healthy skin magazine - volume 8; issue 3

8/8/2019 Healthy Skin Magazine - Volume 8; Issue 3

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TAKE THE

PINK GLOVE

SURVEYPage 80

Free CE Inside!

How to Prepare forEmergencies & Disasters

The DanceGoes On:

PINK GLOVE

DANCE SEQUEL

Survivors

Share TheirStories

Influenza:PreventionGuidelines

Improving Quality of Care Based on CMS Guidelines

Volume 8, Issue 2



Join the team!

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

you’re the experts! You, our readers, are on the front lines of everything that

happens in the healthcare industry – and we want to hear

from you! Have you ever wished you could write an

article that would be publ ished in a large-circulation

magazine? Nowʼs your chance. Healthy Skin is looking

for writers and contributors. Whether youʼd like to try your

hand at writing or offer suggestions for future articles, we

want to hear what you have to say! You never know – the

next time you open an issue of Healthy Skin , it might be

to read your own article!

HEALTHY SKIN

Contact us at [email protected] to learn more!

Content Key

Weʼve coded the articles and information in this magazine to indicate which national quality initiatives

they pertain to. Throughout the publication, when you see these icons youʼll know immediately that

the subject matter on that page relates to one or more of the following national initiatives:

• QIO – Utilization and Quality Control Peer Review Organization

• Advancing Excellence in Americaʼs Nursing Homes

Weʼve tried to include content that clarifies the initiatives or gives you ideas and tools for implement-

ing their recommendations. For a summary of each of the above initiatives, see Pages 6 and 7.



Page 46

9

Page 66

Page 32

Survey Readiness36 CDC, FDA, CMS Issue Infection Control Guidance

66 Emergencies & Disasters: Preparedness Planning for Long-term

Care Facilities

Prevention39 Save Those Heels! Effective Techniques to Help Avoid Heel

Pressure Ulcers

50 Implementing Medlineʼs Pressure Ulcer Prevention Program at

Lacombe Nursing Centre

58 Influenza: Prevention Guidelines and Recommendations

Treatment11 MDS 3.0: Revised Guidelines for Pressure Ulcer Risk Assessment

and Staging

20 Adult Obesity in the United States: A Growing Epidemic

32 Feeding Dementia Patients with Dignity

46 Foot, Skin and Wound Care from the Other Side of the Bed Rail

54 Case Study: Use of Porcine Urinary Bladder in a Dehisced Wound

Special Features13 Wound Care Nurses Win Case Study Abstract Award at 2010

WOCN Conference

14 Third Annual Prevention Above All Conference

62 Control Measures for Influenza

79 CDC Forms New Advisory Committee on Breast Cancer in

Young Women

80 Take the Pink Glove Survey!

86 The Dance Goes On: Pink Glove Dance Sequel

88 Sharing Stories

Caring for Yourself74 Fail-Safe Strategies to Deal with Difficult People

84 Breast Health Tips

92 Taste the Fountain of Youth

94 Healthy Eating: Tuscan Tomato Soup

Forms & Tools96 Announcing New Online Skin & Risk Assessment Competency

98 SKINSAVERS Initiative: A Pressure Ulcer Prevention Tool

103 Impact of Healthcare Reform on Home Health

105 Patient Handout: Medicare and the New Health Care Law –

What it Means for You

109 A National Framework and Preferred Practices for Palliative and

Hospice Care Quality

111 Ten Tips for Cleaning and Disinfecting Shared Medical Equipment

114 Some Things Should Not be Reused

115 CDC Clinical Reminder: Use of Fingerstick Devices

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 Team

Clay 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 Board

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, CWOCN

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 86

About MedlineMedline, headquartered in Mundelein, IL, manufactures and distributes more

than 100,000 products to hospitals, extended care facilities, surgery centers,home care dealers and agencies and other markets. Medline has more than 800

dedicated sales representatives nationwide to support its broad product line andcost management services.

Meeting the highest level of national and international quality standards, Medline

is FDA QSR compliant and ISO 13485 certified. Medline serves on majorindustry quality committees to develop guidelines and standards for medical

product 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.

Improving Quality of Care Based on CMS Guidelines 3

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



Dear Reader,

September 17th Medline launched the Pink Glove

Dance Sequel. If you haven’t seen it, I highly recom-

mend you to go to pinkglovedance.com and take

a look.

The first video, launched in November 2009, now has

over 11.5 million hits on YouTube. It has been all over

the globe. When it hit the Netherlands and the com-

ments were in Dutch, my daughter and I were so

excited. Emily Somers, you see, is the choreographer,

and this year she has been super busy traveling for

the making of the Pink Glove Dance Sequel. Shortly

after the video release last year, both St. Vincent’s

Hospital in Portland, Ore., and Medline began receiv-

ing countless phone calls and e-mails about people’s

experiences with breast cancer.

One daughter wrote, my mom has not smiled nor has

she gotten off the couch since she was diagnosed.

Once she saw the video, she smiled for the first time

in months. Another woman said she was getting treat-

ments for stage 4 breast cancer, and the video was so

uplifting. Several hospitals and nursing homes asked

if we would do a pink glove dance at their facility.

So, September 17, 2010, Medline launched the Pink

Glove Dance Sequel. Starting at St. Vincent’s in Port-

land, you will see healthcare workers from 10 hospi-

tals and 3 nursing homes in North America dance,

and as a special note of appreciation, you will see

breast cancer survivors from coast to coast dance in

appreciation of their healthcare workers—caregivers

and survivors coming together celebrating. More than

4,000 people participated. We are thrilled, honored

and filled with the hope that this sequel will spur more

people to talk about breast cancer, support each

other through tough times, and give everyone hope.

With so many participants in the film it was hard to

condense hours of footage into four short minutes. In

order to give everyone a chance to dance, we will be

launching an additional video for every hospital that

participated, a video for the nursing homes and a

video of all of the breast cancer survivors. These will

be released the first week of October, to see the

schedule go to pinkglovedance.com. It is our goal to

spread the word to as many people as possible about

saving lives and early detection.

On behalf of all the breast cancer survivors and their

families, I want to extend a heartfelt thank you to the

healthcare workers who continue to show compas-

sion and care for those diagnosed and their families.

You are spectacular!

Enjoy this edition of Healthy Skin! And, take a moment

to reflect on all the good you do. Watch the video,

share it with friends and spread the cheer.

My deepest thanks to all of you,

Sue MacInnes, RD, LD

Editor

”

“ I want to extend

a heartfelt thank

you to the health-

care workers who

show compassion

and care to those

diagnosed and

their families.

HEALTHY SKIN Letter from the Editor

4 Healthy Skin



Introducing

Starring in “The Pink Glove Dance”

Deb!

In her Generation Pink™

Gloves, pink bouffant capand scrubs, Deb danced

in the Pink Glove Video

Sequel. To watch the

video, go to

www.pinkglovedance.com.

To order your own

Deb doll, visit

www.medline.com/dolls.

of Breast Cancer Awareness Month

Some historical facts

marks the 25th anniversary of Breast Cancer Awareness Month, whose purpose is to remind

women about the value of early detection and

mammograms.

Evelyn Lauder, senior corporate vice president

of the Estee Lauder Companies founded the

Breast Cancer Research foundation and began

distributing pink ribbons to symbolize breast

cancer awareness.

was chosen as the breast cancer ribbon color

because it symbolizes health and femininity.

2010

25th

Anniversary

1993

TAKE THE

PINK GLOVE

SURVEYPage 80

Free CE Inside!

How to Prepare forEmergencies & Disasters

The DanceGoes On:

PINK GLOVE

DANCE SEQUEL

SurvivorsShare TheirStories

Influenza:PreventionGuidelines


Volume 8, Issue 2

Breast Cancer Awareness Month was created

in October 1985 as a collaborative effort among

the American Academy of Physicians, Cancer-

Care Inc. and various other sponsors.

1985

Pink

www.pinkglovedance.com



6 Healthy Skin

Two Important National Initiativesfor 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 “Ninth

Scope of Work” plan became effective August 1, 2008 and is a three-year work plan.

Purpose: To carry out statutorily mandated review activities, such as:

• Reviewing the quality of care provided to beneficiaries;

• Reviewing beneficiary appeals of certain provider notices;

• Reviewing potential anti-dumping cases; and

• Implementing quality improvement activities as a result of case review activities.

Goal: In the 9th SOW, the QIO Program has been redesigned with a framework for accountability and also in content. The

content now consists of four themes with the goal to help providers, both in long-term care and acute-care facilities,prevent illness, decrease harm to patients and reduce waste in health care.

Of note: QIOs will be required to help Medicare promote three overarching themes: adopt value-driven healthcare,

support the adoption and use of health information technology and reduce health disparities in their communities.

Under the direction of the Centers for Medicare & Medicaid Services (CMS), the QIO Program consists of a national

network of 53 QIOs located in each of the 50 U.S. states, the District of Columbia, Puerto Rico and the Virgin Islands.

Quality Improvement Organization Program’s 9th Scope of Work ThemeThe official Executive Summaries for the 9th SOW Theme are available at:

http://providers.ipro.org/index/9SOW_summaries

Origin: A coalition-based, two-year campaign initiated on September 26, 2006 to improve quality of life for nursing home

residents and staff. The coalition has continued the campaign beyond its first-round end of August 25, 2008 for an

additional 2 years (until September 26, 2010).

Purpose: A coalition consisting of the Centers for Medicare & Medicaid Services (CMS), organizations representing providers,

consumers and government that developed a grassroots campaign to build on and complement the work of existing

quality initiatives including Nursing Home Quality Initiative (NHQI), Quality First and the culture change movement.

Goal: To ensure that continuous quality improvement is comprehensive, sustainable and consumer-focused, the coalition

has adopted goals that seek to improve clinical care, incorporate nursing home resident and family satisfaction

surveys into continuing quality improvements and increase staff retention to allow for better, more consistent

care for nursing home residents.

Participating providers will commit to focusing on at least three of the eight measurable goals, including at least one clinical goal and

one operational process goal. Current participants may choose to continue with the same goals, add additional goals or change goals

for the next two-year campaign.

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

1. Improving immunizations as a clinical goal

2. Including target setting in all goals

3. Changes to the order in which the goals are presented

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

Advancing Excellence in America’s Nursing Homes2



Trends in Goal SelectionEach nursing home participating in Advancing Excellence selects a minimum of three goals (outlined above).

The goals – and the percentage of participating nursing homes that have selected them – are listed below.

Goal 1: 70.9% 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 onnine Tasks:1. Case reviews

2. Quality improvement activities (QIAs)

3. Alternative dispute resolution (ADR)

4. Sanction activities

5. Physician acknowledgement monitoring

6. Collaboration with other CMS contractors7. Promoting transparency through reporting

8. Quality data reporting

9. Communication (education and information)

Theme #2: Patient Pathways/Care Transitions Activities will focus on three Tasks:1. Community and provider selection and recruitment

2. Interventions

3. Monitoring

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

Staphylococcus aureus (MRSA) infections2. Reducing rates of pressure ulcers in nursing homes and hospitals

3. Reducing rates of physical restraints in nursing homes

4. Improving inpatient surgical safety and heart failure treatment

in hospitals

5. Improving drug safety

6. Providing quality improvement technical assistance to nursing

homes in need

Theme #4: Prevention Activities will focus on nine Tasks:1. Recruiting participating practices

2. Identifying the pool of non-participating practices

3. Promoting care management processes for preventive services

using EHRs

4. Completing assessments of care processes

5. Assisting with data submissions

6. Monitoring statewide rates (mammograms, CRC screens, influenzaand pneumococcal immunizations)

7. Administering an assessment of care practices

8. Producing an annual report of statewide trends, showing baseline

and rates

9. Submitting plans to optimize performance at 18 months

There will be two periods of evaluation under the 9th SOW. The first

evaluation will focus on the QIO's work in three Theme areas (Care

Transitions, Patient Safety and Prevention) and will occur at the end of

18 months. The second evaluation will examine the QIO's performance

on Tasks within all Theme areas (Beneficiary Protection, Care Tran-

sitions, Patient Safety and Prevention). The second evaluation will take

place at the end of the 28th month of the contract term and will be

based on the most recent data available to CMS. The performanceresults of the evaluation at both time periods will be used to determine

the 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 restraints

Goal 3: Improving pain management for < 4% 3%

longer-term nursing home residents

Goal 4:Improving pain management for <15% 19%

short-stay, post-acute nursing

home residents

Operational/Process Goals: Goal ActualGoal 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: 7,481Percentage of participating nursing homes:* 47.6%Participating consumers: 2,233

Average number of goals pernursing home: 3.8



Each package is a 2-Minute Coursein Advanced Wound Care™

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

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




BREAKING NEWS

What to Expect This Flu SeasonFlu season is here, and the Food and Drug Administration has

approved eight vaccines made by six companies. One of the

eight is a new high-dose version meant for people 65 and older.1

The 2010-2011 vaccine contains killed or weakened

forms of three viruses:1

1. Swine flu (technically known as A/California/7/09 (H1N1)

2009 influenza

2. A/Perth/16/2009 (H3N2)-like virus

3. B/Brisbane/60/2008-like virus

FLU FACTS2

• The Centers for Disease Control and Prevention(CDC) announced on June 22, 2010 that it wouldnot be endorsing mandatory influenza vaccinationsfor healthcare workers this flu season.

• The CDC now recommends thathealthcare workers wear surgicalface masks instead of N-95respirators when working withinfluenza patients.

• Flu vaccination rates increasedby an average of eight percentduring the 2009-2010 flu season.

HHS Grants $159.1 Million to Train Healthcare Workers3

The Department of Health and Human Services (HHS) has

awarded $159.1 million in grant money to support healthcare

worker training to be targeted to nursing and geriatric-targeted

programs, as well as Centers of Excellence programs for minor-

ity students. The funding is made possible through the Ameri-

can Recovery and Reinvestment Act and Patient Protection

and Affordable Care Act. A state-by-state chart of grantaward recipients is available at www.hhs.org.

Health Care Spending Among Obese Adults

Increases 30 Percent Over 20 Years4

Health care spending per adult grew rapidly among obese

patients between 1987 and 2007, according to an analysis

recently released by the Congressional Budget Office. Spending

per capita for obese adults exceeded spending for adults of

normal weight by about eight percent in 1987 and by about 38

percent in 2007. If recent trends continue, the adult obesity rate

would rise from 28 percent in 2007 to 37 percent in 2020. Percapita spending on health care for adults would increase by

about 3 percent more than it would if the obesity rate were

unchanged, CBO estimates.

References

1. Grady D. Flu vaccines are approved and urged for most. The New York Times.

July 30, 2010. Available at: http://www.nytimes.com/2010/07/31/health/policy/31-

flu.html?_r=1&ref=health. Accessed August 9, 2010.

2. Bartlett JG. Need-to-know news about influenza. From Medscape Infectious

Diseases. Available at: http://www.medscape.com/viewarticle/725532.

Accessed August 4, 2010.

3. Costello MA. HHS awards $159.1 million in heath care workforce grants. AHA

News Today. August 6, 2010.

4. How does obesity in adults affect spending on health care? Congressional Budget

Office web site. September 8, 2010. Available at: http://www.cbo.gov/doc.cfm?

index=11810. Accessed September 10, 2010.

BREAKING NEWS



Happy residents, healthy skin and fewer pressure ulcers

are what you want to see in your facility. That's why you

should take a look at PUP -- the Pressure Ulcer Preven-

tion program from Medline.

One glance shows that this program is comprehensive.

It includes:

• Curriculum for you to help train your staff: RNs,

LPNs, CNAs, MDs

• Practical tools to help reduce the incidence of pressure ulcers

• Innovative products supported by evidence-based

information that results in better patient care

When Tewksbury State Hospital, a 250-bed facility in

Massachusetts, began using Medline's Remedy and

Ultrasorbs products in June 2009, there were 55 facility-

acquired pressure ulcers. By April 2010 they had only six

facility-acquired pressure ulcers -- that's an 89 percent

reduction in nine months.The number of pressure ulcers

decreased another 67 percent by June 2010 after staff

completed their PUP education program.1

For more information on the Pressure Ulcer

Prevention Program, contact your Medline

representative, call 1-800-MEDLINE or visit

www.medline.com/pupp-webinar to register

for a free informational webinar.


