healthy skin magazine - volume 8; issue 2

SURVEY RESULTS & Winners

Free CE Inside!

WOUNDPhotography

Guidelines

Choosing Nutritional

Supplements

EMBRACING NEW TECHNOLOGY

iPhone App Just Launched at www.medlineuniversity.com!

Improving Quality of Care Based on CMS Guidelines

Volume 8, Issue 2

VOLUME 8, ISSUE 2

HEALTHY SKINw

ww

.medline.com

PRESSURE ULCER PREVENTION IN LONG-TERM CARE

Learn more about continuous quality improvement for the prevention of avoidable pres-sure ulcers and F-Tag 314 citations, factors leading to pressure ulcers in long-term carefacilities and comprehensive pressure ulcer prevention strategies and solutions.

Sign up at www.medline.com/PUPP-webinar

J U N E3rd 12:00 pm - 1:00 pm10th 1:00 pm - 2:00 pm23rd 11:00 am - 12:00 pm

J U LY8th 1:00 pm - 2:00 pm14th 1:00 pm - 2:00 pm22nd 11:00 am - 12:00 pm

A U G U S T12th 12:00 pm - 1:00 pm 18th 1:00 pm - 2:00 pm 20th 11:00 am - 12:00 pm

S E P T E M B E R7th 11:00 am - 12:00 pm 9th 1:00 pm - 2:00 pm 14th 12:00 pm - 1:00 pm

INNOVATION IN THE PREVENTION OF CAUTI

J U N E7th 11:00 am - 12:00 pm9th 2:00 pm - 3:00 pm11th 12:00 pm - 1:00 pm18th 12:00 pm - 1:00 pm21st 11:00 am - 12:00 pm22nd 2:00 pm - 3:00 pm

J U LY7th 11:00 am - 12:00 pm 7th 2:00 pm - 3:00 pm 8th 12:00 pm - 1:00 pm 20th 11:00 am - 12:00 pm 20th 2:00 pm - 3:00 pm 21st 12:00 pm -1:00 pm

A U G U S T12th 11:00 am - 12:00 pm 12th 1:00 pm - 2:00 pm 16th 11:00 am - 12:00 pm 16th 2:00 pm - 3:00 pm 25th 11:00 am - 12:00 pm 25th 2:00 pm - 3:00 pm

S E P T E M B E R1st 11:00 am - 12:00 pm 1st 2:00 pm - 3:00 pm 2nd 12:00 pm - 1:00 pm 22nd 11:00 am - 12:00 pm 22nd 2:00 pm - 3:00 pm 27th 1:00 pm - 2:00 pm

Join your colleagues from around the country to learn more about strategies to preventcatheter-acquired urinary tract infections as well as Medline’s ERASE CAUTI system.

Hosted by Connie Yuska, RN, MS, CORLNand Lorri Downs, RN, BSN, MS, CIC

All schedules are Central Daylight Time.

Free WebinarsNew Techniques for Pressure Ulcer Prevention,

Hand Hygiene and CAUTI Prevention

MKT210090/LIT108R/35M/SEL5©2010 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.

J U N E14th 11:00 am - 12:00 pm17th 12:00 pm - 1:00 pm

J U LY8th 11:00 am - 12:00 pm 21st 2:00 pm - 3:00 pm

A U G U S T17th 2:00 pm - 3:00 pm 23rd 1:00 pm - 2:00 pm

S E P T E M B E R2nd 11:00 am - 12:00 pm 27th 2:00 pm - 3:00 pm

As the number one defense against healthcare-acquired conditions, hand hygiene playsan important role in the prevention of infections. Learn how hospitals and healthcarefacilities are combining best-in-class products and education to achieve hand hygienecompliance while dramatically improving the skin condition of healthcare workers.

HAND HYGIENE COMPLIANCE IMPROVEMENT STRATEGIES

Sign up at www.medline.com/handhygiene

Sign up at www.medline.com/erase/webinar.asp

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Join the team!

When it comes to hot topics in long-term care,

you’re the experts!

You, our readers, are on the front lines of everything thathappens in the healthcare industry – and we want to hearfrom you! Have you ever wished you could write anarticle 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

Contact us at [email protected] to learn more!

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 gives you ideas and tools for implement-ing their recommendations. For a summary of each of the above initiatives, see Pages 8 and 9.

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Improving Quality of Care Based on CMS Guidelines 111

4. Catheterization

Catheter — Type __________________________________ Size: ____________________________

Medical Justifications:

■ Urinary retention that cannot be treated medically or surgically, related to:• Post void residual volume over 200 ml• Inability to manage retention/incontinence with intermittent catheterization• Persistent overflow incontinence• Symptomatic infections• Renal dysfunction

■ Contamination of stage III or IV pressure ulcers with urine which impeded healing.

■ Terminal illness/severe impairments – which makes positing/changing uncomfortable or associated with intractable pain.

What is the MDS Score on B.4 (Cognitive skills for daily decision-making)?

Based on above, the resident may be a candidate for ______________________________

Resident is not a candidate for a bladder program due to: ❏ Indwelling catheter ❏ Confusion/dementia Other ___________________

3. Evaluate for Behavioral Program

If 2, 3Prompted Voiding or Scheduled Voiding

Residents with the following conditions could still benefit from par-ticipating in a prompted or scheduled voiding program:

• Those who cannot feel “urge” to urinate• Agitated or disoriented residents• Bedridden residents or those with mobility limitations

If 0, 1What is MDS score on G1Ia?

(ADL Self-Performance /Toilet Use)

If 0, 1Pelvic Floor Rehab

Bladder Rehab

If 0, 1, 2, 3, 4Prompted VoidingScheduled Voiding

Notes:

URINARY CONTINENCE ASSESSMENT & IMPLEMENTATION FORM

Urinary Continence Assessment Forms & Tools

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Page 20

Page 66

Page 10

Survey Readiness45 Urinary Incontinence Assessment: A Very Good Place to Start83 Mount Baker Care Center: Proactive Quality Assurance Measures

Help Improve Resident and Family Member Satisfaction

Prevention18 Editorial: Shedding Light on Pressure Ulcers and the CMS

Hospital-Acquired Conditions (HAC) Policy 62 The CNO Perspective: What the Board Needs to Know About

Pressure Ulcer Prevention66 Announcing New Online Skin & Risk Assessment Competency

Treatment10 Why Wet to Dry?24 A Picture Can Be Worth a Thousand Words32 What Type of Wound Is It?34 Caring for the Oncology Patientʼs Skin39 EPUAP/NPUAP Publish New Pressure Ulcer Guidelines for

Palliative Care68 Nutritional Supplements: What Approach is Best for Your Resident?

Special Features5 The Survey Results Are In!

20 The Future is Now for New Learning Technologies50 Ten Tips for Bathing the Uncooperative Resident56 Six Sticky Wickets That Commonly Occur in Wound Care Lawsuits76 Preparing Your Organization for Color-by-Discipline Uniforms99 Introducing Deb! Starring in “The Pink Glove Dance”

Regular Features8 Two Important Initiatives for Improving Quality of Care

51 Hotline Hot Topic: Incontinence Care

Caring for Yourself90 Win-Win Negotiation: How to Get More of What You Want

100 Healthy Eating: Syrian Salad

Forms & Tools103 Bilingual Application Guide – Adult Brief105 Reducing Pressure Ulcers – for CNAs108 Wound Photography Validation Checklist109 Photography Consent Form110 Urinary Continence Assessment & Implementation Form

HEALTHY SKIN

EditorSue MacInnes, RD, LD

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

Managing EditorAlecia Cooper, RN, BS, MBA, CNOR

Senior WriterCarla Esser Lake

Creative DirectorMike Gotti

Clinical TeamClay Collins, BSN, RN, CWOCN, CFCN, CWS, DAPWCA

Lorri Downs, BSN, RN, MS, CIC

Cynthia Fleck, BSN,MBA, RN, CWS, DNC, CFCN, DAPWCA, FCCWS

Joyce Norman, BSN, RN, CWOCN, DAPWCA

Kim Kehoe, BSN, RN, CWOCN, DAPWCA

Elizabeth OʼConnell-Gifford, BSN, MBA, RN, CWOCN, DAPWCA

Jackie Todd, RN, CWCN, DAPWCA

Connie Yuska, RN, MS, CORLN

Wound Care Advisory BoardMary Brennan, MBA, RN, CWON

Zemira M. Cerny, BS, RN, CWS

Patricia Coutts, RN

Cindy Felty, MSN, RN, CNP, CWS

Evonne Fowler, MSN, RN, CNS, CWOCN

Lynne Grant, MS, RN, CWOCN

Diane Krasner, PhD, RN, CWCN, CWS, BCLNC, FAAN

Dea J. Kent, MSN, RN, NP-C, CWOCN

Andrea McIntosh, BSN, RN, APN, CWOCN

Linda Neiswender, BSN, RN, CPN

Laurie Sparks, BSN, RN,CWOCN

Lynne Whitney-Caglia, MSN, RN, CNS, CWOCN

Laurel Wiersema-Bryant, RN, ANP, BC

Linda Woodward, BSN, RN, OCN, CWOCN

Deborah Zaricor, RN, CWOCN


Page 90

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

Meeting the highest level of national and international quality standards, Medlineis FDA QSR compliant and ISO 13485 certified. Medline serves on major industry quality committees to develop guidelines and standards for medicalproduct use including the FDA Midwest Steering Committee, AAMI Steriliza-tion and Packaging Committee and various ASTM committees. For more information on Medline, visit our Web site, www.medline.com.


©2010 Medline Industries, Inc. Healthy Skin is published by Medline Industries, Inc. One Medline Place, Mundelein, IL 60060. 1-800-MEDLINE.


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Dear Reader,

At 112 pages, this is our largest and most fact-filled

edition of Healthy Skin ever! The truth is I just couldn’t

cut anymore. There was so much powerful information,

so many new materials, technology and ideas.

Not only is it bigger … we’re also printing more copies.

Why? Because we ran out of the last edition early, and

we didn’t want that to happen this time. Our readership

keeps increasing.

Here’s what we have in store for you…

First, I’d like to share with you the results of the survey

in our last issue. (See opposite page.) One of the things

I thought you’d find interesting is the diversity of our

readers: 40% come from long-term care, 37% from

acute care and 14% from home health and hospice.

Our survey respondents included directors of nursing,

wound care nurses, staff nurses, clinical educators,

risk/quality managers, LPNs, nursing aides and nurse

managers. The top three priorities you are concerned

with are: 1. skin and wound care, 2. staff education and

3. pressure ulcer prevention, which is why we start this

edition with an article on page 10 entitled “Why Wet to

Dry?” It may be old school, but it is still happening.

Next, along with the survey submission, we asked our

readers to share successes by responding to a brief

essay question. I‘d like to recognize Kathy Cook from

Adventist La Grange for her winning response on how

her facility implemented innovative initiatives that made

a significant impact on quality and patient/resident care.

Take a look at Kathy’s submission on page 6.

And, then there was … the rest of the survey, where we

asked you about technology. Who had an iPhone, a

Blackberry, an iPod, a computer…we asked because

we had a hunch that regardless of the year we were

born, all of us are beginning to adapt to new ways to

communicate and learn.

For that reason, our first announcement is that we are

so proud to launch our brand new iPhone app for Med-

line University. Now you can listen to courses, watch

live videos and take CE tests on your iPhone or iPod

Touch. All for FREE! Now how cool is that? And, if that’s

not enough, by mid-June we will have Medline Univer-

sity available for the iPad as well. So, there are many

ways to learn, and we want you to have access to all

of them!

Best Regards,

Sue MacInnes, RD, LD

Editor

”

“There are manyways to learn, and we want youto have access toall of them!

Best Regards,

Sue MacInnes, RD, LD

4 Healthy Skin

HEALTHY SKIN Letter from the Editor

ON THE COVERChief Marketing Officer

Sue MacInnes and Director of e-Business Jignesh Thakkar

introduce the all-new Medline University iPhone app at the

2010 National Meeting in Houston, Tex.

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The Survey Results Are In!Thank you to everyone who took the time to complete the Medline Healthcare Surveyin the last issue of Healthy Skin.

We are pleased to report that everyone who completed the survey will be receiving our new“Deb” doll for free.

In her Medline Generation Pink Gloves, pink bouffant cap and scrubs, Deb energetically raisesawareness for breast cancer and the “Together We Can Save Lives Through Early Detection”campaign. To learn more, visit www.medline.com/dolls.

Where you workNursing home or long-term 40%care facilityHospital 37%Home health/hospice 14% Other 9%

What you doWound care nurse 34%Staff nurse 18%Director of nursing (DON) 13%All other positions 35%

Your top three priorities1. Skin and wound care 34%2. Staff education 33%3. Pressure ulcer prevention 23%

Clinical position of most concern for successful implementation of necessary changes at your facilityAides/technician 42%Nurse 30%Physician 14%

Skin TearsAverage number of skin tears 10at your facility per month

Average amount of time 16 minutesspent on skin tears during new employee orientation

Pressure UlcersAverage pressure ulcer incidence 4.6%

Your biggest barriers to pressure ulcer preventionLack of staff compliance 25%Proper patient or resident positioning 19%Lack of staff education 19%

Organizations involved 27%in a lawsuit regarding pressure ulcers

Clinicians personally 10%involved in a lawsuit regarding pressure ulcers

TechnologyKinds of technology devices you usePDA (Blackberry®, Palm®, iPhone®) 32%Cell phone 87%iPod®/mp3 35%Computer 93%

Blackberry and Palm are registered trademarks of Research In Motion Limited, iPhone, iPod and iPad are registered trademarks of Apple Inc.Kindle is a registered trademark of Amazon Technologies, Inc., Sony is a registered trademark of Sony Corporation

Turn the page to see the bonus question winners!

Introducing Deb!

Special Feature


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6 Healthy Skin

As part of a pride project I developeda wound documentation tool. Thesheet is a “to do” list of importantdocumentation which should be donewhen a patient has a wound. Thisincludes patient outcomes, nutritionconsults, and wound nurse consult, ifnecessary. Since this sheet has beenimplemented on all the units, docu-mentation regarding wounds hasimproved. With nurses being moreaware of their patients’ needs whohave wounds, they will be able to takebetter care of the patients. If a patientis transferred from one unit to another,the sheet moves with the patient sono information is missed with thetransfer. With time, we hope to have100% compliance with the new toolensuring patients get the most com-plete and up-to-date treatments.

Samantha Conha, BS, RNExeter HospitalExeter, NH

Our grand prize winner will receive an engraved plaque and the entireMedline Doll Collection, which includes eight dolls in all. Our four otherwinners will receive the entire Medline doll collection.

Our Skin School three times a yearhas saved many wounds. It generatesquestions regarding anatomy of woundhealing, VAC dressings, ostomy care,staging of pressure ulcers, formulariesand "tips" to nurses. Have our out-comes improved? YES! Nurses aremore confident, thus taking chargeto tackle all dressing changes.

Helena Jerinsky, RNDelray Medical Center,Delray Beach, FL

We currently utilize the CAP programthrough our company. It stands for C –Cleanse the skin, A – Apply moisturebarrier ointment, P – Pressure relief.We place baseball CAP stickers ondoors of those residents who score 10or below on Norton Scale or who haveactual breakdown to alert staff thatthese residents have potential for skinbreakdown.

Kay Grond, LPN, WCCTwin Falls Care CenterBuhl, ID

One WOCN developed a wound careprogram within two months for fourbranches of our home health company.This program incorporated all staff inthe prevention and management ofwound patients. She created uniquePowerPoint presentations to “reach”her audiences. Her wound programbegins with the liaison in the field priorto admission, and continues until thepatient is healed. This approach hasmade everyone feel empowered andaccountable, creating a huge costsavings for the company. The real pay-off, however, does not lie in the moneysaved, but in the lives impacted.

Michelle Fritze, RNEvergreen HealthCare CenterStafford Springs, CT

Grand Prize Winner

When we hire any nursing staff, we do onehour on overall wound issues, prevention, offloading, positioning and treatments. For thelicensed staff we include a video on woundvac, and a more detailed educational programthat covers all of the above including woundrounds, the usual products we use, and howto measure, document and apply the dressingsupplies. We also have a quarterly hands-oninservice with dressings, learning with picturesand bringing in sales reps for the products weuse. We give each new physician our protocolsto read so they understand what we do as afacility for wound care. The nurse managers dothe weekly wound rounds and I do educationwith rounds to the RNs and LPNs. I play ques-tion-and-answer with the NAs on a daily basis,and they can now actively participate in theprogram to help us with positioning needs andthe individuals’ likes and dislikes as far as howtheir treatments are going. When we dischargeresidents to home with home nursing services,we do education with caregivers who will bedoing the treatment, and then have themdemonstrate for us so we know they knowhow and why they are doing the treatment.We also give education sheets with signsand symptoms of infection, hand hygiene,and for diabetics, the signs and symptomsof hypo/hyperglycemia.

Kathy Cook, MSN RN APN CWOCNAdventist La GrangeLa Grange, IL

Congratulations to our SURVEY WINNERS!

Winners

HealthySkin16.3-mag:Layout 1 5/4/10 11:20 AM

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The American Health Care Association (AHCA) and the NationalCenter for Assisted Living (NCAL) are pleased to invite you to our Congressional Briefing, June 8-9, 2010, in Washington, D.C.

Accommodations for this event will be at the beautiful and convenient Hyatt Regency Washington on Capitol Hill, a fewshort blocks to congressional offices.

We look forward to seeing you there!

To register for Congressional Briefing visit: cb.ahcancal.org

For more information, email: [email protected]

Additional questions? Please call (202) 842-4444

AHCA/NCAL CONGRESSIONAL BRIEFINGHYATT REGENCY WASHINGTON ON CAPITOL HILL

©2010 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.

Sponsored by

June 8-9, 2010Save the Date


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8 Healthy Skin

Two Important National Initiatives for Improving Quality of Care

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

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

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. The content now consists of four themes with the goal to help providers, both in long-term care and acute-care facilities, prevent illness, decrease harm to patients and reduce waste in health care. Of note: QIOs will be required to help Medicare promote three overarching themes: adopt value-driven healthcare, support the adoption and use of health information technology and reduce health disparities in their communities. Under the direction of the Centers for Medicare & Medicaid Services (CMS), the QIO Program consists of a national network of 53 QIOs located in each of the 50 U.S. states, the District of Columbia, Puerto Rico and the Virgin Islands.

Quality Improvement Organization Program’s 9th Scope of Work Theme The official Executive Summaries for the 9th SOW Theme are available at:http://providers.ipro.org/index/9SOW_summaries

Origin: A coalition-based, two-year campaign initiated on September 26, 2006 to improve quality of life for nursing home residents and staff. The coalition has continued the campaign beyond its first-round end of August 25, 2008 for an additional 2 years (until September 26, 2010).

Purpose: A coalition consisting of the Centers for Medicare & Medicaid Services (CMS), organizations representing providers, consumers and government that developed a grassroots campaign to build on and complement the work of existing quality initiatives including Nursing Home Quality Initiative (NHQI), Quality First and the culture change movement.

Goal: To ensure that continuous quality improvement is comprehensive, sustainable and consumer-focused, the coalitionhas adopted goals that seek to improve clinical care, incorporate nursing home resident and family satisfaction surveys into continuing quality improvements and increase staff retention to allow for better, more consistent care for nursing home residents.

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 Excellence The 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 Organization 9th Round Statement of Work1

Advancing Excellence in America’s Nursing Homes2


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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: 70.9% Goal 5: 32.1%

Goal 2: 45.3% Goal 6: 62.8%

Goal 3: 54.2% Goal 7: 41.2%

Goal 4: 39.6% 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 on nine 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 Activities will focus on three Tasks:1. Community and provider selection and recruitment2. Interventions 3. Monitoring

Theme #3: Patient Safety Activities will focus on six primary 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 performance results 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%Goal 2: Reducing the use of daily < 5% 3%

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

longer-term nursing home residentsGoal 4: Improving pain management for < 15% 19%

short-stay, post-acute nursing home residents

Operational/Process Goals: Goal Actual

Goal 5: Establishing individual targets for > 90% 36.5%improving quality

Goal 6: Assessing resident and family 22.5%satisfaction with quality of care

Goal 7: Increasing staff retention 13.9%Goal 8: Improving consistent assignment 26.6%

of nursing home staff so that residents receive care from the same caregivers

Clinical and Operational/Process Goals

Participating nursing homes: 7,481 Percentage of participating nursing homes:* 47.6% Participating consumers: 2,233

Average number of goals per nursing home: 3.8

Regular Feature

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10 Healthy Skin

‘‘Why Wet to Dry’’?

Journal of the American College of Certified Wound Specialists (2009) 1, 109–113

Prior to the 1960s, clinicianscommonly believed the perfectwound healing environment wasdry and dressings simply pluggedand concealed ulcers. However,research in recent decades hasconfirmed that a moist woundenvironment where dressingshave the opportunity to interactwith the wound helped promotehealing and reduced the risk ofpain and infection while increas-ing outcomes.

Cynthia A. Fleck, BSN, MBA, RN, ET/WOCN, CWS, DNC, CFCN, FACCWS


If you answered ‘‘All of the above,’’ you are correct. Why,then, are the majority of wounds dressed with this archaic,barbaric treatment modality? Let’s uncover the issues sur-rounding moist gauze and wet-to-dry ‘‘therapy,’’the worstoxymoron in our wound care vocabulary.

Historical Use of GauzeThrough World War I, the task of changing dressings wasin the domain of physicians and medical students. In the1930s, caring for wounds was passed over to experiencednurses and became recognized as part of a nurses’ scopeof practice. For the next 40 to 50 years, the mainstays ofwound coverings and fillers were gauze, cotton wool pads,impregnated gauze, absorbent cotton, and adhesive pads.The 1960s saw the start of a change in dressings and thephilosophy of their use. However, the practice of usingmoist saline-soaked gauze and wet-to-dry saline gauze isstill widely utilized. This is an outdated tradition that persistsdespite mounting evidence against it.

Gauze DressingsGauze dressings can be dry woven or nonwoven materials,sponges, and wraps with varying degrees of absorbency,based on design. Fabric composition may include cotton,polyester, or rayon. They are available sterile or nonsterile,in bulk, and with or without adhesive border. The gauzemay be impregnated with other products, such as hydrogel(to hydrate) or sodium chloride (to absorb and draw).

Wet-to-Dry and Moist GauzeIn the United States, wet-to-dry and gauze dressings arestill the most commonly used primary dressing substance.1

Reasons for the persistence of gauze and saline as woundmanagement mainstays include lack of knowledge on thepart of physicians and other clinicians of advanced dress-ings and how they work, confusion due to the plethora ofadvanced products, and the incorrect view that advanced

dressings come at a high price. The most common reasonis the perception that gauze is a ‘‘one size fits all’’ modalitythat is readily available and inexpensive. In addition, thesedressings have been used throughout history since thepractice is propagated in medical schools and surgicaltraining.2 There is also evidence that they are usedinappropriately.2 Recent journal articles and texts, as wellas expert opinion, support the principle of moist woundhealing, but in practice the use of gauze, predominantly asa wet-to-dry dressing, does not guarantee a moist woundenvironment.3

Wet-to-dry dressings are described in the literature as ameans of mechanical debridement.4 Debridement is themainstay of wound bed preparation since devitalizedmaterial harbors bacteria, delays healing, and increases therisk of infection.5 However, it is the opinion of this authorand others that wet-to-dry or moist gauze does not consti-tute advanced wound care or advanced therapy. Granted,wet-to-dry gauze is a form of nonselective debridement;however, it is painful if the patient is sensate and canproduce numerous negative outcomes. Gauze dressingsare not the best wound care choice for the patient, thecaregiver, or the health care system and facility. Gauzedressings do not support optimal granulation and healingand are more labor intensive than advanced dressings suchas polyacrylates, transparent films, hydrocolloids, alginates,hydrogels, and foams. Therefore, these archaic regimesshould be abandoned since they are not considered stan-dard of care. The previous Agency for Healthcare Researchand Quality (AHRQ), formerly the Agency for Health CarePolicy and Research (AHCPR), in its Clinical Practice Guide-lines for Treatment of Pressure Ulcers,6 supported the useof wet-to-dry dressings for debridement only by maintain-ing that their use is backed by expert opinion (rated as C ontheir hierarchy of evidence).7

Let’s begin with a quick quiz:

The following is true about wet-to-dry dressings:a. They are appropriate only for mechanical debridement.b. They can cause pain and suffering to the patient.c. Each dressing change and wound bed disturbance

causes hypoxia, vasoconstriction, cooling,and destruction.

d. Removal of the dried dressing from the wound disperses significant bacteria into the air.

e. All of the above.


