia, where all surveyors will soon be registered QISsurveyors and they will be conducting only QIS sur-veys statewide.

Improved QIS software coming in 2010CMS has begun to discuss their approach to full nationalimplementation of the QIS with more detail available this sum-mer about how states will be scheduled. In addition, severalmajor developments are underway to the QIS process. First,under contract CMS is programming new QIS softwarefor the state surveyors to use. The original software wasprogrammed about eight years ago and is now outdated andinefficient with all the new developments in QIS. This will notchange any of the QIS questions and logic, but the improvedsoftware will enable more efficient national implementation.The surveyors will be trained on their new software in early2010. This will not require changes to the abaqis qualityassurance system.

More enhancementsSeveral other development activities are underway. One is anadaptation of the QIS process so that surveys of small facil-ities can be conducted more efficiently. Another is the devel-

opment of a QIS process for complaint investigations that arenot conducted during the standard annual survey. And a thirdis further refinement and automation of the QIS revisitprocess. All of these investments by CMS provide evidenceof their commitment to roll out QIS nationwide, ultimately asthe only survey process in use.

Nursing homes are beginning to see the benefits of a moreobjective, consistent, and resident-centered survey process.Those that are taking advantage of these benefits are theproviders that are most proactive about using the QIS formsand tools like abaqis for ongoing quality assurance and qual-ity improvement.

8 Healthy Skin

Update

Survey Readiness

by Andrew Kramer, MD

With training of state surveyors underway in Washington and Maryland, 11 states will be rolling out QISby this summer. As of early April 2009, more than 1,700 QIS surveys have been conducted, and thenumbers are growing fast in all QIS states.

About the authorAndrew Kramer, MD is Head of theDepartment of Medicine’s Health CarePolicy and Research Division at the Uni-versity of Colorado and the first recip-

ient of the Peter W. Shaughnessy Endowed Chair in HealthCare Policy. His research interests focus on strategies for im-proving care provided to frail older adults across the healthcarecontinuum. He has authored more than 90 publications andpol icy reports, is a frequent advisor to the Centers forMedicare & Medicaid Services, Office of the Assistant Secre-tary for Planning and Evaluation, Senate Committee onAging and the Institute of Medicine.

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

The new Quality Indicator Survey (QIS) for nursing homes

is more resident-centered, with more information obtained

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

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 26 care areas

guide you to what surveyors will be targeting in your facility.

That gives you a unique advantage in preparing for your

survey – and in meeting your resident’s needs.

abaqis® is sold exclusively through Medline.Learn more by signing up for a free webinardemo at www.medline.com/abaqisdemo.

“ There are nosurprises anymorewhen the nursing homesurveyor comes to ourfacilities. And when hewants to talk to ourresidents, we know exactlywhat he is going to ask.

How?We’re an abaqis user.”Suzanne GiangrassoAdministratorLorien Mt. AiryMt. Airy, MD

10 Healthy Skin

New Jersey passeslaw mandating nursinghome use of pressureredistribution mattresses

The New Jersey legislature unanimouslypassed a bill in February 2009 to require

nursing homes to replace regular mattresses with pressure redis-tribution mattresses within three years. Nursing homes will haveto buy the upgraded mattresses when replacing older ones, be-ginning one year from the bill’s enactment.1

Sponsors of the bill acknowledge that pressure redistribution mat-tresses may cost more initially than standard spring mattresses,however, they said they cannot put a price on the continuedhealth and wellness of the state’s most vulnerable senior citizens.1

This new law is especially significant, considering the positiveresults achieved by the New Jersey Pressure Ulcer Collaborative,a pressure ulcer prevention program sponsored by the New JerseyHospital Association.

After nearly two years of applying best practices and preventivetechniques, 150 hospitals, nursing homes and home care agenciesin New Jersey tracked a 70 percent reduction in the incidenceof new pressure ulcers in their patients. Data was tracked fromSeptember 2005 through May 2007.2

Of the organizations taking part in Pressure Ulcer Collaborative,48 reported achieving results of no new pressure ulcers for a period

of at least three months. In addition, data showed that the preva-lence of existing pressure ulcers as patients moved from one caresetting to another was reduced by 30 percent.2

The organizations involved in the project were given a reviewof various positioning and support surface devices to helpunderstand the principles behind each type of device and howthey may be used with different patient populations.2

Improvement techniques used by staff across care settingsincluded:2

• an evaluation of the risk of skin breakdown• implementation of preventive strategies, such as properpositioning and use of assistive devices

• ongoing observation of the condition of patients’ skin,particularly for those identified as being at high risk fordeveloping a pressure ulcer

Indiana Pressure Ulcer QualityImprovement Initiative SelectsMedline’s Wound Care Handbookas Standard Resource Guide

Medline donates 200 handbooksto help standardize pressureulcer education

The Indiana Pressure Ulcer Quality Improvement Initiative hasselected Medline’s wound care handbook as a resource guide forinformation and treatment regarding pressure ulcers and wounds.

Prevention


The comprehensive guide provides information on the basics ofwound care and how various treatments are applied by practi-tioners in the field. Medline will donate more than 200 copies ofthe manual, enough for each healthcare facility (including hospi-tals, nursing homes and home care agencies) participating in thecollaborative.

“Not every facility has a wound care expert,” said Dea Kent, MSN,RN, NP-C, CWOCN, a clinical faculty member for the IndianaPressure Ulcer Quality Improvement Initiative. “Medline’s woundcare handbook contains all the basic information on skin andtreating pressure ulcers and explains it in an easy-to-understandformat that any clinician can follow.”

Spearheaded by the Indiana State Department of Health and theUniversity of Indianapolis Center for Aging and Community (CAC),the initiative is a collaboration of healthcare organizations acrossthe spectrum of care to develop a program of education, trainingand technical assistance to reduce the incidence of pressureulcers in healthcare settings across the state of Indiana.3

Wisconsin Forms PressureUlcer Coalition

Healthcare leaders from acrossWisconsin have formed the WisconsinPressure Ulcer Coalition to help reducepressure ulcers in the state’s nursinghomes and hospitals.

According to coalition leadership, the coalition is intended toaddress pressure ulcer prevention across the continuum of careby bringing together all players to help facilitate communicationand problem-solving at many levels.4

The goals of the Wisconsin Pressure Ulcer Coalition are to:4

• Decrease the incidence of pressure ulcers inhealthcare settings

• Continue to educate caregivers and leaders abouteffective preventive measures

• Improve assessment when an individual is admittedto a healthcare facility, as well as continue tomonitor appropriately.

• Develop appropriate prevention strategies within 24 hoursif an individual is identified to be at risk of developingpressure ulcers

• Improve communication between providers to providebetter continuity of care

Pennsylvania Launches PressureUlcer Partnership

The Pennsylvania PressureUlcer Partnership is a statewidecollaborative to provide a compre-hensive approach to the identifica-tion, prevention and treatment ofpressure ulcers within the state.

The program launched October 21, 2008, with a series of regionaleducation sessions for healthcare professionals from acute carehospitals, long-term care facilities and home health organizations.Participants received the latest evidence in pressure ulcer pre-vention and treatment from national experts, learned practical andeffective prevention strategies and planned next steps for theirown organizations in reducing the incidence and severity of pres-sure ulcers.5

In order to measure and demonstrate improvement across thestate and within their own organizations, program participants areencouraged to commit to monthly data collection and submis-sion based on metrics selected by the Partnership. These datameasure evidence of risk assessment and reassessment, skininspection, prevention strategies and presence of pressure ulcersand their stages.5

References1 New state law to mandate nursing homes use pressure-relief mattresses to fight pressure

ulcers. McKnight’s Long Term Care News & Assisted Living Web site. February 9, 2009.Available at http://www.mcknights.com/New-state-law-to-mandate-nursing-homes-use-pressure-relief-mattresses-to-fight-pressure-ulcers/article/12706. Accessed February10, 2009.

2 Tom, P. The sleeper of the season? Home Care magazine Web site. October 1, 2007.Available at http://homecaremag.com/mag/bed_sales_increase. Accessed April 3, 2009.

3 Indiana State Department of Health Long Term Care Newsletter: Pressure Ulcer InitiativeUpdate Issue 08-31. December 5, 2008. Available at www.in.gov/isdh/files/ltcnews083.pdf.Accessed April 24, 2009.

4 Wisconsin a Leader in Pressure Ulcer Initiatives. Medical News Today Web site. PostedNovember 30, 2008. Available at www.medicalnewstoday.com/articles/131120.php.Accessed March 13, 2009.

5 Current Activities of the Pennsylvania Pressure Ulcer Partnership. The Health CareImprovement Foundation Web site. Available at http://www.hcifonline.org/section/programs/pennsylvania_pressure_ulcer_partnership.

12 Healthy Skin

NPUAP and EPUAP Draft NewInternational Pressure Ulcer Guidelines

By Jackie Todd RN, CWCN, DAPWCA

The National Pressure Ulcer Advisory Panel (NPUAP) andthe European Pressure Ulcer Advisory Panel (EPUAP)presented their newly drafted joint guidelines on pressureulcer prevention and care at the 11th Biennial NPUAP Con-ference February 27-28, 2009, in Washington, DC.

The guidelines will be available for widespread use in earlysummer 2009, according to NPUAP member Joyce Black,PhD, RN, CWCN, CPSN, Associate Professor, College of Nurs-ing, University of Nebraska Medical Center.

Both the prevention and treatment of pressure ulcers are ad-dressed in the new guidelines. Prevention areas include eti-ology, risk assessment, nutrition, skin assessment, positioningand support surfaces.1 Treatment areas include pressureulcer classification, assessment and monitoring of healing,nutrition, pain assessment and management, support sur-faces, infection assessment, cleansing, debridement, dress-ings, biophysical agents, negative pressure wound therapy,growth factors and biological dressings, operative care andpalliative care.2

An urgent need for up-to-date guidelines3NPUAP and EPUAP recognized an urgent need forrevised pressure ulcer guidelines and began collaborativedevelopment plans in 2005.

Other groups, including the Wound, Ostomy and ContinenceNurses Society (WOCN), the Wound Healing Society (WHS),Registered Nurses’ Association of Ontario (RNAO), and evenEPUAP, had also produced guidelines on pressure ulcers,but each set had its own viewpoint, and there were manygaps to be filled.

In addition, a thorough literature review for guidelines hadnot been done in more than a decade, and considerableadvances in pressure ulcer prevention and care had takenplace during that time. Advances include new techniquesfor reducing pressure, adjunctive therapies (such as nega-tive-pressure wound therapy), new dressings and additionaltopical and systematic medications including woundgrowth factors.

Also, because pressure ulcers are a significant global issue,NPUAP and EPUAP determined the need to address theproblem from an international perspective. Pressure ulcerprevalence rates are more than 25 percent in Canada,

Germany, Italy and the Netherlands,according to Scope Document 3.0,developed by the EPUAP and NPUAPCollaboration to Produce a Clinical Prac-tice Guideline.3

The document also states that costs oftreating pressure ulcers consume onepercent of healthcare expenditures in theNetherlands and four percent in theUnited Kingdom. Annual pressure ulcertreatment costs in the United Statesrange from $9.1 to 11.6 billion.3

The development processAn official NPUAP/EPUAP planning meeting took place inearly 2007 to set the ground rules for inclusion of literature,review processes and writing style. The developmentprocess began with a review of existing guidelines and ev-idence tables, looking for trends, themes and gaps in infor-mation. Literature was compiled and further reviewed bysmall working groups with expertise in specific sub-areas, such as nutrition, pain assessment and wounddressings.3

As the working groups began developing guidelines withintheir specialty areas, they presented their drafts to theguideline development committee for editing and critiquing.When all the guidelines were complete, the draft documentswere posted on the NPUAP and EPUAP Web sites in early2009 for review by the professional public.

For more information and updates,visit www.pressureulcerguidelines.org.

References1 European Pressure Ulcer Advisory Panel (EPUAP) and National Pressure

Ulcer Advisory Panel (NPUAP) Pressure Ulcer Guidelines Web site.Available at www.pressureulcerguidelines.org/prevention. Accessedon April 13, 2009.

2 European Pressure Ulcer Advisory Panel (EPUAP) and National PressureUlcer Advisory Panel (NPUAP) Pressure Ulcer Guidelines Web site.Available at www.pressureulcerguidelines.org/therapy. Accessed onApril 13, 2009.

3 European Pressure Ulcer Advisory Panel (EPUAP) and National PressureUlcer Advisory Panel (NPUAP) Pressure Ulcer Guidelines Web site.Scope Document 3.0 – Pressure Ulcer Prevention: A European PressureUlcer Advisory Panel & National Pressure Ulcer Advisory PanelCollaboration to Produce a Clinical Practice Guideline. Available athttp://www.pressureulcerguidelines.org/prevention/page12817.html.Accessed on April 13, 2009.

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14 Healthy Skin

Special Feature


Evonne FowlerRevolutionizing Wound Carewith Passion and Commitment

EVONNEFOWLER

Whether she’s caring for patients at the bedside or planning awound care symposium, Evonne Fowler fuels her career withsteadfast passion and commitment.

One of the first graduates of The Cleveland Clinic enterostomal ther-apy program – birthplace of the wound care field, Fowler is alsofounder of the Symposium on Advanced Wound Care (SAWC) and thefounding president of the Association for the Advancement of WoundCare (AAWC).

She’s helped forge the way for today’s professionals as one of thegreat pioneers in wound care.

The creation of the SAWC“I would say the SAWC (Symposium on Advanced Wound Care) is myclaim to fame,” Fowler said. As co-chair of the event every year sinceit began 21 years ago, she does everything she can to make sure theSAWC is brimming with “passion and enthusiasm to get peopleexcited about what they’re doing.”

The first SAWC took place in 1988 in Long Beach, Calif. With about450 participants, it was so well-attended that they ran out of seatsand people were sitting in the aisles. The symposium has continued togrow over the years, and today, more than 2,000 participants attend.

The symposium came to fruit ion when Fowler began a casualconversation with the head of HMP Communications at a nursing

By Healthy Skin Staff Writer

“

16 Healthy Skin

conference in Las Vegas in the mid 1980s. He askedFowler for ideas on new communication and educa-tion mechanisms for wound care nurses, “and a fewyears later we held our first symposium,” Fowlershared, in her usual matter-of-fact manner.

The SAWC has grown more interdisciplinary over theyears. Physicians, who in the past would defer to“whatever the nurse recommends,” are becomingmore actively involved in wound care. Podiatrists,vascular specialists and physical therapists alsoparticipate.

The AAWC is the “voice for wound care”The SAWC had clearly become a success, but thesymposia were held only once a year. What couldFowler do to keep enthusiasm up during the rest ofthe year? The answer was to form the Association forAdvanced Wound Care (AAWC). The organizationofficially made its debut in 1995 and now claims morethan 1,600 members.

Fowler encourages all wound care professionals toconsider joining AAWC because it is “the voice forwound care and has the viabi l i ty to be agentsto change.”

She also points out that joining the AAWC is a greatway to meet people from different disciplines. TheAAWC’s motto reflects its openness to anyone pas-sionate about wound care: “One mission, manyfaces, one family.”

“We need people from all walks of life, and we reallyare a family,” she added.

Making a difference every step of the wayFowler believes there is a place for everyone in woundcare and recommends making the most of whereveryou are in your career. “No matter who you are or

where you are, someone needs you,” Fowler said.“Be passionate and persistent as you offer your best.”

Today Fowler offers her best to her husband, who isthe one who needs her most right now. Two yearsago, when advancing Alzheimer’s led to incontinenceand other difficulties with the activities of daily living,Fowler left an exciting 20-year post at the helm of thebusy Chronic Wound Care Clinic 80 miles away atKaiser Permanente in Bellflower, Calif., to spend moretime caring for him.

“It was a tough decision, but you do what you have todo,” Fowler said. “I never thought I would have my

Collaborating witha co-worker.

Reviewing a patient’s chart.

We need people from allwalks of life, and we reallyare a family”


own patient right at home, but all of the skills I’ve hadand all of the compassion I’ve had – I’m now usingto care for him.”

With her humble, take-it-in-stride attitude, she added,“I’m not unusual. I’m usual. I’m ordinary. This is whatpeople do.”

She also works part-time close to home at 76-bedSan Gorgonio Hospital caring for patients with pres-sure ulcers and incontinence dermatitis. “I often sayI’ve gone from the bedside, to the boardroom, andnow back to the bedside. This is where I am at rightnow, so I am doing my best for these patients.”

Reflecting on the early daysEarly in her nursing career, Fowler was working as anassistant head nurse at a county hospital. “We hadall the train wrecks – the people who had all the skinproblems,” she recalls. Fowler saw an opportunityto make a positive impact on the care those patientsreceived. And then, when she was approached aboutbecoming head of enterostomal therapy, she said toherself, I can do something here.

Entering the advanced wound care field wasn’t some-thing a lot of nurses were clamoring to do at that time.“When I started in wound care, nobody else wantedto do it. You have to have passion and compassion.”

At that time, advanced wound care focused primarilyon patients who had wounds associated withostomies, such as periostomal denuding of the skin.

“Our mission was to keep the patient clean, dry andcomfortable – and free from pain – while we figuredout what else was going on,” she said.

Although they were a small group at first, Fowlernoticed a common trait that united wound carenurses. “They had passion and commitment for whatthey were doing,” she said. “Patients knew we reallycared. That passion and commitment kept me going,and I haven’t lost it yet.”