1. Medline Industries, Inc. Data on file.

What you see......is because of what you don't see




Revised Guidelinesfor Pressure Ulcer Risk Assessment and Staging

MDS 3.0

The Centers for Medicare & Medicaid Services implemented

the Minimum Data Set (MDS) 3.0 on October 1, 2010. MDS

3.0 includes revisions to Section M: Skin Conditions, which

changes how wounds are tracked and recorded in Medicare-

certified skilled nursing facilities. MDS 3.0 presents pressure

ulcer risk in a more sophisticated, thorough and clinically

relevant way that requires greater collaboration between

caregivers and physicians or primary care providers. The net

result is an assessment tool that is more in keeping with

residents’ needs.1 The following is a summary of the

major changes that apply to pressure ulcer risk assessment

and staging.

Reverse staging no longer allowed

MDS 3.0 illustrates a change in philosophy based on the

National Pressure Ulcer Advisory Panel’s (NPUAP) conclusions

that applying the pressure ulcer staging system in reverse

order is erroneous and can lead to inappropriate wound care

and reimbursement. For example, if an ulcer reaches Stage

IV and then granulates and epithelializes, it may appear

clinically shallow like a Stage II, but it still must be

documented as a healing Stage IV.1

(M0300B-G) Now included! Present on admission

(POA)/reentry data

MDS 3.0 includes new coding for pressure ulcers that are

present on admission or upon reentry to the nursing facility.

POA ulcers that worsen during the resident’s stay at the

nursing facility are then coded at the higher stage and are no

longer considered POA. Also, if a pressure ulcer is unstageable

at admission, but then becomes visible and stageable, it must

then be coded as POA.1

M0610)Now included!

Measurement of largestpressure ulcer

If the resident has one or more unhealed (non-epithelialized)

Stage III or IV pressure ulcers or an unstageable pressure

ulcer due to slough or eschar, you must identify the pressure

ulcer with the largest surface area (length × width) and record

it in centimeters.2

(M0800, M0900) Now included! Tracking of

changes in pressure ulcers over time

These items document whether overall skin status has

worsened since the last assessment. To track increasing skindamage, this item documents the number of new pressure

ulcers and whether any pressure ulcers have worsened to a

higher (deeper) stage since the last assessment. Most Stage

II pressure ulcers should heal in a reasonable timeframe. Full

thickness Stage III and IV pressure ulcers may require longer

healing times.2

(M0300G) Pressure ulcer blisters associated with

signs/symptoms of suspected deep tissue injury

(sDTI) must be coded as unstageable sDTIs

As of June 2010, MDS 3.0 instructed clinicians to code all

blisters related to pressure as Stage II pressure ulcers. These

instructions changed in August 2010. Upon consultation with

clinicians it was decided to further clarify coding related to

pressure ulcer related blisters and sDTIs to emphasize the

assessment findings of the wound and the surrounding

tissue, rather than the color of the fluid in the blister. The

emphasis is on complete and comprehensive assessment of

the resident and the type of skin injury rather than just solely

on the type of fluid in the blister.3



12 Healthy Skin

Deep tissue injury may precede the development of a Stage

III or IV pressure ulcer even with optimal treatment. Quality

health care begins with prevention and risk assessment, and

care planning begins with prevention. Appropriate care

planning is essential in optimizing a resident’s ability to avoid,

as well as recover from, pressure (as well as all) wounds.

Deep tissue injuries may sometimes indicate severe damage.

Identification and management of suspected deep tissue

injury (sDTI) is imperative.2

Further understanding of MDS 3.0

For a more in-depth look at MDS 3.0 Section M: Skin

Conditions, visit http://journals.lww.com/aswcjournal/pages

and search for the articles referenced below.

To locate a complete copy of MDS 3.0 and related training

materials, go to http://www.cms.hhs.gov/NursingHome-

QualityInits/01_Overview.asp#TopOfPage. Section M:

Skin Conditions is located in Chapter 3 of the MDS 3.0

RAI Manual.

The information presented here was current when this article

was published in mid-September 2010.

References

1. Levine JM, Roberson S, Ayello EA. Essentials of MDS 3.0 Section M: Skin Conditions. Ad-

vances in Skin & Wound Care. 2010;23(6):273-283.

2. MDS3.0 RAI Manual August 2010. Centers for Medicare & MedicaidServices. Available at:

http://www.cms.gov/NursingHomeQualityInits/45_NHQIMDS30TrainingMaterials.asp#TopOf-

Page. Accessed September 10, 2010.

3. Ayello EA & Levine JM. CMS updates on MDS 3.0 Section M: Skin Conditions—change in

coding of blister pressure ulcers. Advances in Skin & Wound Care. 2010;23(9):394-397.

MDS 3.0

© 2010 Medline Industries, Inc. Medline and Marathon are registered

trademarks of Medline Industries, Inc.

Problem: Peristomal Irritation

Solution: Marathon® Cyanoacrylate LiquidSkin Protectant

Peristomal irritation can lead to decreased wear time, pain

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against irritation and maceration by creating a barrier

against moisture and chemical assault.

Marathon, a cyanoacrylate, bonds to the skin surface,

integrating with the epidermis on a molecular level to

seal in moisture. While other skin protectants may flake

off, Marathon stays in place, offering robust protection

and increased wafer wear time.

To learn more, visit

www.medline.com/skincare.

Stoma site beforetreatment with Marathon.1

Same stoma site after treatment with Marathon.1

\ Cy∙an∙o∙a∙cry∙late \ A fast-acting adhesive that bonds with the skinto create a barrier against moisture and friction.

1. Data on file




Left to right: Tricia Corvino,

MSN, RN, CWOCN,

co-author; Phyllis Bonham,

PhD, MSN, RN, WOCN,

DPNAP, president, Wound,

Ostomy and Continence

Nurses Society; Amparo

Cano, MSN, RN, CWOCN,

co-author; and Margaret

Falconio-West, BSN, RN,

APN/CNS, CWOCN,

DAPWCA, senior vice

president, clinical education,

Medline Industries, Inc.

Wound care nurses Tricia Corvino and Amparo Cano won a

merit award for their case study, “Use of a Porcine Urinary Bladder

Matrix (UBM) in a Dehisced Wound Between Stomas Promoted

Closure Facilitating Regular Pouch Changes in a Premature

Neonate,” which they presented at the 42nd Annual Wound,

Ostomy and Continence Nurses Society Conference June 12-16,

2010, in Phoenix, Ariz. Turn to page 54 to review the study.

Wound Care Nurses Win

Case Study Abstract Award

at 2010 WOCN Conference

Special Feature



14 Healthy Skin

The heat is on in health care like never before. Error

prevention, efficiency and cost containment have been

top priorities for a very long time, but now, with the

introduction of healthcare reform, they are absolutelycritical for survival, according to Joint Commission

President Mark Chassin, MD, MPP, MPH.

What to expect from healthcare reform

Dr. Chassin delivered the keynote address at Medline’s 3rd

Annual Prevention Above All Conference devoted to sharing

new strategies for delivering cost-effective, high-quality, evi-

dence-based health care. An audience of more than 100 hos-

pital CEOs, chief nursing officers and other executives attended

the meeting August 16 and 17, 2010, in New York City.

“Today’s message is clear,” Dr. Chassin said. “Solve safety and

quality problems. Don’t say you’re trying; just solve them. Take

care of 30-plus million more people in your organizations. Be-

come or participate in an accountable care organization. Figure

out bundled payments. Adopt electronic medical records

quickly. And one more thing. You can’t have any more money.”

Overall, Dr. Chassin explained, healthcare reform increases

coverage while experimenting with some new payment and

care delivery ideas. Reform will increase federal costs, and

there is only one vehicle for cost containment: limiting payment

to providers.

Dr. Chassin cautioned, “You will never be paid better than you

are being paid now. This was true six months ago, it’s true now,

and it will be true tomorrow and next week.”

So how do healthcare providers control costs and avoid major

payment cuts and benefit reductions while also maintaining

quality? Dr. Chassin outlined several keys to survival in today’s

era of healthcare reform.

Employ a quality-driven strategy to eliminate overuse of health

services. Examples include discontinuing wasteful practices

such as prescribing antibiotics for colds and inducing labor ear-lier than 39 weeks.

“This is one part of health policy that has not received any at-

tention,” Dr. Chassin explained. “It’s been overlooked for

decades in the research community. We must come together

to do this.” Two more keys to survival are eliminating the waste

inherent in needlessly complex care delivery processes and

putting an end to preventable complications.

Strategies for Thriving in theNew Era of Healthcare Reform

Third Annual Prevention Above All Conference




Deborah Adler, Trent Haywood,

Mark Chassin and Mikel Gray

answer questions from the

audience at the Third Annual

Prevention Above All Conference

held at the Hudson Theatre in

New York City.

Special Feature



16 Healthy Skin

A look into the future

Speaking from his experience as CEO of New York City’s Mount

Sinai Hospital, one of the nation’s largest and busiest hospitals,

Wayne Keathley provided a firsthand look at what he predicts

will be the norm for the average U.S. hospital amidst the newera of healthcare reform—having to do a lot more with a lot less

at average capacity levels of 95 percent.

“A fair number of you probably don’t recognize the kind of con-

gestion, overcrowding and difficulties with flow that I’m about

to describe,” Keathley said. “I would ask you to indulge in a lit-

tle suspension of disbelief and assume for a minute that as

health reform evolves, possibly because of a whole new group

of patients who will come to you for care … and more likely

because the economics will require you to rethink capacity and

the way you manage it — that the situation I’m going to

describe for us, in fact has some meaning for you.”

Mount Sinai is operating at 95 percent capacity, and they are

currently working with GE Healthcare to implement new

systems to accommodate this level of activity.

Keathley advocates improvement through fixing systems,

not by adding more resources. For example, whereas hospi-

tals often rely on intuition and personal judgment when man-

aging patient flow and locating empty beds, Keathley suggests

that studying capacity patterns and related data leads to

more efficient use of resources. He also encourages collabo-ration among departments, viewing the hospital as a whole

rather than operating as individual silos.

“If money were no object, we would add more beds, add more

operating rooms, hire more nurses, and we could drive

occupancy back down to the ideal 85 percent,” Keathley

said. “But I am telling you, that fantasy doesn’t exist.”

Prevention Above All

Another solution to meeting the challenges of healthcare reform

lies in preventing costly medical errors and infections that are

indeed preventable. Sue MacInnes, Medline’s Chief Marketing

Officer and host of the Prevention Above All Conference,

reviewed Medline’s growing offering of preventive strategies

for healthcare providers:

The Gold Standard Surgical Safety Program to help prevent

operating room errors, the Hand Hygiene Compliance Pro-

gram, the Pressure Ulcer Prevention Program, Educational

Packaging, the ClearCount Surgical System to help prevent

sponges from being left behind and the Catheter-Associated

Urinary Tract Infection (CAUTI) Foley Catheter Management

System to help prevent CAUTIs.

These six strategies are targeted, focused and achievable evi-

dence-based solutions that are also practical. They fit with

everyday processes and systems currently in place at most

healthcare facilities.

MacInnes emphasized, “Sometimes the simplest solutions

make the biggest difference.”

Left: Keynote speaker

Joint Commission President

Mark Chassin, MD, MPP, MPH.

Above (left to right): Medline

President Andy Mills, Deborah Adler, Medline Chief Marketing

Officer, Sue MacInnes, RD, LD,

Atul Gawande, MD, MPH,

Medline COO Jim Abrams.

Right: The Third Annual

Prevention Above All Conferencetook place at the historic Hudson

Theatre in New York City.




Caroline Fife, MD and Kevin W. Yankowsky, JD

Lawsuits, Technology and Wound Care: How Electronic

Health Records Change Your Legal Risks

“Any time a lawsuit is filed, you and your facility and your

practitioners lose. The only question is the question

of degree ... I would suggest and recommend that you

take a moment to focus on how, in addition to improving

your clinical care, you can take steps to absolutely mini-

mize your risk of ever being involved in the legal system; of

ever being sued in the first place.” - Kevin W. Yankowsky

Trent T. Haywood, MD, JD

Social Practice: Observation

for Understanding and Improving

“One of the key things people have taught us in anything

that has to do with practice improvement is not really what

you don’t know; it’s what you think you know that ain’t so.”

Dale Bratzler, DO, MPH

Healthcare-Associated Infections

and Public Accountability

“Clearly, if there is a single practice that we can do betterthat will dramatically reduce healthcare-associated infec-

tions, it would be hand hygiene.”

Mikel Gray, PhD, FNP, CUNP, CCCN, FAANP, FAAN

Evolution of Evidence: New Models

for Demonstrating Effectiveness

“Insufficient evidence remains the primary challenge

of evi dence-based practice; demystification of the

research process is urgently needed.”

Abdul Gawande, MD, MPH

Author, The Checklist Manifesto

“What we have today, though, is a volume and complex-

ity of medical discovery that has now exceeded our ability

as individual specialized artisans to be able to deliver that

care to the right person, the right way, at the right time

without waste of resources,” Dr. Gawande said.

For video clips of the speakers’ presentations from

the 3rd Annual Prevention Above All Conference,

visit www.medline.com/media-room. Or contact

your Medline representative for a free set of DVDs.

What the Experts Are Saying ...

Fife Yankowsky

Haywood Bratzler

Gray Gawande



Practicing Advanced Medicine

Within Outdated Systems

Atul Gawande, MD, a Harvard professor and author of several

books, including his most recent, The Checklist Manifesto,

addressed the challenges of delivering highly advanced medical

care within outdated systems.

He pointed out that we’ve entered a complex medical world in

which we have 13,600 different diagnoses, 6,000 prescription

medications and more than 4,000 medical and surgical

procedures.

Compounding matters, we’ve inherited a structure from 50

years ago that didn’t have nearly so many diagnoses, drugs

and procedures. At that time, the doctor was considered an

artisan, and all you really needed was the physician’s brain,

along with an operating room, a few simple tools and some

skills behind that.

“What we have today, though, is a volume and complexity of

medical discovery that has now exceeded our ability as

individual specialized artisans to be able to deliver that care to

the right person, the right way, at the right time without waste

of resources,” Dr. Gawande said.

The Checklist Manifesto: How to Get Things Right

Atul Gawande, MD, MPH

We l ive in a world of great and

in creasing complexity, where even

the most expert professionals strug-

gle to master the tasks they face.

Longer training, ever more advanced

technologies — neither seems to pre-

vent grievous errors. But in a hopeful

turn, acclaimed surgeon and writer

Atul Gawande finds a remedy in the

humblest and simplest of techniques:

the checklist.

Bedside Clinicians as Researchers

Mikel Gray, PhD, FNP, CUNP, CCCN, FAANP, FAAN,

editor-in-chief of the Journal of Wound, Ostomy and

Continence Nursing, described the research process,

focusing on randomized controlled trials, which are con-

sidered the gold standard for establishing the efficacy

of an intervention.

According to Dr. Gray, the primary challenge of evi-

dence-based practice is an overall lack of research. He

feels that doctoral prepared researchers from universi-

ties are not the only ones qualified to perform meaning-

ful clinical research. And as a way to generate more

research, he believes there is an urgent need todemystify the research process to encourage bedside

clinicians to conduct studies based on their every-

day practice.

“Bedside clinicians can and do perform meaningful

research if provided proper support, mentoring from

sympathetic researchers and adequate resources,” he said.

Dr. Gray shared an example of

one such clinician, Dea J. Kent,

MSN, RN, NP-C, CWOCN, man-

ager of the Wound Ostomy Clinic

at Riverview Hospital in Noblesville,

IN, who compared the effects of

educational materials for wound

dressing application that were

attached to dressing packag-

ing versus traditional wound care education.

The study showed that none of the 139 nurses who

used traditional dressing packaging were able to apply

the wound dressing correctly. On the other hand, 88

percent of the nurses who used the package with the

educational guide attached to it were able to apply the

dressing correctly. The study will be published in the No-

vember 2010 issue of the Journal of Wound, Ostomy

and Continence Nursing.

To download a free copy of Kent’s study, “Effects of a

Just-in-Time Educational Intervention Placed on Wound

Dressing Packages” visit http://journals.lww.com/jwoc-

nonline/pages/default.aspx.

18 Healthy Skin




“

17 new wound care courses for nurses at

www.MedlineUniversity.com.

Join us on Twitter

Be the first to know when we add new courses and content

Access courses on your computer or iPhone.

M E D L I N E

MUU N I V E R S I T Y

“

Just

whatI waslooking

for.

Medline University has just launched an all-new wound

care curriculum offering 23 total credits, and all courses

are free.