Treatment


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12 Healthy Skin

Changing PhilosophyEarly preclinical and clinical research in the 1960s started todefine the idea of moist wound healing and the benefit inoptimizing wound healing. Preserving an optimally moistwound bed, homeostatic temperature, and occlusion havebeen shown to produce better outcomes than practicesthat allow wounds to dry out.7-19 The theory that moistwound care provides for better outcomes began to receiveserious consideration in the late 1970s and 1980s. Prior tothis time, drying of the wound was accepted and accom-plished by several mechanisms: the use of povidone iodineas a drying agent, heat lamps, wet-to-dry dressings, andexposure of the open wound to air.10 Transparent film dress-ings and hydrocolloids were the first widely used productsthat addressed moisture retention. Throughout the 1980sand early 1990s, there was an explosion in the realm ofdressing products. Alginates, hydrogels, and foamsappeared on the market in a wide variety of dressings andtopicals. Antimicrobials were beginning to become moresophisticated by providing time-released delivery systemsthat allowed longer wear time and cost savings. The con-

cept of passive dressings began to change. Dressings werebecoming active in their role of changing the wound milieuin the healing process. The advent of growth factors andother biosynthetics such as collagen began the movementto interactive dressings.

Today, research and development is being focused on thecellular level. New understanding of interactions of the cel-lular components within the chronic wound environmentand of ways interactive dressings can alter the woundenvironment is putting dressing technology on the cuttingedge. What is next may be limited only by our understand-ing of how the body changes from normal healing of anacute wound to healing of a chronic wound, our techno-logical ability to create products, and our imagination abouthow to get there.

GuidelinesThe Centers for Medicare and Medicaid Services Guidanceto Surveyors in long-term care states that the use of wet-to-dry dressing may be appropriate in limited circumstances,



but repeated use may damage healthy granulation tissuein healing ulcers and may lead to excessive bleeding andincreased resident pain.11,12 In addition, the American MedicalDirector’s Pressure Ulcer Guidelines state that wet-to-drydressings are not recommended because they adhere tovital tissue as well as eschar, removing tissue nonselectivelywhen the dry dressing is removed, and tend to be painful.13

EvidenceSome problematic issues with wet-to-dry dressings includean increased chance of external contamination and infec-tion, as well as cross-contamination because gauze dress-ings do not present any physical barrier to the entry ofbacteria, which can travel through 64 layers of gauze.14 Fre-quent (3 or 4 times daily) dressing changes lead to a dropin wound temperature, causing vasoconstriction anddecrease in blood perfusion. This further drastically impairsthe ability of oxygen to clear bacteria from the wound, lead-ing to an increase in tissue infectability. Each time the dress-ing is changed, cooling and destruction of the woundmicroenvironment lead to hypoxia, which impairs leukocytemobility and phagocytic efficiency.15 Wet-to-dry dressingsdo little to impede fluid evaporation and do not providemoist wound healing unless kept continuously wet.Wet-to-dry dressings also prolong the inflammatoryphase of wound healing, counterproductive to all effortsat wound closure.16

Wet-to-dry dressings are cost prohibitive secondary tocaregiver time and frequency of change, as licensednurses’ salaries and benefits tend to be one of the highestexpenses for a facility. Wet-to-dry is a painful and traumaticdressing that can cause substantial patient discomfort andwound bed disturbance as well as poor patient compliance

or adherence.17 Furthermore, wet-to-dry is a nonselectiveform of mechanical debridement that causes tissuedestruction and injury at each dressing change, whichultimately delays healing.

As saline evaporates, it becomes hypertonic, and fluid fromthe wound is then drawn into the dressing, promoting des-iccation of the tissue. As the wound dries, cell migrationand proliferation are impeded.18 Then, the dried dressingremoval disperses significant amounts of bacteria intothe air.19

Armstrong and Price discovered that many physicianswould prescribe various gauze dressings, including wet-to-dry, rather than advanced modalities such as alginates,foams, hydrocolloids, and hydrogels. The research entaileda questionnaire sent to 127 general surgeons and achieveda response rate greater than 50%. Gauze dressings wereoverwhelmingly prescribed over the alternatives for allwounds except for venous leg ulcers. Almost half therespondents selected wet-to-dry dressings as their choicefor open surgical wounds that are left open to heal by sec-ondary intension. The data also showed that although 75%of the respondents had access to the advanced therapies,they did not use them.20

Ovington describes gauze as the most widely used woundcare dressing and says it may be erroneously considered astandard of care.2 Her article comments that wet-to-dry andwet-to-moist are frequently used in clinical practice in afashion that makes them interchangeable. She describeshampered healing due to local tissue cooling, disruption ofangiogenesis by dressing removal, and increased infectionrisk from frequent dressing changes, strike through and

Continued on page 15



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We’re confident you’ll find TenderWet Active more effec-tive than wet gauze therapy because TenderWet Activecan be left in place for up to 24 hours without drying outwhile simultaneously removing harmful microorganismsand stubborn necrotic tissue.

By debriding necrotic tissue, absorbing and retainingpathogens and keeping the wound moist, TenderWetActive helps create an ideal healing environment.

For a free trial of TenderWet Active and informationon Medline’s complete line of advanced woundcare products, contact your Medline representativeat 1-800-MEDLINE.

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prolonged inflammation as good reasons to abandon this‘‘traditional’’ dressing technique.2 Ovington also offers acost-effectiveness argument for change. She illustrates thecosts of saline and gauze compared with an advanceddressing (Tielle, Johnson & Johnson Wound Management,Somerville, NJ) over a 4-week period, performed by a homehealth nurse.2 The largest contribution to cost is nursingtime; even with the patient and/or family doing some of thecare, the cost is decreased with the advanced dressingsecondary to fewer dressing changes and better outcomes(less time to closure).

In Capasso and Munro’s research, wet-to-dry dressingswere compared to hydrogel dressings in the home care set-ting. Although wound healing rates were similar betweenthe two groups, the cost of wound care was substantiallyhigher in the wet-to-dry group because of more frequentdressing changes and an increase in labor intensivenessand more frequent home visits.21

Colwell, Foremen, and Trotter conclude that a semiocclu-sive dressing that had higher hard dollar costs and requiredless frequent dressing changes provides for faster healingoutcomes and is less expensive to use than wet-to-dry.This is contrary to the belief that wet-to-dry dressings arecost-effective.22

In an international survey study, the European Wound Man-agement Association illustrated that gauze is most likely tocause pain and be the most adherent product in woundcare and no longer recommended as best practice.

Newer products such as hydrogels, hydrofibers, alginates,and soft silicones are least likely to cause pain and wererecommended as a result.23

Another investigator, Coyne, examined the cost–benefit ofwet-to-dry compared with another advanced dressing,polyacrylate moist wound dressing (TenderWet, MedlineIndustries, Advanced Skin and Wound Care, Mundelein, IL),in a nationwide, 65-location home care agency (TLC/StaffBuilders) and was able to realize a 26% savings annually,and pointed out that wet-to-dry treatments cause pain,slower healing, and an increased infection rate.24 There areother important considerations in the choice of a dressing,such as clinical outcome, quality-of-life issues, discomfort,disruption of daily routines and how the patient can copewith daily activities, that can all be addressed by modernproducts.25 A comparison of wet-to-dry gauze with anadvanced alternative, polyacrylate moist wound anddebriding dressings, is summarized in the Table 1.

Polyacrylate Moist Wound and Debridement DressingsThis activated absorbent polyacrylate polymer core dress-ing absorbs large protein molecules (necrotic tissue andbacteria) while irrigating with Ringer’s solution, a physiolog-ical fluid, creating a ‘‘rinsing effect’’ (see Figure 1). Theinteractive dressing supports both moist wound healingand autolytic debridement, gently removing dead tissuefrom the wound bed while creating an ideal healing envi-ronment. Polyacrylates debride at a mean rate of 38%.34

Research has shown that polyacrylate gel absorbentsdebride just as well as collagenase does.36 Recent researchhas also shown that the product may be effective in reduc-ing wound bioburden by interfering with biofilm as well asabsorbing planktonic or freefloating bacteria.35

As the old adage goes, ‘‘What we permit is what we pro-mote!’’ Question this outdated tradition, challenge the oldestablishment, demand a more comfortable experience onbehalf of your patients, refuse to participate in outdated

Prior to application into thewound, the TenderWet padis activated with Ringer’ssolution.

Due to the polyacrylate’shigher affinity for proteinsthan for salts, the absorbentcore simultaneously takesup and binds wound debris,necrotic tissue and microor-ganisms in exchange forRinger’s solution.

The 24-hour rinsing actionrapidly establishes a cleanwound bed, allowing for active wound healing totake place. There is tissuegrowth, angiogenesis andcellular migration.

Ringer’s Solution

Wound Debris

Microorganisms

Necrotic Tissue


003-056_65528_MedCal:Layout 1 5/4/10 4:42 PM

customs, promote advanced wound caring and patientadvocacy TODAY. Why ‘‘wet-to-dry,’’ I ask. No longer canwe sit idle and complacent when options and evidence arereadily available that have shown positive cost and clinicaloutcome. Help me abolish this archaic wound treatmentonce and for all. Repeat after me, ‘‘Wet-to-dry needs to die!’’

References1. Mc Callon ST, Knight CA, Valiulus P, et al: Vacuum-assisted closure versus

saline-moistened gauze in the healing of postoperative diabetic foot wounds.Ostomy/Wound Management. 2000;46(8):28–34.

2. Ovington LG: Hanging wet-to-dry dressings out to dry. Home Health Nurse.2001;19(8):1–11.

3. Bolton LL, Monte K: Moisture and healing beyond the jargon. Ostomy Wound Manage. 2000;46(1A):51S–62.

4. Bryant RA: Acute and Chronic Wounds. 2nd ed. St. Louis, MO: Mosby; 2000.5. Kirsner R: Wound bed preparation. Ostomy/Wound Management.

2003;49(2A):2–3.6. Bergstrom N, Bennett M, Carlson CE, et al. Treatment of pressure ulcers.

Clinical practice guidelines (15). Public Health Service Agency for Health Care Policy and Research; 1994. Rockville, MD, Publication # 95-652.

7. Winter GD, Scales JT: Effect of air exposure and occlusion on experimentalhuman skin wounds. Nature. 1963;197:91.

8. Hinman CD, Maibach HI: Effect of air exposure and occlusion on experimentalhuman skin wounds. Nature. 1963;200:377.

9. Winter GD: Formation of the scab and the rate of epithelialization of superficial wounds in the skin of the young domestic pig. Nature. 1963;193:293–294.

10. Winter GD, Scales JT: The effects of air-drying and dressings on the surface of the wound. Nature. 1963;197:91–92.

11. Department of Health and Human Services, Centers for Medicare andMedicaidServices. CMS Manual System Pub. 100–007 State OperationsProvider Certification. November 12, 2004.Available at http://www.cms.hhs.gov/manuals/pm_trans/r4SOM.pdf. Date accessed August 2009.

12. Fleck CA: New pressure ulcer guidelines. ECPN. January/February2005;37–42.

13. American Medical Directors Association: Pressure Ulcers in the Long-Term Care Setting Clinical Practice Guideline. Columbia, MD: American Medical Directors Association; 2008.

14. Lawrence JC: Dressings and wound infection. Am J Surg. 1994; 167(1A):21S–4.

15. Spear M: Wet-to-dry dressings—evaluating the evidence. Plast Surg Nurs.2008;28(2):92–95.

16. Ovington LG: Hanging wet-to-dry dressings out to dry. Home Healthcare.2001;19(8):477–483.

17. Sibbald RG, Williamson D, Orsted HL, et al: Preparing the wound bed: Debridement, bacterial balance and moisture balance. Ostomy Wound Manage. 2000;46(11):14–35.

18. Lim JK, Saliba L, Smith MJ, McTavish J, Raine C, Curtin P: Normal saline wounddressing—Is it really normal? Br J Plast Surg. 2000;53:42–45.

19. Lawrence JC, Lilly HA, Kidson A: Wound dressing and airborne dispersalof bacteria. Lancet. 1992;339(8796):807.

20. Armstrong MH, Price P: Wet-to-dry dressings: Fact and fiction.Wounds. 2004;16(4):56–62.

21. Capasso VA, Munro BH: The cost and efficacy of two wound treatments.AORN journal. 2003;77(5):984–992.

22. Colwell JC, Foreman MD, Trotter JP: A comparison of the efficacy and cost effectiveness of two methods of managing pressure ulcers. Decubitus.1993;6(4):28–36.

23. Moffat CJ, Franks PJ, Hollinworth H: Pain at wound dressing changes,European Wound Management Association Position Document. London, UK:Medical Education Partnership Ltd.; 2002:2.

24. Coyne N: Eliminating wet-to-dry treatments. Remington Report. September/October 2003;(sup):8–11.

25. Armstrong MH, Price P: Wet-to-Dry gauze dressings: fact and fiction. Wounds.2004;16(2):56–62.

26. Bruggisser R: Bacterial and fungal absorption properties of a hydrogel dressingwith a superabsorbent polymer core. J Wound Care. 2005; 14(9):1–5.

27. Eming S, Smola H, Hartmann B, et al: The inhibition of matrix metalloproteinaseactivity in chronic wounds by a polyacrylate superabsorber. Biomaterials.2008;29:2932–940.

28. Fleck CA, Chakrararthy D: Continuous debridement options in wound bedpreparation—examining the ‘‘D’’ in the D.I.M.E.S. wound bed preparation model. Adv Skin Wound Care (in press).

29. Coyne N: Eliminating wet-to-dry treatments. Remington Report.September/October 2003:8S-11.

30. Konig M, Vanscheidt W, Augustin M, Kapp H: Enzymatic versus autolytic debridement of chronic leg ulcers: a prospective radomised trial. J Wound Care.2005;14(7):320–323.

31. Paustian C, Stegman MR: Preparing the wound for healing: the effect of activated polyacrylate dressing on debridement. Ostomy/Wound Manage.2003;49(9):35S–42.

32. Lawrence JC, Lilly HA, Kidson A: Wound dressing and airborne dispersalof bacteria. Lancet. 1992;339(8796):807.

33. Flemister B. The use of a superabsorbent wound dressing pad for interactivemoist wound healing. Paper presented at: 13th Annual Symposium on Advanced Wound Care, April 1-4, 2000; Dallas, TX.

34. Paustian C, Stegman MR: Preparing the wound bed for healing: The effect ofactivated polyacrylate dressing on debridement. Ostomy/Wound Manage.2003;49(9):34–42.

35. Bruggisser R: Bacterial and fungal absorption properties of a hydrogel dressingwith a superabsorbent polymer core. J Wound Care. 2005; 14(9):438–442.

‘‘Wet to dry needs to die!’’

16 Healthy Skin


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Reference1 The Centers for Disease Control and Prevention. Home Health Care Patients:Data from the 2000 National Home and Hospice Care Survey. Available at:www.cdc.gov/nchs/pressroom/04facts/patients.htm. Accessed April 12, 2008.

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BRINGING IT HOME TO YOU


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First of all, relax. You’re not the only one who’s still confusedabout the Centers for Medicare & Medicaid Services (CMS)Hospital-Acquired Conditions (HAC) Policy.

Although it’s been over a year and a half since the policy wasimplemented, I’m still finding a great deal of misunderstandingout there among the healthcare professionals I’m meeting atvarious meetings and conferences.

As you may know, effective October 1, 2008, CMS nolonger reimburses hospitals for the care of a list ofhigh-cost, yet reasonably preventable conditions if the condi-tions occur while a patient is hospitalized. Stage III and IV pres-sure ulcers are the most costly of these conditions, estimatedby CMS to be $43,180 per hospital stay.1 The purpose for with-holding reimbursement is to incentivize hospitals to take greatercare to prevent pressure ulcers and the other conditionsincluded in the policy.

As a way to keep track of which patients develop pressureulcers while they are in the hospital, CMS developed the Pres-ent on Admission (POA) Indicator, which identifies if a hospitalpatient has a pressure ulcer at the time the order for admission occurs.

Ideally, each patient receives a skin assessment upon admis-sion, and the provider* 2 determines and documents whetherthe patient has any pressure ulcers at that time.

Although physician/provider documentation is requiredby CMS, the expertise of wound assessment in hospitals ispredominantly within nursing. Competence of the provider inassessment is critical to do an accurate skin assessment.3

If a pressure ulcer is discovered and documented uponadmission, the hospital will receive Medicare reimbursementto care for the wound. For patients who have no pressureulcers, prevention becomes a key focus for clinicians to makesure none develop.

In May 2008, in anticipation of the upcoming implementation ofthe CMS HAC Policy, I joined my colleagues on the Interna-tional Expert Wound Care Advisory Panel for a roundtable dis-cussion about the policy and ways to help prevent pressureulcers.** The outcome of our discussion was a white paper,“New Opportunities to Improve Pressure Ulcer Prevention AndTreatment: Implications of the CMS Inpatient Hospital CarePresent on Admission (POA) Indicators/Hospital AcquiredConditions (HAC) Policy,” which was subsequently published inthe Journal of Wound, Ostomy, Continence Nursing.

To learn more about the issues we discussed, download a free copy of the article at http://www.medline.com/media-room. As corresponding author for the article, I welcomerelated inquiries at [email protected].

* CMS defines “provider” as “a physician or any qualified healthcare practitioner who is legally accountable for establishing the patient’s diagnosis.”

** The work of the International Expert Wound Care Advisory Panel is supported by an educational grant from Medline Industries, Inc.

References1. Centers for Medicare & Medicaid Services. Medicare Program; Proposed Changesto the Hospital Inpatient Prospective Payment Systems and Fiscal Year 2009 Rates.Federal Register. 2008; 73(84):23550-23553. Available at:http://edocket.access.gpo.gov/2008/pdf/08-1135.pdf. Accessed April 28, 2010.

2. Present on Admission (POA) Indicator Reporting by Acute Inpatient ProspectivePayment System (IPPS) Hospitals. Centers for Medicare & Medicaid Services. Decem-ber 2007. Available at:http://www.cms.hhs.gov/HospitalAcqCond/Downloads/poa_fact_sheet.pdf. AccessedApril 28, 2010.

3. Armstrong DG, Ayello EA, Capitulo KL, Fowler E, Krasner DL, Levine JM, et al. Newopportunities to improve pressure ulcer prevention and treatment: implications of theCMS inpatient hospital care Present on Admission (POA) Indicators/Hospital AcquiredConditions (HAC) Policy. Journal of Wound, Ostomy Continence Nursing.

2008;35(5):485-492.

An editorial by wound care expert Diane L. Krasner PhD, RN, CWCN, CWS, MAPWCA, FAAN

18 Healthy Skin

Prevention

and the CMS Hospital-Acquired Conditions (HAC) Policy

Shedding Light on Pressure Ulcers

003-056_65528_MedCal:Layout 1 5/4/10 4:44 PM

How 4 square inches of Puracol® Pluschanged chronic wound care.

Forever.

This is Puracol Plus Micro-

Scaffold as seen through an

electron microscope. Its open,

cellular structure allows easy

fibroblast migration.2 The high

strength of the MicroScaffold2

also assists in establishing a

fresh wound bed. Each Puracol package is

a 2-Minute Course™ in

Advanced Wound Care.

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

Chronic wounds tend not to heal when unbalanced levelsof elastase and MMPs (inflammatory enzymes) destroy thebody’s own collagen and growth factors.1

But apply Puracol Plus and help restore nature’s balance.

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

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

©2010 Medline Industries, Inc.Puracol is a registered trademark of Medline Industries, Inc.Medline is a registered trademark of Medline Industries, Inc.


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20 Healthy Skin

NOW

Other colleges and universities are catching on to theiPhone as an educational tool as well. Students enrolled inthe undergraduate journalism program at the University ofMissouri are required to have an iPod Touch® or an iPhoneto download course material.2 And the Blackboard app isgaining popularity at many high schools and colleges as away to post assignments, grades, documents, discussionboards and anything else associated with a course.3

Posted on wired.com by: Panacea | 12/8/09 | 6:04 pm1

The community college where I teach nursing piloted givingiPods to students a few years ago, with the idea of usingiTunes U. They like being able to replay lectures. I don’t doa traditional lecture in class anymore. The students down-load their lectures. Class time is for interactive assignmentssuch as care mapping, case studies, and discussion. Stu-dents still get to ask questions about the iTunes content.Grades have been steadily improving over the last 3 yearssince I’ve moved to iTunes U. Retention has improved 15%.

The Futureis

for New LearningTechnologiesDon’t get left behind!

Advances in technology have resulted in numerous onlineeducational opportunities that are both free and easy toaccess. In fact, electronic learning tools have nearly elimi-nated the need to actually attend a class for continuingeducation. Online webinars, e-textbooks and podcasts arejust a few of the options. And how about iPhone® apps?

Beginning with the 2008-2009 school year, all incomingfreshmen at Abilene Christian University in Texas arerequired to have an iPhone. Apps are used to turn in home-work, look up campus maps and check class schedulesand grades. For classroom participation, there’s evenpolling software so students can digitally raise their hand toanswer questions.1

William Rankin, a professor at Abilene Christian, comments,“This is a question of how do we live and learn in the 21stcentury now that we have these sorts of connections?I think this (the iPhone) is the next platform for education.”1


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Teaching & Learning: THE DIGITAL AGE

Course activity typically focuses on students contextualizing,practicing, or using information with presentation of infor-mation occurring at home through media or online access.

Access to course content is augmented by electronicsources and media, and access is often recursive or“on-demand,” allowing students to return to content whenand as often as they’d like.

In addition to classroom access, students and teachershave access to one another via “virtual” means – onlinediscussions, e-mail, chat, social networking, etc.

References:1. Chen BX. How the iPhone could reboot education. Wired – Gadget Lab. Available at: http://www.wired.com/gadgetlab/2009/iphone-university-abilene. Accessed March 29, 2010. 2. Dignan L. Apple’s iPod Touch, iPhone as education tool: should universities dictate whether you’re a Mac or PC? Available at: http://blogs.zdnet.com/BTL/?p=17775. Accessed March 29, 2010.3. The Next Generation of Educational Leadership: A blog for educational leaders who want to learn, share and discuss 21st-century education leadership strategies. March 29, 2009. Available at:

http://nextgeneduleaders.blogspot.com/2009/blackboard-app-for-iphone-great-tool.html. Accessed March 31, 2010.

Teaching & Learning: THE PRINT AGE

Course activity typically focuses on presentation of infor-mation with students contextualizing, practicing or usinginformation at home.

The classroom is the primary site of access to course con-tent, and access is often “linear” – students cannot typicallyreturn to previous class presentations.

Students and teachers have access to one another prima-rily in the classroom.

Source: Dr. William Rankin, “Abilene Christian University 2008-09 Mobile-Learning Report.” Available at: http://www.acu.edu/technology/mobilelearning.