Improvising and experimentingBack in the ‘70s and ‘80s, the wound care nurse’stoolbox was largely limited to ostomy care products,and nurses would experiment with products tocreate what they needed. Fowler recal ls usinga stoma adhesive as an occlusive dressing over pres-sure ulcers and stomas.

“The wound products sales reps would go on patientrounds with us, and then we would tell them what we

Caring for apatient atSan GorgonioHospital.

Fowler believes the current emphasis on biomolecular

approaches to wound care will continue into the future.

Stem cell gene therapy, biological dressings, systemictherapies, improvements in vascular techniques andregenerative medicine are all on the SAWC’s radar.

The SAWC is also pushing for a physician specialty inwound care – something that would bring the organi-zation closer to its goal of being an “umbrella organi-zation” that represents multiple disciplines.

“We want to create a stronger voice because there isstrength in numbers,” said Evonne. “That would be mydream.”

As the AAWC eyes the future, they see a changinglandscape in health care – and they’re ready for it. AsCMS revamps its reimbursement policies, the AAWCwill continue to be an advocate for wound care. Evonneexpressed an interest in leading AAWC in the directionof becoming a political action group.

What’s on the horizon in wound care?

Pearls of Career Wisdomfrom a Wound Care Pioneer

Make the most of whereyou are right nowWhether you are a nursingassistant or a director ofnursing, Fowler advisesdoing your very best everystep along the way. Therewards will follow. “Yougive, you get. You give, youget. That’s what I believe.”

Learn all you canFirst, there is formal education with variousdegrees and certifications. “But that only gets usso far,” Fowler shared. Throughout your career,continue to learn from mentors, by attending pro-fessional conferences and keeping up with thelatest research, studies and trends, while alsodrawing on your personal bank of experience.

Keep your passion and commitmentThis is the fuel that feeds the wound care nurse.“It’s what’s kept me going all these years. And Ihaven’t lost my passion yet,” Fowler said.

needed. They would develop new products based onour input, and come back with items that did what weneeded. When I think back on it now, we really werepioneers.”

The product selection might not have been the best,but the goals of wound care back then are still in linewith what is happening today. “We’re still doing a lotof things 30 years later that we did then,” Fowler said.“As I age, I can see there’s room for everything interms of product use.”

A long and winding careerFowler has held myriad positions across the contin-uum of care. Along the way, she also earned bache-lor’s and master’s degrees in nursing and becamelicensed as a clinical nurse specialist. She is founderand president of Dynamic New Directions, an educa-tional and research company that provides educationto healthcare professionals on skin-related concerns.She also continues as co-chairperson of the SAWC.

In the past she shared her talents as an assistant clin-ical professor at the UCLA School of Nursing and asco-chair of the multidisciplinary advisory board for theUSC ET program.

To learn more about the AAWC and SAWC, check outtheir Web sites!www.aawconline.orgwww.sawc.net

Assessing aquality improve-ment project.

Coping with CMSReimbursement changesThe recent changes to the Centers for Medicare &Medicaid Services (CMS) reimbursement policy fora select group of “never events” have health carebuzzing. Fowler says preventing the never eventsis especially challenging because, “half the patientswe see have three or four or five of those condi-tions, and they snowball,” she said. Still, she thinks“this change is really going to help both patientsand providers once we get over the shock!”

18 Healthy Skin

©2008 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.www.medline.com

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20 Healthy Skin

C. difficile:

By Deb Tenge MS, RNC

Facts and Interventions for Long-Term Care

The geriatric population is especially susceptible toClostridium difficile (C. difficile) infection due to riskfactors such as intense antibiotic exposure, prolongedlength of stay, multiple underlying diseases and poor hostimmune responses. C. difficile is a spore-forming, bacterialpathogen that can cause a wide spectrum of infection inthe elderly. Intense use of antibiotic therapy disrupts thenormal flora in the bowel, allowing for overgrowth andtoxin production of the C. difficile bacteria.

C. difficile is frequently found in healthcare facilities and isresponsible for approximately 20 percent of all inci-dences of antibiotic-associated diarrhea. Colonization ofC. difficile has been noted to be 10 to 25 percent in theacute care setting and four to 50 percent in the long-termcare setting.

Treatment


Current studies indicate that residents who exhibit C. difficilecolonization may have protective qualities against the devel-opment of C. difficile-associated disease. However, theseresidents also have a significantly higher rate of skin andenvironmental contamination than non-colonized residents.They may even contribute to the spread of C. difficile withinthe facility.

Epidemiology changes for C. difficile have noted anincrease in the overall incidence. Hospital discharges withC. difficile have gone from 82,000 in 1996 to 178,000 in2003. The severity has increased as well, with life-threateningsymptoms going from 1.6 to 3.2 percent. Complicationsincrease with age (19 percent for age 65 and older; sixpercent for age 18-64).

Checklist for Preventing C. Difficile� Use antibiotics judiciously� Use Contact Precautions for residents/patients withknown or suspected C. difficile-associated disease

� Perform hand hygiene � Use gloves during patient/resident care or when handling contaminated clothing and linens

� Use gowns if soiling of clothes is likely� Implement an environmental cleaning and disinfection strategy (refer to the CDC’s “Guidelines for Environmental Infection Control in Health-Care Facilities”)

Risk factors for C. Difficile• Watery Diarrhea• Fever• Loss of appetite• Abdominal pain• Nausea• History of antibiotic use (cephalosporins, fluoroquinolones and clindamycin have been linked to C. difficile)

• History of C. difficile (Approximately 20% of residentswill experience a single recurrence and 45 to 65 percent will go on to develop additional recurrence)

• History of gastrointestinal procedure• Lengthy hospital stay • Hospital discharge within the last 60 to 90 days

Tests for Diagnosing C. Difficile• Stool culture is the most sensitive test• Antigen detection for C. difficile. This is a rapid test (less than one hour) that detects the presence of C. difficile antigen

• Toxin testing for C. difficile, which detects toxin A, toxin B, or both A and B. (Same-day results)

Note: C. Difficile toxin is very unstable. The toxin degrades at roomtemperature and may be undetectable within two hours after collectionof a stool specimen. False-negative results occur when specimens arenot promptly tested or kept refrigerated until testing can be done.

Sources 1. Centers for Disease Control and Prevention Web site. CDC Frequently

Asked Questions-Information for Healthcare Providers. Available athttp://www.cdc.gov/ncidod/dhqp/id_CdiffFAQ_HCP.html. Accessed February 19, 2009.

2. Clostridium Difficile Infections-Best Strategies for Care of Older Adults. CE presentation by Erik. R Dubberke, MD and Suzanne F. Bradley.

ANY SURFACE,device or material (commodes,

bathing tubs, rectal thermometers)that becomes contaminated with feces may serve as a

reservoir for C. difficile spores.

Differences Between C. difficile Colonization and C. difficile-associated Disease

C. difficile Colonization1. Patient/resident exhibits no clinical symptoms2. Patient/resident tests positive for C. difficile organism and/or its toxin

3. More common than C. difficile-associated disease

C. difficile-associated Disease1. Patient/resident exhibits clinical symptoms2. Patient/resident tests positive for C. difficile organism and/or its toxin

22 Healthy Skin

The case studies shown here are excerpted from:

Regenerative Medicine: Urinary Bladder Matrix* Assistancewith High Risk Diabetic Limb Salvage Presented at the Symposium on Advanced Wound Care (SAWC) and Wound Healing Society, Dallas, TX, April 2009

Joseph Gonzalez, DPMThe Foot Wound InstituteCapital Foot & Ankle Centers Okemos, Michigan

Case 132 year-old male with a past medical history for poorly controlled type IIdiabetes with peripheral neuropathy presented with a 1 week history ofan abscess at the lateral aspect of his right heel. He could not recall anytrauma to the area or any other inciting events. He stated that he recentlynoticed a red, swollen blister with pus draining. Upon presentation, hisvascular status was intact and he had a deep, tunneling abscess, just an-terior to the Achilles tendon on the lateral aspect of his heel. The wound

measured 0.5cm x 0.7 cm with 1.5 cm of depth. The abscess was ini-tially drained and debrided. ECM/Basement Membrane material waspacked into the deep tunnel and covered with oil emulsion, negativepressure wound therapy and a mildly compressive dressing. The patientwas given a post-op shoe to wear. He returned weekly for serialdebridements. The ECM/Basement Membrane was packed into thewound at each visit. At 4.5 weeks, the wound had epithelialized completely.

Case 2A 43 year-old female with a past medical history of type II diabetes withneuropathy was involved in a motor vehicle accident, causing displacedfracture of her right calcaneus. She underwent open reduction withinternal fixation with plate and screws two days later. At her two-monthfollow-up appointment, it was noted that the incision had not healed,and she visited the wound center for treatment. Upon initial presenta-tion, her vascular status was intact and the corner of the wound had de-hisced and was completely fibrotic at the plantar lateral heel with a smallcorner of the plate exposed. Sharp debridement was performed toremove the fibrotic tissue. The wound was covered with BasementMembrane/ECM Wound Matrix, covered with oil emulsion, and negative

pressure wound therapy was implemented. The patient was alreadyprescribed a six-week course of IV antibiotics and was seen weekly forserial debridements and local wound care with the Basement Mem-brane/ECM Wound Matrix was applied every 7 days. Within three weeks,the wound had granulated completely over the exposed plate. Weeklydebridements and Basement Membrane/ECM Wound Matrix applica-tion was continued, however edema control was difficult to achieve dueto poor patient compliance. Appropriate compression therapy was uti-lized with the Basement Membrane/ECM Wound Matrix and the woundhealed after 20 weeks without the need for hardware removal oraggressive surgical intervention.


CASE STUDY

Case 3A poorly controlled, type II diabetic female presented with an abscess inher left hallux which had been present for at least one week. She hadperipheral neuropathy and her vascular status was noted to be intact.She had a red, hot, swollen, deep, tunneling ulceration at the left halluxdistal phalanx which measured 0.6cm x 1.0cm x 1.0cm deep. It didprobe to bone and she was placed on antibiotic driven IV antibiotics forsix-weeks. The wound was debrided down to healthy bleeding tissue

and then packed with Basement Membrane/ECM Wound Matrix and covered with oil emulsion, negative pressure wound therapy and mildlycompressive dressing. She was placed in an accommodated surgicalshoe. She returned weekly for serial debridements and Basement Mem-brane/ECM Wound Matrix was packed into the wound at each visit.Within four weeks, the wound had granulated to the surface. BasementMembrane/ECM was continued until wound closure at twelve weeks.

Case 4A 63 year-old female with a past medical history significant for typeII diabetes with neuropathy, rheumatoid arthritis, Charcot neu-roarthropathy right ankle and left below-knee-amputations wasseen in the hospital for a septic right ankle joint, present for oneweek. The infection source was noted to be from a staple in thetalonavicular joint and was surgically removed. The patient wasoffered a right below-knee-amputation and subsequently refused,as she still was not ambulating from the previous left below-kneeamputation three months earlier. Wound Center consultationswere sought for limb salvage options. The initial medial woundover the talonavicular joint measured approximately 5.0cm x5.0cm and tunneled to the ankle joint, causing a lateral blow outof the ankle and a second wound measuring 3.0cm x 1.5cm.There was a significant amount of purulent drainage, as well aserythema and edema. A thorough bedside debridement was per-formed and dilute betadine irrigation was utilized for three days.

Once the purulent drainage was reduced to a minimum, Base-ment Membrane/ECM Wound Matrix was packed into the tun-neling wounds and negative pressure wound therapy was utilized.The patient was discharged on an 8-week course of culture spe-cific antibiotics and followed up weekly at the Wound Center.Serial debridements were utilized with continued use of BasementMembrane/ECM Wound Matrix and negative pressure woundtherapy. Compression therapy was utilized following negativepressure wound therapy, and the wounds subsequently healedafter three months of treatment. The patient was able to utilize herprosthetic on the left below-knee amputation and is currentlyincreasing her ambulation in physical therapy. We continue to usecompression therapy to control the edema, but the medial woundcontinues to open and close periodically due the excessive shoepressure on this prominent area of her Charcot foot.

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At the same time, SilvaSorb Gel helps woundsremain neither wet … nor dry … but moist. Theideal environment for healing a wound. Whichmakes SilvaSorb Gel ideal, for cavity wounds…even burns.

Each SilvaSorb package, like every other Medline woundpackage, is a 2-minute course on Advanced Wound Care.

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Randomized Clinical Study of SilvaSorb®Gel in Comparison to Silvadene® SilverSulfadiazine Cream in the Managementof Partial-Thickness Burns

This prospective, randomized study

assessed the clinical, microbiological,

and patient comfort characteristics of

two silver-based topical agents in the

management of partial-thickness burn

wounds. Pediatric patients were ran-

domly assigned to treatment with

either Silva-Sorb® Gel (Medline Industries, Mundelein, IL) or

Silvadene® silver sulfadiazine cream (King Pharmaceuticals,

Bristol, TN) for up to 21 days or to the point of full reepithelializa-

tion of the wound. Inclusion criteria were patients ranging in age

from 2 months to 18 years with TBSA ranging from 1 up to 40%.

A total of 24 patients were enrolled and completed the study.

Findings demonstrated that the use of SilvaSorb Gel was asso-

ciated with less pain and greater patient satisfaction when com-

pared with Silvadene. No statistically significant differences

were found when assessing the rate of infection, time to

reepithelialization, or the number of dressings changes

required during treatment. The reduction of pain and improved

overall patient satisfaction with the use of SilvaSorb Gel

compared with Silvadene indicates an important role for

SilvaSorb Gel in treatment of partial-thickness burns in a

pediatric population.

Reprinted with permission. © 2009. Journal of Burn Care Research.

2009;30(2):262–267

CLINICAL STUDY

Paul M. Glat, MD, Wade D. Kubat, DO, John F. Hsu, DO, Tarek Copty, MD, Brooke A. Burkey, MD, Wellington Davis, MD, Isak Goodwin, MD

Perioperative Pressure Ulcer Education.

More important than ever before

“I have seen an increase in the number of legal issueslinking facility-acquired pressure ulcers to post-surgicalpatients. A pressure ulcer program for the OR is morecritical 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 www.medline.com/pressureulcerprevention.

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 pollutantsReusable, to reduce waste in landfills

Water-conservingMinimally packaged

ApparelEnviro ISO gownReusable surgical gownsReusable ISO gownsReusable briefs and underpadsScrubs

Diagnostic EquipmentBlood pressure cuffs (reusable)SphygmomanometersStethoscopesThermometers

Environmental ServicesDisinfectant productsEco floor matsEco floor mopsGeneral cleanersHard surface germicidalsMicrofiber cleaning clothsMicrofiber mopsPillowsRecycling sorting containersReusable hamper bagsSuper-concentrated detergents

and lubricantsTouchless sensor faucets

and flushersTile, grout and bathroom

cleaner/deodorizerToilet paper, facial tissue

and hand towelsTrash linersUpholstery cleanerUrinals

Food ServiceBiodegradable paper cupsRecyclable plastic cups and strawsPatient utensils

Infection ControlAdvanced Bowie Dick testBio-zolve pre-soak instrument spray Sterilization containers

Latex-Free Surgical ProductsAneroidsAnesthesia breathing bagsAnesthesia circuitsAnesthesia masksAnti-fog solutionBand bags and equipment coversBone waxDisposable safety scalpelsElectrosurgical disposables

(tips, ground pads, pencils and tip cleaner)

Esmark bandagesInsufflation tubing and needlesLight handle coversSharps safety products (magnetic

drapes, transfer trays, scalpel holders)

Skin markersStockinettesSuture bootsThermoform molded traysTube holders (amnio hook,

umbilical cord clamp, umbilical cord clamp cutter)

Vessel loops

MiscellaneousConnecting tubesDrain bagsEco-friendly foam positionersMed-PackOxygen concentratorPeak flow unitsReusable nebulizer cupsSafesorbSilver Foley cathetersSuction 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.

Environmentally conscious Medline products

Ask your Medline rep for detailson ordering these products.

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

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

www.medline.com

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

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Best Practices for Blood Glucose Monitoring

Glucose testing plays an important role in treating diabetes.Your residents, whether they have Type 1 or Type 2 diabetes,should be tested routinely, per physician’s orders, and careshould be provided based on the results obtained.

Testing blood glucose in a long-term care facility followsOccupational Safety and Healthy Administration (OSHA),Joint Commission and Centers for Disease Control (CDC)guidelines to promote safety and best standards of care. Theglucose monitor, proper finger stick site location and typeof lancets used play an important role in obtaining accu-rate results.

Resident Blood Glucose Testing Procedure• Explain the procedure to the resident.• Check the expiration date on the test strips.• Calibrate the monitor (if necessary) according to the manufacturer’s instructions.

• Ensure the displayed calibration code matches the code on the calibration bar and the code on the test strip package insert.

• The calibration bar is stored in the carrying case until all of the test strips in that box have been used.

Prevention

30 Healthy Skin

• Ensure that the monitor and test strips are at room temperature. If there is a temperature change,the monitor and test strips should sit at room temperaturefor 10 to 12 minutes.

• Insert a test strip in the monitor according to the manufacturer’s instructions.

• Lance the resident’s finger, obtain a sample of blood. • Apply the blood sample to the test strip when promptedby the monitor.

• If your monitor allows for the addition of a second drop of blood, please refer to the user’s manual for detailed instructions.

• Dispose of the used lancets and test stripsimmediately according to the facility’s policies or the state mandates.

• Record the result in the resident’s recordand follow physician orders for notification and providing care.