Here’s a sampling of the offerings:

• The Basics of Wound Care

• Identifying, Assessing and Documenting Types of Wounds

• Wound Care for Pediatric, Burn, Bariatric and Cancer Patients

• Using DIMES and the Wound Care Algorithm

• Adjunctive Therapies

• Tools for Wound Healing

• Discharge Planning and Grant Writing

• Developing a Certified Wound Care Team

• Preventing Pressure Ulcers

• Legal Issues in Wound Care

* Courses approved for continuing education by the Florida Board

of Nursing and the California Board of Reigistered Nursing.




As nurses, we are used to educating patients about health

problems, including excess weight. But for many nurses it’s

time for a refresher course on the science behind weight gain

and loss. The pounds we shed can bring us added energy and

better health — and the pride of accomplishing something

important for our own well-being. Losing weight is certainly a

hard task, with the inevitable setbacks and frustrations, but a

worthwhile one.

Anyone who is overweight has lots of company these days.

Obesity as a major public health issue has moved to the fore-

front and for good reason. Obesity among U.S. adults has

become epidemic in proportion. Progressively increasing in

recent years, American obesity rates are the highest in the

world, with 68 percent of adults categorized as overweight,

one-third of whom are clinically obese.1,2

Factors that increase the risk of obesity include genetics

(affecting the amount and areas of body fat storage), family

history (having two obese parents increases the chances of

being obese, due to the influence of genetics and learned pat-

terns of behavior) and age (which increases inactivity).

A variety of other factors contribute to obesity. At a basic level,

obesity is an issue of energy imbalance. Excess weight is the

result of the intake of more calories from food than are

expended through activities of daily living plus physical exer-

cise. However, obesity is an expansive and complex health

issue that also results from a combination of factors, among

them genetics, metabolism, behavior, environment, culture and

socioeconomic status.3

Body mass index, also known as the Quetelet index, defines

body mass in relation to both height and weight. (BMI is based

upon metric measurements, dividing weight in kilograms by

height in meters; BMI = weight/height2.) A strong relationship

exists between BMI and mortality in adults.4 The most widely

accepted obesity scale, the World Health Organization obesity

criteria, is based upon BMI and calculates that a BMI of

between 25 and 29.9 kg/m2 is overweight, a BMI of between

30 kg/m2 and 39.9 kg/m2 is obese, and a BMI over 40 kg/m2

is severely or morbidly obese.5

The body requires some body fat for insulation and to provide

shock absorption and store energy for potential use later. How-

ever, along with the cosmetic concerns, too much body fat

can have serious health implications, among them the propen-

sity for hypertension, diabetes and cardiac disease. The med-

ical costs directly attributable to obesity are estimated at $147

billion per year.6 Combined with smoking, alcohol use and high

levels of stress, excessive weight can have seriously detri-

mental effects upon the body.

by Cathy S. Birn, RN, MA, CGRN, CNOR

We all intend to eat right and exercise, but life intervenes. We’re too rushed for a real

meal and grab something from the vending machine. After a 12-hour shift or a longcommute, we crave sleep and comfort food instead of exercise and veggies.

The pounds creep up on us despite our best intentions.

A GROWING EPIDEMIC

Adult Obesity in the United States

Treatment



22 Healthy Skin

Where’s the Beef?In the United States, society facilitates obesity. Food is readily

available and often comes in “super-sized” portions. Passiveentertainment has become the norm as the bulk of the popula-

tion has morphed into a modern cliché, the “couch potato.” Stud-

ies have shown that only a small fraction of the population

achieves the minimally recommended exercise goals.7

Environment and lifestyle play a significant role in the develop-

ment of obesity. Obesity is not only a product of our eating habits

and exercise patterns, but also a manifestation of our modern

lifestyle. More people choose to drive around the block than to

walk, to eat in restaurants or order take-out than to cook and to

snack on high-caloric vending machine selections than to con-

centrate on healthier alternatives.7

Cultural background also affects weight. Foods specific to certain

cultures may be high in salt and fat. Family gatherings often prof-

fer large quantities of food, along with an excellent excuse not

only to socialize, but to overindulge.7

Certain preexisting conditions and illnesses can lead to a propen-

sity for overweight and obesity. Hypothyroidism lowers the body’s

metabolic rate, resulting in a slower and reduced expenditure of

energy. Cushing’s disease, a hormonal disorder, commonly

causes upper-body obesity and increased fat around the neck.

Increasing evidence exists that insufficient sleep may lead toweight gain over time as does polycystic ovarian syndrome

(which is characterized by high levels of male hormone), irregular

or missed menstrual cycles and multiple, small cysts in the

ovaries. Certain drugs — such as steroids, some antidepressants

and medications used to treat psychiatric illnesses and seizure

disorders — may cause weight gain by slowing the metabolic

rate, stimulating the appetite or causing water retention.9

I Came, I Saw, I AteObviously, diets that include large portions of high-calorie foods

contribute to weight gain. Foods high in fat can be heavy in

caloric content since fat has more calories per gram than carbo-

hydrate or protein. Foods and beverages such as soft drinks,

candy and desserts have not only a high sugar content, but also

a high caloric content.

Sedentary people are more likely to gain weight since they are

not burning calories through physical activity. Some people gain

weight when they quit smoking. Nicotine raises the body’s meta-

bolic rate, resulting in more calories burned. In addition, food typ-

ically tastes and smells better after one stops smoking, and

eating a natural stopgap for hands and mouths no longer filled

with a cigarette.10 In addition, many women find it difficult to lose

pregnancy weight after giving birth, contributing to the develop-

ment of obesity.

Also of note is the distribution of body fat as it can have an impact

on illnesses that are directly attributable to obesity. Excessive body

fat in the abdominal area significantly increases the probability of

diabetes mellitus, hypertension and hypercholesteremia.11

Distribution of Body Fat

women

“pear”

shapemen

“apple”shape

People who are obese are more likely to develop a number of

significantly serious and chronic diseases. Among these are

hypertension; elevated cholesterol levels; diabetes; coronaryartery disease; stroke; osteoarthritis, sleep apnea and respiratory

difficulties; some cancers (endometrial, breast and colon); nonal-

coholic fatty liver disease; endocrine problems; gallbladder dis-

ease; and fertility and pregnancy complications. The greater the

weight, the more likely a chronic health problem will develop.

A reduction of body weight by as little as 5 to 10 percent can sig-

nificantly improve overall health status.13

Women typically collect fat in

the hips and buttocks, giving

them a “pear-shaped” look.

Men typically develop more

of an “apple” shape, generallyaccumulating fat around the

abdomen. Women with a

waist measurement of more

than 35 inches and men with

a waist measurement of more

than 40 inches run a higher risk of

developing weight-related complications

related to the distribution of body fat.12



activity provides both direct and indirect benefits. While

increasing energy expenditure and reducing the risk of car-

diovascular disease, it also helps preserve muscle mass at

the same time it is decreasing body fat. Physical activity can

be in the form of walking, running, dancing, gardening or par-

ticipating in sports. A person should engage in some form of

physical activity to achieve an optimally healthy lifestyle.

Adults should take part in at least two and a half hours of moderate exercise or one hour and 15 minutes of vigorous,

aerobically beneficial exercise every week.15

Crash diets are never recommended, because they can com-

pound existing health issues by creating vitamin deficiencies.

People can shed weight quickly with very low calorie diets,

which consist of 800 calories per day (most adults consume

2,000 to 2,500 calories daily), but they generally regain the

weight quickly when they resume a regular diet.14

A successful weight loss program requires changes in

behavior and more than just the reduction of caloric intake inisolation. A solid weight loss plan consists of alterations in

physical activity, as well as a thorough examination of eating

habits and realistic and achievable goals. Goals set too high

too quickly will result only in failure. Obesity does not have to

become a chronic disease. A healthy diet, daily exercise and

a strong commitment to a healthy lifestyle can derail obesity

and its health complications.

It’s Not a Diet — It’s a Lifestyle

The goal of any weight loss program is to achieve and main-

tain a healthy weight. The treatment of choice depends upon

the level of obesity and a person’s overall health and readi-

ness to devote the effort to a weight loss plan. Any weight loss

regimen should begin with dietary and lifestyle modifications.

Weight loss will result primarily from a decrease in overall food

intake, which will decrease calorie intake. (A calorie is a unit of

energy that is supplied by food.) An excess of about 3,500calories results in the accumulation of one pound of body fat.

Simply by reducing caloric intake by as little as 250 calories

per day, a person can loose a half a pound per week.

Decreasing intake by 500 to 1,000 calories a day will produce

a weight loss of about one to two pounds per week. This can

be accomplished by replacing high-calorie food of low nutri-

tional value, typically highly processed foods with a high sugar

and solid fat content, with nutritious, low-calorie foods, such

as fruits, vegetables and whole grains.14

Physical activity in conjunction with a modified dietary intake

plays an important role in preventing overweight and obesity. Although the body burns a certain amount of calories natu-

rally as it cycles through its daily functions of breathing,

digestion and activities of daily living, most people still ingest

more calories than they expend. To remain in balance, the

calories consumed from food must equal the calories

expended in physical activity. Too many calories will cause

weight gain while too few will lead to a weight loss. Physical

Continued on page 25




Introducing one pad for dryness and positioning. Ultrasorbs

ES provides the same protection from wetness as Ultrasorbs AP,

plus it’s strong enough to be used to lift or position individuals

up to 325 pounds.

Today more than 1,000 hospitals choose Ultrasorbs AP to help

protect patients’ skin from many causes of skin breakdown,

especially moisture and heat buildup. Another cause of skin

breakdown is pressure caused by layers of material stacked

under patients to help with lifting and positioning. UsingUltrasorbs ES, caregivers no longer need those additional

layers to lift and move patients. Fewer stacked linens mean

less pressure points against the skin.

To request a free sample of Ultrasorbs ES,

send an e-mail to [email protected].

A DRY PAD & DRAW SHEET ALL IN ONE

NEW!




Orlistat, on the other hand, prevents absorption of fat in the

intestines; fat is eliminated in the stool instead of being absorbed

and becoming fat itself. By keeping the body from absorbing

dietary fat, orlistat reduces the total amount of energy from calories

absorbed by the body and, taken as directed, can block up to 30

percent of ingested fat.18 The adverse effects include oily and fre-

quent bowel movements and diarrhea, as well as a reduction in

absorption of essential fat-soluble vitamins and nutrients. Orlistat

must be taken with vitamin and nutrient supplements.18

Most FDA-approved weight-loss medications are appetite sup-

pressants not suggested for use for more than 12 weeks.

Examples include phentermine (Fastin) and diethylpropion (Ten-

uate). Other medication classifications that cause weight loss as

a side effect include the diabetic medication metformin HCl (Glu-

cophage), antidepressive medications including bupropion (Well-

butrin) and antiseizure medications that include topiramate

(Topomax) and zonisamide (Zonegran). Researchers are studying

these drugs for their unequivocal usefulness in treating obesity. 19

Research is ongoing on the long-term effects of medications pre-

scribed specifically for weight loss. Currently, except for orlistat

(released in 2007 in an over-the-counter variety), all weight loss

medications are controlled substances because of the potential

for abuse and development of dependency. Many people on

weight-loss medication are nonadherent with diet and exercise

programs because they believe the medication will control their

weight for them. However, although many of the adverse effects

The Drug’s the Thing

The most therapeutic weight loss approach involves a solid diet,

exercise plan and behavior modificationsystem set up, ideally, in con-

junction with a physician and a nutritional counselor. However, peo-

ple who have found this approach to be unsuccessful, have a BMI

greater than 30 and have developed obesity-related medical com-

plications can explore additional regimens of weight loss. The phar-

macological management of obesity has gained attention as a

greater portion of the population strives to lose weight. Weight-loss

medications should be considered only in conjunction with a diet and

exercise plan, and only if lifestyle modifications have not proved to

be effective.

Medications to treat obesity can be divided into three categories:

those that reduce food intake, those that alter metabolism and

those that increase energy expenditures. Many medications are

sold over-the-counter or by prescription to enhance weight loss

in individuals who are obese. Although most weight-loss med-

ications are approved for short-term use only, two that have been

approved by the FDA for long-term use are sibutramine (Meridia)

and orlistat (Xenical). Sibutramine alters the brain chemistry in theappetite center of the brain by extending the amount of time that

serotonin and noradrenaline are free to work. The increased rate

of activity of these combined chemicals results in appetite sup-

pression. While its most common adverse effect is hypertension,

sibutramine can also cause tachycardia, headaches, dry mouth,

constipation and insomnia.17 It should not be used by a person

with or at a high risk for cardiovascular disease.



26 Healthy Skin

Big Eyes, Small Stomach

Weight-loss surgery, known as bariatric surgery, bypass sur-

gery or gastric banding, is recommended for people who

have clinically severe obesity (once called “morbid obesity”)

and have failed to lose weight through diet and exercise.

Weight-loss surgery is suggested for people with a BMI of 40

or greater, men who are 100 pounds or more overweight and

women who are 80 pounds or more overweight.22 Surgical

intervention provides a medically sustained weight loss for

more than five years in most patients.23 However, it is not a

miracle cure and still requires a life-long commitment to a

healthy lifestyle consisting of a low-calorie diet and a healthy

exercise program.

Gastric bypass surgeries limit the amount of food a person can

consume and digest by surgically altering the anatomy of the

GI tract. There are different types of bypass surgeries, and their

use depends on surgeon preference and patient requirements.

The Roux-en-Y gastric bypass is the most common weight-

loss surgery in the United States. A surgery that combines the

principles of “restriction” and “malabsorption,” it consists of the

stapling of a portion of the stomach together to form a smaller

pouch that cannot contain a large amount of food at any one

time. This limits food intake. In addition, a Y-shaped section of

the small intestine is attached to the pouch, which causes food

to bypass both the duodenum and the first portion of the

jejunum, leading to reduced caloric and nutrient absorption.24

of these medications are mild, rare, serious and even fatal

outcomes can and do occur. In addition, when people stop

taking these drugs, weight gain tends to reoccur. 20

Patients should use caution when considering the many OTC

products advertised for weight loss. The FDA issued warn-

ings against more than 70 “tainted weight-loss products” that

contained undocumented or dangerous pharmaceutical in-

gredients. Many contained prescription drugs in amounts that

exceeded maximum recommended doses or contained

undeclared and dangerous chemical components.21


Patients shoulduse caution when

considering the

many OTC productsadvertised for

weight loss



28 Healthy Skin

Gastric banding is a “restrictive” surgical procedure. An

adjustable silicone band is placed around the upper portion of

the stomach, molding it into two separate but connected cham-

bers. Saline is added or removed from the band through an

injection port attached to the abdominal wall underneath the skin

and connected to the band with soft, thin tubing. Adding saline

to the band through the port increases restriction and limits

intake, helping patients feel full sooner with less food. Potential

benefits of this procedure include an improved quality of life,

improved physical function, improved social and economic

opportunities, and improvement of obesity-related comorbidities,

including diabetes, hypertension and high cholesterol. The downside is that although the procedure restricts the amount of food

that can be ingested at any one time, it doesn’t eliminate the

desire to eat. Diet, an exercise plan and behavior modification

must still be a definitive part of any surgical resolution of obesity.27

As miraculous as the results of these surgeries may be, they are

not without risks and complications. Pneumonia, blood clots and

infection can occur after any surgical procedure. Rapid weight

lose can predispose a person to gallstones. The gastric bypass

itself can cause “dumping syndrome,” which occurs when the

contents of the stomach move through the intestines too quickly,resulting in nausea, vomiting, diarrhea, dizziness and sweating.28

Weight-loss surgeries can produce dramatic and startling effects

not only on a person’s weight, but on his or her overall health sta-

tus and quality of life. Within the first two years postprocedure,

people can shed 50 to 60 percent of their excess weight. 12 Ded-

icated maintenance of a healthy lifestyle will ensure that weight

loss is permanent.29

The Invisible Man

Obesity carries a negative connotation in numerous societies.

Many cultures judge beauty by weight. (Consider the saying “You

can never be too rich or too thin.”) Many people view the over-

weight as slothful, gluttonous and lazy. People who are over-

weight are often overlooked and ignored. As a result, obesity can

have serious psychological, social and economic consequences.

Society’s weight bias leaves people who are obese vulnerable to

depression, anxiety, lowered self-image and, in some instances,

suicidal ideation.

A more extensive and complicated gastric bypass surgery is the

biliopancreatic diversion. It involves removing the lower portion of

the stomach and attaching the small pouch remaining directly to

the small intestine, bypassing the entire duodenum and jejunum.