Treatment


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CONVENIENT

• Online interactive courses and competencies

• Podcasts for downloading to your mp3 player

• Downloadable pdf documents

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COMPREHENSIVE

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• Live webinars presented by clinical and industry experts

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online sources

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Skin, The OR Connection and Infection Prevention Now

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Prepared by highly qualified clinicians, Medline Universitycourses are approved for continuing education contact

hours by:

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Your personalized Medline University home page displayswhat’s of interest to you based on your healthcare role,

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ATURES

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Courses approved for continuing education by the Florida Board of Nursing and the California Board of Registered Nursing.

003-056_65528_MedCal:Layout 1 5/4/10 5:37 PM

At home, at work or on the go…earn free CE credits It’s even easier to maintain licensure and certificationand validate competencies! All Medline Universitycourses are now available as a free iPhone® and iPodtouch® app that can be downloaded from TheApple® Store.

As always, you can also access courses online on your computer and download podcasts to yourMP3 player. New courses and competencies aremore interactive with graphics, sound and animationto make learning fun.

Nurses Are Getting WIREDIn a recent poll of 762 Medline customers and subscribers of The OR Connectionand/or Healthy Skin magazine:

• 41 percent were RNs• 10 percent own an iPhone

Of those who own an iPhone:• 89 percent said they would download

available content from Medline

• 88 percent have downloaded content from the iTunes store

• 64 percent were 40 or older

• 30 percent currently use their iPhone as a reference at work

Medline UniversityIntroduces ...iPhone® App

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* Courses approved for continuing education by the Florida Board of Nursing and the California Board of Registered Nursing

003-056_65528_MedCal:Layout 1 5/4/10 4:53 PM

A PICTURE CAN BE

WORTH A THOUSAND

WORDS

24 Healthy Skin



The use of photo documentation in wound care

Whether you are questioning the value of an already establishedwound photography protocol at your facility or agency, or youare considering putting one into place, here are some issues toponder regarding this beneficial, yet sometimes controversialpractice.

Why add photography?Photographing wounds provides many clinical benefits.Photos provide a visual to accompany the written woundassessment, they serve to document the wound’s progressover time, they may protect the facility during a lawsuit, improvecoordination of care among clinicians and serve as a tool forpatient and family education.

Wound assessment. A comprehensive wound assessmentand documentation of the findings are essential componentsof wound care. In fact, care of a wound, particularly a pressureulcer, can be a visual art, often yielding insights beyond thoseof a word description.1 As illustrative as they are; however, pho-tos do have their limitations. For example, they cannot showfactors such as wound odor and warmth.2 In addition, clinicalexperts agree that although photographs of wounds are a

useful complement to the clinical record, they cannot standalone and should not replace the written word.1

Documenting progress. Wound photos taken at intervalsduring the care process can provide evidence that the woundwas regularly assessed and staged. They can show either aprogression of healing, or at least show how new treatmentswere introduced to address a non-healing wound.1

According to the National Pressure Ulcer Advisory Panel(NPUAP), photography may offer a more accurate means forassessment of wound dimensions and wound base over time.NPUAP also states that rates of healing, and therefore meas-ures of therapeutic efficacy, are more readily appreciated whenthe data are in a visual format.3

Legal protection. Wound photography can be beneficial iflegal issues arise, although opinions vary greatly on this matter,and some say wound photos can be detrimental in a lawsuit.

On the positive side, photographs can assist in protecting yourfacility from liability for the wound occurring while the person

A picture often says more than any number of words possibly could. Think about it.No matter how poetically you might describe the beautiful scenery from your lastvacation, a photo of that gorgeous mountain view says it all. Similarly, even the mostexperienced wound care nurse’s detailed chart notes describing a wound simply donot deliver the same impact as a color photo.

By Elizabeth O’Connell-Gifford, MBA, BSN, RN, ET/CWOCN, DAPWCA

Treatment


26 Healthy Skin

was under your care. This is a particularly frequent issue withpressure ulcers. If a nursing home resident with no wounds orskin injuries is transferred to the hospital, and then returnsto the nursing home with a pressure ulcer, each facility oftenpoints the finger at the other regarding under whose care thepressure ulcer occurred.

If the nursing home was proactive, however, in documentingthe condition of the skin with photos upon admission anddischarge, it could more easily protect itself from liability. Forexample, let’s say a nursing home photographs areas of a res-ident’s body that are prone to pressure ulcers (sacrum, heels,elbows) right before the resident is discharged to the hospital.The photos and clinical record are documented with the date,time and a written description, and they show intact, wound-free skin.

Then, the nursing home takes photos of the same areas of theresident’s skin as soon as he or she returns from the hospital.Again, the photos and record are documented with the date,time and a written description, and now the photos show red-dened skin with signs of tissue breakdown. Comparing thebefore and after photos and documentation, it would be diffi-cult to place blame on the nursing home for the skin injury.

In this case, wound photography, can prove to be highlybeneficial. Under different circumstances, however, woundphotographs could inflame a jury and hurt a defendant’s case.4

This side of the debate will be covered under the “Issues toconsider” section of this article.

Improving coordination/continuity of care. Again, no mat-ter how thorough a nurse’s written documentation of a wound,there is some degree of subjective interpretation, which a photocan mitigate, especially if the reader is unfamiliar with wound-related terms used, such as slough, eschar, granulation tissue,friable tissue or undermining.4 If a nurse includes a woundphoto with her shift report or documentation right before thenew nurse takes over the patient’s care, the photo, along withnotes in the record, gives a more comprehensive overview ofthe wound. The photo also clearly identifies areas within andaround the wound that require monitoring.

After trialing a wound photography program for pressure ulcerprevention at a tertiary care Level I trauma facility, the facility ex-perienced enhanced communication between nurses duringshift-to-shift report and unit-to-unit transfers. Wound photog-raphy also improved the ability to monitor wound status despitedifferent nurses caring for the patient.5

Arterial Wound

Venous Wound

003-056_65528_MedCal:Layout 1 5/4/10 5:07 PM


Patient/resident and family education. Wound photo-graphs can be especially useful for patient/resident and familyeducation. Aside from dressing changes, wounds are coveredmost of the time. If a family member wanted to see a wound,the dressing would have to be removed, potentially disturbingthe granulation tissue. If a photo were available, the nurse couldsimply show the family member the chart.

For patients or residents with wounds in areas that are difficultto see, such as on the feet, or obese patients’ pannus injuries,a photo allows the patient to view a wound he or she other-wise could not see. Putting a visual picture of the wound in theresidents’ or patients’ mind can be a useful way to motivatethem to be compliant with care.1

Issues to considerAs beneficial as wound photography can be, it certainly requiresexercising caution concerning litigation, patient privacy andconfidentiality.

Legal concerns. Much the same as wound photography canbe helpful in defending a medical malpractice case, it can alsoput the defendant in a poor light.

According to attorney Annemarie Martin-Boyan, photographsmay make the defense attorney’s job more difficult becausegruesome photographs tend to arouse the jury’s sympathy forthe plaintiff at the expense of the healthcare team.4

Perhaps because of these “tricky” issues surrounding woundphotography, the National Pressure Ulcer Advisory Panel(NPUAP) and the Wound, Ostomy and Continence NursesSociety (WOCN) neither recommend nor discourage the use ofphotography as a documentation tool for pressure ulcers. BothNPUAP and WOCN; however, do agree that facilities shouldmaintain written guidelines regarding if and when photographyis to be used.6

Patient privacy and confidentiality. If you decide to initiatewound photography at your facility or agency, it is advisable todiscuss your decision with your risk manager and legal coun-sel. Each state has its own rules on photography, and your pol-icy must be consistent with these laws.1

As you develop your wound photography policy, you also willwant to include a section on patient consent. The Joint Com-mission on Accreditation of Healthcare Organizations stronglyadvises organizations to obtain informed consent before pho-tographing a patient. The Health Insurance Portability andAccountability Act (HIPAA) guidelines also mandate protectionof patient privacy through written informed consent.1

The photography consent form, to be signed by the patient orlegal representative, should state the planned use of the woundimages, such as monitoring the progress of wound treatment

Necrotic Wound

Neuropathic Diabetic Wound

003-056_65528_MedCal:Layout 1 5/4/10 5:11 PM

28 Healthy Skin

and consulting with a wound care specialist. If there is a possi-bility that the images will be used for educational purposes orpublication in a journal, these intentions also should be visiblyacknowledged in the consent form.2 (See page 109 of this issuefor a sample photography consent form.)

Other important considerations regarding patient privacyinclude never photographing the patient’s face or other distin-guishing characteristics such as birthmarks, tattoos or jewelryand never altering a photo by adding, adjusting, removing ormoving anything.2

Maintaining confidentiality of wound photos goes hand in handwith patient privacy. After taking photos, transfer them to asecure, password-protected computer, and then delete theimages from the camera.

Editor’s note: For sample copies of a wound photography compe-tency checklist and a photography consent form, go to the “Forms &Tools” section of this issue.

References1. Langemo D, Hanson D, Anderson J, Thompson P, Hunter S. Digital wound photogra-phy: points to practice. Advances in Skin & Wound Care. 2006; 19(7):386-387.2. Buckley KM, Adelson LK, Hess CT. Get the picture! Developing a wound photogra-phy competency for home care nurses. Journal of Wound, Ostomy and ContinenceNursing. 2005; 32(3):171-177.3. FAQ: Photography for pressure ulcer documentation. National Pressure Ulcer Advi-sory Panel website. Available at: http://www.npuap.org/faq.htm. Accessed April 27,2010.4. Calianno CA & Martin-Boyan A. When is it appropriate to photograph a patient’swound? Advances in Skin & Wound Care. 2006; 19(7):304-306.5. Scardillo J, Hanna L, Sigond K, Labarre L, Vaughan C, Maskell-Amirault M, et al. Apicture is worth a thousand words … implementation of a wound photography programin surgical and medical intensive care units. Journal of Wound, Ostomy and ContinenceNursing. 2007; 34(3S):S46.6. Ayello EA, Capitulo KL, Fife CE, Fowler E, Krasner DL, Mulder G, et al. Legal issues inthe care of pressure ulcer patients: key concepts for healthcare providers. Journal ofPalliative Medicine. 2009; 12(11):995-1008.7. Buckley KM, Tran BQ, Adelson LK, Agazio JG, Halstead L. The use of digital imagesin evaluating home care nurses’ knowledge of wound assessment. Journal ofWound, Ostomy and Continence Nursing. 2005; 32(5):307-316.

Approximately five million patients in the United States have chronic wounds,

with 1.5 to 1.8 million new woundcases added each year.7

1. Place camera with carrying case in a clean area

separate from the patient and wound supplies.

2. Wash hands and put on exam gloves.

3. Remove the wound dressing, position and drape

the patient and place a disposable measuring

tape next to the wound.

4. Remove and discard gloves.

5. Wash hands again with alcohol-based gel,

remove camera from the case and place it next

to the patient on a clean surface.

6. Take the photos, making sure the camera does

not touch the patient. Do not wear gloves;

powder from gloves can damage the camera.

7. Put camera back in the clean area, cleaning it

with sanitizing wipes before removing it from

patient area.

8. Sanitize hands and put on new clean gloves.

9. Re-dress the wound.

10. Remove and discard gloves; sanitize hands

and bring camera to docking station to

download photos.

10 STEPSfor Infection Control When Photographing Wounds2



General tipDigital photos are always preferred.

Patient selectionApproach each patient as if they/their wounds will become aposter/case study. Get in the habit of using good photographytechniques every time to improve your photo outcomes. Maketime to compose your shot and your patient.

PermissionObtain photo consent, as required by your agency or facility.

FrequencyPhotos should be taken on admission, weekly thereafter, and atwound closure. All efforts should be made to protect patientprivacy with regard to HIPAA compliance.

LightingUse natural light (no flash) when possible. Be careful that thesun does not wash out the subject or distort the surface tex-ture. If the light source is behind you, make sure your body doesnot create a shadow.

Background The objective is to showcase the wound on a solid background.Drape the patient in a dark blue or black cloth as it helps toabsorb the flash and decrease the reflection off the patient’sskin. Shiny underpads that reflect the flash should alsobe avoided.

Composition• Avoid clutter in the background and clothing or towels

with prints. • Include a ruler with date, length, width and depth of

the wound(s) in each photo. • Position the patient in the same manner for each set of

photos to best show consistency as the wound progresses.• Take the photo from the same angle each time. It’s best

to have the camera pointing perpendicular at the woundinstead of down from the top.

• Take the photos at the same time of the day to help with consistency in lighting.

• To avoid blurry photos, stand firmly with your feet shoulder width apart and tuck your elbows tight to prevent any shaking.

• Take a minimum of three shots per wound site at each visit.

• Shoot photos from a distance of four feet.• Two-foot closeup – 90% person and 10% background• Two-foot with zoom – highlight tissue texture, drainage• Preview shots taken to ensure pictures are clear

and visible. Retake if necessary.

Additional photos of wound care procedures that highlightdressing removal, amount and absorption of drainage, prod-uct performance, wound pre- and post-irrigation, and dressingapplication steps are all of interest.

Guidelines for Wound Photography


creo

True/False1. Wound photos can stand alone without

any written documentation in the clinical record. T F

2. Polaroid photos are always preferred over digital. T F

3. Use natural light (no flash) whenever possible. T F

4. After taking wound photos, transfer them to a secure, password-protected computer and delete them from the camera. T F

5. Facilities should maintain written guidelines regarding if and when photography is to be used. T F

Multiple Choice6. Which of the following organizations neither

recommends nor discourages the use of photos as a documentation tool for pressure ulcers?a. The Centers for Medicare & Medicaid

Services (CMS)b. The National Pressure Ulcer Advisory Panel

(NPUAP)c. The Wound, Ostomy and Continence Nurses

Society (WOCN)d. Both b and c

7. Choose the FALSE statement below: a. Photos serve to document a wound’s progress

over time b. Wound photos may protect a facility during

a lawsuit c. It’s important to include the patient’s face in

wound photosd. Wound photos can serve as a tool for patient

and family education

8. Approximately ___ million patients in the United States have chronic wounds.a. 3b. 10c. 5d. 1

9. Which of the following is one way to protect a patient’s or resident’s privacy when taking photos of wounds?a. Requiring the patient or resident to sign a photo

consent formb. Only taking photos of wounds on the hands or feetc. Only showing the photos to the physician d. None of the above

10. How can wound photography improve coordination of care among clinicians?a. By improving the ability to monitor wound status

despite different nurses caring for the patientb. By clearly identifying areas within and around the

wound that require monitoringc. By giving a more comprehensive overview of

the woundd. All of the above

30 Healthy Skin

“A Picture Can Be Worth a Thousand Words –The Use of Photo Documentation in Wound Care”

Submit your answers at www.medlineuniversity.com and receive 1 FREE CE credit


003-056_65528_MedCal:Layout 1 5/4/10 5:37 PM

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32 Healthy Skin

Damage to the skin or underlying struc-tures as a result of tissue compression andinadequate perfusion

Usually over a bony prominence

Usually circular

Can have viable or necrotic tissue

Can be very large or very small

Can vary from none to heavy

Can be localized, usually not seen

Usually not present

N/A

N/A

Usually, but often undertreated

• Remove necrotic tissue

• Maintain optimal moisture

• Protect periwound skin

• Control bioburden

• Remove pressure

Failure of venous valve function in return-ing blood from the lower extremities to theheart causing venous congestion, leadingto venous hypertension

Gaiter area (ankle to mid calf), often me-dial malleolus, may be circumferential

Irregular shaped

Usually shallow, can have viable ornecrotic tissue

Usually large

Can vary from none to heavy to general-ized weeping

Generalized edema to lower extremity

Usually seen

> 0.8

Usually normal, or undetectable due to edema

Often in dependent position, with edema

• Compression

• Remove necrotic tissue


• Protect periwound skin

• Control bioburden

• Ensure lower extremity moisturization

Definition

Location

Wound Margin

Wound Bed

Wound Size

Exudate

Edema

Limb Staining

Ankle Brachial Index (ABI)

Pedal Pulses

Pain

Best Practice

Wound Appearance

PRESSURE VENOUS

WHAT TYPE OF


WOUND IS IT?


Wounds caused by ischemia, related tothe presence of arterial occlusive disease

Distal aspect of arterial circulation, can beanywhere on the leg (i.e. toes and feet)

“Punched out,” well defined borders

Pale wound bed, little or no granulation,necrotic tissue is common

Can be small, often increases due to lackof arterial perfusion

Minimal to no exudate

If present, localized

Usually not present

< 0.8 < 0.5 - indicates inability to heal

Usually reduced or absent

Occurs at rest, nocturnal, or when ex-tremity is elevated

• If perfusion not adequate, consider vascular consult

• If perfusion is adequate, follow protocolbased on wound assessment and characteristics

• If dry, stable eschar leave intact

Neuropathy is often associated with dia-betes. Wounds result from damage to theautonomic, sensory or motor nerves andhave an arterial perfusion deficit

Can be anywhere on the lower extremity,often on the foot

Similar to arterial, usually with a callous edge

Similar to arterial, usually with a callous edge

Often small

Similar to arterial

Similar to arterial

Similar to arterial

Not reliable, sometimes > 1.0 falsely eval-uated due to calcification

Not reliable

Due to neuropathy, pain may be absent orsevere


• Control diabetes, if appropriate

• Repetitive removal of callous

• Bioburden control and preventionof systemic infection

• Remove pressure with appropriateoffloading shoe or other appliance

NEUROPATHIC/DIABETIC

Definition

Location

Wound Margin

Wound Bed

Wound Size

Exudate

Edema

Limb Staining

Ankle Brachial Index (ABI)

Pedal Pulses

Pain

Best Practice

ARTERIAL

Wound Appearance

Treatment


creo

34 Healthy Skin

As the largest organ of the body, the skin is a reflection of overall health. For individualsin the oncology setting undergoing chemotherapy, radiation, biotherapy and other formsof cancer treatment, safe and healthy wound and skin care can be challenging.1

Cutaneous manifestations of internal diseaseSome cutaneous diseases are frequently associated with internal diseases. The skin prob-lem may be inconsequential, but the underlying disease process should be thoroughlyinvestigated.2 Paraneoplastic syndromes are actually diseases that appear before or con-currently with an internal malignancy. In some instances the cutaneous changes arethought to result from the production of hormones, growth factors or antigen-antibodyresponses induced by the tumor. Paraneoplastic syndromes are thought to happen whencancer-fighting antibodies or white blood cells (known as T-cells) mistakenly attacknormal cells in the nervous system.3

Over the past 20 years or so, new antineoplastic treatments have been developed.Collectively these are known as targeted therapy agents. Many of these agents interfere

By Linda Woodward BSN, RN, OCN®, CWOCN



with signal transduction, such as epidermalgrowth factor receptor (EGFR) inhibitors.4 They

are associated with dermatologic complicationsthat are usually dose-limiting.5 One such agent can

cause bullous, blistering and exfoliative skin condi-tions, including reported cases of Stevens-Johnsonsyndrome or toxic epidermal nycrolysis, which in somecases can be fatal.

External malignant tumorsFungating wounds present physical and emotional chal-lenges to patients, family members and healthcareproviders.6 These lesions may be the result of a primarycancer of the skin, metastases of a distant tumor to theskin or a direct extension of the primary tumor to the skin.

Patients can present with external tumors any time duringtheir cancer treatment. Many times the goal of wound careis palliative, addressing odor management, exudate andperiwound skin. The goal for palliative patients is manag-ing symptoms in order to provide a good quality of life.7

Cancer treatment and skin problemsRadiotherapy, either internal or external, has a major effecton the skin. The effects of radiation rapidly divide cells andcause cell death. The skin can become erythematous,painful and the patient may experience desquamationresulting in partial and/or full thickness wounds.Chemotherapy can cause hyperpigmentation, hypersensi-tivity and photosensitivity.8

Dressing Suggestions for Fungating Wounds

Pain Management Control of Bleeding Odor Management Exudate Control Peri Wound Skin Mgmt Debridement

Nontraumatic Hemosatic dressings Wound cleansing Wound Skin friendly tapes Autolyticdressings cleansing

Non-adherent Gentle pressure Antimicrobial Alginates or Wraps Enzymaticdressings hydrofibers

Gels, creams Charcoal dressings Absorptive Skin preps Polyacrylatepowders

Ointment- Cyclodextrin Wound pouches Sharps impregnated dressings

Contact layers Foams

Treatment

003-056_65528_MedCal:Layout 1 5/4/10 3:33 PM

36 Healthy Skin

Alopecia. Another common complication of chemother-apy is alopecia, or hair loss. It is the most commondermatologic complication caused by chemotherapy.9

Radiation recall. This refers to the augmentation ofradiotherapy effects. This may appear as dry or moistdesquamation or as erythema and edema. It is an inflam-matory skin reaction that occurs in a previously irradiatedbody part following drug administration.4 Care of irradiatedskin includes promoting cleanliness and hydration, recom-mending loose fitting clothing, using mild cleansers,bathing with tepid rather than hot water, and avoidingpetrolatum-only products and those containing alphahydroxy acids (AHA). Also, instruct your patients to avoidsilver impregnated dressings and silver wound care oint-ments, as the silver can interfere with the radiation. Advisepatients to inform their radiation oncologist of any wounds,dressings or creams that they have applied prior totheir treatment.9

Palmar plantar erythrodysesthesia. Palmar plantarerythrodysesthesia (PPE) is also called hand-foot syn-drome or acral erythema. It is an unpleasant or painful feel-ing in the palms of the hands and the soles of the feetcaused by certain types of chemotherapy.10 Sometimes,these areas are tender or swollen with tingling or burningsensations. The skin of the palms and soles often turns red

or dark pink at the same time.11 Care of patients with PPEincludes application of an emulsion at the start ofchemotherapy and continuing two to three times a daythroughout the course of treatment.

Skin tears. Cancer treatment can “thin” the skin and makeit extremely fragile. Skin tears in the oncology patient arevery common. Older patients and oncology patients arevery vulnerable to skin tears primarily because the epider-mis thins.12 The first and most widely cited skin tear grad-ing system, by Payne and Martin (1993), involves gradingthe skin tear as a I, II or III.13

I Skin tear without tissue loss. The skin flap can be approximated so that no more than 1 mm of dermis is exposed.

II Skin tear with partial tissue loss. III Skin tear with complete tissue loss.

The epidermal flap is absent.

Managing skin reactions to cancer therapyFor patients undergoing cancer treatment, the manage-ment of skin reactions is an important part of gettingthrough treatment. Many everyday skincare products con-tain ingredients that are unhealthy for the cancer patient’sskin, which can become sensitive to some of these ingre-dients. The most frequent culprit of adverse reactionsis fragrance. Read labels carefully and follow directionsexactly. When in doubt, check with your oncologist ordermatologist for product recommendations.

Malignant fibrous histiocytoma

Leukemia cutis


003-056_65528_MedCal:Layout 1 5/4/10 3:33 PM

Independent outcomes research1 was conducted in an acute care facility where, after implementation of a prevention program, the only additional change during the reduction period was the focus of improving skin care by using Medline Remedy products* exclusively, as part of a formal skin care regimen. The results were amazing!

Medline Remedy®

Serious care. Serious results.

Nosocomial pressure ulcers reduced by

50% after 3 months1

Nosocomial pressure ulcers reduced to zero

after 8 months1

Estimated cost savings of $6,677.11

per patient

* A silicone-based dermal nourishing emollient (SBDNE)

1. Shannon RJ, Coombs M, et al. Reducing hospital-acquired pressure ulcers with a silicone-based dermal nourishing emollient-associatedskincare regimen. Adv Skin Wound Care, 2009;22:461-7.

©2010 Medline Industries, Inc. Medline and Medline Remedy are registered trademarks of Medline Industries, Inc.