• Document all interventions in the resident’s medical record.

Fingerstick Testing Using a Safety LancetThis section addresses best practices regarding how toprepare for and perform a fingerstick test while protectingthe nursing staff from infectious cross-contamination.

When to conduct a fingerstick testAlways follow physician orders. Some recommendations forscheduled fingerstick tests are:• Before a meal• 1 to 2 hours after a meal• Before bed

Choosing the correct lancetUsing the correct lancet is as important as using propertechnique. Blood sample size varies depending on theglucose monitoring system you choose. A higher gauge(thinner) lancet can be used for smaller sample sizes andmay result in less discomfort for the resident. However, keepin mind that one lancet type may not serve the needs of allof your residents.

Although there are a variety of safety lancet brands on themarket, there are only two lancet designs:Pressure Activated – the lancet is activated by applyingpressure to a person’s fingertip.Non-Pressure Activated – the lancet is activated by press-ing a button, or a firing pad, on the device.

Test site recommendationsHere are some guidelines regarding preferred test sitelocations:• The puncture should occur on the side or the top of the finger.

• It is better to test either the side or tip (not the center) of the finger because tissue is about half as thick there and a finer gauge (thinner needle) can be used.

• Never lance directly on a resident’s fingerprint, as the nerve endings there could cause a great deal of discomfort.

• Preferred puncture sites are the middle and ring fingers.

KEEP IN MIND that one lancet type may not serve the needs of all of your residents.


Preparing the finger1. For optimal blood flow, it is recommended that you warm the test site prior to lancing. Place a warm, moist towel on the area for three to five minutes; at a temperature no higher than 107 degrees F, or 41.7 degrees Celsius (this increases arterial blood flow and will not burn the skin). Alternately, you can warm the skin by massaging the hand, beginning from the palm and slowly working toward the fingertips.

2. Next, cleanse the site using a 70 percent isopropyl alcohol solution.

3. Allow the area to air-dry so that the alcohol’s antiseptic action can take effect (if skin isn’t dry, test results can be inaccurate).

Performing the testAfter you have prepped and cleaned the finger, it is time toperform the test. Puncture the site, and then use a gauzepad to wipe away the first drop of blood. Apply the blood tothe testing strip, being sure to follow the manufacturer’sinstructions. Once the test is over, use a 2'' x 2'' gauze padto wipe away any excess blood, and then apply slight pres-sure (or follow your facility’s policy and procedure).

Test site rotationSome residents have their blood sugar tested daily, whileothers might be tested as often as four to six times a day.The more frequent the testing, the greater the chance offingertip soreness. That is why it is important to rotate thepuncture site with each fingerstick. Additionally, site rotationhelps to minimize callous formation. Avoid “milking” a finger,since it can cause tissue fluid contamination of a specimenand result in a false low reading.

SourceD.O.N. Instruction Manual. A Diabetes Resource for Long-Term Care. Medline Industries, Inc., Mundelein, IL. 2009.

C O M P A S SFit Right ProgramSurvey Readiness Tag F315 & Q ISBe survey ready at all times with Medline’sCompass Fit Right Program— an inconti-nence reference for front-line caregivers.

Compass Fit Right Program – SurveyReadiness Tag F315 & QIS includesquality improvement forms and tools,plus the following:

• Program Manual Binder provides an overview to implementing a thorough incontinence program and compiles program manager guidance on how to use the various components of the program.

• Practical Guide to Understanding F315 & QIS

• CNA & RN Workbooks

• DVD Education (with CE hours)

•Continuous Pressure Ulcer Prevention Tablets

• Measuring Tapes

©2008 Medline Industries, Inc. Medline and Silvertouch are registered trademarks of Medline Industries, Inc.

Catheter-associated urinary tract infections (CAUTI) represent

approximately 40 percent of all healthcare-acquired infections.1

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References 1. http://cdc.gov/ncidod/dhqp_uti.html

* In-vitro test data on file.

To learn more about Silvertouch catheters, contactyour Medline representative or call 1-800-MEDLINE.

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Don’t gamble with patient safety.

By Janet Nau Franck, MBA, RN, CIC

Have you ever wondered what it must be like to have anindwelling foley catheter? Do your residents really understandwhat a urinary catheter is and how it works? Do they know howto prevent an infection and how to care for their catheter whenthey go home? Surveyors are certain to ask for documentation thatverifies that residents and their families receive education.1

Urinary tract infections account for up to 40 percent of all hospital-acquired infections (HAIs), and the majority of these infections areassociated with urinary catheters.1 The increasing numbers of theseinfections can create a tremendous clinical and financial burden forthe healthcare facility. This has made education to prevent infectionan even greater priority.

Providing residents with guidelines for urinary catheter care andinfection prevention helps include the resident in their care plan andcan assist caregivers to provide better care. Turn the page for aguideline for residents and their families that you may find useful.

Resident and Family Education Strategies to Combat CAUTI


Prevention

What is a urinary catheter?A urinary catheter is a thin tube placed in the bladder to drainurine. Urine drains through the tube and empties into a collec-tion or indwelling “foley” bag. A urinary catheter may be used:• If you are unable to urinate on your own.• To measure the amount of urine produced.• During and after certain types of surgery or tests.

What should you know about your catheter?• Catheters are inserted by a trained individual and should be removed as soon as possible.

• Caregivers clean their hands by washing them with soapand water OR by using an alcohol-based hand rub before and after touching your catheter.

• If you do not see your caregivers cleaning their hands, please ask them to do so.

How can I reduce my chances of getting an infection?• Clean your hands with soap and water or use hand sanitizer before and after coming in contact with your catheter.

• Keep the catheter secured to your leg to avoid pulling on the tubing whenever possible.

• Always keep your urine bag below the level of your bladder. • Do not twist or kink the catheter connection tubing.• Tell your caregiver if you notice that the bag is more than half full.

• Keep the drainage spout from touching anything while emptying the bag.

• Do not disconnect the catheter or drainage tube.• Ask your caregiver every day if you still need the catheter.

What is a “catheter-associated urinary tract infection”?A urinary tract infection (UTI) is caused by germs that do notnormally live in the urinary tract. If germs are introduced while aurinary catheter has been inserted, they can travel along thecatheter and cause an infection called a catheter-associatedurinary tract infection (or “CAUTI”). Germs can enter the urinary tractwhen the catheter is being put in or while the catheter remains in thebladder. For this reason, patients with urinary catheters have agreater chance of getting a urinary tract infection.

How do you know if you have a urinary tract infection?Some of the common symptoms of a urinary tract infection are:• Burning or pain in the area below the stomach • Fever• Bloody urine • Urinating more frequently or more urgently than normal after the catheter is removed

• If you have questions, be sure to contact your doctor. An antibiotic may be prescribed.

What do you need to do when you go home?• If you will be going home with a catheter, your doctor or nurseshould explain everything you need to know about taking careof the catheter.

• Make sure you understand how to care for your catheter before you leave the facility.

• Before you leave the facility, make sure you know who to contact if you have questions after you get home.

My doctor’s name and office phone number is

Adapted from: Frequently Asked Questions (FAQs) about CatheterAssociated-Urinary Tract Infections (collaborative fact sheet),co- sponsored by several organizations, including the Centers for Dis-ease Control and Prevention (CDC), http://www.cdc.gov/ncidod/dhqp/pdf/ guidelines/CA-UTI_tagged.pdf, 2008.

For additional copies of patient education materials, visit MedlineUniversity at www.medline.com/CAUTI.

34 Healthy Skin34 Healthy Skin

Caring for Your Urinary Catheter Infection Prevention Guidelines for Residents

About the author

Janet Nau Franck, RN, MBA, CIC has more than 30 yearsof experience as an infection preventionist and consultant. As aninternational leader, she has served as past president of theAssociation for Professionals in Infection Control (APIC), adjunctfaculty at Loyola University-Chicago, and has received numerousawards for having lectured and published worldwide. She canbe reached at [email protected].

Reference1. Beaver M. CMS reimbursement changes put spotlight on prevention

of catheter-related infections. Infection Control Today Web site. Available at http://www.infectioncontroltoday.com/articles/cms-regulations-catheter-infections.html. Accessed April 22, 2009.


Implementing Medline’s Pressure UlcerPrevention (PUP) Program at Rest Haven-York

Rest Haven-York is a 180-bed independently ownednursing home in York, Pennsylvania, that employs75 registered nurses and 115 nursing assistants. Staffmembers completed Medline’s Pressure Ulcer Prevention(PUP) program this spring and celebrated their newfoundknowledge with the awarding of certificates and pins.

The Pressure Ulcer Prevention Program is a strategic productbundle consisting of skin care products and incontinencegarments to assist in reducing or preventing pressure ulcersand incontinence-associated skin conditions.

The program also packages together education and trainingtools so a healthcare team can implement an effective pressureulcer prevention program and immediately begin reducing theincidence of healthcare-acquired pressure ulcers. Included areworkbooks, patient and family education brochures, a CD withprintable electronic forms and tools, and a staff rewards program.In addition, the new MD Education DVD includes everythingthe physician needs to recognize, assess and documentpresent–on–admission (POA) indicators for stage III and IVpressure ulcers.

QWhat sold you on the need for the PUP program at Rest Haven York?

Diane Krasner:The wound team at Rest Haven-York has been offeringcontinuing education on pressure ulcers for many years. Butthere was never any good way to measure patient outcomesor demonstrate staff competencies. The PUP programpre-test/post-test format and its ability to measure outcomesare what really sold me. After completing the program, ourRNs, LPNs and nursing assistants appreciated seeing onpaper how much they had learned. We placed a copy ofeveryone’s CE certificate in their human resources file. We nowhave demonstrated and recorded competencies for ournursing staff.

Tom Clopp, MSEdDiane Krasner, PhD, RN, CWCN, CWS, BCLNC, FAAN

Rest Haven-York PUP Program Test Scores Compared to National AveragesNursing assistants and nurses at Rest Haven-York scored higher than the national averages on the PUP program pre- and post-tests.1

PUP Pre-test % Post-test %

Nursing Assistant (NA) Average 58 80Rest Haven-York NA Average 67 96

Nurse Average 78 88Rest-Haven York Nurse Average 80 99

Tom Clopp and Lisa LeBeau of Medlinepresent CE certificates to Rest Haven

staff. In the foreground is nursing assis-tant Missy Strayer.How sweet it is! Chastity Williams, LPN; Jan Daley,

RN - Nursing Supervisor and Sue Hoch, LPN.

Prevention

QWhy was the focus on prevention importantfor your facility?

Diane Krasner:Prevention is where the rubber meets the road. Our woundteam oversees the plan of care for our residents with pressureulcers, but prevention is the responsibility of the nursing staffat the bedside. The PUP program reinforces the importance oftheir eyes and ears as our first line of defense in pressure ulcerprevention.

QWhat was the best part of the program for you?

Diane Krasner:Our staff members were so thrilled to have accomplished theirfirst self-paced learning activity. Tom Clopp arrived from Med-line with pins, certificates and cookies, and we all celebrated!

QWhat were the biggest successes and challenges in implementing the PUP program at Rest Haven-York?

Tom Clopp:The biggest challenge was getting buy-in from staff tocomplete a program on a topic that they felt they were alreadyup-to-date on. The successes were much greater. After com-pletion, many of the staff realized that there were things theydid not know or had forgotten about. They really enjoyedreceiving the CE certificates and pins and participating in ourawards ceremony. Beyond that, the success of the programwas shown in the measurable decrease in pressure ulcers andskin tears facility-wide.

Q You have introduced this program at many long-term care facilities and hospitals across Pennsylvania. Why do you think it works so well across the continuum of care?

Tom Clopp:The key elements apply to every care setting. Pressure ulcerprevention has been instilled in long-term care staff for years, yeta refresher course on best practices is extremely beneficial.Hospitals are now bound by the new Centers for Medicare& Medicaid Services (CMS) guidelines and will risk loss ofreimbursement if pressure ulcers develop during patient stays.

Similarly, long-term care facilities are bound by F-tag 314, whichstates that “A resident who enters the facility without pressuresores does not develop them unless the individual’s clinicalcondition demonstrates that they were unavoidable.”3 Aboveand beyond that, patient care is at the top of every healthcarefacility’s list.

36 Healthy Skin

WHEN PREVENTION BUNDLES (toolkits) are employed, pressure ulcers are reduced.2

CLOSE TO 40 PERCENTof the facilities participating in the PUPprogram are nursing homes or LTCs.1

CONTINUOUS PROFESSIONALdevelopment trains staff members onan ongoing basis in their work settingand results in confirming current practice,changing current practice or causingthe learner to seek more information.2

Rest Haven-York nurses display their PUP continuing education (CE)certificates. (Left to right): Rosie Grow, LPN; Lois Brunson, NA; Laura Rivera, NA and Brandi Hollerbush, LPN.

QWhy are value-added services, like the PUP program, so appreciated by the clinicians you call on?

Tom Clopp:Value-added services help clinicians in a lot of ways. Numberone is a program, like PUP, that is already built – because itsaves facilities both time and money. Nurses are busy enoughwith their daily tasks. Building a program like PUP from scratchwould take months. It realistically could be a full-time projectfor a wound care nurse who is already needed for consults,treatments and education.

Although PUP is an out-of-the-box program, it can becustomized for each facility. The accompanying CD featuresa variety of forms and tools in different formats, so clinicianscan choose the format that fits in best at their facility. Thefacility logo also can be added to the printable forms.

References1 Medline Industries Inc. Pressure Ulcer Prevention (PUP) program. Data on file.2 Armstrong DG, Ayello EA, Capitulo KL, et al. Opportunities to improve pressure

ulcer prevention and treatment: implications of the CMS inpatient hospital care present on admission (POA) indicators/hospital acquired conditions (HAC) policy. Adv Skin Wound Care. 2008;21(10):469-78.

3 Thomas DR. The new F-tag 314: prevention and management of pressure ulcers. Clinical Practice in Long-Term Care. 2006;7(8):523-531.

Tom Clopp, MSEd is an advanced wound

and skin care product specialist for Medline

Industries, Inc.

Diane Krasner, PhD, RN, CWCN, CWS,

BCLNC, FAAN, WOCN is a special projects nurse

at Rest Haven-York.

For more information on pressure ulcer prevention efforts at Rest

Haven-York, visit http://www.medline.com/special/PAA/pup.asp.


CLINICIAN TRAINING AND education is an ideal opportunity for thewound care community to partner withassociations or industry to develop appropriate programs and materials that can be implemented quickly.2

Medline’s Tom Clopp presents a PUPP continuing education (CE) certificate to Wound Team Manager Wendy McKinney, LPN, CWCA.

It was an exciting and educational experience for all the nursing staff. It broadened everyone’sknowledge base and awareness of prevention ina fun way!

Chrissy Leppo, RNDirector of NursingRest Haven-York

The PUP program was presented in an easy,interesting format. The nursing assistants werereally receptive and they appreciated beingincluded - it gave them a sense of being part of the team.

Sandy Augustine, LPN Wound TeamRest Haven-York

1

38 Healthy Skin

Are Your Physicians Making the Grade?

A recent survey graded physiciansʼ abilities to recognize, assess and document Stage III and IV pressure ulcers at a “D” level. Medlineʼs newPressure Ulcer Prevention Program MD EducationCD 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 MedlineʼsPressure Ulcer Prevention Program is critical foracute-care facilities to ensure that physicians understand their role in recognizing and accuratelydocumenting POA pressure ulcers.” -Michael Raymond, MD, Associate Chief Medical Quality Officer, NorthShore University HealthSystem,Skokie Hospital, Skokie, IL

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 www.medline.com/pressureulcerprevention.

The results are in the numbers. Be a part of out national

benchmark scorecard to measure your progress and reduce

facility-acquired pressure ulcers

Hospitals currently enrolled 232

Nursing homes currently enrolled 83

Average test scores Pre-test Post-test

Nursing Assistant 58 87

LPN/RN – Core 77 95

LPN/RN – Advanced 80 91

Pressure UlcersAverage Facility-acquired Incidence

Before implementing 6 pressure ulcers (16%)

Medline PUP program

After implementing 3 pressure ulcers (3%)

Medline PUP program

Source: Data on file. Medline Industries, Inc.

Celebrating 1 YearMedline’s Pressure Ulcer Prevention Program!


Product

By Janet Jones, BSN, RN, PHN, CWOCN, DAPWCA

Skin Breakdown is a national health concern whether yourpractice setting is acute care, long-term care, long-termacute care or home care. Most care settings are affectedby monetary fines related to skin breakdown, which willultimately change the care of those residents with skin andwound issues.

Early treatment and protection against wounds are keys tosuccess in minimizing in-house acquired wounds. Themost vulnerable areas are over bony prominences wherefriction is an issue or areas that remain moist.

MARATHON Liquid Skin Protectant is a non-stinging,cyanoacrylate based monomer that forms a fully con-formable, flexible and remarkably strong protective layerover intact or damaged skin. MARATHON bonds to the skin surface and integrates with the epidermis as thecyanoacrylate polymerizes at the molecular level whilesupporting the natural integrity of the skin.1 It provideshigher strength1,4 and higher resistance to wash off thanother thin film barriers.2 MARATHON Liquid Skin Protec-tant is resistant to external moisture, yet it allows the skinto breathe.

MARATHON Liquid Skin Protectant is designed to protectintact or damaged skin from breakdown caused by frictionor moisture.

MARATHON:Minimizes friction and reduces the risk of developingskin tears.- Creates a strong physical barrier against abrasive forces.- Also recommended for damaged skin to protectagainst further breakdown.- Can be applied to pressure points to avoid the risk of skin breakdown.