Although successful as a weight-loss surgery, it is not extensively

performed as it carries a high risk for nutritional deficiencies since

so much of the area of the small intestine is not absorbing poten-

tially essential nutrients.25

Sleeve gastrectomy is another example of a “restrictive” bariatric

surgery. Typically considered a surgical option for patients who

have a BMI of 60 or greater, sleeve gastrectomy involves creat-

ing a sleeve-shaped stomach pouch about the size of a banana,

larger than the pouch created during a Roux-en-Y bypass sur-

gery. Sleeve gastrectomy is usually the first of a two-part surgi-

cal treatment plan that is completed with the performance of a

gastric bypass surgery.26



Weight loss not only helps control diseases exacerbated by

obesity and related to increased mortality rates, but also

decreases the likelihood of developing such diseases in the

first place. There is no rule of thumb for the treatment of

weight loss. Basic principles of obesity therapy and treatment

are a “pyramid” with a base of diet, exercise and behavior

modification. The next level is pharmacological intervention

and, at the top, surgery if necessary. Noninvasive interven-tions include acupuncture, hypnosis and herbal remedies and

supplements. In the end, weight loss and control is a jour-

ney, not just a destination, with the goal a comprehensive

improvement in overall health.

Weight Management and Obesity Resource List

• The Obesity Society: www.obesity.org

• Obesity Action Coalition: http://obesityaction.org/

home/index.php

• CDC resources: www.cdc.gov/obesity/

resources.html

About the author

Cathy S. Birn, RN, MA, GRN, CNOR practices endoscopy at

memorial Sloan-Kettering Cancer Center in New York, NY; is

the cochair woman of the education committee of The Soci-

ety of Gastroenterology Nurses and Associates and is a for-

mer member of the board of directors of the Gastroenterology

Nursing Journal.

Copyright [2010]. Nursing Spectrum Nurse Wire

(www.nurse.com). All rights reserved. Used with permission.

The stigma of obesity affects all areas of a person’s life.30

Under the umbrella of weight bias are employees who are

treated poorly by their coworkers and obese students who

are ridiculed by their peers. It is no wonder that depression

and feelings of inadequacy can result. Unhealthy coping

mechanisms can emerge, and people may react to negative

stimuli by overindulging on comfort food, isolating themselves

or responding negatively to others and refusing to diet. Pos-itive coping mechanisms can include stress management,

stimulus control, cognitive restructuring and the cultivation of

a strong and supportive social network. A positive self-image

that includes developing self-love and acceptance, dieting,

refusing to hide and educating others about the very real

dilemma of weight bias can go a long way in alleviating the

burden of prejudice.31

The Long and Winding Road

Weight loss and maintenance are life-long. Management

includes the reduction of excessive weight in combination

with the maintenance of weight loss and control of any obe-

sity-related comorbidities. It is as much a state of mind as a

way of life. Weight loss and maintenance of a healthy weight

involve a healthy diet low in fat and high in carbohydrates and

a plan for regular physical activity. Successes should be

rewarded, but not with food. A person can adjust to smaller

portions by eating more slowly and taking smaller bites of

food at a time. Weight loss can be charted, and successes

can be documented and celebrated. The conscientious mon-

itoring of progress increases motivation.32




30 Healthy Skin

17. Wooltorton E. Obesity drug sibutramine (Meridia): hypertension and cardiac

arrhythmias. CMAJ. 2002;166(10):1307-1308.

18. Genentech USA Inc. Xenical (orlistal) product information. Xenical Web site.

http://www.xenical.com/hcp/3_productinfo.asp. Accessed July 9, 2010.

19. Boss, Olivier; Karl G. Hofbauer. Pharmacotherapy of Obesity: Options and

Alternatives. Boca Raton, FL: CRC Press. 2004.

20. Wing RR, Phelan S. Long-term weight loss maintenance. Am J Clin Nutr. 2005;

82(1 Suppl):2225-2255.

21. FDA uncovers additional tainted weight loss products. FDA Web site.

http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/-

ucm149547.htm. Updated March 20, 2009. Accessed July 9, 2010.

22. DeMaria EJ. Bariatric surgery for morbid obesity. N Engl J Med.

2007:356(21):2176-2183.

23. Echols J. Obesity weight management and bariatric surgery case management

programs: A review of literature. Prof Case Management. 2010;15(1):17-26.

24. Buchwald H, Olen DM. Metabolic/bariatric surgery worldwide 2008. Weightloss

Surgery Vitagarten Web site. Published 2009. Accessed July 9, 2010.

25. Piazza L, Pulvirentil A, Ferrara F, et al. Laparoscopic biliopancreatic diversion: our

preliminary experience with 201 consecutive cases. Chir Ital. 2009;61(2):143-148.

26. Sammour T, Hill AG, Singh P, Ranasinghe A, Babor R, Rahman H. Laparoscopic

sleeve gastrectomy as a single-stage bariatric procedure. SpringerLink Web site.

http://www.springerlink.com/content/3145284114518783. Accessed July 9, 2010.

27. Tice JA, Karliner L, Walsh J, Petersen AJ, Feldman MD. Gastric banding or by

pass? A systematic review comparing the two most popular bariatric procedures.

Am J Med. 2008;(10):885-893.

28. Apovian CM, Cummings S, Anderson W, et al. Best practice updates for multi-

disciplinary care in weight loss surgery. Obesity. 2009;17(5):871-879.

29. Farrell TM, Haggerty SP, Overby DW, Kohn GP, Richardson WS, Fanelli RD.

Clinical application of laparoscopic bariatric surgery: an evidence-based review.

SpringerLink Web site. http://www.springerlink.com/content/

121234v000452321. Accessed July 9, 2010.

30. Puhl RM, Heuer CA. Obesity stigma: important consideration for public health.

Am J Public Health. 2010;100(6):1019-1028.

31. Wardle J, Cook L. The impact of obesity on psychological well being. Best Pract

Res Clin Endocrinol Metab. 2005;19(3):421-440.

32. Butryn ML, Phelan S, Hill JO, et al. Consistent self-monitoring of weight: a key

component of successful weight loss maintenance. Obesity. 2007;15 (12):3091-3096.

References

1 Flegal KM, Carroll MD, Ogden CL, Curtin LR. Prevalence and trends in obesity

among U.S. adults, 1999-2008. JAMA 303(3):235-241, 2010.

2. AOA fact sheets: obesity in the U.S. American Obesity Association Web site.

http://www.obesity.org/information/factsheets.asp. Accessed July 8, 2010.

3. Adams KF, Schatzkin A, Harris TB, et al. Overweight, obesity, and mortality in alarge prospective cohort of persons 50 to 71 years old. N. Engl J Med. 2006

355(8):763-778.

4. About BMI for adults. CDC Web site. http://www.cdc.gov/healthyweight/assess-

ing/bmi/adult_bmi/index.html. Accessed July 9, 2010.

5. Obesity and overweight for professionals: data and statistics. CDC Web site.

http://www.cdc.gov/obesity/data/trends.html. Accessed July 9, 2010.

6. Obesity and overweight for professionals: economic consequences. CDC Web site.

http://www.cdc.gov/obesity/causes/economics.html. Accessed July 9, 2010.

7. Caprio S, Daniels SR, Drewnowski A, et al. Influence of race, ethnicity, and culture

on childhood obesity: implications or prevention and treatment: a consensus

statement of Shaping America; Health and the Obesity Society. Diabetes Care.

2008;(11):2211-2221.

8. Chaput JP, Despres JP, Bouchard C, Tremblay A. The association between sleep

duration and weight gain in adults: A six-year prospective study from the Quebec

family study. Sleep. 2008;31(4):517-523.

9. Reutsch O, Viala A, Bardou H, Martin P, Vacheron MN. Psychotropic drugs in-

duced weight gain: s review of the literature concerning epidemiological data,

mechanisms, and management. Encephale. 2005:507-516,

10. Lerman C, Berrettini W, Pinto A, et al. Changes in food reward following smoking

cessation: a pharmacogenetic investigation. Psychopharmacology. 2004;174:571-577.

11. Bessesen DH. Update on obesity. J Clin Endocrinol Metab. 2008;93(6):2027-2034.

12. Guh D, Zhang W, Bansback N, Amarai Z, Birmingham C, Anis A. The incidence of

co-morbidities related to obesity and overweight: a systematic review and meta-

analysis. MC Public Health Web site. http://www.biomedcentral.com/1471-

2458/9/88. Published March 25, 2009. Accessed July 9, 2010.

13. Shai I, Stampfer MJ. Weight-loss diet: can you keep it off? Am J Clinical Nutrition.

2008;88 (5):1185-1186.

14. Gorin AA, Phelan S, Wing RR, et al. Promoting long-term weight control: does

dieting consistency matter? Int J Obes Relat Metab Disord. 2004;28(2):278-281.

15. Physical activity for everyone. Department of Health and Human Services Web

site. http://www.cdc.gov/physicalactivity/everyone/guidelines/

adults.html. Accessed July 9, 2010.

16. Bray GA. Lifestyle and pharmacological approaches to weight loss: Efficacy and

safety. J Clin Endocrinol Metab. 2008;93(11 Suppl 1):S81-S88.



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32 Healthy Skin



DIGNITY She would chew away at her food, coughing and sput-

tering and spitting up but swallowing very little, said her

daughter, Cyndy Viveiros. And like many relatives caring

for patients with advanced dementia, Ms. Viveiros had to

decide whether or not to have a gastric feeding tube

inserted.

This quandary — which usually arises near the end, when

Alzheimer’s begins to destroy the part of the brain that

controls eating — is often presented as a stark choice

between providing nourishment and withholding it.

But social workers advising Ms. Viveiros suggested

another option: continuing to have her mother carefully

fed by hand, giving her only as much as she wanted and

stopping if she started choking or became agitated.

“I had this realization — wow — that no matter what wedid, Mom was never going to get better,” Ms. Viveiros

said. “We were just prolonging the inevitable, and poten-

tially causing more suffering.

“Mom was already dying. Alzheimer’s is a terminal disease.

There’s no stopping it,” she said.

Mrs. DeFelice, of Providence, R.I., died about eight months

later.


Feeding DementiaPatients With

By Roni Caryn Rabin

Treatment

Doctors are calling this new option in palliative care “com-

fort feeding only.” In a recent paper in The Journal of the

American Geriatrics Society, the authors argue that feed-

ing tubes do not necessarily prolong life in patients with

advanced dementia, and that surveys indicate that a vast

majority of nursing home residents say they would rather

die than live with a feeding tube.

But medical orders l ike “no artificial hydration and

nutrition” — used to indicate that the patient should not

be given a feeding tube — are often interpreted as “do not

feed.” And few people can tolerate the idea that a loved

one may be starving to death.

Comfort feeding offers another alternative.

“We believe careful hand-feeding is a much more humane

way of taking care of these people, and preserves thepatient’s dignity,” said an author of the paper, Dr. Joan

Teno, a professor of community health at Brown Univer-

sity’s medical school. “They can still have that human

interaction and intimate contact that comes with being fed.

“Just imagine someone interacting with the patient, talking

to them, cueing them into eating,” Dr. Teno said, “as

opposed to someone walking to the bedside and pouring

a bottle of Ensure down the feeding tube.”



34 Healthy Skin

Nancy Berlinger, a bioethics research scholar at the

Hastings Center, a research institute in Garrison, N.Y.,

said the feeding-tube dilemma was “not a choice peo-

ple tend to want to face with reference to their mother,

who probably fed them at an earlier age.”

Eating is a pleasurable activity, and feeding is associ-

ated with love and nurturing, Dr. Berlinger went on, so

the question “Should we put a feeding tube in, or do

you want to stop feeding her?” is almost like asking, “Do

you love your mother or not?”

Feeding tubes are used in about a third of all nursing

home residents with advanced dementia, in part

because the homes worry they could face regulatory

scrutiny if their patients are losing weight. Hand-feedingcan also be time-consuming and labor-intensive. In

addition, the United States Conference of Catholic Bishops

issued a directive last year stating that Catholic health

facilities have “an obligation to provide patients with

food and water, including medically assisted nutrition

and hydration for those who cannot take food orally.”

Yet studies suggest that the tubes do not necessarily

prolong survival. Nor do they always prevent aspiration

in people who have trouble swallowing, since they are at

risk of aspirating their own saliva.

Moreover, the tubes can be very uncomfortable, and

people with dementia must often be physical ly

restrained or sedated to prevent them from yanking the

tubes out.

As many as 5.1 million Americans have Alzheimer’s

disease, the most common cause of dementia, and the

number is expected to rise as the baby boom genera-

tion ages. The disease is progressive and terminal,

though it may take years to run its course; it is the sixth

leading cause of death in the United States, killing more

than 71,000 a year, a figure many experts think is

understated.

Sometimes the ability to eat is lost in the early stages of

Alzheimer’s, not toward the end. Seymour Geffner says

it was one of the first signs that something was wrong

with Blossom, his wife of 63 years.

He started feeding her four years ago, while she went

through a series of tests to figure out what was wrong.Now that she lives at Schervier Nursing Care Center in

Riverdale, in the Bronx, he spends every day there,

hand-feeding her lunch and dinner.

Each feeding takes 45 minutes to an hour, said Mr.

Geffner, 86.

“Some days are better than others,” he said. “The food

is puréed, and she doesn’t eat a full meal. But I always

give her at least half a banana every day, and strawberries

in season.”

“The bottom line is she doesn’t go hungry,” he said.

“She looks good.”

From The New York Times, © August 3, 2010 The New York Times All rights reserved. Used by permission and protected by the Copyright Laws of the

United States. The printing, copying, redistribution, or retransmission of the Material without express written permission is prohibited.

Photos published here did not run with the original New York Times article.

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36 Healthy Skin

CDC, FDA, CMS ISSUE

INFECTION CONTROL GUIDANCE

The Centers for Disease Control and Prevention (CDC) recently

released new guidelines regarding blood glucose monitoring and

insulin administration when people are assisting others, (i.e., inhealthcare settings). Not all of the CDC information is new; how-

ever, it clarifies how to prevent infection when using a glucose

monitor. Some of this information has been available from the

CDC since 2005. The latest language states:

CDC is alerting all persons who assist others with blood glucose

monitoring and/or insulin administration of the following infec-

tion control requirements:

• Fingerstick devices should never be used for more than

one person

• Whenever possible, blood glucose meters should not

be shared. If they must be shared, the device shouldbe cleaned and disinfected after every use, per the

manufacturer’s instructions. If the manufacturer does

not specify how the device should be cleaned and

disinfected, then is should not be shared.

• Insulin pens and other medication cartridges and syringes

are for single patient use only and should never be used

for more than one person.

An underappreciated risk of blood glucose testing is the opportunity

for exposure to bloodborne viruses, such as hepatitis B virus

(HBV), hepatitis C virus and HIV through contaminated equip-

ment and supplies if devices used for testing and/or insulin

administration are shared. Examples of these devices includeblood glucose meters, fingerstick devices and insulin pens.

Outbreaks of HBV infection associated with blood glucose mon-

itoring have been identified with increasing regularity, particularly

in long-term care settings, where residents often require assis-

tance with monitoring of blood glucose levels and/or adminis-

tration. In the last 10 years alone, there have been at least 15

outbreaks of HBV infection associated with providers failing to

follow basic principles of infection control when assisting withblood glucose monitoring. Due to under-reporting and under

recognition of acute infection, the number of outbreaks due to

unsafe diabetes care practices identified to date are likely to be

underestimated.

Although the majority of these outbreaks have been reported in

long-term care settings, the risk of infection is present in any

setting where blood glucose monitoring equipment is shared

or when those assisting with blood glucose monitoring and/or

insulin administration fail to follow basic principles of infection

control.

For example, at a health fair in New Mexico in 2010, dozens of attendees were potentially exposed to bloodborne viruses when

fingerstick devices were inappropriately reused for multiple persons

to conduct diabetes screening. In addition, at a hospital in Texas

in 2009, more than 2,000 persons were notified and recom-

mended to undergo testing for bloodborne viruses after individ-

ual insulin pens were used for multiple persons.

Fingerstick devices should never

be used for more than one person.

Full guidelines can be found at http://www.cdc.gov/injection-

safety/blood-glucose-monitoring.html.