To receive a FREE TRIAL of our effective Remedy skincare products, contact your Medline representative.


creo

38 Healthy Skin

Skin Care Tips for Cancer Patients:1. Talk to your oncologist or dermatologist regarding

a specific course of anti-cancer therapy. Find out the integumentary side effects and recommended treatments.14

2. Check the labels of all topical creams and lotions. Avoid products that contain parabens, lanolin, p-phenylenediamine (PPD) and propylene glycol. These are some of the more frequent skin irritants.10

3. Cleanse skin by gently patting it with a mild soap. Do not scrub the skin. When patients receive chemotherapy, their platelets and white blood cells are diminished. Overzealous cleansing can cause skin tears, which can become infected in the immunocompromised patient.14

4. Use a petrolatum-free lip balm. Drying of lips and oral mucous membranes is common during cancer treatment.14

5. Remember to use sunscreen. Many cancer drugs cause photosensitivity, so sunscreen is necessary even on cloudy days.14

ConclusionThe management of potential skin complications requiresthe application of wound healing principles under the careof a WOC nurse. As with other chronic wounds, goals canrange from healing to palliation and symptom manage-ment. Collaboration among the oncology nurse, the WOCnurse and other healthcare providers is valuable to estab-lish guidelines for the specialized care of oncology patients’skin issues.15,16

References1. Woodward L & Haisfield-Wolfe ME. Management of a patient with a malignant

cutaneous tumor. Journal of Wound, Ostomy, Continence Nursing. 2003;30(4):231-236.

2. Habif T. Clinical Dermatology. St. Louis, MO: Mosby; 2004: 8953. Paraneoplastic Syndromes Information Page. National Institute of Neurological

Disorders & Stroke. Available at: www.ninds.nih.gov/disorders/paraneoplastic/paraneoplastic.htm. Accessed April 16, 2010.

4. Froiland K. Challenging skin management related to targeted therapy. Wound, Ostomy, Continence Nurse Education Program Lecture at the University of Texas M. D. Anderson Cancer Center, Houston, TX, May 2009.

5. MedWatch: The FDA Safety Information and Adverse Event Reporting Program. Available at: www.fda.gov/medwatch. Accessed April 16, 2010.

6. Bryant R & Nix D. Acute & Chronic Wounds. 3rd ed. St. Louis, MO: Mosby; 2007: 471-489.

7. The Wound Care Handbook. Mundelein, IL: Medline Industries, Inc.; 2007: 158-160.8. Groenwald S, Frogge MH, Goodman M, Yarbro CH. Clinical Guide to Cancer

Nursing. 4th ed. Sudbury, MA: Jones & Bartlett; 1998: 203-220.9. Dermatologic Complications of Cancer Therapy. Available at:

www.ncbi.nlm.nih.gov/bookshelf/br.fcgi?book=cmed&part=A38915. Accessed March 2, 2010.

10. Skin Care Advice for Cancer Patients. Chrysalis Spa & Skin Care Center. Available at: www.abcn.ca/artman2/publish/Tests_amp_Treatment_52/Skin_care_for_cancer_patients. Accessed February 26, 2010.

11. Palmar Plantar Erythrodysesthesia. Available at: www.huntsmancancer.org/patientdocs/hci/drug_side-effects/handfoot.html. Accessed March 2, 2010.

12. Exploring best practice in the management of skin tears in older people. Available at: http://www.nursingtimes.net/nursing-practice-clinical-research/specialists/wound-care/exploring-best-practice-in-the-management-of-skin-tears-in-older-people/ 5000502.article. Accessed April 16, 2010.

13. Payne RL & Martin ML. Defining and classifying skin tears: need for a common language. Ostomy Wound Management. 1993; 39(5): 16-20, 22-24, 26.

14. Is There Effective Skin Care for Cancer Patients? Available at: http://www.futured-erm.com/2008/12/19/is-there-effective-skin-care-for cancer-patients. Accessed February 26, 2010.

15. Woodward L. Wound & skin care in the leukemia & lymphoma patient. (Poster Presentation). Oncology Nursing Society. May 2004.

16. Woodward L. Effective Management of Externalized Malignant Tumors. (Poster Presentation). Symposium on Advanced Wound Care. May 2003.

About the author

Linda Woodward is a certified wound, ostomy, continencenurse at The University of Texas M. D. Anderson Cancer Centerin Houston, Tex.

Malignant melanoma

003-056_65528_MedCal:Layout 1 5/4/10 3:34 PM


Dealing with the end of a loved one’s life is difficult enough,but when wound and skin care issues are involved, the deci-sions about how to manage the patient can be even morechallenging. The European Pressure Ulcer Advisory Panel(EPUAP) and National Pressure Ulcer Advisory Panel (NPUAP)have added a new section on palliative care to their pressureulcer treatment guide to help clinicians navigate through someof these difficult treatment decisions.

Pressure Ulcer Treatment: Quick Reference Guide nowincludes a section on “Pressure Ulcer Management in Individ-

uals Receiving Palliative Care,” which is reproduced on thefollowing pages for your reference. The palliative careperspective is woven throughout, showing how to focustreatment decisions on maintaining the patient’s comfortin terms of pressure redistribution, nutrition and hydration,skin care, pain assessment and management and resourceassessment.

Clinicians caring for terminal patients with pressure ulcers willfind this resource tremendously helpful.

EPUAP/NPUAP Publish NewPressure Ulcer Guidelines for

Palliative Care

Treatment


40 Healthy Skin

2.1. Use a general screening tool such as the Braden Scale,Norton Scale, Waterlow Scale, Braden Q (for pediatric patients), or other age-appropriate tool in conjunction with clinical judgment. (Strength of Evidence = C)

2.2. Use the Marie Curie Centre Hunters Hill Risk Assessment Tool, specific to individuals in palliative care, in conjunction with clinical judgment for an adult individual. (Strength of Evidence = C)

Assessment

Pressure Ulcer Management in Individuals Receiving PalliativeCare Patient and Risk Assessment

1. Reposition and turn the individual at periodic intervals, in accordance with the individual’s wishes and tolerance.(Strength of Evidence = C)

1.1. Establish a flexible repositioning schedule based on individual preferences and tolerance and the pressure-redistribution characteristics of the support surface. (Strength of Evidence = C)

1.2. Pre-medicate the individual 20 to 30 minutes prior to a scheduled position change for individuals who experience significant pain on movement. (Strength of Evidence = C)

1.3. Observe the individual’s choices in turning, including whether she/he has a “position of comfort,” after explaining the rationale for turning. (Strength of Evidence = C)

1.4. Comfort is of primary importance and may supersede prevention and wound care for individuals who are actively dying or have conditions causing them to have a single position of comfort. (Strength of Evidence = C)

1.5. Consider changing the support surface to improve pressure redistribution and comfort. (Strength of Evidence = C)

1.6. Strive to reposition an individual receiving palliative care at least every 4 hours on a pressure-redistributing mattress such as viscoelastic foam, or every 2 hours on a regular mattress. (Strength of Evidence = B)

1.7. Individualize the turning and repositioning schedule, ensuring that it is consistent with the individual’s goals and wishes, current clinical status, and combination of co-morbid conditions, as medically feasible. (Strengthof Evidence = C)

1.8. Document turning and repositioning, as well as the factors influencing these decisions (e.g., individual wishes or medical needs). (Strength of Evidence = C)

2. Consider the following factors in repositioning:2.1. Protect the sacrum, elbows, and greater trochanters,

which are particularly vulnerable to pressure. (Strength of Evidence = C)

2.2. Use positioning devices such as foam or pillows, as necessary to prevent direct contact of bony prominences and to avoid having the individual liedirectly on the pressure ulcer (unless this is the positionof least discomfort, per individual preference). (Strengthof Evidence = C)

2.3. Use heel protectors and/or suspend the length of the leg over a pillow or folded blanket to float the heels. (Strength of Evidence = C)

2.4. Use a chair cushion that redistributes pressure on the bony prominences and increases comfort for an individual who is seated. (Strength of Evidence = C)

Pressure Redistribution

1. Complete a comprehensive assessment of the individual. (Strength of Evidence = C)

2. Assess the risk for new pressure ulcer development on a regular basis by using a structured, consistent approach which includes a validated risk assessment tool and a comprehensive skin assessment, refined by using clinical judgment informed by knowledge of key risk factors (see Risk Assessment section). (Strength of Evidence = C)

Source:European Pressure Ulcer Advisory Panel and National Pressure Ulcer Advisory Panel. Prevention and treatment of pressure ulcers: quick reference guide. Washington DC: National Pressure Ulcer Advisory Panel; 2009.



1. Maintain skin integrity to the extent possible. (Strength of Evidence = C)

1.1. Apply skin emollients per manufacturer’s directions to maintain adequate skin moisture and prevent dryness. (Strength of Evidence = C)

1.2. Minimize the potential adverse effects of incontinence on skin. See Prevention section.

Skin Care

1. Strive to maintain adequate nutrition and hydration compatible with the individual’s condition and wishes. Adequate nutritional support is often not attainable when the individual is unable or refuses to eat, based on certain disease states. (Strength of Evidence = C)

2. Allow the individual to ingest fluids and foods of choice. (Strength of Evidence = C)

3. Offer several small meals per day. (Strength of Evidence = C)

4. Offer nutritional protein supplements when ulcer healingis the goal. (Strength of Evidence = C)

Nutrition and Hydration


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42 Healthy Skin

Pain management, odor control, and exudate control are theaspects of pressure ulcer care that tend to be most closely related to supporting the individual’s comfort.

1. Set treatment goals consistent with the values and goals of the individual, while considering family input. (Strength of Evidence = C)

1.1. Set a goal to enhance quality of life, even if the pressureulcer cannot be healed or treatment does not lead to closure/healing. (Strength of Evidence = C)

1.2. Assess the impact of the pressure ulcer on quality of life or the individual and his/her family. (Strength of Evidence = C)

1.3. Assess the individual initially and with any significant change in condition, to re-evaluate the plan of care. (Strength of Evidence = C)

2. Assess the pressure ulcer initially and with each dressing change, but at least weekly (unless the individual is actively dying), and document findings.(Strength of Evidence = C)

2.1. See Assessment and Monitoring Healing section for general assessment information.

2.2. Monitor the ulcer in order to continue to meet the goals of comfort and reduction in wound pain, addressing wound symptoms such as odor and exudate. (Strengthof Evidence = C)

3. Manage the pressure ulcer and periwound area on aregular basis as consistent with the individual’s wishes. (Strength of Evidence = C)

3.1. Cleanse the wound with each dressing change using potable water (i.e., water suitable for drinking), normal saline, or a noncytotoxic cleanser to minimize trauma tothe wound and help control odor. (Strength ofEvidence = C)

3.2. Debride the ulcer of devitalized tissue to control infection and odor. (Strength of Evidence = C)

3.2.1. Debride devitalized tissue within the wound bed or at edges of pressure ulcers when appropriate to the individual’s condition and consistent with the overall goals of care. (Strength of Evidence = C)

3.2.2. Avoid sharp debridement with fragile tissue that bleeds easily. (Strength of Evidence = C)

3.3. Choose a dressing that can absorb the amount of exudate present, control odor, keep periwound skin dry, and prevent desiccation of the ulcer. (Strength of Evidence = C)

3.3.1. Use a dressing that maintains a moist wound-healing environment and is comfortable for the individual. (Strength of Evidence = C)

3.3.2. Use dressings than can remain in place for longer periods of time to promote comfort related to the pressure ulcer care. (Strength of Evidence = C)

3.3.3. Use a dressing that meets the needs of the individual for overall comfort and pressure ulcer care. See section on Dressings. (Strength of Evidence = C)

3.3.3.1. Consider use of an antimicrobial dressing to controlbioburden and odor. (Strength of Evidence = C)

3.3.3.2. Consider use of a hydrogel to soothe painful ulcers. (Strength of Evidence = C)

3.3.3.3. Consider use of foam and alginate dressings to control heavy exudate and lengthen wear time. (Strength of Evidence = B)

3.3.3.4. Consider use of polymeric membrane foam for exudate control and cleansing. (Strength of Evidence = C)

3.3.3.5. Consider use of silicone dressings to reduce pain with dressing removal. (Strength of Evidence = B)

3.3.4. Protect the periwound skin with a skin protectant/barrier or dressing. (Strength of Evidence = C)

4. Control wound odor. (Strength of Evidence = C)4.1. Cleanse the ulcer and periwound tissue, using care to

remove devitalized tissue. (Strength of Evidence = C)4.2. Assess the ulcer for signs of wound infection:

increasing pain; friable, edematous, pale, dusky granulation tissue; foul odor and wound breakdown; pocketing at base; or delayed healing. (Strength of Evidence = B)

4.3. Use antimicrobial agents as appropriate to control known infection and suspected critical colonization. See Infection section. (Strength of Evidence = C)

4.3.1. Consider use of properly diluted antiseptic solutions for limited periods of time to control odor. (Strength of Evidence = C)

4.3.2. Consider use of topical metronidazole to effectively control pressure ulcer odor associated with anaerobic bacteria and protozoal infections. (Strength of Evidence = C)

4.3.3. Consider use of dressings impregnated with antimicrobial agents (e.g., silver, cadexomer iodine, medical-grade honey) to help control bacterial burden and odor. (Strength of Evidence = C)

4.4. Consider use of charcoal or activated charcoal dressingsto help control odor. (Strength of Evidence = C)

4.5. Consider use of external odor absorbers for the room, (e.g., activated charcoal, kitty litter, vinegar, vanilla, coffee beans, burning candle, and potpourri). (Strengthof Evidence = C)

Pressure Ulcer Care



1. Perform a routine pressure ulcer pain assessment every shift, with dressing changes, and periodically as consistent with the individual’s condition (see Pain Management section). (Strength of Evidence = B)

2. Assess pressure ulcer procedural and non-procedural paininitially, weekly, and with each dressing change. (Strength of Evidence = C)

3. Provide systematic treatment for pressure ulcer pain (see Pain Management section). (Strength of Evidence = C)

4. If consistent with treatment plan, provide opioids and/or non-steroidal antiinflammatory drugs 30 minutes prior to dressing changes or procedures, and afterward. (Strength of Evidence = C)

5. Provide local topical treatment for ulcer pain:• Ibuprofen-impregnated dressings may help decrease

pressure ulcer pain in adults; however, these are not available in all countries.

• Lidocaine preparations help decrease pressure ulcer pain.

• Diamorphine hydrogel is an effective analgesic treatmentfor open pressure ulcers in the palliative care setting. (Strength of Evidence = B)

Pain Assessment and Management

1. Assess psychosocial resources initially and at routine periods thereafter (psychosocial consultation, social work, etc.). (Strength of Evidence = C)

2. Assess environmental resources (e.g., ventilation, electronic air filters, etc.) initially and at routine periods thereafter. (Strength of Evidence = C)

3. Validate that family care providers understand the goals and plan of care. (Strength of Evidence = C)

Resource Assessment

6. Select extended-wear-time dressings to reduce pain associated with frequent dressing changes. (Strength of Evidence = C)

7. Encourage individuals to request a time out during a procedure that causes pain. (Strength of Evidence = C)

8. For an individual with pressure ulcer pain, music, relaxation, position changes, meditation, guided imagery, and transcutaneous electrical nerve stimulation (TENS) are sometimes beneficial. (Strength of Evidence = C)

003-056_65528_MedCal:Layout 1 5/4/10 7:41 AM


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Urinary Incontinence Assessment A Very Good Place to Start It may be no surprise – especially to healthcare professionals whowork with the elderly – that more than 65 percent of nursing homeresidents experience some type of urinary incontinence. In fact, it’sthe second most common reason – just behind dementia – that individuals enter long-term care.1

Survey Readiness



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BioCon™- 500 Bladder Scanner Safely Measures Bladder VolumeMinimize unnecessary catheterizationResearch has shown that 80 percent of urinary tract

infections acquired at healthcare facilities are associated

with an indwelling urethral catheter.1 This type of infection

is known as CAUTI, or catheter-associated urinary

tract infection.

Avoiding unnecessary catheter use is a primary strategy

for preventing CAUTI, and clinical guidelines recommend

the consideration of alternatives to catheterization.2

Bladder scanners can be used in place of a urinary

catheter to assess bladder volumes, and many

catheterizations can be avoided.3

1. Lo E, Nicolle L, Classen D, Arias A, Podgorny K, Anderson DJ, et al. SHEA/IDSA practice recommendation: strategies to prevent catheter-associated urinary tract infections in acute care hospitals. Infect Control Hosp Epidemiol. 2008;29:S41-S50.

2. Stokowski, LA. Preventing catheter-associated urinary tract infections. Medscape Nursing Perspectives. February 3, 2009.

3. Stevens E. Bladder ultrasound: avoiding unnecessary catheterizations. Med/Surg Nursing. 2005; 14(4):249-253.


To learn more about CAUTI prevention, visitwww.medline.com/eraseor contact your Medline sales representative.


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Despite its prevalence, however, knowledge on how best to assess and manage urinary incontinence has been lacking. In2005 in an attempt to change this, the Centers for Medicare &Medicaid Services (CMS) issued a surveyor guidance for incon-tinence and urinary catheters under F-Tag 315, which focusesheavily on incontinence assessment.

F-Tag 315 expects long-term care facilities to have systems andprocedures in place to ensure continence assessments aretimely and appropriate interventions are defined, implemented,monitored and revised as necessary within current standards of practice. F-Tag 315 places emphasis on treating urinary incontinence from the time of admission. The resident is to beevaluated at admission and whenever a change in cognition,physical ability or urinary tract function occurs. The intent of theguidance document is to ensure that:1

• Incontinent residents are identified, assessed and providedappropriate treatment to maintain as much normal urinaryfunction as possible

• Indwelling catheters are not used without medical justifica-tion; if not justified they should be removed

• Residents receive appropriate care to prevent urinary tract infections

Benefits of a Comprehensive Continence Assessment2

• Residents with reversible causes of urinary incontinence will get proper treatment, which in turn will help them maintain their independence.

• Staff will be able to better target time-consuming toileting assistance to residents who truly need it.

• The facility may score better on publicly reported qualitymeasures that reflect the quality of incontinence care.

Components of a urinary incontinence assessmentAssessment of incontinence is the key focus of the CMS guidance and emphasizes identification of the cause. Assessmentshould include a history with documentation of previous treat-ment, a physical exam and clinical testing. The clinician assessing the resident also should consider the side effects ofmedication as reasons for incontinence and other bladder-relatedconditions, such as urinary retention.1,3 Although not specificallymentioned, the assessment is often best accomplished with thehelp of nursing staff (particularly CNAs) who can provide more detailed resident information.3

Once the resident is assessed, a plan of care should be developed to optimize bladder function and to prevent the useof an indwelling catheter or urinary tract infection. Each planmust be specific to the resident and his or her type of incontinence and include the rationale for a specific treatmentplan or management system.1

History, physical and testing. In a study of 30 nursinghomes, the Borun Center for Gerontological Research, a jointventure between the David Geffen School of Medicine at the Uni-versity of California – Los Angeles (UCLA) and the Los AngelesJewish Home, found that staff obtained medical histories for mostincontinent residents, but less than 14 percent of those residentsreceived comprehensive physical exams. Rarer still wererecommended dipstick urinalyses, post-void residual measure-ments and 24-hour voiding records.2

Post-void residual (PVR) testing determines the amount of residual urine left in the bladder after a voluntary void. PVR measurement helps identify individuals in need of further medicalevaluation.4 Elevated PVR levels, signified at greater than 150 to 200 ml, can increase the risk of urinary retention and urinarytract infection.1

There are two methods for measuring PVR: urinary catheterizationand bladder ultrasound. There are many disadvantages of usingcatheterization, including patient discomfort, risk of urethraltrauma, emotional distress and urinary tract infection. Catheteri-zation also can be time-consuming.4 These downsides of directurinary catheterization, are compelling in the frail elderly and arerelated to the low rate of PVR measurement.3

The safer alternative is the use of noninvasive portable ultrasound measurement of PVR. The device is easy to use, it’snon-invasive, time-efficient, minimizes medical waste and suppliesand determines when catheterization is medically appropriate.Portable 3-D ultrasound devices also have been shown to pro-vide highly accurate measurements of bladder volume.4

Uses for Portable Bladder Ultrasound5

• Measuring post-void residual urine volume• Verifying an empty bladder or urinary retention• Identifying an obstruction in an indwelling urinary catheter• Evaluating bladder distension and determining if

catheterization is needed



48 Healthy Skin

References1. Newman DK. Urinary incontinence, catheters and urinary tract infections: anoverview of CMS Tag F 315. Ostomy Wound Management. 2006; 52(12):34-36.

2. Incontinence Management. Borun Center website. Available at:http://www.geronet.med.ucla.edu/centers/borun/modules/Incontinence_manage-ment. Accessed April 21, 2010.

3. Lekan-Rutledge D. The new F-Tag 315. Journal of the American Medical DirectorsAssociation. 2006; 7(9):607-610.

4. Kelly C. Evaluation of voiding dysfunction and measurement of bladder volume.Reviews in Urology. 2004; 6(Suppl 1):S32-S37.

5. Patraca K. Measure bladder volume without catheterization. Nursing. 2005;35(4):46-47.

6. Newman DK. Using the BladderScan for bladder volume assessment.Seek Wellness website. Available at: http://www.seekwellness.com/incontinence/using_the_bladderscan.htm. Accessed April 21, 2010.

Medication side effects.6 In addition to other factors, sideeffects from some medications can contribute to incompletebladder emptying, primarily certain anticholinergics, tricyclicantidepressants, antipychotics, anti-Parkinson’s drugs, narcoticsand anesthetic agents. The clinician evaluating the residentshould review all medications and consult with the physician(s)regarding possible alternatives that would not contribute toincomplete bladder emptying.

Benefits of a urinary incontinence program4

In addition to increased dryness, benefits of implementing aurinary incontinence program at your facility include promotion ofmobility, range of motion, weight bearing, balance, skin integrity,bowel function, social interaction and emotional well-being.

Also, urinary incontinence researchers Johnson and Ouslanderrecommend that nursing homes market and promote theirurinary in continence services as a way to showcase their careand clinical achievements. They believe this kind of promotioncould be quite successful knowing that many families strugglewith urinary incontinence care before deciding on nursing homeplacement, and after admission, they express a high degree ofconcern about urinary incontinence care vocalizing their distressto the facility if this care is unsatisfactory.3

In one nursing home where the Duke School of Nursingimplemented a comprehensive urinary incontinence programcollaboratively with staff, the director of nursing reported thatfamily complaints on Monday mornings went from 20 to virtuallynone after implementing prompted voiding.

The director of nursing said having nurse aides administer theprompted voiding program on 12-hour shifts seven days a weekensured continuity of care and good outcomes. In addition, theaides took pride in their role, calling themselves the “Quality CareCNAs,” reflecting their ownership of the program.

Focusing on evidence-based clinical services such as urinaryincontinence care certainly has the potential to distinguish high-quality facilities and attract new admissions in competitivemarkets while gaining community recognition.3

Indicators of aQuality Urinary

IncontinenceAssessment

The following are quality indicators for a basic residentassessment of urinary incontinence. These indicators weredeveloped as a collaboration among the Borun Center,other UCLA colleagues and researchers at RAND, asouthern California think tank.

1 a nursing home resident has urinary incontinenceon admission or the new onset of urinary incontinencethat persists for over one month,

IF

a targeted history should be obtainedthat documents each of the following:• Mental status• Characteristics of voiding• Ability to get to the toilet• Prior treatment for urinary incontinence• Importance of the problem to the resident

THEN

2 a nursing home resident has new urinaryincontinence that persists for over one month orurinary incontinence on initial assessment,

IF

the following tests should be obtained orthere should be documentation explaining why thetest was not completed:• Dipstick urinalysis• Post-void residual volume• 24-hour voiding record

THEN

HealthySkin16.3-mag:Layout 1 5/4/10 11:59 AM

2

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It’s another level of

comfortand

protection

1 Shannon R., Fisher K. A Nursing and Rehabilitation Center Project in New Jersey: Expected Value of Remedy Skin Care and Restore Briefs in an At-Risk Resident Population for Pressure Ulcer and Incontinence-Associated Dermatitis Prevention. ©2010 Medline Industries, Inc. Medline

is a registered trademark of Medline Industries, Inc.