Protects skin from prolonged exposure to moisture,which weakens and damages the skin surface andmakes it more susceptible to breakdown.3

- Incontinence: MARATHON should be used on at-riskareas such as the sacrum, buttocks and groin.- Stomas and drain sites: Helps protect the area aroundstomas and drain sites from breakdown caused bybody fluids, exudate and the effect of adhesives.

Maintains skin integrity.- Applying MARATHON to the skin once it has closedshould help protect it and maintain integrity.

MARATHON can be applied to pressure points to avoid friction and reduce the risk of skin breakdown. Examples include toes, soles of the feet, heels, ankles, ears, shoulders, scapulas, spine, elbows, coccyx, trochanters and ischium.

SpotlightMARATHON Liquid Skin Protectant

40 Healthy Skin

How should MARATHON be used?MARATHON Liquid Skin Protectant comes in a single-usesterile applicator. Each 0.5 gram applicator can cover a4-inch x 4-inch (10 cm x 10 cm) area. The product shouldbe applied in a very thin layer, without covering the sitemore than once.

MARATHON can be used when the epidermis is broken ordamaged. However, it should not be applied directly todeep, open, chronic or bleeding wounds. It adheres to theskin and dries in less than a minute. It can remain on theskin for several days. It will wear off naturally as the skin re-generates. Reapplication is usually every one to three daysdepending upon location and contact with caustic effluentsuch as urine, stool, or moisture from a wound or gas-trostomy sites.

Incorporating MARATHON Liquid Skin Protectant intoyour “wound care tool chest” will give you a more durableliquid barrier product. Upon initial application it should beclear that the product is much more durable in protectinghigh-risk areas than a skin barrier wipe.

References

1 Bond P. Scanning Electron Microscope Examination and Assessment of SUPERSKIN

(Liquashield [REGISTERED SYMBOL]). 2001. University of Plymouth, UK. Data held on file at

MedLogic Global Limited.

2 CyberDERM Clinical Studies. Study to Compare the Wash-off Resistance of Two Barrier

Films Exposed to Synthetic Urine. Data on file.

3 The Merck Manuals Online Medical Library. Pressure Sores. Available at

http://www.merck.com/mmhe/sec18/ch205/ch205a.html?qt=moisture%20skin%20dam-

age&alt=sh#sec18-ch205-ch205a-262. Accessed on April 9, 2009.

4 CyberDERM Clinical Studies. Abrasion Test. Data on file.

About the author

Janet Jones, BSN, RN, PHN, CWOCN, DAPWCA is a board-certified wound, ostomy and continence nurse. She has extensive experience in long-term and home care and has developed wound prevention and treatment programs for many national healthcare groups. She’s also ready to take your call on Medline’s Educare Hotline!


Nope – it’s a nursing home!

Medline, the company that knows health care, brings you luxury you can depend on.

Our Feels Like Home™ line of textiles includes everything from

soft and cozy towels to 100 percent terry robes and 310 thread

count reverse sateen sheeting. All of Medline’s Feels Like Home

products provide the same comfort and quality that your residents

expect in their own homes.

Feels Like Home products don’t stop at luxury – they’re practical,

too. All of these products were designed with nursing input to

ensure that they meet the needs of patient-centered care. They’re

also incredibly durable and have been tested to withstand the

wear and tear of commercial laundering.

To learn more about theFeels Like Home line,please call 1-800-MEDLINE,visit www.medline.com orspeak to your Medlinesales representative

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Is This a Four-Star Hotel?

Education, Products that Work and Celebration

The secret ingredients for a successful skin care program

By Lisa Bogle, RN

When I became the director of nursing at Liberty Village ofClinton four years ago, we were a new facility, and it was clearwe had inherited a problem with skin and wound care.We hadmultiple wounds of varying stages. Our physicians were prescribingdifferent products and protocols. We might have three or four waysto treat a skin tear and certainly dozens of wound care products onthe shelf. This was a project I had to tackle right away, but I knew itwould take a multifaceted approach.

Educating all levels Our first step was to give the staff some solid education. Nurses,CNAs and even our families learned the importance of moisturiz-ing the skin, protecting with barriers when necessary and usingproper positioning techniques. The direct care staff was an impor-tant part of the solution. They had to know that they could trulymake an impact and that they were the eyes and ears of the unitnurse. We utilized our infection/skin report more effectively and alsoimplemented regular skin checks on every resident.

We even changed our admission process to include a swallowing eval-uation and weekly weighing of residents so that we could catch andtreat the nutritional aspects so important for skin health.

Products that workOur direct care staff was given the task to test skin care products andevaluate which ones made a difference. We targeted a group of resi-dents with extremely fragile skin and a history of skin tears. At thattime, our 134-bed facility typically had four or five skin tears per week.After years of using inexpensive and random lotions, we decided totest a high-quality skin protectant with some science behind it and touse it consistently. After 30 days of using Remedy® Skin Repair Creamtwice a day, we only had two residents experience a superficial skintear. We are now expanding the use of this product to include all res-idents unless contraindicated.

We looked for other residents who could benefit from a therapeuticskin care plan. An example was a newly admitted resident with a long,chronic history of lower extremity venous stasis ulcers. She had beenvery uncomfortable with this condition for many years. We imple-mented the Remedy Skin Repair Cream and over the course of two


Prevention


Is This a Four-Star Hotel?

42 Healthy Skin

months, her ulcerated, fragile skin showed exceptional improve-ment.

When new residents were admitted with purple-tinged legs, com-mon to vascular disease, within days of our new skin care plan,their families were surprised to see the visible improvements; lighter,plumper, healthier-looking skin.

I am particularly proud of our success with another resident who ex-perienced discomfort from an extreme case of scleroderma. Herskin has many areas of tightness and pain. She has expressedgreat relief after moisturizing and protecting her skin with RemedySkin Repair Cream.

CelebrationNo amount of education or miracle product will change behavior ifmanagement does not continue to make skin care a priority. We doeverything we can to celebrate our skin care success. We recog-nize our staff by name in our meetings for their ideas and sugges-tions and tell them, “Great job!” We have a healthy competitionamong our four units, and each one wants to be the best. We tryto find the humor in everything. If there is a laugh to be had, we’llhave it.

It may sound cliché, but we try to give ownership of the skin careprogram to the front line employees. We have plenty of the inven-tory available and allow them the autonomy to choose the skin careproduct (moisturizer, barrier, skin paste) that they think is best for thesituation. We ask their opinions and truly listen to their feedback.When one CNA shared that she felt good about talking with theresident while applying the cream, it made all of us remember thatgiving residents individualized one-on-one time is so important forquality of life and our own job satisfaction.

Keeping the program aliveTherapeutic skin care is a daily part of the care Liberty Village pro-vides. We have reduced nursing treatment time and cost by re-ducing the occurrences of skin tears and pressure ulcers. Wecontinue to celebrate good skin. In fact, I’d like to give a “shout out”to our terrific staff that makes all the difference. “Great job!”

Lisa Bogle, RN, is director of nursing at Liberty Village of Clinton inClinton, Illinois.

Lisa Boyle, RN,inspires her residents throughpersonal touch.

Leslie Taylor,CNA, spendsextra time listen-ing to a resident’sstory while sheapplies RemedySkin RepairCream to her feet.

Lisa Bogle, RN,compliments aresident on herhandmade necklace.

Leslie Taylor,CNA, noticesimprovement asshe inspects aresident’s skin.

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 irritation.

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-

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

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

For more information about Comfort-Aire, contact your Medline representative or call us at 1-800-MEDLINE.

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Just one touch...

Extra-wide, skin-safe refastenable tape tabs

Soft cloth-like outer cover

Enhanced, super-absorbent core

Breathable side panels

44 Healthy Skin

Pain is a common symptom of end-stage illness,affecting between 70 and 90 percent of patients withadvanced cancer and large numbers of patients expe-riencing other life-threatening illnesses.1 It is a complexand individual experience, often requiring creative approachesto identify causes and seek solutions for relief.2

The concept of “total” pain was first described by hospicefounder Dame Cicely Saunders in the late 1960s, followingher extensive work with terminally ill patients in London. Totalpain encompasses physical, social, emotional, spiritual andpsychological aspects, which interact through com-plex mechanisms, resulting in each person’s uniquepain experience.2

Total pain management is increasingly viewed as the respon-sibility of the multidisciplinary healthcare team. For hospice,primary team members include nurses, certified nursingassistants (CNAs) and/or home health aides, physicians, asocial worker, a chaplain and patient care volunteers.

By M. Susan Stanek, RN

Reducing Total Pain at the


Hospice of the Western Reserve (HWR), a recognized leader in end-of-life care that serves four counties in northeastern Ohio, developeda highly effective, multidisciplinary pain management model for palliativecare that addresses total pain.1

Performance improvement mechanisms are a critical component of anypain management program, especially for hospice organizations, whichnow must comply with the new QAPI (Quality Assessment and Per-formance Improvement) regulation implemented by The Centers forMedicare & Medicaid Services (CMS). The QAPI requires hospice or-ganizations to develop a customized quality assessment and perform-ance improvement program to meet their needs. Hospice organizationsare directed to focus on high-risk, high-volume or problem-prone areaswhere quality and patient outcomes could be improved.3 Pain manage-ment is one possible area for improvement. (See story on page 51 formore details on QAPI for hospice.)

When first implementing their new pain management model, HWR set agoal of decreasing patients’ average pain intensity scores to 4 or lower(out of 10) within 24 hours of admission to hospice. After piloting the newpain management model, improvements in pain scores were evident atthree and six weeks into the program.1

The HWR pain management program incorporates threemajor steps for pain management: screening, assessmentand education.1

Pain screeningPain screening is an important mechanism that helps identify pain. Allmembers of the HWR transdisciplinary team screen for pain and docu-ment the report at every visit on a form called the transdisciplinary painflow sheet. A set of four laminated pocket-sized cards guide themthrough the screening process. The cards include a pain intensity scale,a list of analgesics, an opioid reference table and a conversion formulathat gives the accepted doses for different opioid medications.1

An RN or LPN documents screening scores. In addition to screening forphysical pain, nursing, social work, spiritual care, expressive therapy andbereavement coordinators screen for emotional and/or spiritual pain onevery patient visit.1

Emotional pain. In addition to addressing physical pain, good painmanagement seeks to alleviate the stress caused by the patient’semotional issues, such as troubled relationships and the many fearsinvolved with facing mortality.4

Patients at the end of life can achieve comfort and a sense of completionin personal relationships by talking with a social worker or counselor andaddressing the following five key points to help work through therelationship(s) causing distress. These talking points were discovered byIra Byock, MD, a longtime palliative care physician and director of pallia-tive medicine at Dartmouth-Hitchcock Medical Center:8

• “I forgive you.”• “Forgive me.”• “Thank you.”• “I love you.”• “Goodbye.”

Spiritual pain. Science continues to demonstrate a connection betweenspirituality and health. Likewise, consideration of patients’ spirituality isthought to be vital for providing quality care, especially in patients expe-riencing critical and life-threatening illness.9

The availability of a planned, formalized assessment tool that facilitatesthe gathering of objective information ensures that spiritual information willbe addressed and retained. The spiritual assessment tool should beeasy-to-use, flexible, adaptable and not time-consuming. The style andlanguage should be clear and simplistic to promote patient participation.9

Key questions to include on a spiritual assessment address the sourceof the patient’s meaning and purpose in life, where and how he derivesstrength and hope, how the patient feels about being seriously ill andwhat the patient thinks will happen as the result of his illness.9

Pain assessmentThe gold standard of pain management is pain assessment. Simply ask-ing patients about their pain is the best way to obtain this information.6

A comprehensive assessment of pain includes all the information fromthe screening, in addition to the type of pain, use of pain medications, thelevel of sedation, side effects and non-drug interventions. At HWR, thisdetailed assessment is completed by nursing whenever pain is present,

Science continues to demonstrate a connection between spirituality and health.

Treatment

46 Healthy Skin

new pain develops, an incremental increase in pain occurs, the painlevel is unacceptable to the patient or caregivers, or there is a per-ceived change in a non-verbal patient’s pain level.1

Assessing pain in non-verbal patients. Patients are not always ableto verbalize their pain, especially those with dementia. Staff membersmust learn how to assess subtle signs of pain such as acting-outbehaviors, facial grimaces or moaning.4 A comprehensive list andreview of currently published tools for assessing pain in nonverbal peopleis available at http://prc.coh.org/PAIN-NOA.htm. See also sidebar,“Principles for Assessing Pain in People with Advanced Dementia.”

At a minimum, an initial pain assessment should include the following:9

• Quality and description of pain (sharp, dull, throbbing, etc.)• Location (use a drawing of the body and ask the patient to mark the area(s) of pain)

• Intensity of pain (using a pain scale)• Frequency of pain• History of pain (when it started, when it gets worse, when it gets better)

• Effects of pain (sleep, appetite, relationships, emotions)• Satisfaction and effectiveness of current/past treatments

Pain medications. Before pain medications are prescribed, anassessment is required to determine the nature of the pain, taking intoaccount the physical, social, emotional, spiritual and psychologicalaspects. Analgesics work most effectively when all aspects of totalpain have been explored.6

Opioids are often the medication of choice for end-of-life pain. They aresafe and effective for the treatment of patients with moderate to severepain, and they have side effects that can be managed effectively.Nausea, sedation and pruritus are common temporary side effects ofopioids and usually resolve within three to five days.6

Patients and their families may delay the use of opioids fearing their useforetells imminent death, and patients may fear that opioid use early intheir care will diminish the effectiveness of such medication. It isimportant to counsel patients that this result will not be allowedto occur.6

Alternative methods for relieving pain. Alternative therapies haveproven beneficial in relieving spiritual, emotional and psychologicalpain, which can contribute to physical pain. Although expectancy andplacebo factors undoubtedly contribute to all techniques, subtle


energy factors are often evoked, which explain the demonstrated ef-fectiveness of techniques such as Reiki/therapeutic touch, acupunc-ture and homeopathy (the use of extremely dilute preparations ofnatural substances) in placebo-controlled studies.7

Reiki masters at the National Institutes of Health Palliative Care Serv-ice in Bethesda, Maryland, use Reiki (pronounced RAY-KEE) to soothepatients’ psychosocial-spiritual discomfort. They say Reiki not only ad-dresses anxiety and pain, but also the spiritual suffering that frequentlypresents as anxiety and pain. Preliminary research on biological mark-ers support Reiki’s ability to precipitate the relaxation response.10 (Seestory on page 49 for more information on Reiki.)

Educating patients and familiesInadequate pain relief is often associated with concerns about addic-tion and side effects of pain medications. Patients and their familieshave their own ideas about pain and their own reasons for not want-ing to talk about it. Some fear that worsening pain means worseningdisease.11 There is also a false, widespread belief that pain at theend of life cannot be relieved. To address these concerns, HWRdeveloped a patient education sheet that answers frequently askedpain-related questions.1

Another way to improve pain relief is to get doctors and nurses to talkto patients about pain. These conversations help patients realize theimportance of reporting when they are in pain, understanding differenttreatments for pain and expecting that pain will be relieved. Clinicalstaff can comfort patients, letting them know that their final months orhours need not be overwhelmed by pain.11

As patients and families begin to understand their right to haveadequate pain management at the end of life and the myths aboutpain management are removed, barriers to are easily broken.1

Educating staffIn a 2006 study that investigated pain management among 42 hospiceand 65 non-hospice nursing home residents, data from nurse interviewsdisclosed that staff were inadequately prepared to provide end-of-lifecare. Many of the nurses either lacked pain assessment skills or did nothave time to perform assessments.12

At HWR, staff education features orientation, life-long learning andevaluation as integral components. During general orientation, all newemployees attend a presentation, “Pain at the End of Life: Myths,Realities, and Responsibilities.” All clinical disciplines also must attenda comprehensive pain management class.1

HWR enhances life-long learning by offering advanced-level painclasses, publishing a monthly newsletter with articles on pain man-agement and sharing current literature from journals and conferencesamong staff members. Pain management competency is evaluatedannually. Staff members must complete a multiple choice test, com-ment on a case study and demonstrate hands-on clinical skills, suchas how to use an infusion pump.1

Principles for Assessing Pain in People with Advanced Dementia13

Self-report. Although self-report of pain is often possible in patientswith mild to moderate cognitive impairment, as dementia progresses,the ability to self report decreases and eventually is no longer possible.

Searches for potential causes of pain and discomfort.Considercauses of chronic pain common in older persons, such as a history ofarthritis or lower back pain. A recent fall, injury or the end-of-life illnessitself could be causing pain.

Observation of patient behaviors. Observe for recognized indica-tors of pain, such as facial expressions, vocalizations, body move-ments, changes in interpersonal interactions, changes in activity andmental status changes. Some behaviors are common and typicallyconsidered pain-related (e.g., facial grimacing, moaning, groaning, rub-bing a body part), but others are less obvious (e.g., agitation, rest-lessness, irritability, confusion, combativeness or changes in appetite).

Reporting of pain by caregivers, family or friends. The certifiednursing assistant (CNA) is a key healthcare provider who has beenshown to be effective in recognizing the presence of pain. Educationon screening for pain should be a component of all CNA training. Fam-ily members and friends are also likely to have the most familiarity withtypical pain behaviors or other changes that might suggest the pres-ence of pain.

Attempt an analgesic trial. Estimate the intensity of pain based oninformation obtained from prior assessment steps and select anappropriate analgesic.