The Food and Drug Administration (FDA) recently posted a

Safety Alert on reusable fingerstick devices and point of care

testing devices. They stated that fingerstick devices should

never be used for more than one person. When possible, POC

blood testing devices, such as blood glucose meters and

Point of care testing in healthcare settings

Survey Readiness



PT/INR anticoagulation meters, should be used only on one

patient and not shared. If dedicating POC blood testing devices

to a single patient is not possible, the devices should be prop-

erly cleaned and disinfected after every use as described in the

device labeling.

The full alert can be found at: http://www.fda.gov/Safety/Med-

Watch/SafetyInformation/SafetyAlertsforHumanMedicalProd-

ucts/ucm224135.htm?sms_ss=email

If shared, blood glucose meters

should be cleaned and disinfected

after every use.

Similar to the CDC and FDA, the Centers for Medicare & Medi-

caid Services (CMS) issued a memo in late August 2010

regarding infection control standards for nursing homes. The

memo is a reminder:

• not to reuse fingerstick devices for more than one resident

• not to use a blood glucose meter or other point-of-care device

for more than one resident without cleaning and disinfecting

it after each use

Also, if the manufacturer does not specify instructions for clean-

ing and disinfection between uses of a point-of-care device,

then the device should not be used for more than one resident.

CMS also clarifies that reuse of fingerstick devices for more than

one resident should be treated as immediate jeopardy. Failure to

clean and disinfect blood glucose meters used for more than

one resident is a deficiency in infection control that warrants

corrective action; however, it may not constitute immediate

jeopardy.

A copy of the CMS memo to state survey agency directors is

located at www.cms.gov/surveycertificationgeninfo/downloads-

/SCLetter10_28.pdf.

Turn to the Forms & Tools section at the back of the mag-

azine for pullout fact sheets on the topics mentioned in

this article.

PERIOPERATIVE PRESSUREULCER EDUCATION.

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SAVETHOSE

HEELS!

E F F E C T I V E

T E C H N I Q U E S

T O H E L P A V O I D

H E E L P R E S S U

R E

U L C E R S

With their drier skin and bony prominences, the heels are par-ticularly vulnerable to injury. People with medical conditions

requiring them to spend long periods of time in bed are espe-

cially susceptible to heel injuries – particularly pressure ulcers

– in the absence of proper prevention strategies. In addition,

the soles of the feet have no sebaceous glands, resulting in a

lack of skin lubrication. This makes the heels vulnerable to dry-

ness and damage from friction, another precursor to pressure

ulcers.1

Complex heel pressure ulcers represent one of the most costlycomplications in the elderly.2 They are the most common

facility-acquired pressure ulcers in long-term care facilities and

the second most common among all healthcare settings. In

fact, long-term care facilities have reported pressure ulcer

prevalence rates as high as 27.3 percent, with 23.6 percent of

the ulcers occurring on the heels. In acute care and mixed

acute care/long-term care settings, heel pressure ulcers

account for approximately one third of all pressure ulcers.

Continuing Education Article


Prevention

by Alecia Cooper, RN, BS, MBA, CNOR



40 Healthy Skin

They can be physically debilitating and painful, possibly lead-

ing to serious complications, including infection, cellulitis,

osteomyelitis, septicemia, limb amputation, and even death.3

Risk assessment

To avoid these complications, it is best to prevent heel pres-sure ulcers altogether. And with appropriate preventive care,

most heel pressure ulcers can be avoided.3 Prevention begins

with a thorough assessment to determine which individuals

are at greatest risk. The most effective assessment of pressure

ulcer risk blends the results of general screening tools, knowl-

edge of common risk factors and nursing judgment.4

The Braden Scale is a widely used risk assessment tool that

screens for the individual’s degree of sensory perception,

exposure to moisture (usually caused by incontinence),

amount of activity, degree of mobility, nutrition level and

amount of exposure to friction and shear. Each of these areas

is scored numerically, with lower numbers indicating greater

risk. A copy of the Braden Scale is available online at

www.bradenscale.com/images/bradenscale.pdf.

Preventive interventions should focus on specific Braden

categories in which the patient has a low score. For example,

if a patient scores low under exposure to friction and shear,

interventions should focus on ways to minimize friction and

shear. Preventive measures also should be pursued in patients

whose total score indicates they are at risk.5 A total score

of 18 or less indicates a person at risk for developing pres-sure ulcers.

Risk factors

Certain physical conditions also increase the risk for pressure

ulcers, including:6

• Decreased circulation and low blood pressure

• Being obese or underweight

• Advanced age• Specific illnesses

• Medications

Decreased circulation and low blood pressure. Blood

supplies the body’s tissues with oxygen and nutrients, so

when blood flow is blocked or reduced, the tissues can liter-

ally starve. The result is the death of skin cells, which can lead

to the development of pressure ulcers.

People with diabetes often experience decreased circulation,

particularly in the legs and feet, making it more difficult for

a sore or infection to heal. Proper foot care is essential for

these individuals and necessary to prevent foot ulcers and in-

fection. Preventive measures include inspecting feet daily for

any cuts, sores, blisters or calluses. Feet should be washed in

warm water and dried thoroughly.7

Being obese or underweight. Two body types are at in-

creased risk for pressure ulcer development: people who are

obese and those who are extremely underweight. Obesity

causes higher risk because blood circulation to fatty tissue is

not as good as circulation to leaner muscular tissue. The poor

circulation means less oxygen and fewer nutrients, which canlead to pressure ulcers. Very thin people are at risk as well be-




cause they have less fatty tissue to cushion bony promi-

nences.

Advanced age. Age is an uncontrollable risk factor for pres-

sure ulcers. Older skin tends to be drier and thinner. It also

breaks down more easily and forms new cells more slowly.

Specific illnesses. Specific medical conditions also put indi-

viduals at greater risk for heel pressure ulcers. The following

groups of patients have the highest risk:8

• Those who cannot move their legs because of fractured

hips, joint replacement surgery, spinal cord injury, Guillain-barre syndrome, stroke or another medical condition.

• People with diabetes and peripheral neuropathy,

which lessens the feeling of pressure or pain in the feet.

• Individuals with dementia who are confused and dis-

traught may inadvertently rub their heels on the bed,

causing heel abrasions from shear and friction.

These abrasions can result in pressure ulcers.

Medications. The side effects of certain medications can also

put individuals at increased risk for pressure ulcers. For ex-

ample, long-time use of steroids for the treatment of asthma

and other chronic respiratory disorders have a tendency to

thin the skin.

Once you have identified an individual at risk for heel pressure

ulcers, the next step is to create a personalized prevention

plan, including a thorough skin assessment with results doc-

umented in the chart. When assessing heels, a normal heel

may be defined as clean and dry with intact skin. An abnor-

mal heel could be one that is pink, red, blistered or containing

an existing pressure ulcer.9

Tools for prevention

In addition to basic pressure ulcer prevention techniques, such

as regular turning and making sure the patient is well-nourished

and hydrated, there are several products that can aid in

preventing pressure ulcers on the heels. Preventive devices

should be selected on the basis of effectiveness, ease of use,

and cost. For preventing heel pressure ulcers, the best products

achieve the following:5

• Reduce pressure, friction and shear• Separate and protect the ankles

• Maintain heel suspension

• Prevent foot drop

In patients at risk, the primary goal is to reduce pressure, fric-

tion and shear on the heels. Several types of products are

available to achieve one or more of these objectives. Some

examples include: pillows, heel offloading devices, padding

devices, moisturizers and pressure-relieving mattresses.

Pillows. The National Pressure Ulcer Advisory Panel (NPUAP)

recommends the use of pillows as an effective, convenient

and cost-effective way to elevate the legs of cooperative indi-

viduals for short periods of time. Raising the heel off the bed

with pillows is best achieved when the pillow is placed longi-

tudinally underneath the calf with the heel suspended in air.3

Pillows are not recommended, however, for individuals who

are at risk for moving the leg off the pillow or in cases when the

leg(s) must be elevated longer than 24 hours. For these

“ ” Heel pressure ulcers are the most common

pressure ulcers in long-term care facilities.




HEELMEDIX™ Heel ProtectorPressure relief and skin protection all in one

The heels are the most common site for facility-acquired pressure ulcers in long-term

care, and the second most common site in all healthcare settings.1 According to clinical

experts, the most effective aspect of pressure ulcer prevention for heels is pressure relief,

also known as offloading.1,2 Offloading is achieved with the use of pillows or heel protection

devices that relieve pressure by elevating the heel off the bed or other surface.

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 provides

maximum ventilation



patients, it’s best to use a product that stays on the foot during

movement – perhaps in the form of a heel offloading device.4

Heel offloading devices. The type of product most often

used to elevate the foot and keep it in place is called ahee l offloading device. Heel offloading devices can be more

efficient than pillows because they can remain in place around

the clock.3 Look for a device that is comfortable for the patient,

easy for the caregiver to use and permits repositioning with-

out increasing pressure in other areas. Most are shaped like a

large boot, surrounding the foot and ankle on all sides, but

also allowing open spaces for needed air flow. The advantage

of these devices is that they both relieve pressure and greatly

reduce friction and shear on the skin. They also separate and

protect the ankles and prevent foot drop. One area of cau-

tion: remember to remove protective boots routinely (i.e.,

every shift) to inspect the individual’s skin for redness.

To help determine the effectiveness of heel offloading devices

as a way to prevent heel pressure ulcers, Meyers studied

53 sedated ICU patients at high risk for pressure ulcers. All 53

wore a heel offloading device. As a result, none of the patients

developed a hospital-acquired heel pressure ulcer.9

Padding devices. Padding devices such as sheep skin and

“bunny boots” protect the heels from friction and shear but

do not remove pressure.

Moisturizers. Moisturizers also minimize friction. In addition,

they may contain topical nutrients to nourish the skin and/or

ingredients such as dimethicone, which adds a layer of

protection on top of the skin. Moisturizers do not, however,

provide any protection from excessive pressure.5

Pressure-reducing mattresses. Air fluidized beds consis-

tently reduce heel pressure below minimal capillary pressure.

However, some benefit may be lost if the head of the bed is

elevated to 30 degrees – a technique recommended to pre-

vent pressure ulcers on the upper body.5 Also, make sure the

mattress is positioned properly. Many pressure-reducing mat-tresses have a definitive head and foot. Placing the mattress

upside down on the bed, so that the individual’s feet are rest-

ing on the head portion, can lead to heel problems.

Conclusion

With heel pressure ulcers being the most common type of

pressure ulcer in long-term care and the second most com-

mon in all healthcare settings, there is still much to be learned

about prevention. Overall, information on the prevention of

heel pressure ulcers is lacking; however, medical needs are

changing. Higher patient acuity and the growing elderly pop-

ulation will continue to keep this issue in the forefront.10 Further

studies are needed to document the effectiveness of existing

interventions and develop new ones.

References

1. Langemo D, Thompson P, Hunter S, Hanson D, Anderson J. Heel pressure

ulcers: stand guard. Advances in Skin & Wound Care. 2008;21(6):282-292.

2. Walsh JS. Keeping heels intact: using a nursing professional practice model

can improve outcomes. Advance for Nurses. 2010; 8(24):25.

3. Fowler E, Scott-Williams S, McGuire JB. Practice recommendations for

preventing heel pressure ulcers. Ostomy Wound Management. 2008;54(10).

Available at www.o-wm.com/content/practice-recommendations-preventing-

heel-pressure-ulcers. Accessed August 25, 2010.

4. Cuddigan JE, Ayello EA, Black J. Saving heels in critically ill patients.

WCET Journal; 28(2):2-8.

5. FAQs: Preventing heel pressure ulcers in immobilized patients. Advances in

Skin & Wound Care; 18(1):22.

6. Pressure Ulcer Prevention Program Nurse Workbook. 2nd edition. Medline

Industries: Mundelein, IL. 2010.

7. Saccomano SJ. Handle with care: proper foot and skin care are necessary

to prevent complications in diabetic residents. Advance for Long-Term Care

Management. July/August 2010:24-26.

8. Black J. Preventing heel pressure ulcers. Nursing. 2004; 34(11):17.

9. Meyers TR. Preventing heel pressure ulcers and plantar flexion contractures

in high-risk sedated patients. Journal of Wound, Ostomy and Continence

Nursing. 2010; 37(4):372-378.




44 Healthy Skin

True/False

1. People who spend long periods of time

in bed are more susceptible to heel

pressure ulcers. T F

2. Obesity increases an individual’s risk for

developing pressure ulcers. T F

3. Heel pressure ulcers are the most

common facility-acquired pressure ulcers

in long-term care. T F

4. Heel pressure ulcers account for approximately

one half of all pressure ulcers in acute care and

mixed acute care/long-term care settings. T F

5. People with diabetes often experience decreased

circulation, especially in the legs and feet. T F

Multiple Choice

6. A low score on the Braden Scale means the

individual is

a. At lower risk for pressure ulcers

b. At higher risk for pressure ulcersc. Anemic

d. None of the above

7. Which of the following is NOT a common risk

factor for developing heel pressure ulcers?

a. Guillain-Barre syndrome

b. Joint replacement surgery

c. Dementia

d. Urinary tract infection

Multiple Choice (cont)

8. Which of the following devices protect heels from

friction and shear but do NOT remove pressure?

a. Sheep skin

b. Heel offloading devices

c. Moisturizers

d. Both a and c

9. Heels are more prone to pressure ulcers than

other parts of the body because

a. They have bony prominencesb. The skin lacks sebaceous glands and tends to

be dry

c. They are usually covered with shoes and socks

d. Both a and b

10. Heel pressure ulcers are the second most

common type of pressure ulcers among

a. All healthcare settings

b. Home health care

c. Hospitals

d. Day care centers

Effective Techniques to Help Avoid Heel Pressure Ulcers

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

Submit your answers at

www.medlineuniversity.com

and receive 1 FREE CE credit

SAVE THOSE HEELS!

CE TEST




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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 cause

pressure that contributes to skin breakdown.2,3

References

1. Diversified Testing Laboratories, Inc. ASTM D 6614-07, “Standard Test

Method 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-Study

Course. 2008. Available at: http://www.oregon.gov/DHS/spd/provtools/nurs

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46 Healthy Skin

In January, I had what I like to describe as

Extreme Makeover — Foot Edition. While my

show didn’t include Ty Pennington’s yelling from

his megaphone, rebuilding homes for deserving

folks on a Sunday night, I couldn’t take the agony

of da feet any more and needed more than just my

custom orthotics. I needed something drastic to

alleviate the years of pain and suffering my poor

peds had endured.

I was a ballerina growing up, then spent my teenage and young-

adult years as a competitive long-distance runner. This, coupled

with some genetics from my maternal grandmother Florence, left

me with some motor changes in my feet and pain that became

increasingly worse — to the point that walking through an airport

or standing to give a presentation in anything other than sneakers

became excruciating!

by Cynthia Ann Fleck

RN, BSN, MBA, CWS, DNC, CFCN

Reprinted with permission

from AAWC News.

www.aawconline.org

Treatment



48 Healthy Skin

Figure 1. Dr. Larry and Cynthia’s foot. Figure 2. Cynthia’s edematous post-op foot. Figure 3. Cynthia on a tricycle offloader.

a shower, working, and relieving my pain. I will share some

insight into what worked. Sometimes it’s not just about evi-

dence-based medicine, nursing, and outcomes — but rather

about patient choice, consumer satisfaction, and overall

experience. Isn’t that what life is about, anyway: the experience?

So, here’s what we did. I had three osteotomies, some hard-

ware, an implanted xenograft, and five incisions, so infection

was a concern. Right out of surgery, a silver transparent film

was applied to reduce my chances of succumbing to a sur-

gical site infection (see Figure 4). The remarkable thing

about the silver transparent film is that it liberated ionic silver

to all my sites, and I was able to shower the next day. The

dressing didn’t have to be removed for 7 days, which dra-

matically decreased my pain since there was no manipulation

of the tender incision sites. Keep in mind, the most frequent

time patients experience wound pain is at dressing change. 1

One of the best parts is that the silver transparent film let me

and my surgeon view the incision lines without removing the

dressings. A plus for nurses is that it’s often a nursing decision

to use such a dressing.

When my dressing and sutures were removed, I immediately

moved to a cyanoacrylate monomer protectant that remained

in place an average of 5 to 7 days (see Figure 5). This cousin

of Dermabond® has 510(k) approval as a device so it’s

another nurse-mediated dressing. The nurse pinches the little,

glow-stick-like device to activate it, then paints it directly on

and around the wounds and incisions. I simply reapplied

when I no longer could see the lavender color. It chemically

Looking back at my grandmother’s things when she passed

and helping clean out her home, I found all sorts of concoc-

tions, bunion pads, foot creams, etc. It was all-too reminis-

cent of the 2 x 2 hydrocolloids and special skin creams

always in my handbag, medicine cabinet, and suitcase whenI need to pad the many hot spots on my feet.