Purchase a 12-month supply of Restore briefs and receive one month free. For details contact your Medline representative or call 1-800-MEDLINE.

Restore® briefs provide maximum dryness with skin nourishment built right in.

Restore briefs not only keep wetness away from your residents’ skin, they also help provide protection from skin irritation with a coating of Medline’s Remedy®

Skin Repair Cream on the inner liner. Using a combination of the Remedy skincare line and the Restore brief was shown to keep the pressure ulcer incidence rate and incontinence-associated dermatitis prevalence rate down according to a retrospective,cohort study conducted at Meridian Nursing and Rehabilitation in Brick, NJ.1

The brief’s absorbent UltraCare core helps provide maximum dryness for improved comfort and protection. And the cloth-like outer cover is comfortable against the skin, helping to minimize rash or irritation.

003-056_65528_MedCal:Layout 1 5/4/10 5:15 PM

10 TipsBy Lorri A. Downs, BSN, MS, RN, CIC

Most caregivers have experience with bathing residents; however,the uncooperative resident can present safety challenges tothemselves and employees.

Here are 10 tips to make the bath experience easier and

more enjoyable.

1. Eliminate anything that could make the bath experience uncomfortable. Provide the bath in a private area, keepingthe resident warm and covered. This can help reduce embarrassment and increase cooperation.

2. Move slowly and communicate clearly to express reassurance.

3. Consistently assign the same caregiver to the same residentto help develop trusting relationships.

4. Take time to ask about the individual’s bathing preferences to personalize the experience, decrease anxiety and increase participation.

5. Remain flexible, using different bathing techniques to meetindividual needs and preferences.

6. Develop policies and procedures that allow caregivers todefer bath time in cases when the resident is feeling uncomfortable. Educate the resident’s family and explain this plan of care. Forced bathing does not work and only increases the resident’s anxiety.

7. Create a home-like atmosphere in the bathing area. A familiarenvironment creates a pleasant experience and encouragesparticipation.

8. Save time by individualizing the bathing experience. Whenthe resident participates and the experience is person-centered, it actually facilitates the bathing process to move more quickly and efficiently with little or no conflict.

9. Adjust bathing terminology accordingly. Using the word“bath” invokes a negative feeling in some residents. Instead invite the resident to “wash up,” which may sound less threatening.

10. Perform hair washing separately. Create a “beauty shop” experience, which is less threatening because the resident is fully clothed.

for Bathing the Uncooperative Resident

50 Healthy Skin

Special Feature


Hotline Hot Topic

By Elizabeth O'Connell-Gifford, BSN, MBA, RN, ET/CWOCN, DAPWCA

Question:We are looking for some ideas for an independent 80-year-old female patient who would qualify for skilled care, butrefuses to leave her home. She fell 18 months ago andfractured her femur. She had an ORIF done, completedrehab, and then returned home with limited mobility. Sheis a Medicaid patient, so she only qualifies for certaindisposable incontinence and skin products and limitednurse’s aide visits. Her 60-year-old daughter helps on theweekends.

The patient has two open areas on her buttocks measur-ing 4 cm x 3 cm x 0.4 cm. The aide reports that the patientis usually lying in a very saturated brief. Her hydrocolloiddressing usually has fallen off due to the excessive moisture.

The patient is essentially bedbound when no one is thereto help her. The aide cleanses the patient with antibacter-ial soap and helps her to the toilet. Before leaving, the aideapplies a thick coating of petrolatum-based ointmentand a disposable brief.

Answer: First, identify the issues as skin-related secondary toincontinence and mobility, products inappropriate for thepatient, budget restraints, patient dignity concerns andeducation deficits.

Incontinence is defined by the Centers for Medicare &Medicaid Services (CMS) as the involuntary loss or leak-


Regular Feature


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age of urine.1 Years ago we may have dealt with theincontinence by placing a foley catheter. Today, the evi-dence-based data reveals that catheters put patients atrisk for developing a catheter-associated urinary tractinfection (CAUTI).

It sounds like the patient has functional incontinence.Obtaining an evaluation for improving mobility and accessto a commode when she is by herself would be a goodidea. A thorough assessment of the incontinence prob-lem should be conducted as well.

The low-cost brief the patient has been wearing, whichconsists of cotton fluff and a plastic exterior, can be a hos-tile environment for the skin. The cotton fluff tends to lumptogether and absorb very little, allowing urine, fecalenzymes and bacteria to assault the skin. The plasticbacking is not breathable and contributes to the moistureload, which leads to skin breakdown. The petroleum-based product being used is greasy, can be occlusiveto the skin and can clog the facing/lining of the brief,decreasing absorbency. Newer incontinence managementproducts offer a more cost-effective and efficient alternative.2

A newer disposable product called the Restore® brief notonly keeps wetness away from patients’ skin, it alsohelps provide protection from skin irritation with a coatingof Remedy Skin Repair Cream on the inner liner. The brief’sabsorbent core helps provide maximum dryness forimproved comfort and protection.

Using a combination of the Remedy skincare products andthe Restore brief was shown to keep the pressure ulcerincidence rate and incontinence-associated dermatitisprevalence rate down in a retrospective, cohort study con-ducted at Meridian Nursing and Rehabilitation in Brick, NJ.3

Another important factor would be making sure the brief issized correctly to prevent leakage and skin damage. Thereis a myth that larger briefs absorb more urine or are easierto apply. Oversized briefs require more frequent changingand allow urine to flow out onto the sheets and underpads.Appropriate sizing and a brief that does the job will pro-mote patient dignity, self-esteem, healthier skin and willprove cost-effective in the long run.

Open-airing the buttock and perineal area at night with asuper-absorbent disposable underpad, such as Ultra-sorbs® AP, wicks moisture away from the patient. A stan-dard size pad can absorb a liter of fluid, and the top liningdries in seven minutes. I also recommend the zinc-basedbarrier cream, Calazime®, which acts as a “dressing ina tube.”

Although Medicaid does not reimburse for higher endproducts, the continuing damage to the skin and the factthat the wounds are not healing because they are swim-ming in urine every night, increases the cost of wound careand the frequency of nurse’s aide visits. The cost of careshould be evaluated as a whole with a focus on prevention.

Newer incontinence management products offer a more cost-effective and efficient alternative.

52 Healthy Skin


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References1.CMS Manual System: Revision of Appendix PP – Section 483.25(d) – Urinary

Incontinence, Tags F315 and F316 Tag. Available at: http://www.oashs.org/ content/PDF/2005/incontinence_guidance.pdf. Accessed April 23, 2010.

2.Rothfeld AF & Stickley A. A program to limit urinary catheter use at an acute care hospital. American Journal of Infection Control. 2010. In press.

3.Shannon R., Fisher K. A nursing and rehabilitation center project in New Jersey: expected value of Remedy skin care and Restore briefs in an at-risk resident population for pressure ulcer and incontinence-associated dermatitis prevention. Available at: http://www.medline.com/wound-skin-care/lit/Approved%20New%20Jersey%20Remedy-Restore%20Study.pdf. Accessed April 15, 2010.

About the author

Elizabeth O'Connell-Gifford, BSN, MBA, RN, ET/CWOCN,DAPWCA is a board-certified wound, ostomy and continence nurse.

Remedy is a registered trademark of Medline Industries, Inc.Restore is a registered trademark of Medline Industries, Inc.Ultrasorbs is a registered trademark of Medline Industries, Inc.Calazime is a registered trademark of Medline Industries, Inc.

Are you facing a skin or wound caredilemma with a patient or resident?

Call Medline’s Educare Hotline at 888-701-SKIN (7546) to discuss a wound care issue with one of our experienced wound care nurses. The hotline is availableMonday through Friday, 8 am to 5 pm, Central Time.

PERIOPERATIVE PRESSURE ULCER EDUCATION.MORE IMPORTANT THAN EVER BEFORE

I have seen an increase in

the number of legal issues

linking facility-acquired pressure

ulcers to post-surgical patients.

A pressure ulcer program for the

OR is more critical than ever.”

Diane Krasner, PhD, RN, CWCN, CWS, BCLNC, FAAN

Medline’s 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

“


To learn more about Medline’s Pressure Ulcer Prevention Programsfor long-term care, acute care andperioperative services, call your Medline representative or visitwww.medline.com/pupp-webinar.


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We found THREE more ways to make it even better.

We’re obsessed with engineering new and bettertechnology for healthcare workers. So after we revolutionized the outdated Foley catheter tray with a unique, one-layer system design, we immediatelyturned our attention to addressing how we couldmake it even easier to use. We studied how the tray was being used in the field. The result was three more great improvements.

Combined with the previous innovative tray redesignand comprehensive ERASE CAUTI education, thesethree new features help to improve patient safety andquality, while reducing avoidable costs associated withwaste and urinary tract infections.

To learn about the ERASE CAUTI system, as well asother strategies for minimizing the risk of CAUTI, signup for a free Innovation in the Prevention of CAUTI webinar at www.medline.com/erase/webinar.



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A checklist that fits better in the medical recordThe reformatted checklist is smaller, makingit easier to fit in the patient chart or medicalrecord. It is also available as an attachmentfor electronic documentation.

Education you’ll want to present to your patientThere’s nothing like the new Patient Education Care Card. Designed to lookand feel like a “Get Well Soon” card, ittells patients about catheterization sothey know you are providing them thebest care possible.

1

2

3

Real photography on the outside – so you know exactly what’s insideA photo on the package helps identify thecontents of the kit, serves as an educationaltool for the clinician and can be used todiscuss the procedure with the patient.Also, the label opens up to a booklet withstep-by-step instructions and helpful tipsfor the clinician.


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56 Healthy Skin

Sticky Wickets thatCommonlyOccur in

Wound CareLawsuits

6



With wound care litigation on the rise, it is prudent forhealthcare professionals and facilities to engage inpreventive legal care.1 One approach is to analyze com-mon problems that occur in wound care lawsuits. Basedon a review of more than 40 legal cases, six sticky wicketsand approaches for managing them are identified andelaborated on here.

The Six Sticky Wickets1. 24/7 coverage, holidays and vacations2. Scope of practice3. Symptom management4. SCALE2

5. Communication to the patient’s circle of care and other healthcare professionals

6. Documentation

1. 24/7 Coverage, Holidays and VacationsThe emerging standard of care is to provide wound careexpertise 24/7 for assessments, consults or other rec-ommendations. It is less and less acceptable for a woundpatient who is admitted on a Friday, for example, to waituntil Monday morning for a wound consult. Facilitiesshould have a protocol or some systematic method forwound care services to be delivered in a timely manner.

Options include:• Standing orders or guidelines• Cross training staff to cover (e.g., hospitalists

in acute care; supervisors in long-term care)

In addition, there should be a formalized plan to coverwound services when the “wound nurse” or “woundphysician” is on vacation.

In several recent legal cases I have personally reviewed,the failure occurred when the wound nurse was on vaca-tion. There were significant delays in treatment thatimpacted the plan of care and were difficult to defendin litigation.

2. Scope of PracticeWound care practitioners who practice outside of thescope of their practice – while often admired for theircommitment – open themselves up to serious problemsshould a lawsuit be brought against them or their facility(vicarious liability).

Scope of practice is determined by statutory law (statepractice acts) and varies from state to state. The follow-ing are examples of common scope of practice problemsin wound care that have the potential for wound carepractitioners to lose their license to practice through theadministrative court system:

Example 1. A registered nurse debriding to bleeding tis-sue (wide excision) in a state where RN debridement isrestricted to devitalized tissue. Check with your stateboard of nursing to seek clarification regarding specifics.

Example 2. A non-physician or non-physician extenderordering a prescription topical (e.g., an enzymatic debrider– even by protocol) or an FDA device (e.g. NPWT).

Example 3. In any setting, an LPN/LVN wound nurseassessing wounds and carrying out wound care perprotocol, without ongoing assessments and oversight bya licensed provider (nurse, physical therapist, physicianor physician-extender). LPNs/LVNs monitor; licensedproviders assess.

By Diane L. Krasner, PhD, RN, CWCN, CWS, MAPWCA, FAAN

Special Feature

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58 Healthy Skin

3. Symptom ManagementHolistic patient care requires that patient-centered con-cerns, such as pain management or nutritional support,be addressed by the interprofessional wound team.Excellent local wound care in the absence of total patientcare can be problematic if a lawsuit is filed. Recently, largeadd-on awards have been won for lack of attention topain management in several wound cases (pain and suf-fering awards). Punitive damages have been awarded incases for lack of attention to nutritional support, consid-ered “elder abuse.”

Timely consultation with pain specialists, dietitians orother providers based on an individual’s assessed needsimproves patient outcomes and decreases the risk oflegal problems.

4. Skin Changes At Life’s End (SCALE)Not all wounds are healable,including those wounds associ-ated with Skin Changes At Life’sEnd.1 Failure to acknowledge anon-healable wound in the plan of care and not record-ing that wound in the patient’s medical record creates asticky wicket.

For example, using a boilerplate care plan that states“wound will be healed in 90 days,” when the woundis non-healable, makes the case almost impossible todefend in a lawsuit situation.

In addition, there should be discussion with the patientand his or her circle of care regarding the non-healingnature of the wound. This discussion should be docu-mented in the patient’s medical record.

To download a copy of the SCALE Final ConsensusStatement and related documents, go to www.gaymar.comunder Clinical Support & Education.

5. Communication to the Patient’s Circle of Care and Other Healthcare Professionals

When patients and members of their circle of care(spouses, significant others, caregivers) are included inhealthcare discussions and decision-making, they areless likely to sue. “Lack of knowledge about pressureulcers fuels unrealistic expectations about their treat-ment and prognosis and could set the stage forpotential litigation.”1

Facilities should have quality management or risk man-agement teams who can train and assist wound careclinicians in communicating with patients and their circleof care. Each individual needs to know what level ofcommunication they are responsible for.1

6. DocumentationThe number one sticky wicket in wound care lawsuits isincomplete or missing documentation. The most impor-tant strategy for preventive legal care is documentation.Good documentation is comprehensive, consistent,concise, chronological, continuing and also reasonablycomplete.1

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About the author

Dr. Diane L. Krasner is a wound and skincare consultant in York, Penn. She workspart-time at Rest-Haven York, is leadco-editor of Chronic Wound Care(www.chronicwoundcarebook.com) andserved as co-chair of the SCALE Paneland corresponding author of the SCALE

Final Consensus Statement. You may reach Dr. Krasner [email protected].

What is a

sticky wicket anyhow?The term sticky wicket comes from the British gamecricket and refers to “a pitch that has become wetbecause of rain and therefore on which the ballbounces unpredictably.”3 In common parlance, stickywicket has come to refer to “a difficult or unpredictablesituation.”3

I have frequently observed the following documentationproblems during chart reviews, and they create stickywickets for wound care defense:

• Inconsistent documentation of wound size,stage or location from one provider to another:

ExampleThe physician documents:2 x 3 cm Stage II Sacral decub

On the same patient’s chart, the nurse writes:5 x 6 x 2 Stage IV L hip pressure ulcer

• Incomplete documentation of informationrequiring detail:

ExampleOrder reads: Specialty bed & chair cushion(This order is too vague.)

Order needs to list specific types of products: e.g., low air loss mattress replacement & air-filled chair cushion

• As the risk assessment score changes for a patient (e.g., Braden Scale score falls from 18 to 13), there is no documentation of a change in the plan of care.

ConclusionGood preventive legal care for wound care involves plan-ning and preparing so that unpredictable situations areavoided. Addressing the “Six Sticky Wickets that Com-monly Occur in Wound Care Lawsuits” can help protectyou and your facility from litigation.

References1.Ayello EA, Capitulo KL, Fife CE, Fowler E, Krasner DL, Mulder G, et al. Legal

issues in the care of pressure ulcer patients: key concepts for healthcare professionals: a consensus paper from the International Expert Wound Care Advisory Panel. J Palliat Med. 2009;12(11):995-1008. Available at: http://www.medline.com/media-room. Accessed April 13, 2010.

2.Sibbald RG, Krasner DL, Lutz JB, et al. Skin Changes at Life’s End: Final Consensus Statement. October 1, 2009. Available at: http://www.gaymar.com. Accessed April 13, 2010.

3.Wiktionary website. Available at www.wiktionary.com. Accessed April 13, 2010.

© 2009 Diane L. Krasner


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Join us for this webcast presentation as two industry experts bring you critical informa-tion on how the utilization of the nursing process and proper documentation are vital components in maintaining the standard of care and avoiding litigation.

Dr. Caroline Fife is the Chief Medical Officer of Intellicure, Inc. and isan Associate Professor within the Department of Medicine, Divisionof Cardiology at the University of Texas Medical School at Houstonand Director of Clinical Research at the Memorial Hermann Center forWound Healing and Hyperbaric Medicine. She has served on theBoards of the American Academy of Wound Management and the Association for the Advancement of Wound Care. She is the co-editor of the textbook, "Wound Care Practice" and is the authorof many scientific papers.

Kevin Yankowsky is a partner in the health law litigation group of Fulbright & Jaworski L.L.P.’s Houston office. A true trial lawyer,Kevin’s trial practice encompasses virtually all types of civil litigationfacing the healthcare industry. In addition to his extensive courtroom experience, he advises on Joint Commission investigations, hospitalcommittee and medical peer review matters.

LEGAL IMPLICATIONS OF PRESSURE ULCERS

1 Contact Hour


To view this webcast visitwww.medlineuniversity.com

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HEELMEDIX™ Heel Protector Pressure relief and skin protection all in one

The heels are the most common site for facility-acquired pressure ulcers in long-termcare, and the second most common site overall.1 According to clinical experts, the mosteffective aspect of pressure ulcer prevention for heels is pressure relief, also known as offloading.1,2 Offloading is achieved with the use of pillows or heel protection devices thatrelieve pressure by elevating the heel.

The HEELMEDIX Heel Protector is designed to help eliminate pressure, friction and shear on the skin by elevating the heel. Made of soft, suede-like material on the inside and easy-to-clean nylon on the outside. Adjustable straps are soft against vulnerable skin. Includes a mesh laundry bag with patient ID label to simplify washing and sorting.

Mention this ad to receive a 10 percent discount on your first order.

Contact your Medline sales representative or call 1-800-MEDLINE.

Relieve Pressure on Vulnerable Heels


1Fowler E, Scott-Williams S, McGuire JB. Practice recommendations for preventing heel pressure ulcers. Ostomy Wound Management. 2008;54(10):42:48.

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

Open back providesmaximum ventilation


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62 Healthy Skin

The CNO Perspective:


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By Connie Yuska, MS, RN, CORLN

One of the major responsibilities of the chief nursing officer(CNO) is to lead initiatives and remove barriers to enablethe bedside nurse to deliver high quality, safe patient care.Since the Medicare payment implications for pressure ul-cers as a secondary diagnosis if acquired during a hos-pitalization went into effect October 1, 2008, muchactivity has centered on education programs and use ofappropriate products; all with the goal of reducing hospi-tal-acquired pressure ulcers. The focus of work regardingeducation and reporting of outcomes has been takingplace at all levels, from the staff level to physicians to thehospital board.

CNOs develop targeted communication to a variety ofstakeholders in the institution; however, the boards ofdirectors at hospitals across the country are an especiallyinterested audience. Over the past decade, there hasbeen an increasing focus on the quality of care providedin hospitals and a corresponding shift in attention to qual-ity and safety at the board level.

U.S. healthcare quality initiativesThe drive for transparency in outcomes, coupled withtargeted attention on quality and safety has fueled thisresponse. The 1990s saw rising healthcare costs, alongwith increasing demands from employers and third-partypayers to improve efficiency, lower costs and improvequality.1 Another significant event that occurred to drivethe quality movement was the creation of the NationalQuality Forum (NQF) in 1999. The goal of the organiza-tion was to develop and implement a national strategy forhealthcare quality measurement and reporting.1 Today,the NQF has merged with the National Committee for

Quality Health Care (NCQHC) to become an organizationof health industry leaders focused on promoting publicawareness of solutions to problems confronting theAmerican healthcare system.

Two reports issued by the Institute of Medicine focusedon quality issues in the healthcare system. The first, ToErr is Human: Building a Safer Health System, highlightedthe number of preventable medical events that occur inthe United States each year. Pressure ulcers were amongthe most common preventable events listed. The secondreport, Crossing the Quality Chasm: A New Health Systemfor the 21st Century addressed restructuring the entirehealthcare system to make better use of availableresources and to provide better patient care. This reportfocused on patients with chronic conditions. A recom-mendation in the To Err is Human report, which en-couraged large companies to use employer purchasingpower to promote advances in healthcare quality andsafety, prompted the formation of The Leapfrog Group inlate 2000. The Leapfrog Hospital Rewards Programmeasures hospital performance in key areas and providesinformation to member employers and consumers toassist them in making an informed choice when choosinga healthcare provider.

Getting the board up to speedThe growing demand for improved quality and safetyin the American healthcare system from consumers, gov-ernment agencies, insurers and accrediting bodies placesan increased responsibility on the board of directors toensure the hospital achieves quality outcomes. Boardmembers are trying to understand what is happening at

Prevention


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the bedside. Their responsibilities include ensuring qualitysystems are in place and making decisions regard-ing the al location of resources. It is the CNO’sresponsibility to present the data and describe theenvironment that is needed to ensure that the boardunderstands the issue and will approve programs andproducts nurses at the bedside need to reduce theincidence of pressure ulcers.

Often, hospital board members lack medical background.Many come from a manufacturing environment where thegoal is “zero defects.” Therefore, they may find it difficultto understand how a patient can enter a hospital for careand acquire a pressure ulcer.

Board discussions should include an outline of a compre-hensive plan to educate all nursing staff on the importanceof skin assessment and care, protocols that includeassessing the patient using a validated scale, identifica-tion of high-risk patients and plans to put the patient on acare pathway that will prevent development of a pressureulcer. The CNO also should lead a conversation about theinternal systems in place to prevent pressure ulcers. Thesesystems will include identifying the roles of healthcareteam members, including the physician, nurse, patientcare technician, physical therapist, dietitian and socialworker. In addition, the CNO will find it helpful to presentan overview of a selection process for evidence-basedproducts shown to be effective in protecting the skin todecrease the possibility of developing a pressure ulcer.This demonstrates the value of choosing evidence-basedproducts shown to be effective through research. Finally,a methodology for capturing and reporting data related tothe incidence of pressure ulcers, as well as measurementsfor the amount of learning that occurred from the educa-tion program, should be presented.

The board also will be very interested in the financialreality of non-payment from the Centers for Medicare &Medicaid Services (CMS) for hospital-acquired pressureulcers and the potential impact that will have on thehospital’s financial results. As such, a brief overview ofthe systems to support documentation and coding wouldbe appropriate.

The metrics related to pressure ulcer incidence shouldalso be included on a quality scorecard and be comparedto national benchmarks for pressure ulcer incidence. Formany, benchmarks to lower pressure ulcer incidence willbe built into the nursing strategic plan under the qualityof care section. This will ensure that the metric will befollowed by the board on an ongoing basis.

The goal should be to encourage the board to establishpressure ulcer reduction as a strategic priority. The targetof reducing pressure ulcers should be communicated toboard members, administration, medical directors, physi-cians, other providers, staff and patients and their families.Outcome data also should be communicated regularly toall of the aforementioned groups so progress can betracked and necessary plan modifications can be made.

Building a culture that values transparency and supportseducation and the use of appropriate products from theboard level to administration to the staff will be effective inachieving the goal of reducing facility-acquired pressureulcers and improving the quality of care providedto patients.

Reference1. Getting the Board on Board: What Your Board Needs to Know About Quality

and Patient Safety. Oakbrook Terrace, Ill.: Joint Commission on Accreditationof Healthcare Organizations, 2007.