“OUCH!”

48 Healthy Skin

SummaryAs shown here, using Hospice of the Western Reserve as an exam-ple, implementation of a transdisciplinary pain management model is achievable when all team members are willing to work together to develop and implement a plan. At minimum, such a plan should include mechanisms for pain assessment, pain screening and education. Another critical element is performance achievement measures to track and improve patient outcomes.

Note: All HWR forms and tools mentioned in this article are providedin the “Forms & Tools” section of this issue, beginning on page 74.

References

1 Hospice of the Western Reserve in: Approaches to Pain Management: An Essential Guide for

Clinical Leaders. Joint Commission Resources: Oakbrook Terrace, IL. 2003.

2 Middleton-Green L. Managing total pain at the end of life: a case study analysis. Nursing Standard,

2008:23(6);41-46.

3 Centers for Medicare and Medicaid Services (CMS). Memo to State Survey Agency Directors.

January 2, 2009. Page 50. Available at http://www.cms.hhs.gov/EOG/downloads/EO%200643.pdf.

Accessed April 20, 2009.

4 Delivering comfort and dignity: the role of hospice in pain management. Nursing Homes.

February 2005. suppl. 6-7.

5 Littlehale SB, Niemi JM, Capitosi SG. Advancing excellence in pain assessment: elements for an

effective pain management system. Long-Term Living magazine Web site. Posted December

10, 2008. Available at http://www.ltlmagazine.com. Accessed April 17, 2009.

6 Leleszi JP & Lewandowski JG. Pain management in end-of-life care. Journal of the American

Osteopathic Association. 2005;105(3):suppl 1. S6-S11.

7 Theories of Mechanism of Action for CAM Pain Management Interventions. Tufts University School

of Medicine Web site. Available at www.tufts.edu/med/ebcam/pain/theoriesMechanism.html.

Accessed April 20, 2009.

8 Byock I. Dying Well: Peace and Possibilities at the End of Life. Riverhead Books:New York, 1997.

9 Timmins F & Kelly J. Spiritual assessment in intensive and cardiac care nursing.Nursing in Critical Care.

2008;13(3):124-131.

10 Miles P. Palliative care service at the NIH includes Reiki and other mind-body modalities.

Advances. 2004;20(2):30-31.

11 Lynn J, Schuster JL, Kabcenell A. Improving Care for the End of Life: A Sourcebook for Health

Care Managers and Clinicians. Oxford University Press: New York, 2000.

12 Kayser-Jones JS, Kris AE, Miaskowski CA, et al. Hospice care in nursing homes : does it contribute

to higher quality pain management? The Gerontologist. 2006;46(3):325-333.

13 Herr K, Coyne PJ, Manworren R, et al. Pain assessment in the nonverbal patient: position statement

with clinical practice recommendations. Pain Management Nursing. 2006;7(2):44-52.

About the author

M. Susan Stanek, RN, is a communityhospice nurse for Lifetime Care inRochester, New York. She is also a level III Reiki master and owner of ConsciousHealing, a Reiki therapy practice. Stanek is currently enrolled in a BSN program and will be completing her degree in February 2010.

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No More

ReikiNurses are known to have a sixth sense, or “nurse’s intuition.” It is theability to know when to check on a patient, when to request a doctor to rechecka patient or when to make an unplanned visit to a home care patient justbecause the nurse “has a feeling.” Reiki training enhances this ability to hone inon subtle signs.1

As in nursing, Reiki therapy entails practicing the art of presence and compassion.Reiki practitioners learn to relate to patients’ core or essence, not personality, tolisten without judging patients’ actions, to be willing not to know or understandthe “whys” associated with patients’ presentation, and to let go of viewingpatients’ responses following Reiki treatment as the practitioner’s personalachievement.2

What is Reiki?Reiki is a Japanese energy therapy that promotes relaxation and healing.Similar to what some nurses know as “healing touch,” Reiki can work with anymedical therapy to decrease pain, reduce side effects and support healing. Itworks on the physical, emotional, spiritual and mental levels to balance the wholeperson.3

Reiki is based on the principle that we are alive because life force flows throughus. The life force becomes disrupted by negative thoughts or feelings, whichattach to the energy field and cause a disruption in the flow of life force. Reikihelps by flowing through the affected parts of the energy field, infusing themwith positive energy and causing the negative energy to break apart and fallaway.3

Reiki in the palliative care settingI was able to use Reiki in a medical setting when I spent a few months volun-teering with the palliative care team at a local hospital. I recorded the patients’pain level, provided Reiki, and then reassessed the patient’s pain. I cannotremember when a patient did not state some level of pain relief.

The Pain-Relieving Touch of

Reflections from hospice nurse M. Susan Stanek, RN


Treatment

50 Healthy Skin

The most remarkable experience was a gentleman who described hispain at a level of 8 out of 10 before treatment. He appeared to relax asI provided Reiki, and at the conclusion of his treatment he stated tear-fully that his pain “just floated away.” He was completely pain-free aftera 20-minute Reiki session.

Hospice nursing has been the first area in my nursing career that hasallowed me to incorporate my abilities as a Reiki master. The homehealth agency I work for offers volunteer services for hospice patientsthat include massage therapy, music therapy and Reiki therapy. Reiki isnot part of every patient’s treatment plan, but when a nurse feels that apatient may benefit from Reiki, I am asked to provide nursing care alongwith some Reiki.

Relieving physical pain – and morePain relief is a top priority for all of our hospice patients, but their pain isnot always just physical. Because Reiki treats the whole person, hospicepatients benefit from the mental, spiritual and emotional components, aswell as the physical relief. Reiki has provided many remarkable results forthe patients I have treated.

One male patient had no pain with the insertion of a foley catheter after10 minutes of Reiki to relax him. Another patient stated that he hadsome troubling mental issues to deal with before his death, and the Reikitreatments allowed him to work through the issues and find peace.

Reiki is a therapy that is requested with increasing frequency, is easy tolearn, does not require expensive equipment, and in preliminary researchhas been shown to elicit the relaxation response and help patients feelmore peaceful and experience less pain.4 With its many applications,Reiki has endless potential to assist hospice patients. Alleviating physi-cal pain is only the beginning.

References

1 Lipinski K. Enhancing nursing practice with Reiki. Reiki Web site. Available at http://www.reiki.org/

Healing/NursingandReiki.html. Accessed March 30, 2009.

2 Bossi LM, Ott MJ, DeCristofaro, S. Reiki as a clinical intervention in oncology nursing practice.

Clinical Journal of Oncology Nursing. 2008;12(3):489-494.

3 How does Reiki work? Reiki Web site. Available at http://www.reiki.org/FAQ/HOwDoesReikiWork.html.

Accessed March 30, 2009.

4 Miles P. Palliative care service at the NIH includes Reiki and other mind-body modalities.

Advances. 2004;20(2):30-31.

Where to find more information on Reikiwww.ahna.orgThe American Holistic Nurses Association offers information abouteducation, research, resources, conferences and certification forholistic nursing practice.

www.reiki.orgThe International Center for Reiki provides online access to a monthlynewsletter, articles, stories and a magazine.

www.reiki.caThe Canadian Reiki Association is a federally chartered, nationalnot-for-profit registry of Reiki practitioners and teachers.

www.reikiinhospitals.orgSponsored by the International Center for Reiki, this site lists hospitalsoffering Reiki and Reiki studies funded by the National Institutesfor Health.

www.reikiinmedicine.orgThis site is sponsored by nationally known Reiki master PamelaMiles. It includes training information, resources, articles and a monthlyReiki update.


Leaders from the top 25 hospice agencies met in Orlando,Florida, in February to participate in Medline’s first RoundtableForum for Hospice Executives. Guest presenters covered timelysubjects, including new federal rules that have the potential togreatly change the way hospice organizations conduct business.Participants learned valuable tips on preparing for these newregulations.

New hospice performance requirementsOne of the topics covered was the new quality assessmentand performance improvement (QAPI) requirement, whichplaces increased attention on how hospices perform.QAPIbuilds off the existing quality assurance requirements for hospice,which were originally introduced as part of the Balanced BudgetAct of 2005 under section 418.58.1 Hospice organizations mustfollow these rules in order to remain eligible for Medicare funding.

It’s all about the dataUnder the revised rules, hospice organizations are required togather data as a way to assess and improve quality in all aspectsof hospice care. The intent is for the data to enable hospices todevelop a clear understanding of their strengths and weaknessesin a wide variety of areas.2

At this time, QAPI is not prescribing which areas each hospicemust examine or the precise mechanisms for gathering data.Each hospice is free to decide how to implement the QAPIrequirement in a manner that reflects its own unique needs andgoals. The hospice must document evidence of its QAPI programand be able to demonstrate its operation to the Centers forMedicare & Medicaid Services (CMS).

Program requirementsHospice leaders must ensure that their organization’s QAPIprogram:2

• Reflects the complexity of the hospice and its services• Involves all hospice services• Focuses on indicators related to improved palliative outcomes

• Takes action to demonstrate improvement in hospice performance

Beginning February 2, 2009 hospices must develop, imple-ment and evaluate specific performance improvement projects.2

• The number and scope of distinct performance improvement projects are to be based on the needs of the hospice and must reflect the scope, complexity and past performance of the hospice’s services and operations. The projects are to be conducted annually.

• The hospice must document what performance improvement projects are being conducted, the reasonsfor conducting these projects and the measurableprogress on each.

First Steps for Beginning a QAPI Program1. Identify important aspects of care1

Examples:• Pain and symptom management• Use of standing orders • Delivery and setup of oxygen

2. Select measurable indicators1

Patient and family outcomesExamples:• Pain control to patient’s desired level of comfort within 24 hours

• Shortness of breath relieved to patient’s desired level of acceptance within 24 hours

• Family satisfaction with timeliness of response from hospice staff after hours

Care processesExamples:• Equipment delivery (timeliness, quality, patient education)• Timeliness of completion of interdisciplinary care plan• Timeliness of completion of initial assessment

3. Select or develop data-gathering tools1

References

1 Laff L. Weathering the Storm: Hospice Quality Assurance & Performance Improvement. Medline’s

Hospice Roundtable Forum. Presented February 22-24, 2009, Orlando, Florida.

2 Federal Register. June 5, 2008. 32193, 32207. Available at http://edocket.access.gpo.gov/2008/

pdf/08-1305.pdf. Accessed April 28, 2009.

QAPI for HospiceTracking performance as a condition for Medicare participation

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Caring for U.S. Veterans

at Missouri Veterans

Home

Waiting at the airport for a flight to see my son, I have time to people watch, one of my favoritepastimes. I watch a small group of soldiers; coffeecups in their hands, lugging heavy olive green duffels– back from deployment or maybe on their way.Their young faces and camouflage uniforms makeme think of the residents I care for each and everyday at the Missouri Veterans Home in Cape Gi-rardeau, Missouri.

I have been Director of Nursing Services there foralmost 19 years, and the men and women Iserve, all veterans from World War II, Korea orVietnam, were once young and strong like theheroes in front of me. Forty, fifty or sixty yearsago, my residents were traveling to far-offplaces answering the call for their country.

A different kind of fightIt has been a privilege for me to be part of thiscommunity of veterans. These patriots, as they areknown in our home, are again away from their homes.They are not in a foreign country fighting for our freedom,and they are no longer enjoying the freedom of good health

By Maria Hanschen, BSN, RN-BC

It’s aPrivilege

Special Feature

and living in their homes. This time they may be fighting hopelessness, helplessness and boredom in a long-termcare facility. Each day, from day one afterthey are admitted, we are dedicated tokeeping them engaged in life and withothers. Fishing, St. Louis Cardinals base-ball games, BINGO, casino trips, cook-outs, shopping and even flying kites – wefight to keep them wanting to be part oflife. They come here to live, not to die.

The amount of time they have left to live isnot my or my staff’s decision; however, thequality of life we provide for them is not only our job, it is our duty. Our passionate volunteers, who donated morethan 22,000 hours last year alone, makes it possible for

our veterans to havespecial care. Thesewonderful men andwomen read to our vet-erans, help with mail,help with outings andeven help our patriotsnot burn the marsh-mallows on the sticksat cookouts.

Quality has been a standard at this facility since I openedthe home in June 1990. Our nurses stay current with thelatest technology and evidence-based practice. I person-ally have been in long-term care since 1980, and I have al-ways felt it was my obligation to ensure that the standardsof the industry were raised to the highest level possible.I have demanded that my community of professionalsensure quality to all geriatric residents living in long-termcare facilities. I understand the importance of consistentand persistent quality care and how it enriches everyone’slives, not only the residents.

High-quality, individualized careI would never allow my staff to settle for “getting by” withcare. We always have given individualized care, even when

it was not popular in the private sector.Residents are to be bathed daily if theywish, and they can eat a sandwich anytime of day or night, if they want one.The Missouri Veterans Commissiondemands resident-focused care, andwe always have felt our residentsearned the best we could offer them.

Not everyone is fully prepared for thepersonal attention I expect and striveto foster between my staff and our res-idents. Many will tell stories of my get-ting upset when a resident is served a

cold tray that was supposed to be warm. I have askedmany new employees, “Would you want your father tohave cold food? Then why would you want some else’s father to have cold food?”

Adjustment to our home and to our quality is not alwayseasy for new staff. Many of them learned bad habits inother places, and here, well, you are just expected to dothe right thing for these men and women who put every-thing in their lives on the back burner to protect us. Ourresidents are not placed in pajamas before dinner. They aredressed as they wish to be dressed, most often, appropri-

I never could allow my staff to settle for“getting by” with care.We always have givenindividualized care,even when it was not popular in the private sector.

Maria Hanschen with a “patriot.”

Generations of heroism.


ately for dinner, just asthey did when theylived at home.

Our residents are en-couraged to stay upafter supper. We donot want anyone laiddown for bed until areasonable time un-less they have major

health issues, or they have requested it. It is so muchbetter for them to enjoy BINGO, television, cards or what-ever the activity might be that evening, versus lying in bedin a darkened room.

I often have been asked if there are any special, uniquethings we do to honor our veterans. The most emotionaland special thing we do is celebrate our patriots’ lives witha “Hero’s Homecoming” when they die. We decided yearsago that our residents come to us through the front door,and they should leave through the front door as well.

“A Hero’s Homecoming”When one of our residents passes away, we announceover the intercom, “There will be a Hero’s Homecoming for-------- in five minutes.” Staff, visitors and residents line the halls to honor the resident who has died. Tapsis played, and the residents stand at attention and say amilitary prayer. The family is given the patriotic quilt thatcovers the body as it passes through the halls to the frontdoor. It is a very moving experience, even if you do notknow the resident. Families can see that their husband, orfather or sister or uncle or grandma was loved and honored.

I have so many special memories of the past men andwomen I helped care for. Most of them became dear to myheart. As a nurse and a manager, I understand the diseaseprocess and its effects on our bodies and that we all willdie. Still, I have cried a few tears for many of them whenthey departed this world. It is hard to love someone as afriend and not miss them when they leave.

A choice and a privilegeAs I look up, I notice the last of the soldiers boarding theirplane. A sense of pride comes over me, yet I am not sureexactly why. Am I proud of these men and women who are

flying to some distantreaches of the world toprotect my freedom?Am I proud of the factthat I am part of acommunity providingexcellent care to veter-ans of times past? Irealize “yes” is my an-swer to both questionsas I walk down the jet

bridge to my plane. However, as I take one last look at thecamouflage and laughing faces, I realize the true answer. Iam proud that, like them, duty is expected, but service isa choice, and exceptional service is a privilege.

Maria Hanschen, BSN, RN-BC, is direc-tor of nursing services for the Missouri Vet-erans Home in Cape Girardeau, Missouri.

Dancing with a U.S. veteran.

Sharing war stories.

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Let’s start with a scene from the movie you may rememberfrom almost 20 years ago, “Other People's Money.” GregoryPeck, as the beleaguered president of New England Wire and Cable,is making an impassioned plea to the stockholders to save the com-pany, the plant and the jobs. Danny DeVito, playing LawrenceGarfield (a.k.a. Larry The Liquidator), speaking for the stockholders,says that it’s not that New England Wire and Cable makes a badproduct or provides poor service; in fact, just the opposite. However,the market demands fiber optics. As it turns out, the female leadcomes up with an idea to retool the plant to make the wire meshused in the manufacturing of automobile airbags, then sell the wiremesh to the Japanese. The plant is saved, the jobs are secure andeveryone lives happily ever after.

The moral of this story is clear. Adaptation or evolution has been keyto the survival of American industry. However, this same story couldhave taken place in a medical facility where market demands are call-

ing for another “evolutionary” change: testing closer to the patient. I have clearly stretched this analogy to make a point. The manufac-turers of point-of–care testing (POC) kits and instrumentation knowthat near-patient testing will never replace a visit to the doctor in thesame way that fiber optics replaced wire cable. Rather, point-of-careshould be an addition to the current method of managing patients.It meets the market demands to improve the care of an agingpopulation.

Is the addition of point-of-care testing evolutionary or revolutionary?In order to answer the question, let's first look at forces driving thistrend. For example, why are demands for testing closer to the patientsuddenly on the rise?

To begin with, there are two forces that are accelerating this trend: Anincrease in outpatient care and an increase in the acuity of illness ofthe inpatient population. Attending physicians, therefore, need

By David L. Phillips

Point-of-Care TestingEvolution or Revolution?

Special Feature

58 Healthy Skin

quicker results to make critical diagnostic and therapeuticdecisions. But in addition to being rapid, these results must beaccurate and reliable to provide any real benefit.