So, I finally took the plunge and had my foot deformities surgi-

cally corrected (on my right foot) by my friend, Larry Huels,

DPM, a foot and ankle surgeon (see Figure 1). Five surgeries on

one foot (see Figure 2) meant I was on the OR table almost 4

hours. A tough recovery brought along nausea, vomiting, pain,

immobility, 4 weeks non-weight-bearing, and 12 weeks in a

walking cast (see Figure 3). My husband Joe was a saint — I fell

several times and was quite a handful, I’m sure. I was back out

on the road traveling, flying, and working after only 4 weeks.

I’m still in the midst of 9 months of using my bone-growth

stimulator daily. On the whole, my foot feels and works great

now. I am back in normal shoes — with my orthotics, of

course. And I was back to speed walking on the treadmill

after only a few months. The only complaint: Some inflexibil-

ity remains due to hardware in several toes. Can’t wait until

January to get the other foot done (ugh!), but all good things

come with pain and sacrifice, right?

Enough about that. This is a story about taking care of feet,

wounds, and skin from the patient’s perspective. For me,

nothing was more important as a patient than having a total

experience that let me be independent, moving about, taking



” “


social needs are being met.2 In other words, it’s all about the

experience.

Why not consider making every patient experience as opti-

mistic, pain-free, and supportive as possible? Think beyond

your chronic wounds to your post-op patients like me. After

all, people remember the experience. Of course, kindness,

respect, and gentle, reassuring care didn’t hurt. Patients

return for care and refer future business when you use prod-

ucts that offer a satisfying and atraumatic experience. Plus,it’s the right thing to do.

This positive experience tied a big bow on an already-beau-

tifully wrapped package: my brand new, now-pain-free foot!

Here’s to life on the other side of the bed rail, treatment table,

podiatric chair, or OR table. Being a patient made me think

about the experience of each and every person I treat. I hope

that, as a result, I’m a better caregiver.

References

1. European Wound Management Society Position Document: Pain at Wound

Dressing Changes. London, UK: Medical Education Partnership Ltd., 2002:2,8.

Available at www.aawconline.org (accessed July 19, 2010).

2. Levy F. The World's Happiest Countries. Forbes. Available at

http://travel.yahoo.com/pinterests-35010143 (accessed July 19, 2010).

bonded to my incisions, protecting them and allowing them

to gain strength. Another key advantage was that it reduced

pain from socks and hosiery, the water from the shower, etc.

The protectant is removed only by epidermal turnover.

I’ve progressed greatly at the 6-month mark and am now

cleansing, moisturizing and protecting daily with a nutritional

skin care line that is free of soap and surfactants, and contains

antioxidants and breathable silicones. The products also have

ingredients that offer topical nutrition via amino acids, vitamins,

and a proprietary blend of methylsulphonmethane to reduce

stinging and pain. As a result, my scars are fading beautifully

(see Figure 6).

Maybe it’s due to having gone soap-free. Perhaps it’s the

antioxidants and nutritional blend that are helping the scars

fade. It could also be the breathable blend of silicones that

decrease transepidermal water loss. These are some of the

same products that facilities nationwide are using to reduce

pressure ulcers and skin tears. Post-op skin needs the same

nutrition and coddling, however.

Was my surgery a success? Absolutely! I’m happy with the

result. And, further, my experience was as positive as feasi-

ble because my satisfaction, comfort, and choice were

important to my surgeon, who acted additionally as my

cooperative partner.

Gallup World Poll researchers have found that happiness is

likely to be associated with how well one's psychological and

Figure 4. Nurse Shelly changes Arglaes®

silver transparent dressing.

Figure 5. Marathon® skin sealant protects

the new incision lines on Cynthia’s foot.Figure 6. Remedy® Skin Repair Cream is

applied to nourish the skin and smooth

the scars.

Being a patient made me think aboutthe experience of each and every

person I treat. I hope that, as a result, I’m a better caregiver.

Dermabond is a registered trademark of Johnson & Johnson Company. Marathon and Remedy are registered trademarks of Medline Industries, Inc. Arglaes is a registered trademark of Giltech Limited Corporation



50 Healthy Skin

Treatment

Implementing Medline’s Pressure

Ulcer Prevention (PUP) Programat Lacombe Nursing Centre

Lacombe Nursing Centre is a 98-bed family-owned long-

term care and rehabilitation facility in Louisiana. Rehabilitation

represents the fastest growing segment of the care they pro-

vide. The facility employs 26 registered nurses and 38 certi-

fied nursing assistants (CNAs). They also have a treatment

nurse. Staff members completed Medline’s Pressure Ulcer

Prevention (PUP) program in May 2010 and celebrated their

newfound knowledge with the awarding of certificatesand pins.

The Pressure Ulcer Prevention Program includes a strategic

product bundle consisting of skin care products and incon-

tinence garments to assist in reducing or preventing pres-

sure ulcers and incontinence-associated skin conditions.

Lacombe PUP Program Test ScoresCompared to National Averages

CNAs and nurses at LaCombe scored higher than the na-

tional averages on the PUP program pre- and post-tests.1

PUP Post-

Pre-Test % test %

Certified Nursing Assistant (NA) Average 58 80

Lancombe CNA Average 71 90

Nurse Average 78 88

Lancombe Nurse Average 82 90




Prevention

The program also packages education and training tools to-

gether with the products to allow healthcare teams to imple-

ment an effective pressure ulcer prevention program and

immediately begin reducing the incidence of healthcare-ac-

quired pressure ulcers. Training may be completed on a self-

study basis or conducted classroom style by staff at the

facility. Included are workbooks, patient and family educa-

tion brochures, a CD with printable electronic forms and

tools, and a staff rewards program.

In addition, the MD Education DVD includes everything the

physician needs to recognize, assess and document pres-

ent–on–admission (POA) indicators for Stage III and IV pres-

sure ulcers. There is also a separate version of the PUP

program specifically for home care and hospice.

Lacombe was uncertain at first about trying the program,mainly because purchasing the Remedy® Skin Repair Cream

would add significantly to their supply costs. Once they

moved forward, however, they learned that the product cost

was not even a factor because of the savings achieved by no

longer having to treat as many pressure ulcers or buy addi-

tional wound care products.

50 percent reduction in pressure ulcers

Within 90 days of implementing the PUP educational program

and product bundle, Lacombe saw a 50 percent reduction in

pressure ulcer incidence. Residents were selected to partic-ipate in the program based on particular medical factors,

including diabetes, peripheral vascular disease, history of skin

tears, poor nutrition status and/or low Braden Scale scores.

Residents experienced increased skin integrity and also ben-

efited from one-on-one social interaction with the nurses as

they applied the Remedy Skin Repair Cream. Staff said res-

idents enjoy spending those 20 minutes talking and sharing

with the nurse as they feel the soothing touch and breathe in

the aromatic citrus fragrance of the cream. In addition, resi-

dents with diabetes showed significant improvement in red-

ness and scaling on their legs.

WHEN PREVENTION BUNDLES(toolkits) are employed, pressure

ulcers are reduced.2

CONTINUOUS PROFESSIONALdevelopment trains staff members on

an ongoing basis in their work setting

and results in confirming current practice,

changing current practice or causing

the learner to seek more information.2

Lacombe nurses proudly display their PUP certificates.

Graduates of the PUP program celebrate with cake.



52 Healthy Skin

CNA pride and accomplishment

For the education portion of the PUP program, registered

nurses at Lacombe studied the workbook and completed

the course on their own, and Assistant Director of Nursing

Sheila Smith conducted classroom style sessions for the

CNAs. The CNAs especially praised the program for its focus

on topics that were not covered as part of their professional

training. They l iked the PUP class so much that they

encouraged each other to sign up.

“You should have seen the smiles on the faces of our CNAs

when they received their PUP pins,” Smith said. “They were

so proud.”

Each nurse and CNA who completes the PUP program re-

ceives a personalized certificate and a paw print (“PUP”) lapel

pin from Medline. They display their pins on their ID badges.

Good patient care

Overall, the administrators at Lacombe said they believe in

the PUP program because it represents good patient care.

Developing pressure ulcers limits residents’ ability to socialize

and participate in activities, affects their appetite and

increases their physical pain.

“Anything we can do to minimize poor outcomes and enhance

residents’ enjoyment of life is a good thing,” said Lacombe

Administrator Gwen Aucoin. “Not only does the PUP program

contribute to good patient care, it is also valuable for staff

development. So there’s a double reason to participate in PUP

because it’s good for patients and it’s good for staff.”

References

1 Medline Industries Inc. Pressure Ulcer Prevention (PUP) program. Data on file.

2 Armstrong DG, Ayello EA, Capitulo KL, et al. Opportunities to improve pressure

ulcer prevention and treatment: implications of the CMS inpatient hospital care

present on admission (POA) indicators/hospital acquired conditions (HAC) pol-

icy. Adv Skin Wound Care. 2008;21(10):469-78.

Remedy is a registered trademark of Medline Industries, Inc.

CLOSE TO 40 PERCENTof the facilities participating in the PUP

program are nursing homes or LTCs.1

CLINICIAN TRAINING ANDeducation is an ideal opportunity for the

wound care community to partner with

associations or industry to develop

appropriate programs and materials

that can be implemented quickly.2

Left to right: Gwen B. Aucoin, Administrator; Shiela Smith, Assistant

Director of Nursing; Mona Soileau, Medline Wound Care Representa-

tive; Chrystal Wust, LPN Restorative Nursing.



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 patient1

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.



54 Healthy Skin

Use of Porcine Urinary Bladder Matrix (UBM)* in a Dehisced

Wound Between Stomas Promoted Closure Facilitating Regular

Pouch Changes in a Premature Neonate

PROBLEMMaintaining pouch adherence over neonates’ stomas after

laparotomy for Necrotizing Enterocolitis (NEC) challenges the

NICU staff. The likelihood of achieving a seal decreases when

the pouching surface is an open wound. A typical case of a

NEC patient is LG, who is a five week old female born at the

gestational age of 29 weeks, 4 days with a birth weight 690

gm. At 36 days of age, a laparotomy was performed and the

wound dehisced eight days later. The dehisced abdominal

wound, located between the ileostomy and the mucus fistula,

measured 1.5 cm by 2.5 cm, and was approximately 20percent of the total abdominal surface area. The goal was to

close the wound as quickly as possible in order to provide a flat

pouching surface. This led to a search for a dressing that

promoted wound closure.

PAST MANAGEMENT Two other patients with NEC (Patient A and Patient B) born

at 30 weeks and 32 weeks 2 days, respectively, experi-

enced dehisced wounds similar to LG’s wound described

above. The dehisced wounds of both were treated with a

Hyrdofiber® dressing and hydrocolloid dressing or tape

strips followed by pouch application. Although both

patients’ wounds closed completely, the dressing often

failed to contain effluent and resulted in skin irritation and

wound contamination, necessitating daily or more frequent

pouch and dressing changes. Average closure time was23.5 days.

CURRENT APPROACHPorcine UBM was selected because of its ability to man-

age wounds, and its composition that contains collagen,

elastin, glyscosamionglycans and other materials associ-

ated with wound closure. Wound management consisted

of application of porcine UBM covered with a perforated

silicone sheet that was cut to circumscribe the stoma,

followed by the pouch application. The dressing was

changed twice a week, except for one time when the

dressing had to be changed one day ahead of schedule.

OUTCOMESComplete wound closure was achieved in 17 days of

implementation of porcine UBM. Additionally, the perforated

silicone sheet helped to increase pouch adherence over the

open wound, decreasing the number of pouch changes.

CASE STUDY

9-2-2009

9-24-2009 9-28-2009 9-30-2009




CONCLUSIONS AND DISCUSSION

Wound closure was achieved with the use of porcine UBM,allowing better pouch adhesion and increased wear time in

this premature neonate. Although the study sample size

was small, it is worth noting that the patient who was

treated with UBM was gestationally the youngest, had the

lowest birth weight and the largest open wound, yet the

closure was the most rapid of this group. This type of

advanced material, UBM, is widely used for management

of chronic wounds; however we believe that this is the first

instance where the use of this material in the management

of an acute wound in neonates has been reported. It is pos-

sible that LG had better results due to reduced pouch

change related disturbance of the wound site, coupled with

the use of the advanced UBM material. Clinical trials withgreater sample sizes are recommended.

ACKNOWLEDGEMENT

The authors would like to acknowledge the NICU Nursing andMedical staff at Broward General Medical Center and the

Chris Evert Children’s Hospital for their care of this and all

neonates and for their contributions to this poster.

REFERENCES

1. Angel, C., Daw, S., Phillipe, P, et al. (1992). Pig in a pouch:

A technique for the management of complete wound dehiscence

after Laparotomy for neonatal necrotizing Enterocolitis. Journal

of Pediatric Surgery, 27(1), 67-69.

2. Brown B, Lindberg K, Reing J, Stolz D.B., Badylak S.F. The

basement membrane component of biologic scaffolds derived

from extracellular matrix. Tissue Eng., 12(3):519-526.

3. Hocevar, B., (2005). Home care management of an ostomy

within a dehisced abdominal wound. Journal of WOCN, 32(3),

202-204.4. WOCN. Best practice: Troubleshooting pediatric Ostomies.

http://www.wocncenter.com/uploaded_documents/pdf/Ped.-

Trouble.Shooting.9.10.08.pdf. Accessed October 28, 2009,

Patient A Patient B LG

Gestational Age 30 weeks 32 weeks, 2 days 29 weeks, 4 days

Date of Birth 11-12-07 5-15-09 8-8-09

Birth Weight 1400 gm 1030 gm 690 gm

Laparotomy Date 12-7-07 6-9-09 9-13-093w, 4d after birth 3w, 4d after birth 5w, 1d after birth

Dehiscence Date 12-13-07 6-16-09 9-21-096 days post op 7 days post op 8 days post op

Measurements 0.9 x 1.5 cm 2 x 1 cm 1.5 x 2.5 cm

Date Closed 1-3-08 7-12-09 10-8-093 weeks 3 weeks, 5 days 2 weeks, 3 days

Dressing Used Hydrofiber+ Hydrofiber+ UBM*

* Urinary Bladder Matrix (UBM), MatriStem

is a Registered Trademark of ACell,

Columbia, MD. MatriStem is distributed

by Medline Industries, Inc. Mundelein, IL.

+Hydrofiber. Aquacel is a Registered

Trademark of E. R. Squibb & Sons, L.L.C.

10-5-2009 10-8-2009 10-29-2009

Amparo Cano, MSN, RN, CWOCN

Patricia Corvino, MSN, RN, CWOCN

Broward General Medical Center

and the Chris Evert Children’s Hospital

Fort Lauderdale, FL



CONVENIENT

• Online interactive courses and competencies

• Podcasts for downloading to your mp3 player

• Downloadable pdf documents

• All-new iPhone apps

COMPREHENSIVE

Free registration includes all this and more:

• Live webinars presented by clinical and industry experts

• Real-time healthcare news feeds from hundreds of

online sources

• Access to hundreds of magazine articles from Healthy

Skin, The OR Connection and Infection Prevention Now

CLINICAL

Prepared by highly qualified clinicians, Medline University

courses are approved for continuing education contact

hours by:

• The Florida Board of Nursing

• The California Board of Registered Nursing

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courses are now available as free iPhone® and iPod

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As always, you can also access courses online

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MP3 player. New courses and competencies are

more interactive with graphics, sound and animation

to make learning fun.

Nurses Are Getting WIRED

In a recent poll of 762 Medline customers

and subscribers of The OR Connection

and/or Healthy Skin magazine:

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Infection Control Measures for Prevent-

ing and Controlling Influenza Transmis-

sion in Long-Term Care Facilities

Prevention Guidelines

and Recommendations

Influenza:Influenza is a contagious respiratory disease that

can cause substantial illness and death among

long-term care facility residents and illness

among personnel in long-term care facilities.

Influenza vaccination of health care personnel

and long-term care facility residents combined

with basic infection control practices can help

prevent transmission of influenza. Every effort

should be made to ensure compliance with

influenza vaccination recommendations each

season. However, because influenza outbreaks

can still occur among highly vaccinated long-

term care residents, long-term care facility per-

sonnel should be prepared to monitor personnel

and residents each year for inf luenza and

promptly initiate measures to control the spread

of influenza within facilities when outbreaks aredetected. This document provides general guid-

ance for prevention and control of influenza

transmission in long-term care facilities.