PressureUlcer Prevention

64 Healthy Skin


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“Systematic efforts at education, heightened awarenessand specific interventions by interdisciplinary healthcareteams have demonstrated that a high incidence of pressure ulcers can be reduced.1 The main challenges to having an effective pressure ulcer prevention programare: lack of resources; lack of staff education; behavioralchallenges; and lack of patient and family education.2

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

The Pressure Ulcer Prevention Program from Medline will help you 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 result in better patient care

This has been a great learning experience for

our staff and for our facility as a whole. I am

thankful Medline had this program and that we

were able to access it. I can’t imagine recreating

this wheel!”

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

For more information on the Pressure Ulcer Prevention Program, contact your Medline representative, call 1-800-MEDLINE or visitwww.medline.com/pupp-webinar to register for a free informational webinar.

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.

JOIN THE PROGRAM TO REDUCE PRESSURE ULCERS

We’ve made pressure ulcer prevention easy.

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Announcing New Online Skin & Risk Assessment Competency

The Latest Addition to Medline’sPressure Ulcer Prevention Program

Medline’s Pressure Ulcer Prevention Program – an educational initiative aimed at reducing the inci-dence of pressure ulcers – has added an interactiveonline competency to allow nurses to demonstratewhat they’ve learned in a virtual clinical setting. This approach provides consistency, as eachlearner performs the same assessments.

James is a 44-year-old male whois recovering from a heart attack.

The learner proceeds through the compe-tency using the computer mouse to com-

plete each step – from dispensing handsanitizer at the wall unit to pulling back the

bed linens and patient gown, performingassessments on three separate patients.

An illustrated hand replaces the usualmouse arrow on the screen.

66 Healthy Skin

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At the end of each skin assessment, thelearner completes the Braden Scale todetermine the patient’s level of risk forpressure ulcers.

Sarah is in a coma with a naso-gastricfeeding tube. She has a visible wound on her right arm.

When the learner clicks on Sarah’sarm, a close-up photograph of her

wound and a related multiple choicequestion appear on the screen.

The only way to access the Skin and RiskAssessment Competency is by joining thePressure Ulcer Prevention Program. Visitwww.medline.com/PUPP-webinar to sign upfor an informational webinar to learn more.(See back cover for webinar dates.)

Prevention


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68 Healthy Skin



NUTRITIONAL SUPPLEMENTS

WHAT APPROACH IS BEST FOR YOUR RESIDENT?

Treatment

chewing is compromised or an obstruction prevents foodfrom passing through the digestive system. Decidingwhether to use parenteral or enteral feeding is very muchpatient-specific and should be made after consultation withappropriate members of the treatment team. Informationfacilitating the decision may be gleaned from the numerousclinical studies directed to the use of enteral feeding inpatients treated for trauma, burns, surgery, inflammatorybowel disease, pancreatitis, and protein-energy undernutrition. The following are highlights from several ofthese studies.

Trauma. According to a study published by Moore andJones in 1986, moderately injured trauma patients had asignificantly reduced incidence of pneumonia and intra-abdominal abscesses when fed enterally.1 The study con-sisted of two groups of patients – one group was fed achemically defined diet administered enterally via a jejunos-tomy, and the second group was fed parenterally withfluids containing only dextrose. Neither group included pa-tients with severe intra-abdominal injuries or severe pelvicfractures. The enterally fed group had significantly fewer

It can be challenging to properly nourish individuals whohave functional gastrointestinal tracts but are otherwiseincapable of consuming conventional food orally or in largeenough quantities to be nutritionally effective.

Three options are available for delivering the metabolic sup-port necessary to prevent starvation and the loss of leantissue that accompanies starvation. These include total par-enteral feeding (TPN), which is administered through an IV,enteral feeding, which is delivered directly to the stomachthrough a feeding tube, and oral supplementation withliquid concentrates.

Both parenteral and enteral feeding can adequately meetthe nutritional needs of patients; however, of the twooptions, enteral feeding has proven to be the moreeconomical approach that also is associated with fewerinfections and faster recovery time for the patient.

Applications of Enteral FeedingNutritional support is imperative when the patient’sgastrointestinal tract functions, but either swallowing or


70 Healthy Skin

As a result of these and other clinical studies, many traumacenters consider enteral feeding the preferred option inpatients whose gastrointestinal tract remains functional andcan be accessed at a suitable site.4

Burns. Enteral feeding is generally the preferred nutritionalsupport in patients suffering from severe burns and shouldbe started as early as possible to help reduce the develop-ment of gastroparesis – a condition of “delayed gastricemptying,” in which the stomach takes too long to emptyits contents.4

Surgery. Perioperative nutrition – that is, nutrition providedthrough the night before surgery, during surgery, andimmediately afterward – not only provides surgical patientswith the requisite nutrition, but also enhances their immunesystems, helping reduce complications.5 According to ahost of studies, determining which mode of feeding – par-enteral or enteral – is better appears to be influenced by thepatient’s nutritional status and the severity of the injury orillness. Kondrup et al. found that people with less severeillnesses and a low degree of existing malnutrition gainedlittle benefit from nutritional intervention.6 By contrast, indi-

intra-abdominal abscesses. After critics attributed thehigher rate of infections in the IV group to malnutrition in-duced by the parenteral diet, the study was repeated in theIV group patients.2 This time, the group was fed in twophases: in the first phase, they were randomly assigned toreceive enteral or parenteral feeding; and in the secondphase, all patients were fed parenterally. The repeated studyconfirmed the significant reduction in the incidence ofpneumonia and intra-abdominal abscesses in the enteral-fed group.

Similar results were noted by Kudsk et al. in a study pub-lished in 1992 for a subgroup of patients who had severeinjuries and a 25 percent or greater chance of developingsepsis.3 The injuries of this subgroup affected the intra-abdomen and multiple systems such as the chest, head,skeleton and/or abdomen. The study showed that the riskof infection was low in patients with mild injuries, irrespec-tive of whether they were fed enterally or parenterally. How-ever, in patients with severe injuries, the incidence of septiccomplications – namely pneumonia followed by intra-abdominal abscesses – increased six to 11 times inpatients fed parentally.



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Orange

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Liquid Protein mixes easily intopureed and mechanical soft foods,soups and beverages. One servingprovides 21 grams of protein (equal to nearly four servings of protein powder), plus arginine, leucine, glutamine and zinc to provide support during wound healing and for the immune system. One serving also provides 6mg of lutein, an antioxidant which promotes eyehealth and healthy skin.

Available in two tasty flavors: Citrus Berry Punch and Orange Créme.

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Nutrition FactsServing size: 1 fl. oz. (2 Tbsp) Servings per Container: approx. 32

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Total Fat 0g 0% Saturated Fat 0g 0%

Trans Fat 0g 0%

Cholesterol 0mg 0%

Sodium 20mg 1%

Potassium 30mg 0%

Total Carbohydrate 0g 0% Dietary Fiber 0g 0%

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Protein 21g 42%

Vitamin A 0% Vitamin C 363%

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Phosphorus 6% Zinc 60%

*Percent Daily Values are based on a 2,000 calorie diet


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Medline’s OptiumEZ monitor, manufactured by Abbott Diabetes Care, minimizes the variables that can affect glucose readings with its patented TrueMeasure® Technol-ogy. TrueMeasure Technology screens out common med-ications that may interfere with the accuracy of bloodglucose results. Individual foil wrapping ensures that thetest strips are not compromised by humidity, dust or dirt.

Advanced Technology Made Simple™ for the Post Acute Care Professional.

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viduals suffering from a greaterdegree of malnutrition or moresevere i l lnesses – such asindividuals about to undergohigh-stress surgical proceduressuch as pancreatectomy oresophagectomy – benefited themost and had fewer infectionsand non-infectious complica-tions when fed enterally.

Inflammatory bowel disease/Crohn’s disease. In individualsexperiencing severe attacks ofulcerative colitis, enteral nutri-tion has been shown to be a safeand effective way to delivernutrients. In a 1993 study byGonzález-Huix et al. concerning42 patients with severe acuteulcerative colitis, enteral nutritionwas compared with total par-enteral nutrition as an adjuncttherapy to steroids.7 Patients were randomly assigned toreceive polymeric total enteral nutrition or isocaloric, isoni-trogeneous total parenteral nutrition as the sole nutritionalsupport. Compared with the parenterally fed patients,patients receiving enteral nutrition had more than a 3.6-foldincrease in serum albumin and almost 75 percent feweradverse effects, including fewer post-operative infections.

For patients with active Crohn’s disease, several studies andmeta-analyses suggest that enteral nutrition is an effectivetherapy, though less effective than steroids. Althoughenteral nutrition is rarely used as the sole therapy for adults,it is regarded as the treatment of choice for children.8

Pancreatitis. In the inflammatory disease known as pan-creatitis, the pancreatic enzymes autodigest the gland. Atypical therapeutic regimen includes fluid replacement,bowel rest, parenteral nutrition and antibiotics. For patientstreated with this conventional therapy, resolution generally

occurs fairly quickly. In manysevere cases, however, patientsare unable to consume a normaldiet for several days after an acuteoccurrence of the disease. Forthis group, enteral feedingappears promising, as it offerseffective nutrition support.

Enteral feeding has been shownto reduce the incidence of infec-tions, the length of the patient’shospital stay and the patient’shospital costs. In 2004 Alsolaimanet al. reported on these benefitsfrom a study of 53 patients admit-ted for acute pancreatitis.9 Thepatients were randomized toreceive parenteral feeding or en-teral feeding via a nasojejunaltube. Relative to the parenteralgroup, the enterally fed patientswere on nutrition support for a

significantly shorter time – 6.7 days versus 10 days forparentally fed patients. The enterally fed group also had ashorter hospital stay – that is, an average stay of 14 daysversus 18 days. In addition, 80 percent of the enterally fedgroup transitioned to a normal diet without difficulty, com-pared to 63 percent for the parenteral group.

Protein-energy undernutrition. Managing the careof elderly, undernourished and frail patients remains achallenge. The determination that a patient suffers fromprotein-energy undernutrition (PEU) is typically made aftermeasurement of serum albumin, prealbumin and choles-terol, together with body mass index, weight loss, mid-armcircumference and suprailiac skinfold measurements.10

Enteral feeding is one means of providing adequate dietaryprotein to PEU patients, especially through oral supple-mentation with concentrated proteins. Protein-supple-mented enteral diets improve the nutritional status of the

NUTRITIONAL SUPPLEMENTS


74 Healthy Skin

patients; however, other treatment modalities such as muscle strengthening may be required to improve long-term outcomes.

Reducing the Incidence of InfectionsNumerous studies conducted with trauma and surgicalpatients show that the delivery of nutrients directly to thegut results in a lower rate of infection versus intravenousfeeding. Over the past two decades, researchers have triedto elucidate reasons for the lower incidence of infectionbetween enteral and intravenous feeding. Several hypothe-ses have been advanced.

One early hypothesis attributed the higher infection rate inintravenous feeding to “bacterial translocation” – defined asthe passage of viable bacteria from the gastrointestinal tractto extra-intestinal sites, such as the mesenteric-lymph-nodecomplex, liver, spleen and bloodstream. Promoting bacte-rial translocation are three major mechanisms: 1. intestinalbacterial overgrowth, 2. deficiencies in host immunedefenses, and 3. increased permeability or damage to theintestinal mucosal barrier.11

The concept of bacterial translocation originated from stud-ies conducted on rats fed a parenteral diet.12 The intestinalmucosa of the rats degraded, resulting in a “leaky gut” char-acterized by shorter villa, reduced cellular proliferation andlower levels of mucosal protein.4 Theoretically, the break-down of the intestinal mucosa provided a vehicle for bac-teria to translocate from the gastrointestinal tract to themesenteric lymph nodes in other parts of the body. Thistranslocation hypothesis has been proposed to explain themultiple organ failures and respiratory infections that occurin critically ill or injured patients. Results from human trials,however, fail to confirm the hypothesis.



Another hypothesis, which has presently gainedmore interest, involves the mucosa associated lym-

phoid tissue (MALT).4 MALT is part of the immune sys-tem and consists of localized lymphoid tissue found invarious sites in the body, including the gastrointestinal

tract, thyroid, breasts, lungs, salivary glands, eyes andskin. MALT produces immunoglobulin A (IgA), whichprotects both intestinal and extra-intestinal mucosa frompathogens.

MALT is found in Peyer’s patches, located in the smallintestine. Peyer’s patches are rich in immune cells includingmacrophages, dendritic cells, T-lymphocytes, and B-lym-phocytes – all of which are responsible for protecting theintestinal mucosa. When an antigen stimulates T-lympho-cytes and B-lymphocytes in Peyer’s patches, the sensitizedlymphocytes migrate to the mesenteric lymph nodes, wherethey proliferate. From the lymph nodes, the lymphocytespass into the bloodstream via the thoracic duct and travelto the gut and other MALT-containing sites where they pro-duce IgA and destroy the offending antigen.

Supporting this hypothesis are animal studies, which showthat a lack of enteral stimulation greatly reduces the pro-duction of IgA.13,14,15 One such study, conducted byBreda et al., demonstrates that when animals are fed par-enterally with no enteral stimulation, they have a significantreduction in mRNA specific for the production of MAdCAM-1 – a molecule involved in attracting B-lymphocytes andT-lymphocytes to Peyer’s patches.13 The concomitantlylower production of MAdCAM-1 resulted in fewer lympho-cytes and a reduction in the size of lymphocytes alreadypresent. In broad terms, this hypothesis suggests that inenteral feeding, use of the gastrointestinal tract, where 80percent of the immune system is localized, activates theimmune system, accounting for the reduction in post-surgical and other complications.16

References1. Moore EE, Jones TN. Benefits of immediate jejunostomy feeding after major

abdominal trauma – a prospective randomized study. J. Trauma. 1986; 26:874-881.2. Moore FA, Moore EE, Jones TN. TEN vs. TPN following major abdominal trauma –

reduces septic morbidity. J. Trauma. 1989; 29:916-923.3. Kudsk KA, Croce MA, Fabian TC, et al. Enteral vs. parenteral feeding: Effects on

septic morbidity following blunt and penetrating trauma. Ann. Surg. 1992; 215:503-513.

4. Kudsk KA. Beneficical effects of enteral feeding. Gastrointest Endosc Clin N Am. 2007; 17:647-662.

5. Bengmark S. Enteral nutrition in HPB surgery: past and future. J Heptabiliary Pancreat Surg. 2002; 9:448-458.

6. Kondrup J, Rasmussen HH, Hamberg O. et al. Nutritional risk screening (NRS 2002):a new method based on analyses of controlled clinical trials. Clin Nutr. 2003; 22(3):321-336.

7. Gonzalez-Huix F, Banares-Fernadez F, Esteve-Comas M, et al. Enteral versus parenteral nutrition as adjunct therapy in acute ulcerative colitis. Am J Gatroenterol1993; 88:227-232.

8. Lochs H. To feed or not to feed? Are nutritional supplements worthwhile in active Crohn’s disease. Gut. 2006; 55:306-307.

9. Alsolaiman MM, Green JA, Barkin JS. Should enteral feeding be the standard of care for acute pancreatitis. Am J Gastroenter. 2004; 98:2565-2567.

10. Sullivan DH, Bopp MM, Roberson P. Protein-energy undernutrition and life-threatening complications among the hospitalized elderly. J Gen Intern Med. 2002; 17:923-932.

11. Berg R. Bacterial translocation from the gastrointestinal tract. Trends in Microbiology.1995; 3(4):149-154.

12. Deitch EA. Bacterial translocation of the gut flora. J Trauma. 1990;30:S184-189.13. Breda S, Kudsk KA, Fukatsu K, et al. Enteral feeding preserves mucosal immunity

despite in vivo MAdCAM-1 blockage of lymphocyte homing. Ann of Surg 2003; 23(5):677-685.

14. Li J, Kudsk KA, Gocinski B, et al. Effects of parenteral and enteral nutrition on gut-associated lymphoid tissue. J Trauma. 1995; 39:44-52

15. Kudsk KA. Current aspects of mucosal immunology and its influence by nutrition. Am J Surg. 2002; 183(4);390-398.

16. Bengmark S. Enteral nutrition in HPB surgery: past and future. J Hepatobiliary Pancreat Surg. 2002; 9:448-458.

About the author

John J. Smith, PhD is principal with Cantaleir International Inc.,a consulting firm that advises food, beverage, dietary supple-ment and ingredient companies on innovation, technology devel-opment, project management and product development related tohealth and wellness. Dr. Smith was formerly with a Fortune-100food and beverage company, where his work focused oninnovation and wellness products. You may contact him [email protected].

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76 Healthy Skin

COLOR BY65528_MedCal-B:Layout 1 5/4/10 1:44 AM


DISCIPLINE

Healthcare uniforms have come a long way since the days

when registered nurses wore only white. Today’s nurses –and nearly all other hospital staff members – wear scrubs. Andbecause scrubs come in all different colors, patterns andstyles, it can be difficult to differentiate a registered nurse froma respiratory therapist or a housekeeper.

Staff members representing as many as 13 different disciplinesmay enter a patient’s room each day, leaving the patient won-dering, just “who is my nurse?” It’s not uncommon for patientsto report that “the nurse” gave them instructions, only to findout later that it was a physical therapist or a dietitian.

In an effort to improve patient care and satisfaction by makingit easier for patients to identify their caregivers, many hospitalsacross the country have converted to color-by-discipline uni-form programs. The color of the scrub uniform denotes thediscipline the healthcare professional represents. Patients andstaff are provided with a color key, allowing them to immedi-ately recognize each healthcare discipline according to thecolor they wear. At the Medical Center of the Rockies, in Love-land, Colo., for example, nurses wear blue, lab employeeswear black and radiology employees wear burgundy.

Building supportThe prospect of changing uniforms has the potential to be un-popular at first. We’re all creatures of habit, and change can beuncomfortable. Another argument staff often raise is that uni-forms strip them of their individuality. Employees at the Med-ical Center of the Rockies found a new way to express theirpersonality – with accessories! Kay Miller, the medical center’svice president and chief nursing officer, said some nurses dec-orate their name badges with cute pins, and others wear fun,brightly colored shoes. In addition, the dress code allows staffto wear theme print tops underneath their scrubs for specialoccasions such as Halloween and Christmas.

Similarly, at the Medical University of South Carolina (MUSC)hospital in Charleston, S.C., staff can choose to wear eithersolid-color scrub tops and bottoms designated for their disci-pline or solid-color bottoms with a print top. Registered nursesare also allowed to combine white with their color or print top.This decision was well-received and allowed staff members toexpress their individuality.1

When building support for your proposed color-by-disciplineprogram, introduce the idea gradually by generating discus-

Preparing your Organization for

Color-by-Discipline Uniforms

Special Feature

Carla Nitz, RN, BSN


78 Healthy Skin

sions at department meetings and through hospital memosand newsletters. Many hospitals also appoint a task force con-sisting of representatives from all disciplines (e.g., nursing,pharmacy, radiology, laboratory) to develop their color-by-discipline program. Goals for the task force might include:

• Communicating with other hospitals that have implemented a color-by-discipline program

• Reviewing relevant data from your hospital’s patient satisfaction surveys

• Researching colors and styles of uniforms• Finding a vendor• Revising the hospital dress code• Choosing a target date for implementation

of the new uniform program

Points to consider when choosing a uniform vendor:

• Wide selection of uniform styles and colors• Ability to have on-site sales several times a year• Ease of ordering and distribution (online,

in person, by mail)• Ability to customize scrubs with your facility logo

Choosing colorsIt is important to choose colors that are flattering to most skintones and suitable for both men and women. Connie Yuska,vice president of clinical services at Medline, who implementeda color-by-discipline program while serving as chief nursing of-ficer at a community teaching hospital in the Chicago area, rec-ommends allowing staff to vote for their uniform color. The taskforce at her hospital narrowed the color choices to three perdiscipline and organized a voting process.

Staff members at MUSC also voted on their uniform colors.With guidance from the task force, each discipline selected afew color choices for voting. The different color scrubs weredisplayed in the hospital lobby for two days. A Web-based vot-ing tool was developed giving all staff members the opportu-nity to vote on their color choice. Employees of each MUSCdiscipline voted on their first, second and third choices.1

At the Medical Center of the Rockies, Miller cut to the chase,and instead of voting, she had a representative from each dis-cipline draw a color from a hat on a first-come, first servedbasis. “We decided on that approach because choosing col-ors was where we encountered the greatest bumps in theprocess,” Miller said.



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SuiteStyles by Medline is a color-by-discipline uniform-program that helps residents and family membersquickly identify an employee by the color they are wearing. In addition to the identification benefits, color-by-discipline helps to create a more professional,coordinated look for the employees in your organization.

Think of how great your staff will look when they are visiting with residents and family members in a coordinated color based on their role. The apparel line features breathtaking colors and fabulous styles designed to fit a wide variety of body types.

With SuiteStyles you will also receive:• Scrubs sizing events to try on garments

before ordering• Bag-by-name delivery - orders are individually

bagged, boxed by department and delivered to each department

• Custom online store for employee reorders that complements your unique uniform program

Facilities around the country are making thechange to create a more professional looking staff. You can get started today by visitingwww.suitestyles.com to learn more and to browse a sample online uniform store.

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Nursing (RNs)

Nursing Assistants

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057-110_65528_MedCal:Layout 1 5/4/10 5:21 PM

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Communication planOnce your plan is finalized, you will need to communicate thecolor-coding to staff, patients and visitors. Begin by sharingthe revised dress code with staff about three months prior tothe conversion, recommends Yuska. Effective communicationtools after implementation of the program are tent cards and/orposters in each patient room and throughout the hospital,showing which discipline each color represents and anexplanatory section in the patient admission packet.

At MUSC patients and family members learn about therole-specific scrub schema via the GetWell Network, whichprovides patients and families access to the Internet, enter-tainment, education and communications via their hospital-room television. A website was also developed to display thescrub colors, frequently asked questions and the dresscode policy.1

The Medical Center of the Rockies also includes the colorcoding information in all new employee orientation packets.

Positive outcomesChange can be difficult for everyone, but if a uniform policyallows for choice within parameters it can be very successful.Building consensus and including the staff in the decision-making process will pay off in the end with a successful color-by-discipline program. It will also improve the professionalappearance of your staff, improve your patient satisfactionscores and contribute to an environment in which everypatient, physician and employee can identify the variousmembers of the healthcare team.

A lab employee at the Medical Center of the Rockies said thecolor coding has helped her quickly identify other staff. On oneoccasion, a patient asked her about a radiology procedure.She did not know the answer, but then she spotted a personin burgundy scrubs (radiology) walking down the hall. Eventhough she did not know the person, she immediately identi-fied their role, allowing the patient’s question to be answeredquickly and correctly.

Similarly, a cardiac nurse from the Medical Center of the Rock-ies said color-coded uniforms allow her to quickly identifywhich staff members are visiting her patients – even from downthe hall. If she sees a person in green, for example, she knowsher patient is having his respiratory treatment. “The color cod-ing really is a time saver,” she said. It also saves staff memberstime getting ready for work not having to choose what to wear.

Although many staff members at MUSC were opposed at firstto changing to the new dress code, a number of them latervoiced a change of heart. A psychiatric liaison nurse statedthat she was initially opposed to the plan and felt it would havea negative impact on nurse retention.1

Tips for Success!1. Views on uniform requirements are many and

packed with emotion. Be patient and listen to staff comments.

2. Give all staff members a voice in selection of the uniform. Web-based voting is an effective and efficient method.

3. Set a short time frame for implementation and do not let the process take months to accomplish.Deadlines longer than four months can add tothe opposition and a belief that the change will not occur.

4. Answer staff questions in a timely manner and develop a communication tool such as an intranetsite accessible to all staff members, keeping the process transparent.

5. Provide each staff member with a one-time stipendto aid in the purchase of their initial two sets of scrubs. Offer payroll deduction as an option to pay for additional scrubs.