A new generation of POC testingIn the last decade, a new generation of reliable point-of-care test-ing systems has provided a way to fulfill this need, further drivingthe trend toward patient-side testing. By combining convenienceand fast turnaround time with the reliability of laboratory testing,these new testing systems can prevent unnecessary delays in crit-ical therapeutic decisions or provide more convenient patient man-agement methods for both the healthcare provider and the patient.

This new generation of systems combines precision engineeringwith integrated reagents, therefore minimizing operator interven-tion and making laboratory-quality information available to virtuallyany healthcare provider anywhere. Many of these systems are self-calibrating and have onboard comprehensive self-diagnostics aswell as integrated quality controls to eliminate believable but erro-neous results that could harm the patient.

Taken together, accurate, reliable and rapid results can directlyimprove the care of any patient, especially those with a chroniccondition that needs routine and reliable information.

Clearly, the implementation of point-of-care testing raises issuesabout accuracy, precision, reliability and cost. Is the test resultaccurate? Are the testers proficient? How will POC testing fit intothe requirements of CLIA?

The products that are considered to be point-of-care tests haveproliferated over the last 20 years since the CLIA ’88 regulationswere developed. In the beginning, there were only a handful of tests– approximately 7 – that met the requirement to be considered“waived” tests. Today, in 2009, there are literally hundreds thatmeet the waived test standards.

These tests cover many conditions that need routine monitoring orscreening. The list includes but is not limited to: glucose, PT/INR,cholesterol and lipid screening, cardiac markers, infectious dis-eases such as flu and strep throat, HCG for pregnancy, HIV, fecaloccult blood and drugs of abuse.

Commitment, communication and cooperationWhen implementing a point-of-care program in any institution, it isimportant to incorporate three very non-technical ingredients: com-mitment, communication and cooperation. By combining these

measures with the required technical standards for quality control,any program should realize gains in patient management andorganizational efficiencies very quickly.

No matter what strategy is implemented, and no matter to whatdegree any of the point-of-care tests are adopted, certain key fac-tors should be addressed. These are listed in the checklist below,organized into key areas of focus.

Key Factors to Consider When Choosing a Point-Of-Care Testing Device

Instrument Verification and Maintenance • Performance of initial validation studies: correlation, accuracy and precision.

• Maintenance of records for each instrument, including preventive maintenance, cleaning, storage, troubleshooting and calibration.

Reagent Verification and Maintenance • Designation of reagent supplies purchaser. • Maintenance and control of reagent supply ensuring properstorage and expiration dates.

• Maintenance of reagent supply performance records.

Training Program • Designation of users. • Development of initial user training program and certification tests.

• Development of continuing education activities and recertification tests.

• Maintenance of user training records.

Other Documentation • Development of written standard operating procedures for the central laboratory and near-patient testing site.

• Development of documentation procedure for patient results.

• Development of procedure for the proper disposal of infectious waste.

• Documentation of compliance with other standard safety procedures.

So, is the continuing trend toward point-of-care testing evolution-ary or revolutionary for healthcare providers? Their adoption ofpoint-of-care testing will not only improve the delivery of necessary


diagnostics, but it can have a very positive impact on the future oftesting as well. Today, healthcare delivery is in a position to broadenits product and service offering. And now more than ever, the lab-oratory can be moved to the patient’s side for a larger number oftests. Moreover, in many instances, the patient actually canbecome part of the healthcare team.

Decentralization of healthcare servicesIf we continue the analogy between American industry and healthcare, decentralization of healthcare services is no different fromwhat has already occurred in several American industries. Forexample, it is not unlike the decentralization of information we haveexperienced in the computer industry. The personal computer hascome close to replacing the central processing unit (CPU) but nottotally. It has enhanced and improved the processing of vital datathat can be used more efficiently, because it is immediate and pres-ent with the individual most in need of the information.

Perhaps an even better analogy is the railroad business. In the1940s and '50s, railroad executives were determined to providethe best rail service possible. If you asked them what business theywere in, they proudly responded, “the railroad business.” Had theyinstead responded, “the transportation business,” they would haveknown about and prepared for a market demand that required afaster and more flexible means of transportation. Instead of a com-petitor, air travel probably would be another product offering. Sim-ilarly, healthcare providers are not exclusively in the diagnostictesting business, but rather in the patient care business. As such,there will be times when centralized laboratory testing will not bethe best solution for optimizing patient care.

Putting patients firstSo, if we are “stockholders” like Larry the Liquidator, we look to thehealthcare industry to adapt and evolve. As many physicians state,“If we are honest about making patient care our primary concern,we will welcome the arrival of new, reliable point-of-care testingsystems.” No matter how much we reduce the dwell time of aprocess in the laboratory, there are other components, includingtransporting the sample, or even the patient, to a testing facility.These remain limiting factors.

Healthcare providers must recognize that there are times when theneeds of the patient are best met by a system at the patient’s sideand not at the doctor’s office.

Finally, is the trend toward point-of-care testing evolutionary or rev-olutionary? I believe it is clearly an evolutionary change where thedecentralization of laboratory testing is an “extension” of labora-tory services, not a replacement. And like a surprise ending to astory, the outcome for healthcare providers could be a Hollywoodfinish, where the real winner in all of this is the elderly or chronicallyill patient.

David Phillips is vice president of marketing for Inverness Medical.

Meet Ace Combat Nurse Ace is a tribute to the thousands of real-lifehealthcare heroes serving in the U.S. military.

Turn to page 53 for a story about U.S. veterans fromWorld War II, Korean War and Vietnam War, who areresidents at the Missouri Veterans Home in CapeGirardeau, Missouri.

Contact your Medline sales representative to learn more about Ace Combat Nurse.

Keep Your Job

During Tough

Times

60 Healthy Skin

Keep Your Job

During Tough

Times

by Wolf J. Rinke, PhD, RD, CSP

Given the topic I feel compelled to start with a caveat. Yes,times are tough—even for many in health care. But they are notnearly as disastrous as the media wants you to believe. Here iswhat the media keeps telling us: “Unemployment is like weʼvenever seen before and no one is hiring.” Really? Here are thefacts: The current unemployment rate of 7.2% is bad, but,according to the Bureau of Labor Statistics, it has occurred nineprevious times in the United States since 1948. In 1982 it wasat 10.8%. (That means, on average our current level of unem-ployment has occurred about every six years.) So, yes itʼs bad,but certainly not unusual. The media may also have convincedyou that no one his hiring. Really? The fact, according to theFeb. 2, 2009 issue of Fortune magazine, 72 of the 100 BestCompanies to Work for (72%) are currently hiring, and each hasat least 50 open positions. By the way, of the 100 Best, 11 arehealthcare organizations, and of those, eight (~73%) arecurrently hiring. The moral of the story: donʼt let the media con-trol how you feel. Cut what they tell you in about half, and youmay be somewhat close to reality. Having said all that, the factremains that many people are fearful of losing their job. Here iswhat to do to make sure that does not happen to you.

Be visibleNo one likes to fire people. So when it comes time for layoffsyour boss will likely take the path of least resistance by select-ing people “who are never around.” So be visible. Show up earlyand leave late, attend critical meetings with important people,let the “powers-that-be” know what you are working on, andmake every effort to get to know your boss really well, includinghaving lunch with her at least once a month. It also means thatyou avoid telecommuting even if it is offered to you, and if youare currently doing it, change it—because Woody Allen wascorrect: “80 percent of success is just showing up.”

Donʼt be a “squeaky wheel”Several of my clients are actually doing pretty well (believe itor not), and yet they are selectively laying people off. Why?Because the bad economy is a good excuse to get rid of peoplewho are “squeaky wheels,” high maintenance, troublemakers,or whiners or who exhibit persistent negative attitudes or donʼtcontribute to the bottom line.


Caring for Yourself

62 Healthy Skin

Solve problemsIn this tough economy, you can no longer expect to becompensated for time, only for results and problemssolved. So actively look for a problem, focus on one thatimpacts negatively on the bottom line, put a team togetherand solve it. Then, let others know (especially the powers-that-be) what a great job you and your team did and howmuch your team improved the profitability of your organi-zation. Yes, do give your credit away even in tough times,and be sure not to brag—your boss will figure out that youare the leader of the team. By the way, keeping your bossin the loop of your accomplishments is not bragging, itʼs asmart thing to do during tough times.

Do things your boss does not like to doLetʼs face it. We all have strengths and weaknesses. Itʼsa fact that the things we really like to do (our strengths)always get done. The things that represent our weak-nesses somehow get pushed off to tomorrowʼs “to-do list”or donʼt get done at all. To make yourself indispensable,figure out what your boss does not like to do and do moreof it. Consistently executing this strategy is one of yourbest insurance policies against getting laid off. It may evenget you promoted – even during tough times.

Make your boss feel goodBelieve it or not your boss, just like most people, likes tofeel good. However, the higher you are up the organiza-tional ladder the more crap you catch. So make it a pointto let your boss talk about herself—the more she does, themore you can find out what is important to her, whichmakes it easy to exceed her expectations. Also be sure tocatch your boss doing something right, or to find anythingpositive to say to your boss whenever you accidentally—

on purpose—, run into her. (If you donʼt know what to say,that just means you donʼt know your boss well enough.)And while you are at it, be sure to do the same for yourteam members and colleagues. If you find it difficult tocatch others doing something right and making that payoff for you, devour my Winning Management book or CDalbum, http://www.wolfrinke.com/WMprod.html.

Act as if you own the placeUse this technique any time you are confronted with aquestion, challenge or problem. For example, you feel likegoing home early, buying a new piece of equipment orasking for an assistant. Say to yourself, “Given the currenteconomic climate, what would I do if this were mycompany?” Then act accordingly.

Go beyond the expectedIt may seem obvious, but people who deliver more thanexpected typically are the last to go. So make it your num-ber one priority to be the best at what you do by reading,studying and engaging in continuing education, trainingand development. And if your employer is no longer will-ing to pay for it, then pay for it yourself! You canʼt afford it?I maintain that in these tough times you canʼt afford not toinvest in the most important resource you own—yourself!I wear an attractive 111 percent pin in my lapel that drivesthis concept home. Here is what the card that comes withthe pins says:

Give 100% and youʼll survive.Give 110% and youʼll thrive.Give 111% and you will MAKE It a WINNING Life!!!

Fake it till you make itNo matter how tough things are for you right now, chooseto exhibit a positive, can-do attitude. Letʼs face it, no onelikes to hang out with negative “stinking thinking” people.So when it is time for people to go, guess who gets theirmarching orders early? No matter how tough things get,remember your attitude is always your choice. So chooseto always—yes I do mean always—exhibit a positive atti-tude. Because if you do it consistently, your subconsciouswill internalize it and cause you to “act” accordingly. If youwould like help with this, get yourself a copy of my “PositiveAttitude” CD or DVD at http://www.wolfrinke.com/MIWL.html, or devour my “Beat the Blues” CPE course athttp://www.wolfrinke.com/CEFILES/cepd.html#C178.


ing all senior level meetings you get invited to, reviewingyour corporate Web site at least once a week, and settinga Google alert for your company so you have a bettersense when layoffs are imminent.

If all else fails—donʼt panic—negotiateSo what do you do when your boss tells you that he hasto let you go? Whatever you do, donʼt panic and donʼt getangry. (It is very likely that he does not like this any morethan you do.) First find out why. If the answer is to savemoney, offer to work a reduced work week or maybe evenfor less pay – provided it is for a specified time. If that doesnot work, negotiate for a substantial severance package.(Believe it or not, you are negotiating from a position ofstrength because your employer does not want to be suedfor wrongful termination.) So negotiate for the fattest pack-age you can get away with. And donʼt be timid. (After allwhat are they going to do, fire you?) To help you withthis, devour my Win-Win Negotiation CPE program,http://www.wolfrinke.com/CEFILES/cepd.html#C184.

Dr. Wolf J. Rinke, RD, CSP is a keynotespeaker, seminar leader, management con-sultant, executive coach and editor of thefree electronic newsletters Make It a WinningLife and The Winning Manager. To subscribego to www.WolfRinke.com. He is the authorof numerous books, CDs and DVDs includingWinning Management: 6 Fail-Safe Strate-gies for Building High-Performance Organi-

zations and Donʼt Oil the Squeaky Wheel and 19 OtherContrarian Ways to Improve Your Leadership Effectivenessavailable at www.WolfRinke.com. His company alsoproduces a wide variety of quality pre-approved continuingprofessional education (CPE) self-study courses available atwww.easyCPEcredits.com. Reach him at [email protected].

Do a self assessmentPretend that you are an entrepreneur or a consultant whois selling services to a client (your employer). To make thisrealistic, compute your daily compensation. Be sure to addyour benefits. If you are not sure how much that is, add30%. Then get in the habit of asking yourself: “Have I cre-ated value today that exceeded my daily compensation?”Repeat that question every day you are at work. You mayeven find it helpful to place a nice looking sign on yourdesk that says: “Have you created $_____ of valuetoday?” Consistently saying “yes” to that question will dra-matically increase the probability that you keep your job.

Say good things about others or say nothing at allEven though just about everyone seems to like tocomplain about something or someone—donʼt be likeeveryone else. Be the exception. Donʼt gossip, whine,complain, or say anything bad about other people, yourboss or your company. Right along with that, avoid officepolitics like the plague. And by all means, distance yourselffrom people who engage in any of these counter-produc-tive behaviors.

Become an expert networkerNo matter what you do, there is still a chance that you willbe laid off. It simply is a sign of the times and it has noth-ing to do with you. And when that happens, your network,more than anything else, will determine how fast you willfind your next dream job. To test your networking effec-tiveness, ask yourself who you have been eating lunchwith during the past week. If it is pretty much the samepeople, you are missing tremendous networking opportu-nities—opportunities that you wonʼt be able to bring back.So start today to get in the habit of eating lunch withdifferent people four out of five days a week. Sit withpeople you do not know at meetings and attend confer-ences that are sponsored by groups you donʼt normallyhang out with. Plus, make sure you take advantage ofelectronic marketing techniques and viral technologiessuch as LinkedIn (https://www.linkedin.com) or Facebook(http://www.facebook.com). Heck, itʼs working for Presi-dent Obama. Why shouldnʼt it work for you?

Keep your finger on the company pulseMake it your business to know what is going on in yourcompany or organization. You can achieve that by attend-

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on her office door reads “BEWARE THESTING OF AN ELLERBEE.” Itʼs a testamentto the passion, insightfulness and dogged-ness she brings to her stories.

So itʼs not surprising that Ellerbee has spokenand written extensively about her cancer experience, stressing the need for laughter, encouragement and appreciation for life.Breast cancer, despite being second only tolung cancer as a cause of cancer death inwomen, still abounds with myths and misinfor-mation. In other words, itʼs a prime target forthe sting of the Ellerbee.

Ellerbeeʼs story starts with her finding a lumpin her breast while showering. She informedher doctor, noting that it was painful, to whichhe replied, “Thank goodness. It canʼt be cancer if it hurts.” His response put her at easeuntil six months later when, serendipitously, afriend invited her to speak at an event aimed at

raising money for breast cancer research and awareness.

“I told her Iʼd be happy to do so but I didnʼt know anythingabout it,” she remembers. “I had never had it. No one inmy family had ever had it. I never covered a story aboutit.” In doing research for the speech, however, she discovered that what her doctor had told her was actuallya common myth. “Itʼs now one of the first things I say whenI speak about breast cancer,” she says. “If you have a lumpand it hurts, itʼs your body trying to tell you something.Go to a doctor.”

So, in February of 1992, she saw a cancer specialist, whofound cancer in one breast and a precancerous condition

By Jerreau Beaudoin

She has often been described as the smart, gutsy,outspoken journalist who helped pioneer networktelevision news in the ʼ70s and ʼ80s. But if anything,Linda Ellerbee, the award-winning television producer,best-selling author, breast cancer survivor, mother andgrandmother, is a storyteller.

To say she can tell a good story is an understatement –she has received just about every major television awardthere is, including (so far) three Peabody Awards, twoduPont Columbia Awards and eight Emmys. Her direct,no-nonsense and witty style is uniquely identifiable. A sign

Breast cancer survivor Linda Ellerbee spokeMarch 16 at Medline Industriesʼ Third AnnualBreast Cancer Awareness Breakfast at the 2009 AORN Congress in Chicago.

Special Feature


‘Bee Stories:Linda Ellerbee continues toraise awareness – and noise –about breast cancer.

Phot

o by

Rolf

e Te

ssem

66 Healthy Skin

in the other. When she first got news of the cancer, shewas devastated and remembers feeling like she had gone“into some out-of-body state. I could not believe I couldpossibly have cancer.”

Ellerbee started reading everything she could find aboutthe disease, piling books on her desk and pumping every-body who knew anything about cancer forinformation. “I wanted to be an informedpartner in my treatment,” she said. “I wasnot 14. I did have a brain. And I didnʼt seeany good reason why my brain shouldnʼt beput to good use too.”

The decision to have a double mastectomywas hers. When Larry King asked herabout it in a CNN interview, she straightfor-wardly replied, “Nobody wants to die andno woman really wants to lose her breast,but considering I am still on the right side ofthe grass, my breasts seemed to be, frankly, a small priceto pay.” She says she can laugh about it today, adding,“The good news is that I lived. I lost all my hair and both mybreasts. My hair grew back – my breasts did not.”