Prevention

58 Healthy Skin




Influenza is primarily transmitted from person to person

via large virus-laden droplets that are generated when infected

persons cough or sneeze; these large droplets can then

settle on the mucosal surfaces of the upper respiratory tracts of

susceptible persons who are near (e.g., within about 6 feet) in-

fected persons. Three feet has often been used by infectioncontrol professionals to define close contact and is based on

studies of respiratory infections; however, for practical

purposes, this distance may range up to 6 feet. The World

Health Organization defines close contact as “approximately

1 meter”; the U.S. Occupational Safety and Health

Administration uses “within 6 feet.” For consistency with these

estimates, this document defines close contact as a distance of

up to approximately 6 feet. Transmission may also occur

through direct contact or indirect contact with respiratory

secretions, such as touching surfaces contaminated with

influenza virus and then touching the eyes, nose or mouth. Adults may be able to spread influenza to others from 1 day

before getting symptoms to approximately 5 days after

symptoms start. Young children and persons with weakened

immune systems may be infectious for 10 or more days after

onset of symptoms.

[Transmission]

Prevention and Control Measures

Annual influenza vaccination of all residents

and healthcare personnel

Implementation of Standard and Droplet

Precautions when a person is suspected or

confirmed to have influenza

Active surveillance and influenza testing for

new illness cases

Restriction of ill visitors and personnel from

entering the facility

Administration of influenza antiviral medications

for prophylaxis and treatment when influenza is

detected in the facility

Other prevention strategies, such as respiratory

hygiene/cough etiquette programs

Strategies for the prevention and control of influenza in long-term care facilities include the following:

1

2

3

4

5

6



60 Healthy Skin

Health care personnel (e.g., all paid and unpaid workers

who have contact with residents and visitors, including vol-

unteer workers) and persons at high risk for complications

from influenza, including all residents of long-term care

facilities, are recommended to receive annual influenza vac-

cination according to current national recommendations.

Vaccination is the primary measure to prevent influenza,

limit transmission, and prevent complications from influenza

in long-term care facilities.

Vaccination of persons 65 years and older does not pre-

vent 100 percent of influenza infection, but can reduce

serious complications from influenza in this population.

Vaccination rates of 80 percent and higher among resi-

dents have been shown to decrease influenza outbreaks in

long-term care facilities.

Inactivated influenza vaccine or live attenuated influenzavaccine may be used to vaccinate most healthcare person-

nel. Inactivated influenza vaccine (LAIV) may be given to

healthcare personnel younger than 50 years who do not

have contraindications to receiving this intranasal vaccine.

Healthcare personnel who may receive LAIV include those

who care for immunocompromised patients who do not

require care in a protective environment. Healthcare work-

ers who care for patients with severely weakened immune

systems (i.e., patients who have recently had a hematopoietic

stem cell transplant and require a protected environment)

and who receive LAIV should refrain from contact with

severely immunosuppressed patients for 7 days after LAIV

vaccination.

Source: Centers for Disease Control and Prevention

[ Vaccination]

I Persons with a history of hypersensitivity, including ana-

phylaxis, to any of the components of LAIV or to eggs

I Persons aged 2-4 years who have recurrent

wheezing and healthy persons 50 years and older

IPersons with asthma, reactive airways disease,or other chronic disorders of the pulmonary or

cardiovascular systems

I Persons with other underlying medical conditions,

including metabolic diseases such as diabetes, renal

dysfunction, and hemoglobinopathies; or persons with

known or suspected immunodeficiency diseases or

who are receiving immunosuppressive therapies

I Children or adolescents receiving aspirin or other

salicylates (because of the association of Reye’s syndrome with wild-type influenza infection)

I Persons with a history of Guillain-Barré Syndrome

I Pregnant women

I Administration of LAIV should be postponed among

persons with a fever or significant nasal congestion that

may interfere with delivery of the LAIV although persons

with mild respiratory illness can receive LAIV

The following persons

should receive LAIV...NOT



©2010 Medline Industries, Inc. Medline and Epi-clenz are registered trademarks of Medline Industries, Inc.

Epi-clenz™ Gel Instant Hand Sanitizers contain

70% v/v ethyl alcohol to disinfect hands of most

common disease-causing germs. They also contain

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(MSC097032) to get you started, e-mail

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62 Healthy Skin

Control

Measuresfor Influenza

In addition to influenza vaccination,the following infection control measures

are recommended to prevent person-to-person

transmission of influenza and to control influenzaoutbreaks in long-term care facilities.

1. Educa t i on E ducat e per sonnel about t he i mpor t anceof v acci nat i on, si gns and sy mpt oms of i nf l uenz a, cont r ol measur es and i ndi ca-t i ons f or obt ai ni ng i nf l uenz a t est i ng.

2. Sta nda r d Pr eca utionsDuring the care of any r esident with symptoms of ar espir atory infection, healthcar e per sonnel should adhereto Standar d Pr ecautions:

a. Wear gloves.

b. Wear a gown.

c. Change gloves and gowns af ter each r esidentencounter and per for m hand hygiene.

d. Decontaminate hands bef ore and after contactwith a sick resident.

e. Wash visibly soiled or contaminated hands withsoap (either plain or antimicr obial) and water.

f . If hands are not visibly soiled, use an alcohol-basedhand r ub f or routinely decontaminating hands.

Special Feature



66 Healthy Skin

Survey Readiness




&

Long-term care facilities need to have a

formal working plan to handle emergencies

and disasters before they take place. The

following article was originally published by

the Long Term Care Association of Ontario

and gives an overview of risk factors for

facilities to review and have practical con-

tingency plans for.

Preparedness Planningfor Long-Term Care Facilities

EmergenciesDisasters

By Guy Robertson, MLS



68 Healthy Skin

A good emergency plan starts with a summary of the risks

that prevail at your facility. Every region has its natural risks,

from high winds and winter storms to flooding to earthquakes.

Heat waves and freak storms are increasingly common across

North America. Any of these risks can lead to property dam-

age, power outages and supply problems for care facilities.

Technological risks include computer failures and data loss,

toxic spills, electrical fires and explosions. Contrary to popu-

lar opinion, these risks prevail just as often in less populated

rural regions as in cities and towns. Technological problems

often result from human error. Somebody pushes the wrong

button or forgets to push the right one, and the lights go out

all over town. Somebody else trips over a cable in the server

room, disables an entire network and you lose access to your

electronic files, including those pertaining to essential resi-

dent care.

While human error is unintentional, some harmful actions are

purposeful. These are security risks: theft, sabotage, vandal-

ism and fraud. A thief could steal cash, drugs and residents’

valuables. A prankster might leave a bomb threat on your

voice mail or hack into your website and tamper with its con-

tents. Crooks have been known to get vulnerable long term-

care facility residents involved in different kinds of bogus

financial schemes. While some neighborhoods are more

secure than others, security risks prevail wherever there

are people.

Make a l ist. What r isks threaten your facil ity?

Remember that risks at nearby sites can threaten

you directly. For example, an accident on an

adj acent roadway could isolate your facility for hours. A fuel

spill at the local gas station could lead to an explosion that

cuts your power. And then there’s the fire in the building down

the street that’s making your eyes water. Some of your residents

are starting to cough. Nearby threats are called proximity

risks, and every property manager should be aware of them.

Once you’ve determined the risks to your facility,

consider the best ways to mitigate them. There are

always means of dealing with a risk so that it’s less

likely to disrupt your operations. For example, high winds and

severe winter weather may be unavoidable, but if your build-

ing has a good preventative maintenance program in place,

you’ll experience fewer problems from roof leaks and heating

problems. If you’re concerned about power failures, investi-gate the feasibility of a backup generator. Ask your staff and

residents to report any facility problems promptly. You should

be able to mitigate most of your risks to the point where they

no longer pose serious threats to your facility.

But occasionally risks turn into emergencies. You

need an emergency response plan to deal with the

real thing. You don’t need a huge binder to tell you

Have A Plan

Check List

What risks threaten your facility?

Many organizations rely on business

resumption (or continuity) plans to resume

and restore your administrative operations

Best ways to mitigate them.

!

Emergency Response Plan. !

Assume that 20 minutes from now, a fire breaks out in a building down the street from your facility. Flames

burst from the windows while black smoke shrouds the neighborhood. A firefighter appears at your reception

desk and says that he might ask you to evacuate your staff and residents shortly, “depending on the toxic fume hazard.” Are

you prepared for such an event? Many long-term care facilities aren’t, despite occasional fire drills and binders crammedwith instructions from emergency response agencies.




how to evacuate your building or restore your power. Often

a small brochure containing the standard procedures is

more useful than a binder that only a few of your staff mem-

bers have studied carefully. Besides, you don’t want to start

leafing through a binder when a fire threatens your facilityand the smoke gets in your eyes. As for reviewing emer-

gency response procedures during a power outage, forget

it. You’ll have other uses for those flashlights — if you can

find them.

You can create a small brochure on your office workstation

and reproduce your fire department’s advice to meet the

specific needs of your facility. You can print separate

brochures for staff and residents. You can include handy

reminders and space for notes and personal information,

including room numbers, addresses, family contacts and the

locations of refuge areas and safe gathering sites. Brochures

can be designed to fit in a wallet, coin purse or pocket.

When they’re attractively laid out and contain concise, prac-

tical response measures, brochures are ideal tools for emer-

gency orientation and procedural training. They’re also much

less expensive than those binders.

After an emergency, how can you resume adequate levels of

service and restore your administrative operations? Many

organizations rely on business resumption (or continuity)

plans, which contain solutions to problems that arise after

the storm has died down or the fire has been extinguished.

Often a resumption plan begins with a damage assessment

checklist, which guides you through your facility and points

out those areas where different kinds of damage can occur.

Has a storm damaged your roof? Here’s what to look for:

cracks, pools of water, debris from trees and neighboring

structures, broken wires, leaky skylights. Even if you’re not

a trained property manager, your damage assessment

checklist will help you to make a record of any damage to a

roof or any other part of your facility’s structure.

A key component for any care facility’s resumption plan is a

strategic alliance program. After an emergency, you might

have difficulty obtaining supplies that in normal circum-

stances you would take for granted. What if severe weather

puts your usual delivery service out of action for a few days?

Fortunately, you’ve organized an alliance with a local taxi

firm, which will pick up medications, groceries and office

Meteorological Disasters

Cyclones, typhoons, hurricanes, tornadoes,

hailstorms, snowstorms and droughts

Topological DisastersLand slides, avalanches, mud flows and floods

Disasters that Originate UndergroundEarthquakes, volcanic eruptions and tsunamis(seismic sea waves, also known as tidal waves)

Biological DisastersCommunicable disease epidemics and insect

swarms (locusts)

WarfareConventional warfare (bombardment, blockade and siege)

Non-conventional warfare (nuclear, chemical and biological)

Civil Disasters

Riots and demonstrations, strikes

Criminal/Terrorist ActionBomb threat/incident; nuclear, chemical, or biological

attack; hostage incident

Accidents

Transportation (planes, trucks, automobiles, trains and ships)

Structural collapse (buildings, dams, bridges, mines,

and other structures)

Explosions, fires, chemical (toxic waste and pollution)Biological (sanitation)

Natural Disasters

Man-made Disasters



equipment from suppliers and deliver them to you as soon as

possible. Taxis can also serve as couriers and help staff

members get to and from your facility if the roads are closed.

Taxi companies use radio communications to receive infor-

mation regarding road closures and other lifeline problems,

and are often better prepared to travel in disaster areas than

local police and firefighters.

Your residents might be frightened or disoriented by an

emergency. To restore their good morale, you should include

normalization guidelines in your resumption plan. Getting

residents to talk about their experience during an emergency

is one way to ease their anxiety. Another is to hold a “closure

party,” during which staff and residents are served refresh-

ments and given a chance to celebrate the conclusion of

events relating to the emergency. Sometimes facilities bring

in trauma counselors to address individual concerns or

ongoing fears. But residents are not always disturbed by

emergencies. After a fire near a Vancouver care facility that

resulted in an evacuation, some residents told their care-

givers that they enjoyed the excitement. “It was a nice break

from the usual TV game show,” one resident said.

Your resumption plan can contain advice concerning alter-

native sites for residents, a list of post-emergency service

priorities, a summary of emergency team activities and

advice regarding the auditing and testing of the plan. Since

each care facility is unique, each should have an emergency

plan customized to meet its specific needs. A template plan

will not necessarily give you the most effective guidance. It’s

up to you to ensure that your facility has a plan that takes

into account characteristics that make it different from a

facility in a different part of the country, city or neighborhood.

You have only three minutes until that fire breaks out down

the street and you hear the wail of the sirens. Fortunately this

is only an imaginary scenario. But next time it might be the

real thing. Isn’t it time that you developed a real emergency

plan for your facility?

About the author

Guy Robertson, MLS, is an emergency management consultant

based in Vancouver, British Columbia, Canada. He has over 20

years of experience working with financial institutions (e.g. credit

unions), insurance companies, hospitals, libraries, and private and

public archives. He regularly writes for various professional associ-

ations’ journals and magazines. His knowledge is often presented

with humor and anecdotal examples, making him a sought-after

public speaker. To contact him, send an e-mail to

[email protected].

70 Healthy Skin

Medline Named One of Becker’s

100 Best Places toWork in Healthcare

Becker’s recognizes company for

“Excellence in Promoting Teamwork,

Professional Development”

Medline Industries, Inc. has been named one of the “100 Bes

Places to Work in Healthcare” for 2010 by Becker's ASC Review

and Becker's Hospital Review, well respected industry publications

According to Becker’s, the list was developed “through nomina

tions, recommendations and research, and the organizations were

selected for their demonstrated excellence in creating a work envi

ronment promoting teamwork, professional development and qua

ity patient care.”

Benefits Of A GreatWork Environment

Businesses can improve retention and make their organization

the good place to work by following the five-step PRIDE model:

P – Provide a positive working environment

R – Recognize, reinforce, and reward individual efforts

I – Involve and engage everyone

D – Develop the potential of your workforce

E – Evaluate and hold managers accountable

Source: http://workz.com/content/view_content.html?

section_id=531&content_id=6965

By Greg Smith




The new Quality Indicator Survey (QIS) for nursing homes

is more resident-centered, with more information obtained

from direct questioning of residents and families. In fact,

60 percent of facilities have had more deficiencies in QIS

than in the prior traditional survey, often in regulatory areas

such as quality of life that were not as fully investigated

in the traditional process.

abaqis®

is the only quality assessment and reporting

system for nursing homes that is tied directly to the QIS,

and its quality assessment modules reproduce the same

forms, analysis and thresholds used by State Agency

surveyors. Rich reporting capabilities on 30 care areas

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

That gives you a unique advantage in preparing for your

survey – and in meeting your resident’s needs.

abaqis® is sold exclusively through Medline.

Learn more by signing up for a free 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, DNS

Director of Nursing

Central HealthcareLeCenter, MN



For the first time ever,

Medline University introduces

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Visit today to learn more about:

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• Federal Tag 441 – Infection Preventionand Control

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Fail-Safe Strategies to Deal with

DIFFICULT PEOPLELet’s face it. Certain people just like to make your life difficult. Maybe it’s a

patient who seems to get his jollies from making you miserable. Or a team member

who refuses to perform at an acceptable level. Or what about your colleagues who

drive you nuts? Any of these can be a huge challenge and cause you a great deal

of difficulty and stress. But don’t despair. There are specific steps you can take to

deal more effectively with these kinds of people.

By Dr. Wolf J. Rinke, RD, CSP

74 Healthy Skin

Caring for Yourself



The Most Powerful Stress Control System of All Time

But first let me share with you what I consider the most powerful

stress control system of all time. It’s very simple—only three steps,

but if you can master it, your ability to deal with all types of stress

and conflict, not just difficult people, will be significantly enhanced.

Here they are:

1. Change the Changeable.

Don’t like something? Change it! Don’t fret, complain or whine …

just do it! (I know you’ve heard that before.) Remember, you don’t

have to do anything you don’t want to do. Alright, you caught me.

There is one thing you have to do—die. No choice—not yet. Every-

thing else is a choice. And no matter how badly other people

behave, you always are able to control your response to their

behavior. Notice I said you can control your response, but you cannot

control them or their behavior, so quit wasting time trying to do

the impossible.