She now appreciates the ability to identify at a glance all of thedifferent healthcare professionals by the color of their scrubs.As a consultant with responsibilities on units throughout thehospital, she is now able to immediately identify the patient’snurse and other caregivers.1

At Yuska’s hospital, the implementation date went verysmoothly, and in fact, several nurses commented on theimproved professional appearance of the staff. In addition, onthe first day, a patient said he was so relieved to know that hecould instantly identify who the nurse on the floor was…he didn’thave to guess. He told the manager that the color-coding gavehim a sense of comfort and security in an environment in whichhe felt totally out of control.

“Patients want to know who’s in charge of their care. Andresearch shows that patients who are actively involved in theirown care and communicate with their healthcare team have asafer, more satisfactory experience,” Yuska said. “The goal isto help patients with identification and instill confidence thatthey are being treated by an organized, professional team.”

For more information on Medline’s color-coded uniformprograms, visit www. SuiteStyles.com.

Reference

1. Darby J. Thinking about changing your dress code. Gastroenterology Nursing. 2008; 31(4):295-296. Available at: http://www.nursingcenter.com/library/journalissue.asp?Journal_ID=54035&Issue_ID=810887. Accessed April 1, 2010.

Your Medline Doll Can Lookas Great as You Do!

SuiteStyles Nurse Scrubs and Accessories Set

Brought to you by Medline’s SuiteStyles color-by-discipline uniform program, you and your doll willget noticed by the color you wear!

The doll scrubs and accessories set includes: contrast trim top, drawstring pants, cardigan jacket, stethoscope and Oxypas clogs. The set will be available for sale in June 2010 at www.medline.com/dolls.

Enter the following code at checkout for a discount off your Medline Doll Nurse Scrubs and Accessories Set: DOLL10 - 00022

Discount expires August 31, 2010.



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Our Nursing Home Nestled in the historic FairhavenDistrict of Bellingham, Wash.Mount Baker Care Center is locatedon the east side of Bellingham Bay.At Mount Baker, we want to helpfulfill our residents’ desires for an ex-pedient recovery and a high quality of life. Our residents have anumber of activities to choose fromeach day to remain active and stimulated, including arts and crafts, outings and specialized programs. Our community is located in a picturesque area ofBellingham Bay that is close toshopping, parks, walking trails and a number of other independentsenior apartments, mobile homesand condominiums.

Our 70-bed skilled nursing community provides a true continuum of care for our residentsunder one roof. We provide independent and assisted living,skilled rehabilitation, long-term care and outpatient therapy. We also offer specialty care services forresidents who need it, including

physical, speech and occupationaltherapy as well as wound care, pain management, IV therapy and post-operative recovery for individuals who require around-the-clock care.

Our ChallengeCMS is rolling out the Quality Indicator Survey (QIS) in bands of five to six states over the next few years. The state of Washingtonwas part of the first group of statesselected by CMS to participate inQIS in late 2008 and adopt it as thestate survey of record. We were firstshown by our Medline account representative. He demonstrated how workedand explained that it covered thesame processes and quality indicators as the QIS survey. Wealso learned that the same peoplewho had designed the QIS surveyand were training the surveyors had designed .

It made so much sense to us to usesomething similar to what the statesurveyors were now going to be

MOUNT BAKER CARE CENTER: PROACTIVE QUALITY ASSURANCE MEASURES HELP IMPROVE RESIDENT AND FAMILY MEMBER SATISFACTIONBy Janet R. Engel, Administrator

Survey Readiness

Nursing Home:Mount Baker Care Center

Location:Bellingham, WA

Size:70-bed skilled nursing community with a wide variety of services across thecontinuum of care, includingindependent and assistedliving, skilled rehabilitation, long-term care and outpatient therapy

Challenge:Prepare for the new QualityIndicator survey and create a process for continuous quality improvement

It made so much sense to us to use something similar to what the state surveyors were now going to be using in our state and nationwide.

057-110_65528_MedCal:Layout 1 5/4/10 5:28 PM

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using in our state and nationwide.To make sure we were ready forQIS, we decided to use toprepare for the state survey and discovered that it was an excellenttool for helping with ongoing quality assurance as well.

The Solution We signed up for in October of 2009 and immediatelystarted using it.

The user interface was very easy touse, and we immediately did thewhole building in the first week.

We really liked that uses similar programming and processesas the QIS survey. When CMS developed QIS, it wanted to createa structured, consistent way tomeasure compliance with federalregulations from state to state andfrom nursing home to nursinghome. To do this, QIS covers a verywide range of issues that are tied toCMS regulations and interpretiveguidance. CMS can’t talk to everyresident, family member and nurs-ing staff member in the UnitedStates, so it infers whether nursinghomes are meeting its guidelinesthrough the survey process.

By using , we hoped it wouldhelp us prepare for our annual

survey and discovered that it could also help us with our ongoing Quality Assessment andAssurance (QA&A) process. CMSrequires every facility to have aQA&A committee with at leastthree staff members, the director of nursing and a physician,which meets at least every quarter.The committee’s purpose is to identify quality issues and addressthose issues. (The QA&A requirements are detailed in F520).

Since the survey, we’ve decided toincorporate into our ongoing continuous quality assessment process. When we have a new resident at the facility, we

conduct an assessment of that resident to develop their care planand we also do an assessment of the resident using . This gets us off on the right foot with the resident to understand their preferences, what they find acceptable and unacceptable in theareas of choices and helps us to communicate with their family.

Not only do we do an initial assessment, we also do anotherassessment 30 days later. This givesresidents a chance to become familiar with the facility and startthinking about their life here andthe things that are important tothem as a resident.

When we have a new resident at the facility, we conduct anassessment of that resident to develop their care plan andwe also do an assessment of the resident using .



We also sent out an updated familysurvey. But we didn’t get as manysurveys back as we had hoped. Webelieve the new questionnaire thatwe developed from is a better tool than what we previouslysent to family members.

We also learned about the differences between QIS and traditional state surveys, and therole of resident, family and staff interviews. We discovered that QIStook different tracks depending onthe cognitive state of the residents,which we thought was very important. And it helped us prepare for the observational aspects of the survey.

We prepared for the resident observation aspect of QIS by playing the role of observer ourselves. In QIS, not only do thesurveyors ask residents questionsabout the quality of their care at thenursing home, the surveyors alsoobserve the residents. We did ourown observations to make sure things were orderly. We now takeextra care to monitor these areas aspart of our process with residents.

ResultsWe used not only to prepareour residents and their family members, but also our staff. Wehave a great staff, and because wehad been doing staff surveysthrough they knew what to expect.

In our first QIS survey, our staffmembers felt calm and confidentabout the survey as it was

happening because we were verywell-prepared. Everyone felt comfortable because they had anidea of what was going to happenduring the QIS survey. The surveyors even commented on howwell-prepared our staff was. With

, our staff got to know theresidents even better than they hadin the past and they were able toanswer questions from surveyors.

During our quality assuranceprocess with , we involvedall of our key staff members—casemanagers and floor nurses, socialworkers, the activities team and our rehab coordinator—and weasked them all the questions thatthey might be asked during an actual survey.

For QIS, there are a number of documents to provide to the surveyors immediately, and additional documentation that’s required within one hour andwithin four hours of the entranceconference. They ask for the resident census, facility floor plan,staff schedules and the list of residents on ventilators or dialysis.Because we had used , everyone on our staff knew whereto find all of our key documenta-tion that the surveyors required.

Overall, took a lot of thestress out of the state surveyprocess. It reduced the stress forthe staff because they knew whatquestions they were going to beasked. We had already been throughthe entire process with , sowe knew quickly what was neededand how to respond when the actual state surveyors arrived for our first Quality Indicator Survey.

Going Forward We’ve always sent out surveys tofamily members of our residents toget their feedback. Now, we’re using

to help with our outreach tofamily members. The QIS familyinterview is captured in ,and we are using those same questions as part of our family survey. QIS asks family membersabout 17 different aspects of the resident’s experience. We now askquestions about those same aspectsof the resident’s experience, becausewe know that these issues are important to both the resident and their family. The family interview asks about a number ofimportant quality of care and quality of life considerations such as privacy, personal property and personal funds, the exercise of rights and choices in sleeping and bathing.

During our quality assurance process with , we involved all of our key staff members—case managers and

floor nurses, social workers, the activities team and ourrehab coordinator—and we asked them all the questions

that they might be asked during an actual survey.


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Sometimes with our residents, theremay be a change in status—in termsof their cognition and also theirviews may change. We need to beon top of those changes. We don’talways hear everything that’s a concern and there are a lot ofthings that change. We think it’simportant to sit, side-by-side, andask questions.

For our long-term care residents, wehave a care conference at least oncea year, unless there is a significantchange in the resident’s health. Ifthat is the case, then we will meetmore often. At the care conference,we hand the family members ourquestionnaire, which is based on theQuality Indicator Survey and

. We find that it’s an idealtime to document and get feedbackfrom the family members.

To stay in compliance, you mustconduct quality assurance on an ongoing basis. It’s great to have a report, which we generate from , to give to staff members and ask them to correctproblematic areas.


ABOUT THE AUTHOR – Janet R. Engel is the administrator for Mount Baker Care Center in Bellingham,Wash. a 70-bed licensed skilled nursing facility and 34-bed assisted living facility. Ms. Engel has been working with seniors and in long-term care for the past eight years, and spent eight years prior to that working in corrections.

This module report (similar to the one Mount Baker uses) shows where a facility rates relative to the survey thresholds in the 125 quality of care

and life indicators based on the same logic that is used in a QIS survey.

is not only a survey readiness tool, it is an ongoing QA system. The Stage I Suite examines 125 resident-centered indicators of quality of care and quality of life that are used to identify care areasfor a Stage II in-depth investigation and possible citations during a QIS.These indicators are contained in six modules that replicate exactly the QIS assessments conducted on site during the survey, plus one module that uploads and reviews MDS data. The modules are:

• Resident Interview • Family Interview

• Staff Interview • Resident Observation

• Census Sample Record Review • MDS Data

• Admission Sample Record Review


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The new Quality Indicator Survey (QIS) for nursing homesis more resident-centered, with more information obtainedfrom direct questioning of residents and families. In fact,60 percent of facilities have had more deficiencies in QISthan in the prior traditional survey, often in regulatory areassuch as quality of life that were not as fully investigatedin the traditional process.

abaqis® is the only quality assessment and reportingsystem for nursing homes that is tied directly to the QIS,and its quality assessment modules reproduce the sameforms, analysis and thresholds used by State Agencysurveyors. Rich reporting capabilities on 30 care areasguide you to what surveyors will be targeting in your facility.

That gives you a unique advantage in preparing for yoursurvey – and in meeting your resident’s needs.

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

“ How do we improveour resident and family-centered quality of care and prepare for QIS?

We use abaqis.” Sherri Dahle, RN, DNSDirector of Nursing Central HealthcareLeCenter, MN


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EDUCATIONAL OPPORTUNITIESFOR LONG-TERM CARE PROFESSIONALS

The Role of the CNA in Resident-Centered Care and the New Quality Indicator Survey

Designed for: Nurses and CNAs

You’ll earn: One Continuing Education Credit*

This course covers:

• How the state survey process has evolved into the new Quality Indicator Survey (QIS)

• The importance of the CNA in QIS and resident-centered care

• The different aspects of QIS, including the resident interview, resident observations and family interviews

• How the CNA can help improve the overall quality of care in long-term care facilities

Understanding the Quality Indicator Survey

Designed for: Long-Term Care Administrators

You’ll earn: One Administrator Credit

Approved by the National Association of Long-Term Care Administrator Boards (NAB), this course covers:

• How the Quality Indicator Survey (QIS) process evolved to standardize state surveys in accordance with federal guidelines

• The top six objectives of the QIS

• How surveyors in all states are being trained in a structured and consistent manner

• How the QIS differs from traditional state surveys

Making Sense of the New Quality Indicator SurveyTwo free online courses available at www.medlineuniversity.com

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

057-110_65528_MedCal:Layout 1 5/4/10 5:34 PM

LEARN MORE ABOUT THE ONLY INTEGRATED SOLUTION FOR SURVEY READINESS IN NURSING HOMES

This webinar gives a QIS overview and demonstration on how the abaqis® system canhelp prepare for both the traditional and QIS survey processes. This demonstration alsohighlights how abaqis® provides:

• Rich reporting capabilities to identify which care areas to target for

quality improvement

• Root cause analysis on a facility-wide or individual-resident basis, enabling

prioritization and focusing of interventions for maximum impact

• Emphasis on information reported by residents and families to help identify

the needs of residents, aiding your efforts to improve consumer satisfaction

Now with the new Stage 2 module featuring:• A dashboard view of triggered care areas based on data collected

using abaqis® Stage 1 Suite• Investigative tools to determine deficiencies in triggered care areas

Free Webinar at www.medline.com/abaqisdemo

Quality Assurance System Webinar



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Win-Win Negotiation

How to get more of what

you want

Wolf J. Rinke, PhD, RD, CSP

Times are tough, and virtually all of us have a need to get more “bang for our

buck,” whether it’s when we want to make a purchase, attempt to get a promo-

tion or talk our children out of getting that expensive “must-have” new toy. And

yet most of us consider negotiating or “haggling” a distasteful activity that should

be avoided at all costs. That is especially true if you are a woman. Research

shows that women are far less likely to negotiate than men, and when they do,

they do it in a way that is less assertive. One study found that 20 percent of

women do not negotiate at all. To help you overcome the distaste for negotiation,

master the following strategies, and you will get more of what you want.

Manage Your PerceptionsLots of people lose in negotiations because they don’t manage their perceptions.

For example, have you noticed that when you’ve tried to sell your house, there

seemed to be houses for sale everywhere? Conversely, when you were looking

to buy a house there were virtually none to be found? That happens because of

selective perception—whatever we focus on, we tend to find.

Similarly, how many times have you interviewed for a job and felt the prospective

employer had all the power because you really needed the job while the employer

appeared to have all the applicants in the world? Having been in both roles—

interviewer and applicant—let me assure you nothing could be further from the

truth. The employer almost always needs you just as much as you need him (as-

suming of course you have the right skill set), even during these tough times.

These biases come about because you are committing an “attribution error.” For

example, because the employer has certain visible attributes of power you

assume she has more power than you do which, right or wrong, becomes

your “reality.”

Caring for Yourself


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In other words, your perception controls your reality, which in

turn impacts how you negotiate. For example, back to buying

that house. If you perceive that there are very few houses on

the market you will feel compelled to make a quicker and

potentially higher offer than if your perception is that there are

lots of houses on the market. The same is true when you are

interviewing for a job. If you assume that the employer has all

the power, then you are going to be negotiating from a

position of weakness and you probably will compromise

your expectations.

So the first step in every negotiation is to manipulate your per-

ceptions and “do a positive number on yourself” by convinc-

ing yourself that you deserve to have your needs met. In other

words, you define an empowering positive self-fulfilling

prophecy that at a minimum equalizes the perceived power

between you and the other party. Of course, it is even better

if you can convince yourself you have more power than the

other party, which is quite feasible since you are always in

control of your own perceptions. (If you would like help with

this, devour my Make It a Winning Life book available at

www.WolfRinke.com.)

Be Willing to Walk AwayBeing able to walk away is the single most important concept

to internalize if you want to get more of the things you want!

Anytime you want something so bad you are not willing to

walk away, it is extremely likely you will become a deal taker

not a deal maker.

For example, Superwoman—that’s my wife of over 40 years—

and I are avid cross-country skiers, hikers, bikers and mush-

room hunters. So approximately four years ago we found this

super idyllic resort in Canaan Valley, West Virginia. We fell in

love with a unit that was perfectly decorated and had an awe-

some view. We just had to have it. As a result, when it came

time to negotiate price, we were not willing to walk away, and

we ended up paying full price.

Know Your BATNA, WAP and ROSABATNA – Best Alternative to a Negotiated Agreement – is a

concept developed by Roger Fisher and William Ury, authors

of Getting to Yes. Negotiating Agreement Without Giving In,

one of the most popular negotiation books ever written. Ac-

cording to them, BATNA “is the standard against which any

proposed agreement should be measured.” For example, if

I’m negotiating with a client for a consulting contract I have

priced at $95,000/year, my BATNA may be $95,000 if I value

my free time more than the $95,000. Or it may be $45,000 if

I need the money to pay my mortgage, have very little work in

the pipeline, and could hope to generate about $45,000 from

writing another book in case I do not get the contract. Ac-

cording to Fisher and Ury high quality negotiation is only pos-

sible if you know your BATNA, since it is the only way you can

protect yourself from accepting unfavorable terms or from re-

jecting a minimally acceptable deal.

A WAP or Walk-Away Price, also known as the reservation

price, “is the least favorable point at which one will accept a

deal.” A CEO I coach wanted to sell his business. A protracted

long negotiation ended up with what I thought was a very

sweet deal--$23.5 million for the business and the opportunity

to start a new online business with financial support from the


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new owners. The CEO had established a WAP of $26 million

and his BATNA was that he was going to continue to run his

business as he had in the past, and be open to other offers as

they were coming along. Although I thought it was a very fair

offer, he walked away from it, which he would probably would

not have done if he was not very clear about his WAP and

BATNA. He sold that business several years later and got a

much better deal.

ROSA is your Range Of Satisfactory Agreement. “It is the area

or range in which a deal that satisfies both parties can take

place.” For example, let’s say that you want to buy a used car,

which has a sticker price of $2,900. The seller says to himself,

I will not take less than $2,400. That’s the seller’s WAP, which

usually is not known to the buyer. On the other hand, you say

to yourself, I will not pay more than $2,700. That’s the buyer’s

WAP, which is usually not known to the seller. The ROSA in

this case is the area from $2,400 to $2,700. All other things

being equal, an agreement should be feasible between

$2,400 and $2,700.

If you handle this purchase like a distributive negotiation, (i.e.,

Win-Lose or Lose-Lose, your conversation might go some-

thing like this:

You: This car has quite a few dents and a lot of mileage.

I’ll give you $2,200.

Seller: Thanks, but since that is way below the

“Blue Book” value I’ll wait until I get a better offer.

You: I’m sure you’d like to get it sold and I don’t really

like to haggle. I’ll give you $2,400, take it or leave it.

Seller: $2,600 and it is yours.

You: I tell you what, let’s just split the difference. I’ll

give you $2,500.

Seller: You got yourself a deal.

In this case, even though both parties compromised (Lose-

Lose), they probably feel pretty good about the deal because

they both got a better price than their WAP.

Negotiate Over Interests, Not PositionsLet’s look at a father-daughter encounter.

Father: “Drink your milk.” (That’s his position).

Daughter: “I don’t like milk.” (That’s her position).

Of course, from here on, it all goes downhill. So if the father is

a “Tough Battler,” he might say: “I’m your father and you will

listen to me,” or “I’m smarter than you,” or “I’m wiser than

you” etc; “Now, damn it, drink your milk, or you will be

grounded!” (Win-Lose.)

If the daughter is a “Tough Battler” as well, it might go something

like this: “I hate milk. If you make me drink it I will throw up.”

Even though on the surface it might appear that the father has

all the power, it’s likely that in this case the daughter will win;

after all, the father is probably not particularly keen to clean up

her vomit (Win-Lose).

Of course, the father could compromise with his daughter: “I

tell you what, just drink half of your milk, and I’ll forget you are

being so nasty to your old dad.” (Lose-Lose.)

If all else fails, he might bribe her: “If you drink your milk, I will

take you to the movies.” (Of course, that is reinforcing various

undesired outcomes, such as: “If I rebel, good stuff happens.

So next time I can’t get what I want, I’ll just rebel.”)


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Putting those unanticipated outcomes aside, all of these

approaches will likely end up in either Win-Lose or Lose-Lose

outcomes, which neither the father nor his daughter are going

to be particularly happy with.

Now let’s take a look at how this might work if we focus on

interests, needs or wants instead of positions.

Father: “I understand you don’t like milk. So please

tell me what you really want.”

Daughter: “I want food that tastes good, and milk just

doesn’t taste good to me.”

Father: “I appreciate that. Now let tell you what I want.

I would like you to get food that is nutritious and

high in calcium. Why don’t we take a moment

and come up with a list of foods that meet both

of our needs.” (This is separating option genera-

tion from decision-making. See the next section).

At this point, the father and daughter will probably be able to

come up with a long list of foods that meet both of their

objectives – food that tastes good, is nutritious and high in

calcium – such as cheese, ice cream, yogurt, pizza and the list

goes on. (Win-Win.)

In the Win-Lose approach, we saw how the parties’ egos

became identified with their position. Once that happens, the

negotiators have a new interest to satisfy – such as saving

face – which has nothing to do with the original interests. As

you discovered, the longer the parties attempt to reconcile

positions, the less attention they will devote to addressing their

real concerns, needs or wants. The result is it takes longer; it’s

likely to raise people’s negative emotions such as anger, and

is less likely to generate a Win-Win outcome. Plus, it will likely

damage the relationship between the bargaining parties.

Separate Option Generation from Decision-Making As you learned from the previous example, most of us tend to

focus on two mutually exclusive outcomes: either you get

what you want and I lose, or I get what I want and you lose.

(Win-Lose.) If instead we learn to get in the habit of engaging

the brain power of both parties, many not-so-obvious ideas

can be generated that will meet or even exceed both parties’

needs (Win-Win.). In other words, if we separate option gen-

eration from decision-making, we can almost always make

the pie bigger, and if we can’t, then we can establish objec-

tive criteria before attempting to reach an agreement (see the

next section). Unfortunately, we tend to fall into the trap of

skipping the option generation step because most of us want

to get the negotiation process over with, and one way to do

that is to come up with the answer

both of us can agree on as fast

as possible.

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At this point you might be saying: “That just doesn’t make any

sense.” Going back to the used car selling example, the only

thing both parties are concerned with is price! Not necessar-

ily! It’s likely that both parties had other things that factored

into the sale. For example, if the buyer had said to the seller:

“Before we talk about price, tell me what you want out of this

deal.” The seller might have said, “I’m interested in selling the

car now, but keeping it for another two weeks because my

daughter’s new car won’t be delivered until then.” She might

also have said, “I would like to get cash so I don’t have to

worry about a bounced check.” Or she might have said, “I

love this car like my own child and I would really like to sell it

to someone who will take really great care of it.”

The buyer, on the other hand, might have said: “I would like to

make sure I’m not buying a lemon; I would like a car that has

been well taken care of; I would like to drive it away today; I

would like to deal with someone I can trust”…and the list goes

on. All of these may have economic value to either the seller

or the buyer and hence could have been used not only to in-

fluence the purchase price of the car, but could have resulted

in both parties getting far more than just a good price, i.e.,

getting a Win-Win outcome.

If All Else Fails Resort to Objective CriteriaYou will of course encounter real “fixed pie” scenarios. For

example, if you have only one vacancy in your department

and there are three people applying, even after all the best ne-

gotiations in the world, there will still be two losers and only

one winner. To improve negotiation whenever you are involved

in a true distributive negotiation process, where one party

must lose and the other win, it is wise to resort to objective

criteria such as standards, rules, independent mediators,

arbitration, flipping a coin, drawing straws or other forms of

chance, or any other criteria that produces a perceived fair

outcome. The classical example of this is the challenge of

dividing one piece of cake between two siblings. If you have

children, I’m sure you can identify with this dilemma, and you

may remember how much potential bickering can ensue.

There is of course a very elegant solution to that problem,

which dates back to biblical times. Have one child cut the

cake and the other choose the piece she wants.


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96 Healthy Skin

In the case of hiring a new employee, perceived fairness is

enhanced if you make the selection criteria and the selection

process public. There are other situations where it may be

beneficial for both parties to resort to objective criteria. Let’s

say for example, your best friend is interested in purchasing

your car. In this case, both of you express a desire to arrive at

a fair price without haggling because your relationship is more

important than getting the best price. As a result, you both

agree not to negotiate the price at all and instead abide by

the “Blue Book” value.