Ellerbee says unequivocally that there is nothing about herbreast cancer story that she isnʼt willing to talk about. Shetold Coping magazine that she loves it when women spon-taneously share their cancer experiences with her. “I donʼtknow if it is therapeutic for me to talk about it, but I do feel thatit is necessary. As long as we whisper, nothing gets done.”

Not that anyone has ever accused Ellerbee of beinga whisperer.

Ellerbee began her career at CBS in 1972 and then movedto NBC News, gaining fame for her stints as the networkʼsWashington correspondent and as a reporter on The TodayShow. She anchored the short-lived “Weekend,” and a cou-ple of years later the late-night news program “NBC NewsOvernight,” which has been cited by the duPont ColumbiaAwards as “the best-written and most intelligent news pro-

gram ever.” Her style of mixing humor andwit, employed today by popular reporterssuch as Keith Olbermann and Rachel Mad-dow, attracted a diverse and dedicatedfollowing of viewers, particularly collegestudents. “If the Nielsens had rated col-leges,” she says, “we would probably stillbe on the air.”

Her stories covered everything from poli-tics to pop culture, often in an offbeat way,helping to cement her reputation as a mav-erick newswoman before she left to form

Lucky Duck Productions in 1987. Her experience becamea best-selling book, And So It Goes: Adventures in Televisionand supplied inspiration for one of the all-time classicsitcoms – “ Murphy Brown.”

“Executive producer of ̒ Murphy Brown,ʼ Diane English, toldme that she wanted to do a series with Candice Bergenabout an anchorwoman whose mouth always got her intotrouble, and could they follow me for a couple of months?”Ellerbee told PopEntertainment.com in an interview. “Ananchorwoman whose mouth always gets her into trouble?Whatʼs not to like?”

“Murphy Brown” was so successful that after winning herfifth Emmy – the character was nominated for the award

“OVERNIGHT” SENSATION: The television executive whocancelled the critically acclaimed “NBC News Overnight” said “sometimes being the best isnʼt good enough.”

“I don’t know if it istherapeutic for me to talk about it, but I do feel that it is

necessary. As long as we whisper,

nothing gets done.”


seven times and won five – Bergen declined future nomi-nations for the role. Ellerbee even guest-starred as her-self in a 1989 episode, in which it was revealed that shehad been Murphyʼs main competition for the fictionalshowʼs anchor job. In a memorable scene, Murphy claimsEllerbee stole the catchphrase “And so it goes...” from herafter they had shared a flight.

The showʼs final season would feature apoignant art-imitating-life twist: a year-longstory arc in which Murphy battled breastcancer. The showʼs handling of the subjectwas credited with a 30 percent increase inthe number of women getting mammo-grams, but the storyline was not withoutcontroversy. Conservative groups attackedan episode in which she used medical mar-ijuana to relieve side effects of chemother-apy, and a womenʼs health group protestedan episode in which Murphy, while shop-ping for prosthetic breasts, uttered the line“Should I go with Demi Moore or Elsiethe Cow?”

Cancer and comedy seem like strangebedfellows, but Ellerbee insists that if women are open toit, they will find laughter in the experience. Take, for exam-ple, one of her own experiences with prosthetics, whichshe wrote about in McCallʼs:

“I bought some breast prostheses to use while swimming,but instead of fastening them to my skin with Velcro as thedirections instructed, I simply inserted the prostheses intomy bathing suit. When I came out of the water, one hadmigrated around to my back. Now, how can you not laugh

at such a thing? Either you laugh or you cry your eyes out.”Ellerbee continued to work while she received her cancertreatments – just four days after her surgery, she was sit-ting on a step doing a Nickelodeon special on AIDS fea-turing Magic Johnson (which would later garner a CableACE award for best news program). The chemotherapy lefther nauseated and exhausted, but memories of two little

girls from the special stick out in her mind.

The first involved a little girl sitting behindher who, out of nervousness, swung herfoot into her back at breast height through-out the entire two-hour show. “I still hadsurgical drains under my arms, underneathmy sleeves in my shirt at that point. Itʼsfunny now,” she chuckles, “but at the time...”

The other pertained to little girl namedHydeia Broadbent, who had HIV and wasstruggling to talk about how she felt. Finally,prompted by Johnson, she said in a break-ing voice as she began to weep: “I wantpeople to know that weʼre normal people.”That moment, says Ellerbee, is “one of theways the world has of kick starting you to

start smelling the flowers again.”

“Any life-threatening disease changes you. It takes yourillusions of immortality, which we tend to live with for aslong as possible. It does remind you to stop and smell theflowers. Iʼm 17 years out after breast cancer. I have to becareful because unless I consciously stop and think, I willstart rushing so fast that Iʼll go, ʻWhoops, there goesanother flower.ʼ I have to remind myself again that Iʼm notgoing to be around forever.”

REALITY TELEVISION: Blurring the line between fiction and reality, Ellerbee guest-starred as herself with CandiceBergen on a 1989 episode of “Murphy Brown.”

“I have to be carefulbecause unless Iconsciously stop

and think, I will startrushing so fast that

I’ll go, ‘Whoops,there goes anotherflower.’ I have to

remind myself againthat I’m not going tobe around forever.”

While Ellerbee never missed a day of work during her treat-ment, she admits that owning Lucky Duck Productions,which has produced programs for every major cable net-work and has as its flagship program the childrenʼs newsprogram “Nick News,” played a factor in that. “I had a sofain my office and I could shut the door and lie down for 20minutes if it got too bad. Some days I just felt awful. At onepoint I came to judge New York cab driversby their reaction to my words ʻCan you pullover to the side of the road, please – I amgoing to throw up.ʼ Some assumed that Iwas drunk, but others caught on that I wassick and would run into a deli and comeback with paper towels and other thingsfor me.”

While going through chemotherapy, Eller-bee rarely saw her doctor, noting insteadthat “it was a six-month relationship with mynurse.” She has a fond appreciation for therole nurses play in patient care. “ORnurses, in particular, will have a special place in heaven,”she said, “Because one, they have to put up with arrogantdoctors, and two, often the person being operated on doesnʼteven know of their existence, or meets them only in aconfused and dazed state. And almost never do any of usremember to say thank you.”

From an emotional perspective, however, the best helpEllerbee says she received was from other women whohave had cancer. When her story became public, she sayswomen began stopping her on the street and writing her toshare their own experiences. According to Ellerbee, “theletters and the hugs in the airport gave me encouragementthat neither my family, friends or healthcare workers were

able to. I consider that a major component of my healing.”They also gave her something else that was crucial –permission to laugh in the face of a life-threatening disease.

“All of a sudden I belonged to the worldʼs biggest supportgroup,” she says. “Women still come up to me and whisper,ʻIʼm in the club,ʼ or theyʼll say straight out, ʻIʼve had breast

cancer.ʼ When it comes to the people whoreally made a difference in my recovery,they are at the top of the list, followed bymy family and friends. After that would benurses, and then doctors and other health-care workers.”

She pauses for a moment and then drylyadds, “And I suppose way at the bottomsomewhere I would have to put my HMO.”

Ellerbee built her reputation on just suchdirect commentary, and she uses it whenspeaking to women, telling them, “Look at

me, Iʼm alive! And you know why? I told my doctor about alump and ignored him when he said it was nothing. I didmy research and decided, ʻTo hell with what the worldexpects from my body. Iʼm having a bilateral mastectomy,and Iʼll still be a woman.ʼ”

The intent is to send a message that you can live throughcancer and have a life, even while undergoing treatments.But for many breast cancer survivors, Ellerbee says, thehardest thing of all is when the treatments end. “When youare finally taking no treatment of any kind for breast cancer,there is a part of you that gets very frightened, becauseyou donʼt feel as if you are doing something proactive tofight the return of the cancer.”

KIDS SAY THE DARNEDEST THINGS: In 1991, Ellerbeebegan producing, writing and hosting “Nick News.” Known for the respectful and direct way it speaks to children aboutthe important issues of our time, the show has won fourEmmy Awards.

“All of a sudden I belonged to theworld’s biggest support group,”

she says. “Womenstill come up to meand whisper, ‘I’m in

the club ...’ ”

68 Healthy Skin

Continued on page 70

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70 Healthy Skin

In her case, Ellerbee had six months of chemotherapy, fol-lowed by five years of Tamoxifen. “As happy as you arethat treatment is over, thereʼs also this little worry that if I amnot taking this little pill, or shooting this stuff inside me, wellthen what am I doing to fight this cancer? You feel sort ofout there, all alone and unprotected.” Another thing she

wished someone had told her about wasthe ongoing effects of chemotherapy. “Ithink I thought that when chemo ended Iʼdbe the way I used to be the next weekend.No one told me that the side effects wouldstay with me for another six months.”

And so, 17 years after her diagnosis, thespitfire from Texas continues to tell womento not only laugh in the face of breast cancer,but fight for better medical treatments aswell. Itʼs important to remind women whoowns the disease, she said. “Itʼs not thedoctor, the hospital or the HMO; itʼs not

your friends or family. You own it. You have a right to knoweverything and to have a say in what your treatment will be.”

Clearly, breast cancer hasnʼt taken the fight out of Ellerbee.If anything, itʼs made her louder because, in her words, “itwas not talked about for so many years. I talk about it be-cause I am a woman, and because I have a daughter anda granddaughter. I talk about it because we donʼt have acure. And I will keep on talking about it until we do.”

Then, without missing a beat, she adds, “I am from theʼ60s, you know – I like a little noise.”

SOUL SURVIVOR: In 2000, Ellerbee becamethe first person to be inaugurated into theCancer Survivors Hall of Fame.

“There is a part ofyou that gets very

frightened, becauseyou don’t feel as if you are doing

something proactiveto fight the return

of the cancer.”

As the bariatric population of the country grows, the likeli-

hood that you will have more obese patients admitted to your

facility increases. But bariatric patients can’t use patient aids

designed for smaller people. You want to give bariatric pa-

tients the freedom to move around, not forced to stay in bed

because he or she didn’t have a wheelchair or walking aid to

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equipment not rated for bariatric use.

Medline has a complete line of bariatric patient aids, including:

• Wheelchairs (up to 700 lb capacity)

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Call your Medline rep or go to www.medline.com tofind out more. And check out Medline’s other bariatricproducts, including patient lifts, pressure-reducingmattresses, briefs, furniture and more.

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Residents come in allshapes and sizes.


72 Healthy Skin

Bangers and Mash with Golden Onions (8 servings)

Healthy Eating

• 8 large potatoes• 3/4 cup milk• Salt, to taste• Freshly ground pepper, to taste• Fresh rosemary• Fresh thyme• 3 tablespoons olive oil• 21/2 tablespoons butter• 2 onions, finely sliced• 6 garlic cloves, finely chopped• 12 smoked pork and/or

beef sausages• 1 cup beer• Worcestershire sauce• Whole grain mustard• Sauce thickener, such as

corn starch or flour

Peel and dice the potatoes into even pieces. Cook in lightlysalted water until tender. Drain well.

Bring the milk to a boil. Begin mashing the potatoes, graduallyadding the hot milk and butter, to taste. Season to taste andset aside. Finely chop the fresh rosemary and thyme andadd to the mashed potatoes.

Heat the oil and butter in a large non-stick pan and sautéthe onions and garlic until they are slightly soft.

Heat the oven to 350 degrees.

Using the same pan as the onions and garlic, pan fry thesausages until they are browned all over. Add the beer,Worcestershire sauce and mustard to taste. Add saucethickener until you reach the desired consistency.

Place pan in the oven and cook for 30 minutes, turning thesausage after 15 minutes.

Place mashed potatoes on a platter and top with thesausages and sauce.

This recipe, created by Medline employee Maria M. Rodriguez,won the Gold Medal at Medlineʼs International Cook Off duringEmployee Appreciation Week in 2008. The award qualified Mariato compete further in Medlineʼs Master Chef contest, where shewon the Grand Prize.

In addition to being Medlineʼs Master Chef, Maria works in thehuman resources department processing all employee-relateddata. Sheʼs enjoyed cooking from a young age, picking up tips andtechniques watching her parents and grandparents create authenticMexican specialties.

“Cooking is huge in our family,” she said. “We use lots of freshherbs, and Iʼm always recording and watching cooking shows ontelevision to learn new ideas.”

Maria developed her bangers and mash recipe, a traditional Britishdish, by reviewing several different recipes and combining differentingredients from each.

Nutritional Information Servings: 8

Amount per servingCalories: 429Total fat: 26.1 gSodium: 809 mgFiber: 3.3 g


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

FORMS & TOOLS

Pain Transdisciplinary Pain Flow Sheet ....................74Pain Assessment Cards ....................................76Patient and Family Education ............................78Pain Algorithm ....................................................80

DiabetesTaking Care of Type 2 DiabetesEnglish ..............................................................84Spanish ..............................................................86

HOSPICE OF THEWESTERN RESERVE, INC.

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74 Healthy Skin

Forms & Tools Transdiciplinary Pain Flow Sheet

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

www.medline.com

A Strong Hold Has Never Felt

This Gentle

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being gentle on fragile skin. Your patients will love how it helps

take the pain out of dressing changes, and you’ll appreciate

how Gentac can easily be repositioned. It adheres securely again

and again!

Gentac can be used to secure everything from primary

and secondary dressings to gastronomy and other feeding

tubes. It can be cut to the perfect size and is easy to

apply. Gentac is waterproof and may be left in place

for up to a week!

To learn more about Gentac and the complete Medline family of wound care products, contact your sales representative, call 1-800-MEDLINE or visit us at www.medline.com.

76 Healthy Skin

Pain Assessment Cards for Hospice CareDeveloped by Hospice of the Western Reserve

PAIN

Possible Causes:- Disease Progression - Psychosocial- Disease Treatment - Spiritual- Co-Morbid Disease - Emotional

Assessment Will Occur:- Every visit or contact - Level unacceptable to patient- New Pain - Perceived change in the non-verbal - Increase in existing pain patient’s behavior

Essential Components of a Pain Assessment- Location: Where is the pain? Can it be identified? Does it radiate?- Quality: What does it feel like?

Visceral – dull, gnawing, throbbing, poorly localizedSomatic – aching, sharp, well localizedNeuropathic – shock-like, burning, shooting, lancinating

- Intensity: What is the rating on a 0-10 scale, with 0 being no pain and 10 being the worst you can imagine?- Onset: Did it begin suddenly or gradually?- Temporal Pattern: Does is it come and go? Is it only at night?- Alleviating Factors: What makes it worse?- Associated Symptoms: Are you experiencing any nausea, vomiting, diarrhea, constipation, weakness, appetite or sleep disturbance?

- Previous Interventions: What has been tried in the past to manage the pain?- Effect on quality of life: Does it interfere with your ability to do the activities that are meaningful to you?- Goals for Pain Control: What pain score would be acceptable to you?

Non-Pharmacological Interventions- Active listening/Empathy/Presence - Exercise- Heat/Cold applications - Massage- Positioning - Energy-based therapy - Relaxation techniques (Healing Touch, Therapeutic Touch, Reiki)- Visualization - Expressive therapies (art and music)- Guided imagery - Transdisciplinary team involvement

© Copyright 2001. Hospice of the Western Reserve.

Reprinted with permission.

Forms & Tools Pain Assessment Cards


Pain Assessment Cards Forms & Tools

Pain Assessment Cards (Continued)

Principles of Pain Management- Believe the patient: Pain is what the patient says it is.- Reassesss frequently – monitor regularly to provide ongoing pain control: include non-pharmacological interventions.

- Individualized treatment – Correct dose is the dose that relieves the pain with fewest side effects.- Choice of analgesic agent depends on many factors:

Renal and hepatic functionPast history of regimens, dosages and side effects or allergiesAvailable routes of administrationQuality and type of pain

- Provide preventative therapy. Give analgesics regularly.- Oral, sublingual or rectal route is preferred for drug administration.- Concentrated liquids or finely crushed tablets mixed with several drops of water can be placed sublingually. The absorption via the sublingual route is considered equivalent to the oral route for the purposes of equianalgesic dosing.

- Given rectally, MS Contin tablets are equivalent to the same dose orally.- Subcutaneous or intravenous therapy is reserved for patients with rapidly escalating pain and/or after failed therapy with alternative routes.

- Provide an immediate release/short-acting agent for breakthrough pain.- Breakthrough dosing should be roughly 10 to 15% of the 24-hour dose.- Maintenance dose is usually increased if three or more breakthrough doses are used in a 24-hour period.

- Remember thebowels: Patients will not develop tolerance to constipation.- Manage side effects for optimal opioid clinical response. Typical opioid side effects include sedation, constipation,nausea/vomiting, pruritus, sweating, myoclonus, urinary retention, and mental status changes (confusion, delirium, hallucinations).



Old Maintenance Dose + Breakthrough Dose = New Maintenance Dose24 Hours 24 Hours 24 Hours

78 Healthy Skin

Forms & Tools Patient and Family Education

Patient and Family Education Sheet Hospice of the Western Reserve

CONTROL OF PAIN

What is pain?Pain is what the patient says it is. No two people feel pain in the same way. Pain can be sudden, intense, mild,dull, long-term, etc.

What causes pain?There are many causes of pain: emotional, physical and spiritual. Most of the pain we treat in hospice comes froma tumor. The tumor presses and sometimes destroys nerves, bones or body organs. Other conditions that causepain are arthritis, headaches, past injuries and many other illnesses. Sometimes what appears to be physical painmay also be emotional or spiritual. Sometimes physical pain is not managed until the emotional and spiritual issues are addressed.