According to Fisher and Ury, there are three basic strategies

that will make resorting to objective criteria work:

1. Frame the proposal as a joint search for

objective criteria. In the case of selling our car to

your best friend, you both decided the “Blue Book”

value would represent a “fair” price for the car.

2. Reason and be receptive to the other person’s

reason regarding which standard is most applicable

and should be used to arrive at a “fair” outcome.

If you are selling your house, you may propose to

use an average sales price of three similar houses

that have sold in your neighborhood during the past

year as the “fair” price. The buyer, however, prefers

an average of three independent appraisals as a fair

price. In this case, it’s important to be receptive not

only to the proposal but also the underlying reason

for the proposal.

3. Don’t yield to pressure, yield to principles.

Pressure may come in a variety of forms: bribes,

side payments, threats or a refusal to budge. If the

other side uses these types of pressures, ask him to

tell you the reasoning behind his proposal, suggest

legitimate objective criteria and state why they

represent a fair outcome to both of you. If the other

party can’t do that, stick to your guns, and if that

fails you still have the option to ... you guessed it

. . . walk away.

© 2010 Wolf J. Rinke

About the author

Dr. Wolf J. Rinke, RD, CSP is a keynote speaker, seminar leader,management consultant, executive coach and editor of the free elec-tronic newsletters Make It a Winning Life and The Winning Manager.To subscribe go to www.WolfRinke.com. He is the author of numer-ous books, CDs and DVDs including Make It a Winning Life: Suc-cess Strategies for Life, Love and Business, Winning Management:6 Fail-Safe Strategies for Building High-Performance Organizationsand Don’t Oil the Squeaky Wheel and 19 Other Contrarian Ways toImprove Your Leadership Effectiveness. All are available at www.Wol-fRinke.com. His company also produces a wide variety of quality pre-approved continuing professional education (CPE) self-study coursesincluding Win-Win Negotiation: Fail-Safe Strategies to Help You GetMore of What You Want, on which this article is based, available atwww.easyCPEcredits.com. Reach him at [email protected].


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Snug-fitting sheets for healthier skin.

A patented blend of cotton, polyester and spandex provides softness and a non-abrasive surface, alongwith better air circulation for skin health.

Independent laboratory studies1 showed that SoftSpanfitted sheets had 260% stretch in the width and 98%stretch in the length, compared to a regular knit sheet,which has 104% stretch in the width and 45% in thelength. Regular woven sheets have no stretch at all.

More stretch means a tighter, smoother fit, and no wrinkles. Mayo Clinic and other healthcare experts recommend keeping the bottom sheet pulled tight to prevent wrinkles and bunching, which can causepressure that contributes to skin breakdown.2,3

References1. Diversified Testing Laboratories, Inc. ASTM D 6614-07, “Standard TestMethod for Stretch Properties of Textile Fabrics – CRE Method.” July 29,2009. Data on file.2. Mayo Clinic. Bed sores (pressure sores). Available at http://www.may-oclinic.com/health/bedsores/DS00570. Accessed on February 5, 2010.3. Oregon Department of Human Services. Pressure Sores: A Self-StudyCourse. 2008. Available at: http://www.oregon.gov/DHS/spd/provtools/nurs

SoftSpan sheets with spandex fit snugly on the bed to comfort and protect the skin.

Call your Medline representative or 1-800-MEDLINE to trial two dozen SoftSpan fitted sheets for the same price you’re paying for your current sheets.


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Medline’s Generation Pink latex-free, patented third-generation vinylexam gloves have the comfort, barrier protection and price you love.

Even better, when you choose Generation Pink gloves, you’re helping Medline support the National Breast Cancer Foundation.

Item # Size Unit of Measure

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To watch the “Pink Glove Dance” video and order Medline’s Generation Pink Gloves, go to www.pinkglovedance.com

©2010 Medline Industries, Inc. The cross-fingered pink glove hand image is a trademark of Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.


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Introducing Deb!Starring in “The Pink Glove Dance”

Deb is the coolest person to dance the Pink GloveDance while at the same time skillfully caring for patients, especially those battling breast cancer.

In her Generation Pink Gloves, pink bouffant cap and scrubs, she energetically raises awareness for the “Together We Can Save Lives Through Early Detection” campaign. To order the Deb doll visitwww.medline.com/dolls

Take an online tour of the booklet and view the entire doll collection, visit www.medline.com/dolls

Introduced in 2005, the Medline Doll Collection was created to recognize the caring and dedicated healthcare professionals in our industry. Since then, Medline has introduced seven dolls, including Deb, who made her debut in March 2010.


100 Healthy Skin

Healthy Eating

¥ 1 head romaine lettuce¥ 1 cucumber, thinly sliced¥ 5 radishes, thinly sliced¥ 1 red bell pepper, seeded and sliced¥ 1 green bell pepper, seeded and sliced¥ 2 large tomatoes, cut into wedges

¥ 2 scallions, chopped¥ 1 small red onion, sliced¥ 3 oz. feta cheese, sliced or crumbled¥ ½ cup fresh parsley, coarsely chopped¥ Several black olives¥ 2 tablespoons capers (optional)

Dressing:¥ ¼ c. olive oil¥ Juice of 1 lemon, or 3 tablespoons

lemon concentrate¥ 1 tablespoon wine vinegar¥ 1 clove garlic, pressed or minced¥ Salt and pepper, to taste

Directions:Rinse the romaine, tear into bite-size pieces and put into saladbowl. Arrange other vegetables attractively over the romaine,topping with the feta, parsley, olives and capers. Combine thedressing ingredients and drizzle over the salad.

Vendor data analyst Vicki Mirshak, who works at MedlineÕsVernon Hills, Ill., office, won a silver medal for this recipe in theInternational Cookoff during Employee Appreciation Week 2008.

ÒThis is a light, very easy-to-make salad thatÕs very nutritious. ItÕsespecially good for people who are watching what they eat,ÓVicki said.

She encourages experimenting with different ingredients andherbs. ÒAdd a little more garlic and different herbs. Fresh herbsare always better than dried.Ó

Vicki applies those same principles toother recipes as well. ÒI tend to do a lotwith chicken, trying different herbs andspices and different cooking methods Ðpoaching, grilling, baking. ItÕs best to stickwith a basic recipe, and then add a little toit here and there to change it up.Ó

Syrian Salad (8 servings)

Nutrition Information

Servings: 8Calories: 79Fat: 3.3 gSodium: 273 mgFiber: 3.1 g


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

FORMS & TOOLS

Incontinence CareBilingual Application Guide – Adult Brief ..............103

Urinary Continence Assessment& Implementation Form ..........................................110

Pressure Ulcer Prevention Reducing Pressure Ulcers – for CNAs ..................105

Wound Photography Wound Photography Validation Checklist ..............108Photography Consent Form ..................................109


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Each package is a 2-Minute Coursein Advanced Wound Care™


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

For more information visit www.medline.com/ep.

MEDLINE’S REVOLUTIONARY SHOW-AND-TELL PACKAGING



1. Fold the product in half lengthwise with the backsheet facing to the outside.Doble el producto longitudinalmente por la mitad con la superficie posterior encaradahacia fuera.

2. While folded, insert or apply the product from the “front to the back.” During thisprocess, pull the product up into the perineal area centering it “front to back.”Unfold, spread and center the product across the back-side.

Mantenga el producto doblado e introdúzcalo o apliquelo de delante hacia atrás. Duranteesta operación, lleve el producto hasta la zona perineal y céntrelo do delante a atrás.Desdoble, estire y centre el producto por la parte posterior.

3. Unfold, spread and center the product across the front-side. Gently pull the skin ofeach inner thigh downward or away from the perineal area allowing the leg cuffs tomove into the now exposed crease.

Desdoble, estire y centre el producto por la parte anterior. Con gran cuidado estire hacia abajoo retire de la zona perineal la piel de los muslos interiores permitiendo que los plieguesinternos del producto coincidan con el pliegue que ha quedado visible.

4. Apply the upper tabs while pulling the back wings snugly over the front wings.Apply the lower tabs at a slight upward angle, while tucking the front wings smoothly inand under the back wings. Smooth out all the wrinkles and folds while checking thefit of the product. Adjust as required.

Aplique las cintas de cierre adhesivas superiores y estire simultáneamente las alas posteriorsde forma que ajusten perfectamente sobre las alas delanteraras. Aplique las cintas de cierreadhesivas inferiores de modo que se forme u ángulo ligeramente hacia arriba e introduzca almismo tiempo las alas delanteras ligeramente por debajo de las alas traseras. Alise lasarrugas y pleigues que se hayan formado mientras comprueba la colocación del producto.Ajústelo según sea necesario.

Note: When applying hook tabs,gently press down on the tab and

pull back slightly for a moresecure attachment.

Application Guide/Bilingual Forms & Tools


104 Healthy Skin

Forms & Tools Application Guide/Bilingual



�

Advancing Excellence in America’s Nursing Homes is a national campaign to improve the quality of care and life for the country’s 1.5 million people receiving care in nursing homes. Find out if your nursing home

is part of the Advancing Excellence Campaign. To sign up or get more information, go to www.nhqualitycampaign.org.

�

Reducing Pressure Ulcers

Why is reducing pressure ulcers important? A pressure ulcer or bed sore is an injury to the skin caused by constant pressure over a bony area which reduces the blood supply to the area. Nursing home residents who cannot easily reposition themselves are often susceptible to this condition and need special care. Pressure ulcers can be dangerous and painful for a resident, in part because broken skin can allow infection into the body. If untreated, pressure ulcers can deepen and even expose the bone. Deeper ulcers may be hard to heal or may not heal at all. Sometimes, pressure ulcers can lead to death. The presence of pressure ulcers limits the quality of life for a resident as evidenced by:

• Decrease in bowel and bladder function

• More incontinence

• Decrease in ability to move without help

• Decrease in mental capacity

• Increase in pain

• Increased risk for infection

• Less participation in activities Proven techniques can reduce and almost eliminate this uncomfortable and potentially dangerous condition. Advancing Excellence believes that “Nursing home residents receive appropriate care to prevent and minimize pressure ulcers.”

How can nursing assistants help reduce pressure ulcers?

• Read residents’ care plans to learn who is at risk of developing pressure ulcers.

• Change the position of residents who are immobilized when in bed or when up in a chair.

• Provide frequent incontinence care. Remove urine and/or feces from the skin as soon as possible.

• Provide water to the resident frequently because well-hydrated skin will not break down easily.

• Check the resident’s skin each time you provide care. Note and report redness -- especially over a bony area -- that does not disappear or a new open skin area.

• If the resident’s care plan requires a dressing, make sure it is there.

• Note the resident’s eating habits. Make sure they have nutritious meals. If residents aren’t eating, notify the charge nurse.

• Look for opportunities to increase residents’ mobility through activities and/or socialization.

• Observe residents for pain, and notify the charge nurse if a resident complains of pain or if you observe the signs of pain in non-communicative residents.

• Follow your nursing home’s facility’s protocols for pressure ulcer prevention and treatment.

• Participate in in-services related to pain.

• Talk to the charge nurse if you have a suggestion that you think might work better for a resident.

• Share what you learn and know with other staff.

Reducing Pressure Ulcers – For CNAs Forms & Tools


106 Healthy Skin

Forms & Tools Reducing Pressure Ulcers – For CNAs

�

www.nhqualitycampaign.org

�

Pressure Ulcer Resources

Campaign Resources: • Webinar: Reducing Pressure Ulcers in Nursing Homes: An Interdisciplinary Process

Framework http://www.nhqualitycampaign.org

• Video: Pressure Ulcers: Best Practices http://www.nhqualitycampaign.org

• Implementing Change in Long-Term Care http://www.nhqualitycampaign.org

• Campaign Goals and Objectives http://www.nhqualitycampaign.org

• Top 10 Ideas to Involve All Staff in Advancing Excellence http://www.nhqualitycampaign.org

Best Practice Resources: • Preventing Pressure Ulcers: Evidence-based clinical practice guidelines that offer the latest

in the management of pressure ulcers emphasize an interdisciplinary team approach http://www.ahcancal.org/News/publication/Provider/CaregivingAug2008.pdf

• Pressure Ulcer Plan Is Working http://www.ahcancal.org/News/publication/Provider/CaregivingMay2008.pdf

Lessons Learned Resources: • Getting A Jump On Wound Care: A wound care education program that empowers nurses

and CNAs is able to control pressure ulcers at a Colorado state veterans facility http://www.providermagazine.com/pdf/2007/caregiving-01-2007.pdf

Links to Relevant Organizations: • National Association of Health Care Assistants

http://www.nahcacares.org

• National Network of Career Nursing Assistants http://www.cna-network.org

• Nursing Assistant Resources On The Web http://nursingassistants.net

• American Association for Homes and Services for the Aged http://www.aahsa.org/

• American Health Care Association http://www.ahcancal.org/

• National Long Term Care Ombudsman Resource Center http://www.ltcombudsman.org/


VALIDATION CHECK LIST

Employee’s name_____________________________ Date____________

Reviewer’s signature__________________________

SKILL: PHOTOGRAPHING WOUNDS Objective: The learner will be able to verbalize and demonstrate the photographing of a patient’s wound

Performance Criteria Criteria

Met

Criteria

Not Met

Comments

1. Explain purpose and procedure to patient and caregiver

2. Review photograph permission form and obtain written consent

3. Remove clutter from the area and adjust the lighting if necessary

4. Gather necessary supplies

5. Prepare label with patient ID#, date,

body part

6. Wash hands, apply gloves and position patient. Place drape in the background and put label near the wound.

7. Remove the old dressing

8. Remove gloves, wash hands

9. Stand squarely and position camera perpendicular to the wound

10. Take a minimum of 3 photos of

each wound:

a. From 4 feet to show wound location and surrounding anatomy

b. From 2 feet to capture periwo. Zoom from 2 feet for close-up view

11. Do not touch patient’s skin with camera or contaminated hands

12. Wash hands and complete wound dressing

13. Document wound assessment and photo descriptions in patient record

14. Print images, save file and place photos

Forms & Tools Wound Photography Validation Checklist

108 Healthy Skin

057-110_65528_MedCal:Layout 1 5/4/10 5:30 PM


AUTHORIZATION AND CONSENT FOR PHOTOGRAPHY AND PUBLICATION The undersigned hereby authorizes _____________________________ (facility) and the attending physician to photograph or permit other persons to photograph _________________________(patient's name) while under the care of the above-named facility.

The undersigned agrees that the above-named facility and the attending physician may use and permit other persons to use the negatives or prints prepared from such photographs for such purposes and in such manner as either may deem appropriate. The undersigned agrees the photographs may be used for purposes including, but not limited to, dissemination to hospital staff, physicians, health professionals and members of the public for educational, treatment, research, scientific, public relations and charitable purposes. This photography/filming is intended for the following circumstances: ___________________________________________________________________

___________________________________________________________________Dissemination of the photography/filming may be accomplished in any manner and that such use is subject only to the following limitations: ___________________________________________________________________The undersigned has entered into this agreement in order to assist scientific treatment, educational, public relations and charitable goals and hereby waives any right to compensations for such uses by reasons of the foregoing authorization, and the undersigned and his/her successors or assignees hereby hold the above-named facility and the attending physician and their successors and assignees harmless from any or against any claim for injury or compensation resulting from the activities authorized by this agreement

The term "photograph” as used in the foregoing agreement, shall mean motion picture or still photography in any format, as well as videotape, video disc, electronic, audio media and any other mechanical means of recording and reproducing images or voice.

Date:______________ Time: ______ am/pm

Signature: ____________________ Signature of Witness: ____________________

If signed by other than patient, indicate relationship: Parent / Conservator / Guardian

Photography Consent Form Forms & Tools

057-110_65528_MedCal:Layout 1 5/4/10 5:32 PM

110 Healthy Skin

Forms & Tools Urinary Continence Assessment


Resident ________________________________________________________ Room #___________

Assessed by _______________________________________________ Date: ___________________

Current Product Information: Size: _____ Type: ______________ Frequency of Leakage: ________ times/week ❏ None

Resident is continent N Y → proceed to section 2

Do you leak when you cough, sneeze, exercise, laugh? N Y → stressDo you need to rush suddenly to toilet? N Y → urgeDo you sometimes not make it to the toilet? N Y → urgeDo you urinate more than 7 times/day or 2 times/night? N Y → urgeDo you have a weak stream of urine? N Y → overflowDo you have frequent dribbling? N Y → overflowDo you have burning or blood in urine? N Y → transient

Is the incontinence related to something other than urinary tract,such as inability to undo a zipper? N Y → functional

Does the resident have a postvoid residual greater than 200 cc? N Y → overflowDoes the resident take stool softeners, antipsychotic, anticholergenic,

narcotic analgesics, or other drugs that may affect continence? N Y → further evaluation may be necessary

Select (circle) the type of incontinence that most fits resident based on answers above:

1. Determine Type of Incontinence

PH

YSI

CA

L: F

EMA

LE

PH

YS

ICA

L: M

ALEIs there presence of pelvic prolapse or other abnormal

finding? N Y → stress

Is the vaginal wall reddened and/or thin?N Y → transient

Is there abnormal discharge? N Y → transient

Is the foreskin abnormal (difficult to draw back, reddened)?N Y → transient

Is there drainage from the penis? N Y → transient

Is the urethral meatus obstructed?N Y → overflow

CH

AR

TQ

UE

ST

ION

S

UrgeSudden urge, largeamounts, can’t get to toilet in time

StressLeakage when

coughing, standingup, sneezing

MixedCombination ofurge and stress

symptoms

OverflowWeak stream,

dribbling, incomplete voiding

TransientTemporary or re-

cent onset, variety of causes

FunctionalUnable to get to

toilet without assistance (mobility)

2. Determine Resident’s Voiding Pattern

. . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . .

. . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

. . .

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

. . .

Every resident should have a completed voiding diary upon admission and with significant changes in condition.

Voiding diary scheduled (date) ________________________ Date completed _______________________ Initials__________

Did the resident have a pattern? _______ For pattern, see voiding diary.

Resident ________________________________________________________ Room #___________

Assessed by _______________________________________________ Date: ___________________

Current Product Information: Size: _____ Type: ______________ Frequency of Leakage: ________ times/week ❏ None


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Join the team!

When it comes to hot topics in long-term care,

you’re the experts!

You, our readers, are on the front lines of everything thathappens in the healthcare industry – and we want to hearfrom you! Have you ever wished you could write anarticle 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

Contact us at [email protected] to learn more!

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 gives you ideas and tools for implement-ing their recommendations. For a summary of each of the above initiatives, see Pages 8 and 9.

65528_MedCal-A:Layout 1 5/4/10 1:45 AM Page 2


4. Catheterization

Catheter — Type __________________________________ Size: ____________________________

Medical Justifications:

■ Urinary retention that cannot be treated medically or surgically, related to:• Post void residual volume over 200 ml• Inability to manage retention/incontinence with intermittent catheterization• Persistent overflow incontinence• Symptomatic infections• Renal dysfunction

■ Contamination of stage III or IV pressure ulcers with urine which impeded healing.

■ Terminal illness/severe impairments – which makes positing/changing uncomfortable or associated with intractable pain.

What is the MDS Score on B.4 (Cognitive skills for daily decision-making)?

Based on above, the resident may be a candidate for ______________________________

Resident is not a candidate for a bladder program due to: ❏ Indwelling catheter ❏ Confusion/dementia Other ___________________

3. Evaluate for Behavioral Program

If 2, 3Prompted Voiding or Scheduled Voiding

Residents with the following conditions could still benefit from par-ticipating in a prompted or scheduled voiding program:

• Those who cannot feel “urge” to urinate• Agitated or disoriented residents• Bedridden residents or those with mobility limitations

If 0, 1What is MDS score on G1Ia?

(ADL Self-Performance /Toilet Use)

If 0, 1Pelvic Floor Rehab

Bladder Rehab

If 0, 1, 2, 3, 4Prompted VoidingScheduled Voiding

Notes:


Urinary Continence Assessment Forms & Tools


Cover 65528 MedCal.indd 2 5/4/10 4:17 AM

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SURVEY RESULTS & Winners

Free CE Inside!

WOUNDPhotography

Guidelines

Choosing Nutritional

Supplements

EMBRACING NEW TECHNOLOGY

iPhone App Just Launched at www.medlineuniversity.com!


Volume 8, Issue 2

VOLUME 8, ISSUE 2

HEALTHY SKINw

ww

.medline.com

PRESSURE ULCER PREVENTION IN LONG-TERM CARE

Learn more about continuous quality improvement for the prevention of avoidable pres-sure ulcers and F-Tag 314 citations, factors leading to pressure ulcers in long-term carefacilities and comprehensive pressure ulcer prevention strategies and solutions.

Sign up at www.medline.com/PUPP-webinar

J U N E3rd 12:00 pm - 1:00 pm10th 1:00 pm - 2:00 pm23rd 11:00 am - 12:00 pm

J U LY8th 1:00 pm - 2:00 pm14th 1:00 pm - 2:00 pm22nd 11:00 am - 12:00 pm

A U G U S T12th 12:00 pm - 1:00 pm 18th 1:00 pm - 2:00 pm 20th 11:00 am - 12:00 pm

S E P T E M B E R7th 11:00 am - 12:00 pm 9th 1:00 pm - 2:00 pm 14th 12:00 pm - 1:00 pm

INNOVATION IN THE PREVENTION OF CAUTI

J U N E7th 11:00 am - 12:00 pm9th 2:00 pm - 3:00 pm11th 12:00 pm - 1:00 pm18th 12:00 pm - 1:00 pm21st 11:00 am - 12:00 pm22nd 2:00 pm - 3:00 pm

J U LY7th 11:00 am - 12:00 pm 7th 2:00 pm - 3:00 pm 8th 12:00 pm - 1:00 pm 20th 11:00 am - 12:00 pm 20th 2:00 pm - 3:00 pm 21st 12:00 pm -1:00 pm

A U G U S T12th 11:00 am - 12:00 pm 12th 1:00 pm - 2:00 pm 16th 11:00 am - 12:00 pm 16th 2:00 pm - 3:00 pm 25th 11:00 am - 12:00 pm 25th 2:00 pm - 3:00 pm

S E P T E M B E R1st 11:00 am - 12:00 pm 1st 2:00 pm - 3:00 pm 2nd 12:00 pm - 1:00 pm 22nd 11:00 am - 12:00 pm 22nd 2:00 pm - 3:00 pm 27th 1:00 pm - 2:00 pm

Join your colleagues from around the country to learn more about strategies to preventcatheter-acquired urinary tract infections as well as Medline’s ERASE CAUTI system.

Hosted by Connie Yuska, RN, MS, CORLNand Lorri Downs, RN, BSN, MS, CIC

All schedules are Central Daylight Time.

Free WebinarsNew Techniques for Pressure Ulcer Prevention,

Hand Hygiene and CAUTI Prevention

MKT210090/LIT108R/35M/SEL5©2010 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.

J U N E14th 11:00 am - 12:00 pm17th 12:00 pm - 1:00 pm

J U LY8th 11:00 am - 12:00 pm 21st 2:00 pm - 3:00 pm

A U G U S T17th 2:00 pm - 3:00 pm 23rd 1:00 pm - 2:00 pm

S E P T E M B E R2nd 11:00 am - 12:00 pm 27th 2:00 pm - 3:00 pm

As the number one defense against healthcare-acquired conditions, hand hygiene playsan important role in the prevention of infections. Learn how hospitals and healthcarefacilities are combining best-in-class products and education to achieve hand hygienecompliance while dramatically improving the skin condition of healthcare workers.

HAND HYGIENE COMPLIANCE IMPROVEMENT STRATEGIES

Sign up at www.medline.com/handhygiene

Sign up at www.medline.com/erase/webinar.asp


Cover 65528 MedCal.indd 1 5/4/10 5:41 PM

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healthy skin magazine - volume 8; issue 2

Documents