Why does the hospice team work so hard to relieve pain?When a patient is relieved of pain, many other problems are relieved as well. It is easier to sleep, eat, move anddo normal activities. Relief of pain helps the patient feel less fearful or depressed.

How is pain treated in hospice?Choosing the right treatment for each patient takes skill. Your doctor and the hospice nurse will look for the simplest and most effective pain medicine. Be sure to tell your hospice nurse how the patient feels. This informa-tion helps them to help the patient. Nearly all hospice patients take pain medication by mouth and have goodpain relief. Some patients will use music, prayer or relaxation tapes to help with pain relief.

Why does the hospice nurse want the pain pills taken on a schedule?The best way to control pain is to stop the pain before it starts. Stay on top or ahead of the game. If the patientwaits until the pain is severe, then the pain pill has little chance to work well. The goal is to prevent pain.

What can the patient do to help?First, tell your hospice nurse everything about your pain. Write down times that it seems to increase. Telling the nurse will help you achieve the best pain relief. Also, tell the nurse about your use of other medications.Be sure to check with the nurse before using an over-the-counter medicine. Do not take someone else’s pills.Most important: work with the nurse to set up a plan for medication.

Will the patient become addicted?No! The patient has an illness that causes pain. Taking a pill to stop this physical pain is the treatment, not a badhabit. Studies show that pain medicine used this way will rarely cause addiction. It is important that each patientbe supported with the right kind and amount of pain medicine.




Patient and Family Education Forms & Tools

Call the hospice nurse or physician with any questions regarding your medication.

SIDE EFFECTS OF PAIN MEDICATION

All medicines can have some side effects, but not all people experience them. People react in different ways.Your doctor or hospice nurse can help you work through any side effects you may have.

SleepinessThis happens when the patient begins taking or increasing a pain medicine. Often after two to three days of following a treatment plan, this feeling will pass. The body adjusts to the change. Remember, pain is tiring andwith the relief of pain, the patient will sleep.

Constipation (having no bowel movement or small, hard stools)The patient will feel better when they have a bowel movement. Pain and other medicine often make the patientconstipated. If able, the patient should drink more water and fruit juices. The nurse will talk with the patient abouta laxative. Taking laxatives and/or a stool softener each day will prevent constipation. If the patient gets uncom-fortable or hasn’t had a bowel movement in three days, call hospice.

NauseaWhen the patient starts a new pain medicine, there may be a day or two of nausea. Call the hospice nurse whowill arrange for some medicine to help the patient during these early days. Do not stop taking the pain medicinewithout speaking to the hospice nurse first.

ADDITIONAL INFORMATION ABOUT PAIN

What else can the patient do for pain?There are several things to do for pain. Medicine is important, but try other ways to control pain:- soaking in a tub of warm water - guided imagery- touch, light massage- ice packs, especially if there is swelling- music- relaxation with deep breathing exercises- distraction



80 Healthy Skin

Forms & Tools Pain Scale - Mild

MDD = Maximum Daily Dose©MCW Research Foundation 2000. Reprinted with permission. Medical College of Wisconsin.


Pain Scale - Moderate Forms & Tools

©MCW Research Foundation 2000. Reprinted with permission. Medical College of Wisconsin.

82 Healthy Skin

Forms & Tools Pain Scale - Severe



Pain Scale - Reference Forms & Tools


84 Healthy Skin

Forms & Tools Diabetes

What is type 2 diabetes?Everyone’s blood has some glucose (sugar) in itbecause your body needs glucose for energy.Normally, your body breaks food down intoglucose and sends it into your bloodstream.Insulin, a hormone made by your pancreas, helpsget the glucose from the blood into the cells tobe used for energy. In people with type 2diabetes, the pancreas doesn’t make enoughinsulin or the insulin doesn’t work very well, orboth. Without insulin, your blood glucose rises.

How can type 2 diabetes affect me?Type 2 diabetes sometimes leads to problemssuch as heart disease, stroke, nerve damage, andkidney or eye problems. But the good news isthat keeping blood glucose, blood pressure, andcholesterol on target can help delay or preventproblems.

How is type 2 diabetes managed?Most of the day-to-day care of diabetes is up toyou. Your plan for taking care of your diabeteswill include

• choosing what, how much, and when to eat

• including physical activity in your daily routine

• taking medications (if needed) to help youreach your blood glucose, blood pressure,and cholesterol targets

What can I do to take care ofmy diabetes?• Choose targets for the ABCs of diabetes care:

� A: your A-1-C check for average bloodglucose

� B: your blood pressure

� C: your cholesterol levels

• Work with your health care team to make aplan that helps you reach your targets.

• Keep track of your numbers.

• If you’re not reaching your targets, changeyour plan as needed to stay on target.

Your Blood Glucose Targets established by the American DiabetesAssociation (ADA) are listed below. Yourpersonal targets may differ. Talk with your healthcare team about the best targets for you.

You’ll check your own blood glucose using ablood glucose meter. The meter tells you whatyour blood glucose is at a particular moment.

At least twice a year, your doctor should order anA-1-C check. The results will give your averageblood glucose for the past 2 to 3 months.

ADA Targets forBlood Glucose

My UsualResults My Targets

Before meals: 90 to 130 mg/dl

2 hours after thestart of a meal: less than 180 mg/dl

______ to ______

less than ______

______ to ______

less than ______

ADA Target forthe A-1-C

My LastResult My Target

Below 7%

Regular physical activity can lower your blood glucose,blood pressure, and cholesterol levels.

Toolkit No. 3

Taking Care of Type 2 Diabetes


Diabetes Forms & Tools

Your Blood PressureAt every office visit, your health care team shouldcheck your blood pressure.

Your Cholesterol/TriglyceridesEvery year, your health care team should checkyour cholesterol and triglyceride levels.

What do I need to know aboutmeal planning, physical activity,and medications?

Meal PlanningMany people think that having diabetes meansyou can’t eat your favorite foods. But you canstill eat the foods you like. It’s the amount thatcounts. Ask for a referral to a dietitian whospecializes in diabetes. Together, you’ll design apersonalized meal plan that can help you reachyour goals.

• Count carbohydrates (also called carbs).Carbohydrate foods—bread, tortillas, biscuits,rice, crackers, cereal, fruit, juice, milk, yogurt,potatoes, corn, peas, sweets—raise your bloodglucose levels the most. Keeping the amountof carbohydrate in your meals and snacksconsistent can help you reach your bloodglucose targets.

• Choose foods low in saturated fat. Cuttingdown on foods that have saturated fat canhelp you lower your cholesterol and preventheart disease. Foods high in saturated fatinclude meats, butter, whole milk, cream,cheese, lard, shortening, many baked goods,and tropical oils such as palm and coconut oil.

• Lose weight if needed. Try to lose weight bycutting back on food portions and increasingyour daily activity.

• Increase the fiber in your diet. Includehigh-fiber foods, such as fruits, vegetables,dried beans and peas, oatmeal, and wholegrain breads and cereals, in your diet.

Physical ActivityRegular physical activity helps lower your bloodglucose, blood pressure, and cholesterol levels.It also keeps your joints flexible, strengthens yourheart and bones, tones your muscles, and helpsyou deal with stress. Your health care team maywant to check your heart function before youstart doing new activities. They can help youplan what kinds of physical activities are best foryou. The different kinds of activities include

• Being active throughout the dayExamples: gardening, taking the stairs insteadof the elevator, or walking around while youtalk on the phone—working up to about 30minutes of activity a day

• Aerobic exerciseExamples: walking, dancing, rowing,swimming, or riding a bicycle—working upto about 30 minutes a day, 5 days a week

• Strength trainingExample: lifting light weights several timesa week

• StretchingExample: stretching your whole body,especially your arms and legs

MedicationsMany people need medications along with mealplanning and physical activity to reach theirblood glucose, blood pressure, and cholesteroltargets. If you’ve had type 2 diabetes for a while,you may need a change in your diabetes pills toreach your blood glucose targets. If you needinsulin shots, it doesn’t mean that your diabetesis getting worse. It just means that you need achange in how you reach your target numbers.If it’s difficult for you to reach your targetnumbers, talk with your health care teamabout whether medications can help.

American Diabetes Association1–800–DIABETES (342–2383) www.diabetes.org

©2004 by the American Diabetes Association, Inc. 03/04

ADA Target My Last Result My Target

Below 130/80 mmHg

TypesADA

TargetsMy LastResult

MyTarget

LDL cholesterol Below 100 mg/dl

HDLcholesterol

Above 40 mg/dl(for men)

Above 50 mg/dl(for women)

Triglycerides Below 150 mg/dl

Copyright © 2009 American Diabetes AssociationFrom http://www.diabetes.orgReprinted with permission from The American Diabetes Association.

86 Healthy Skin

¿Qué es la diabetes tipo 2?La sangre de todas las personas tiene un poco deglucosa (azúcar) porque el cuerpo necesita glucosapara tener energía. En lo normal, el cuerpotransforma los alimentos en glucosa y la envía a lacorriente sanguínea. La insulina, que es la hormonaque produce el páncreas, ayuda a captar la glucosa dela sangre y la lleva hacia las células para que éstas lastransformen en energía. En las personas condiabetes tipo 2, el páncreas no produce la suficientecantidad de insulina, o bien, la insulina no trabajamuy bien, o ambas cosas. Sin insulina, la cantidad deglucosa en la sangre aumenta.

¿Cómo puede afectarme la diabetes tipo 2?La diabetes tipo 2 algunas veces desarrolla problemascomo enfermedades del corazón, derramescerebrales, daños en los nervios y problemas en losriñones y los ojos. Pero la buena noticia es que simantiene la glucosa en la sangre, la presión en lasangre y el colesterol dentro de los objetivosestablecidos puede retrasar o prevenir los problemas.

¿Cómo se controla la diabetes tipo 2?La mayor parte del cuidado diario de la diabetesdepende de usted. El plan para cuidar su diabetesincluirá:

• La selección de lo que comerá, el tamaño de susporciones y sus horarios de comida.

• La actividad física en su rutina diaria.

• Las medicinas (si son necesarias) para alcanzar susobjetivos en los valores de la glucosa en la sangre,la presión de la sangre y el colesterol.

¿Qué puedo hacer para cuidar mi diabetes?• Defina los objetivos para los exámenes clave del

cuidado de su diabetes:

! 1: El examen de su A-1-C para establecer el promedio de la glucosa en la sangre

! 2: La presión de su sangre

! 3: Sus niveles de colesterol• Trabaje con el equipo de profesionales que cuida

su salud para hacer un plan que le ayude a alcanzarsus objetivos.

• Lleve un registro de sus resultados.

• Si no está alcanzando sus objetivos, cambie suplan, según sea necesario, para poder cumplirlos.

La glucosa en su sangre En el cuadro de abajo aparecen los objetivosestablecidos por la American Diabetes Association(ADA). Sus objetivos personales pueden serdiferentes. Hable con el equipo de profesionales quecuida su salud sobre cuáles son los mejores objetivospara usted. Usted mismo examinará la glucosa en susangre usando un monitor de glucosa. Este aparato leindica el nivel de glucosa en su sangre en unmomento determinado.

Al menos dos veces al año, su médico debe ordenarleun examen de A-1-C. Los resultados le darán elpromedio de la glucosa en su sangre en los 2 ó 3 mesesanteriores.

Objetivos de ADA para

la glucosa en la sangre

Mis resultados

habituales Mis objetivos

Antes de las comidas:

90 a 130 mg/dl

2 horas después de

empezar a comer:

menos de 180 mg/dl

_ _ _ _ _ _ a _ _ _ _ _ _

menos de ______

_ _ _ _ _ a _ _ _ _ _ _

menos de _____

Objetivo deADApara A1C

Mi últimoresultado Mi objetivo

Menos del 7%

La actividad física regular puede reducir la glucosa en susangre, la presión de la sangre y los niveles de colesterol.

Guía No. 3

Cómo cuidar la diabetes tipo 2

Forms & Tools Diabetes Español


Diabetes Español Forms & Tools

La presión de su sangreEn cada visita que haga al consultorio, losprofesionales que cuidan su salud deben examinarlela presión de la sangre.

Su colesterol/Sus triglicéridosCada año, el equipo de profesionales que cuida susalud debe examinar sus niveles de colesterol ytriglicéridos.

¿Qué necesito saber sobre laplanificación de las comidas, l aa c t ividad física y los medicamentos?

La planificación de las comidasMuchas personas creen que tener diabetes significaque ya no podrán comer sus alimentos favoritos. Perono es cierto, porque sí podrá hacerlo. Lo que cuentaes la cantidad que come. Pida que lo refieran con unnutricionista especialista en diabetes. Usted y estenutricionista diseñarán un plan de alimentación quelo ayude a alcanzar sus metas.

• Cuente los carbohidrat o s.

Los alimentos que contienen carbohidratos—pan,tortillas, bizcochos, arroz, galletas, cereal, frutas,jugo, leche, yogur, papas, maíz, frijoles(habichuelas), dulces—aumentan al máximo losniveles de glucosa. Si come la cantidad adecuadade carbohidratos en sus comidas y meriendaspuede ayudarle a alcanzar sus objetivos de laglucosa en la sangre.

• Prefiera los alimentos bajos en grasa saturadaLa reducción de la cantidad de alimentos congrasa saturada puede ayudarlo a disminuir sucolesterol y a prevenir las enfermedades delcorazón. Los alimentos con mucha grasa saturadaincluyen carnes, mantequilla, leche entera, crema,queso, manteca de cerdo, manteca blanca llamada“shortening”, muchos bizcochitos horneados yaceites tropicales como el aceite de palma y decoco.

• Si es necesario, baje de peso.

Trate de perder peso reduciendo el tamaño de susporciones y aumentando su actividad diaria.

• Aumente la cantidad de fibra en su dieta.Incluya en su dieta alimentos con mucha fibra,como frutas, vegetales, frijoles (habichuelas),granos, avena, cereales y panes integrales.

La actividad físicaLa actividad física regular le ayuda a disminuir laglucosa en la sangre, la presión de la sangre y losniveles de colesterol. También mantiene laflexibilidad de sus articulaciones, fortalece su corazóny huesos, tonifica sus músculos y le ayuda a manejarel estrés. Antes de que empiece con una actividadesnuevas, es posible que el equipo de profesionales quelo atiende desee examinarle el funcionamiento de sucorazón. Ellos pueden ayudarlo a planificar las clasesde actividades físicas que sean las mejores para usted.Entre las diferentes clases de actividades se incluyen:

• Mantenerse activo durante todo el díaEjemplos: trabajar en el jardín, usar las gradas enlugar del elevador o caminar al rededor mientrasse habla por teléfono—aumentando el tiempohasta llegar a 30 minutos de actividad al día.

• Los ejercicios aeróbicosEjemplos: caminar, bailar, correr o manejarbicicleta aumentando el tiempo hasta llegar a 30minutos de actividad 5 días a la semana.

• El entrenamiento tonificanteEjemplo: Levantamiento de pesas ligeras variasveces a la semana.

• Los ejercicios de estiramientoEjemplo: Estirar todo el cuerpo, especialmente losbrazos y las piernas.

Las medicinasMuchas personas necesitan tomar medicinas ademásde seguir un plan de alimentación y hacer actividadfísica para alcanzar sus objetivos en los valores de laglucosa en la sangre, la presión de la sangre y elcolesterol. Si ha padecido de diabetes tipo 2 por algúntiempo, posiblemente necesite un cambio en suspastillas para alcanzar sus objetivos en los resultadosde la glucosa en la sangre. Si necesita inyecciones deinsulina, no quiere decir que su diabetes estéempeorando. Simplemente, significa que necesita uncambio para lograr sus objetivos. Si se le dificultaalcanzarlos, pregúntele al equipo de profesionales quecuida de su salud si las medicinas pueden ayudarlo.

American Diabetes Association

1–800–DIABETES (342–2383) www.diabetes.org

©2005 by the American Diabetes Association, Inc. 07/05

Objetivo de ADAMis últimosresultados

Mi objetivo

Menos de 130/80 mmHg

Tipos Objetivos de ADAMi últimoresultado

Miobjetivo

Colesterol LDL Menos de 100mg/dl

Colesterol HDL

Más de 40 mg/dl(para hombres)

Más de 50 mg/dl(para mujeres)

Triglicéridos Menos de 150 mg/dl

Copyright © 2009 American Diabetes AssociationFrom http://www.diabetes.orgReprinted with permission from The American Diabetes Association.

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

We’ve Made Pressure Ulcer Prevention EasySystematic efforts at education, heightened awareness, and specificinterventions by interdisciplinary healthcare teams have demon-strated that a high incidence of pressure ulcers can be reduced.1

The main challenges to having an effective pressure ulcer preventionprogram are: lack of resources; lack of staff education; behavioralchallenges; and lack of patient and family education.2

Medline’s comprehensive Pressure Ulcer Prevention Program offerssolutions to these challenges.

Pressure Ulcer Prevention ProgramThe Pressure Ulcer Prevention Program from Medline will helpyou in your efforts to reduce pressure ulcers in your facility.

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

To join the fight against pressure ulcers and for moreinformation on the Pressure Ulcer Prevention Program,please contact your Medline sales representative or call1-800-MEDLINE.

www.medline.com

Join the program to reduce pressure ulcers.

References1 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.

This has been a great learning experience for our staffand 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!”

Katrina “Kitty” Strowbridge, RNQuality Improvement CoordinatorSt. Luke Community Healthcare NetworkRonan, Montana

MKT209188/LIT760/30M/SELLS5

healthy skin magazine - volume 6; issue 2

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