2. Remove Yourself from the Unacceptable

Find something or someone unacceptable? Get out of the way.

Sitting with someone who is bitching and griping? Get up and sit

somewhere else. Working for a toxic boss? Start shopping for anew one. About to be sucked into another conversation with an

employee who is always complaining about his team members?

Tell him you are busy and that you prefer that he talk to the other

party directly instead of coming to you. Can’t remove yourself? Min-

imize the time you are exposed to unacceptable people. Whatever

you do, just do it without fretting and whining … I know you’re

catching on!




76 Healthy Skin

10

3. Accept the Unchangeable

There are lots of things beyond your control, such as your

parents. No matter how much you would like them to be

different, they won’t be. So love them the way they are, not

the way they ought to be. (By the way, that is a great pre-

scription for getting along with all people!) Bad weather?

Get a grip. Deal with it. Learn to associate any type of bad

weather with prior positive events in your life. For example,

when it is rainy, misty or foggy, I’ve taught myself to think

back to my days in Germany. When it is freezing cold, I think

of cuddling in front of a toasty warm, roaring fireplace with

Superwoman – my wife and lover of 42 years.

Getting older? Accept it. You are beautiful just the way you

are! A wise person once remarked, “God doesn’t make

junk.” In fact, evaluating both my physical and emotional

health, I have never felt better in my life as I do right now.

(I’m 66—thanks for asking.) One reason is that I have never

been as content and at peace as I am right now. So don’t

sweat your chronological age—something you can’t

change. Instead, take care of your body … that’s something

you can have a positive impact on right now.

Difficult people? Accept that some people like to be miserable.Just don’t try to take it away from them. (I hope you are

smiling. Otherwise you are taking this much too seriously.)

Accept them just the way they are, and minimize the time

you spend with them. If they report to you make sure that

you do not place them in patient sensitive positions, and do

your best to get them out of your team or organization as

soon as possible.

Ten Fail-Safe Strategies to Deal with Difficult People

After you have mastered these three biggies, let’s take a

look at what other strategies you can use to make your life

less aggravating:

1. Change your response to the other person.

As I mentioned earlier, you are the only one you can change.

(And most of us have lots of difficulty achieving that!) In deal-

ing with difficult people, don’t try to change the other per-

son; you will only get into a power struggle, cause

defensiveness, invite criticism or otherwise make things

worse. It also makes you a more difficult person to deal with.

On the other hand you can always control your response to

the other person. So don’t let negative people live in your

head rent free.

2. Manage your perceptions.

Remember that most relationship difficulties are due to a

dynamic between two people rather than one person being

“bad.” In other words it takes two to tango. This is one thing

that has been driven home to me time and time again as a

result of my coaching and consulting experiences. I listen

to one person and they tell me in excruciating detail how




badly someone else has behaved. In fact, because of their

vivid descriptions I’m often tempted to take their word for it.

Until … wait for it … I talk to the other person, and then I find

out that their reality is diametrically opposite of the other

party, and by the way, equally as convincing. In other words

there is no reality, there are only perceptions, and we all cre-

ate our own.

The fastest way to begin to no longer perceive people as

“difficult” is to look for what they are doing right. And then

let them know about that. In other words, look for the pos-

itive aspects in others, especially when dealing with the

important people in your life, and focus on those things. The

neat part of this is that over the long run we all tend to find

what we are looking for. (Read that again!) And before you

know it, the other person will feel more appreciated, and

you will begin to develop a more positive relationship.

3. Minimize the time you spend with difficult people.

I know I’ve mentioned this before so this must be a biggie,

especially for people in leadership positions. Time and time

again I find that managers, supervisors and team leaders

tend to spend a disproportionate amount of time with trou-

ble makers. What they don’t get is that their time is a re-

ward. This means that they wil l get more trouble.

Remember: Whatever you reward is what you will get more

of. Instead, if you want peak performance, then you should

spend the greatest share of your time with the “water walk-

ers”—the people who make you look good.

What about the other difficult people in your life? Know

when it’s time to distance yourself, and do so. If no matter

what you do, the other person still antagonizes you, mini-

mizing your exposure may be the key. If they’re continually

abusive, it’s best to cut ties and let them know why. Explain

what needs to happen if there ever is to be a relationship,

and then let them go. If the difficult person is your boss it

may be time for you to find another job. We spend far too

great a portion of our life at work to be miserable. Life is

simply too short to work for a toxic boss or organization.

4. Avoid discussing divisive issues.

Issues such as religion and politics, or other topics that push

certain people’s “buttons” are best avoided. If the other per-

son tries to engage you in a discussion that has the poten-

tial to become an argument, change the subject or remove

yourself.

5. Don’t beat yourself up. Avoid blaming yourself or the

other person for negative interactions. It may just be a case

of two personalities being like “oil and water.” Remember

that you don’t have like everyone; just being polite goes a

long way toward getting along and appropriately dealing

with difficult people.

6. Respond with a sense of humor. Much can be solved

by just lightening up. Somehow a sense of humor often low-

ers the intensity of a difficult situation and allows both of you

to laugh instead of continuing to escalate the situation.

7. See it through the other persons’ eyes. As cliché as

this may sound, we tend to forget that we become blind-

sided when we are angry or stressed. Instead put yourself

in the other person’s position and consider how you may

have hurt their feelings. This understanding will give you a

new perspective, may help you to become more rational,and help you develop compassion for the other person.



78 Healthy Skin

8. Hang out with positive people. Negative people drain

your battery. Positive people charge your battery. So mini-

mize the time you are together with “stinking thinking” peo-

ple and cultivate other more positive relationships in your

life to offset the negativity of dealing with difficult people.

(If you would like to know more about this, read my Beat

The Blues: How to Manage Stress and Balance Your Life

CPE program. It’s available at www.easyCPEcredits.com.)

9. Don’t fight fire with fire. When you interact with some-

one who is going into attack mode or becoming excessively

defensive, recognize that it is useless to argue with him.

Realize the other person may be behaving in this way

because he is feeling very insecure. Don’t continue to push

or attempt to convince him because he will only get more

difficult. Let it go, and come back at another time.

10. Make the other person right. I’ve left the best for last.

The most effective way you can deal with difficult people is

to make them right by expressing the most powerful conflict

resolution phrase of all time: “You are right about that.” (Try

it in any situation that appears to be spinning out of control.

What you will find will amaze you. It literally makes any type

of conflict evaporate. It’s so powerful that Superwoman and

I no longer even use the five words, we just hold up our

hand with all five fingers extended.) Or express agreement

in any other way you wish. For example you might say, “I

see why you feel that way;” or “I can understand why you

are upset,” or “That’s an interesting perspective.” (The

words are not important as long as you express agreement.)

If you find yourself arguing for the sake of being right, ask

“Does it matter if I am right?” If yes, then ask “Why do I need

to be right? What will I gain?” In virtually all situations you will

find that the only reason you feel a need to be right is to sat-

isfy your ego.

If that still does not let the “hot air out of the balloon” find

something, no matter how small, to agree on. And if noth-

ing else works you can at least agree to disagree, and get

on with your life.

© 2010 Wolf J. Rinke

Dr. Wolf J. Rinke, RD, CSP is a keynote

speaker, seminar leader, management con-

sultant, executive coach and editor of the

free electronic newsletters Make It a Winning

Life and The Winning Manager, available at

www.WolfRinke.com; and a new electronic

newsletter Read and Grow Rich, targeted

specifically to nutrition professionals, avail-

able at www.easyCPEcredits.com. In addi-tion, he has authored numerous CDs, DVDs and books including

Make It a Winning Life: Success Strategies for Life, Love and Busi-

ness; Winning Management: 6 Fail-Safe Strategies for Building

High-Performance Organizations and Don’t Oil the Squeaky Wheel

and 19 Other Contrarian Ways to Improve Your Leadership Effec-

tiveness; all available at www.WolfRinke.com. His company also

produces a wide variety of quality pre-approved continuing pro-

fessional education (CPE) self-study courses, available at

www.easyCPEcredits.com, including his latest Delegation and

Coaching: High Impact Strategies for Doing More with Less,

approved for 15 CPEUs, from which this article was extracted.

Reach him at [email protected].




CDC Forms New Advisory Committeeon Breast Cancer in

Young Women

The Centers for Disease Control and

Prevention (CDC) has just announced the

establishment of the Advisory Committee on

Breast Cancer in Young Women.

The committee has been established to assist

in creating a national evidence-based public

education and media campaign to provide

age-appropriate messages and materials to:

1. Increase awareness of good breast

health habits

2. Identify risk factors based on familial,

racial, ethnic and cultural backgrounds

3. Encourage young women and healthcare

professionals to increase early detection

of breast cancers

4. Increase the availability of healthinformation and other resources for

young women diagnosed with

breast cancer

For more information, contact Ena Wanliss,

MS, Lead Public Health Advisor, Centers for

Disease Control and Prevention, National Cen-

ter for Chronic Disease Prevention and Health

Promotion, Division of Cancer Prevention and

Control, 4770 Buford Highway, Mailstop K-57,

Chamblee, GA 30316. (770) 488-4225.

Source: Federal Register June 24, 2010. Available at

http://edocket.access.gpo.gov/2010/2010-15293.htm.

Accessed July 9, 2010.

Special Feature



To take the survey, go to

www.medline.com/healthyskin/survey

or complete the business reply card.

Answer these questions:

A. What does the Pink Glove Dance mean to you?

B. Do you think pink gloves get people talking about

breast cancer?

Take a look at the Pink Pearl ads on the next three

pages and pick your favorite.

AD 2

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Medline’s newest Generation Pink glove.

Supporting the National Breast Cancer Foundation.

©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.

AD

1

I only wear Pink Pearls.

Only Medline’s Pink Pearl gloves combine

aloe, nitrile and breast cancer awareness.

©2010 Medline Industries, Inc. The Pink Pearl glove is a trademark of Medline

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

AD

2

Yes, They’re Genuine.

Only Medline’s Pink Pearl gloves combine



The Pink Pearl glove is a trademark

of Medline Industries, Inc. Medline is

a registered trademark of Medline

Industries, Inc.

AD

3

Take thePink Glove Survey!

Participate today! The first 1,000 readers to respond

will receive the new Deb doll!

1

2

3

www.PinkGloveDance.com

AD 1

AD 3

80 Healthy Skin

Special Feature



Precious. And Pink.

Soft and shimmery.

Layered with organic aloe.Fashioned from nitrile.

The Pink Pearl.™

Medline’s newest Generation Pink glove.

Supporting the National Breast Cancer Foundation.

©2010 Medline Industries, Inc. Medline is a registered trademark and Pink Pearl

is a trademark of Medline Industries, Inc.

AD

1




I only wear Pink Pearls.

Only Medline’s Pink Pearl™ gloves combine


©2010 Medline Industries, Inc. Medline is a registered trademark and Pink

Pearl is a trademark of Medline Industries, Inc.

AD

2

82 Healthy Skin



Yes, They’re Genuine.

Only Medline’s Pink Pearl™ gloves combine



Medline is a registered trademark

and Pink Pearl is a trademark of

Medline Industries, Inc.

AD

3




84 Healthy Skin

1. In the Shower

Fingers flat – move gently over

every part of each breast.

Use your right hand to examine left

breast, left hand to examine rightbreast. Check for any lump, hard

knot or thickening. Carefully observe

any changes in your breast.

2. Before a Mirror

Inspect your breasts with your arms

raised high overhead. Next, place

your arms at your sides. Look for

any changes in contour of each

breast; a swelling, a dimpling of

skin, or changes in the nipple.

Then rest palms on hips and press

firmly to flex your chest muscles.Left and right breasts will not match

exactly. Few women’s breasts

do match.

3. Lying Down

Place pillow under right shoulder,

right arm behind your head. With

fingers of left hand flat, press right

breast gently in small circular

motions, moving vertically or in

a circular pattern covering the

entire breast.

Use light, medium and firm pressure.Squeeze nipple, check for discharge

and lumps. Repeat these steps on

your left breast.

Breast Self-Examination

Recommended Reading

The U.S. Preventive Services Task Force (USPSTF), a

group of health experts that reviews published research

to make healthcare recommendations, points out

that women who have screening mammograms die of

breast cancer less frequently than women who do not

get mammograms.

Although the USPSTF recently changed their breast

screening guildelines, recommending mammograms to

be performed every two years beginning at age 50.

The American Cancer Society (ACS), Mayo Clinic, and

others, however, have not changed their recommendations.

• The ACS and Mayo Clinic continue to recommend

yearly mammogram screening beginning at age 40

for women at average risk of breast cancer.

• ACS says breast self-exams are optional; however,

Mayo Clinic recommends breast self-exams to allow

women to identify breast abnormalities and become

familiar with their breasts so they can tell their doctor

about any changes.

If you are confused about any of these recommendations,

it is best to talk to your doctor to learn what’s right for you

based on your individual risk factors.

Source: Pruthi S. Mammogram guidelines: what’s changed? Mayo

Clinic website. Available at: http://www.mayocliic.com/health.mam-

mogram-guidelines/AN02052. Accessed July 30, 2010.

Mammograms

Save Lives

Dr. Susan Love’s Breast Book

Susan M. Love, MD

Da Capo Press, 2005

Everything you wanted to know about

breasts and breast cancer. Each treatment

option is reviewed with realistic outcome

statistics. Also check out Dr. Love’s

website www.dslrf.org/breastcancer.

The Breast Cancer Survival Manual:

A Step-by-Step Guide for the Woman

with Newly Diagnosed Breast Cancer

John Link, MD

Henry Holt and Company, 2000

A complete guide on how to survive a

diagnosis of breast cancer: how to pick

a team of specialists, diagnostic tests,

adjuvant therapy choices, management

of side effects and diet.

Caring for Yourself



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 MicroScaffold 2

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 levels

of elastase and MMPs (inflammatory enzymes) destroy the

body’s own collagen and growth factors.1

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

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.



Never in our wildest dreams did we think a videoof a few hundred people dancing in pink gloves at

Providence Medical Center in Portland, Ore., St. Vincent

would become an Internet sensation, generating more

than 11 million views on YouTube and launching a

wave of awareness.

Medline created the original Pink Glove Dance video

to help get people talking about breast cancer early

detection and to spotlight the healthcare workers who

are taking care of breast cancer patients.

The video went viral and Medline received a flood of

calls and e-mails from hospitals and breast cancer

survivors around the country expressing their gratitudefor the video and how much they want to participate

in the next video.

So this summer, the Pink Glove Dance crew traveled

the nation, stopping at 11 hospitals, three nursing

homes and five survivor sites, including New York City,

New Orleans, Chicago, Denver and San Francisco, to

film healthcare workers and breast cancer survivors

dancing in pink gloves and sharing their message of

joy, support and caring.

The Dance Goes On:

Pink Glove Dance Sequel

Special Feature



I absolutely loved partaking in the Pink Glove

Dance sequel video in Times Square. Thanks

again for the opportunity to be part of some-

thing so wonderful and the chance to speak

about something so important to me.

- Lisa Kisternberg-Solomon,

New York City survivor shoot

What an awesome time, experience and

memory. This amazing experience will

stay with me forever. Thank you for

including Chicago.

- Tammy Moletz,

Chicago shoot

Watch the Pink Glove Dance sequel at

pinkglovedance.com.

Follow Medline and Breast Cancer Awareness onFacebook at www.facebook.com/medlinebreast-

cancerawareness and on Twitter at

twitter.com/medlineindustr.

I encourage ANY and ALL Survivors to

participate. As a Breast Cancer Survivor

myself, this was an event that I will

never forget.

- Beth Parrish,

Portland survivor shoot

Thanks for bringing so many people

together, I am so happy to have been able

to participate. It just goes to show there is

nothing we can't do to raise awareness.

- Veronique Nikki Thomas,

Chicago shoot

“

” About 200 healthcare workers and breast cancer survivors

danced at the Chicago shoot.

Here is just a sampling of the comments we heard on the road:



88 Healthy Skin

Sharing Stories

To the Pink Glove Crew (aka Staff of

Providence St. Vincent Medical Center)

This evening, as I was watching ABC World News

Tonight with Charles Gibson, I heard him mention two of

the worst words I have ever heard: Breast Cancer. These

words leave a huge lump in my stomach and can almost

instantaneously bring a tear to my eye. It is because

these two horrific words took my mama, Eleanor Mar-

garet Strelecky away from me August 30, 2004 at 7:45

a.m. She was a mere 56 years of age. I was lucky

enough to say goodbye, but not willingly.

My mother was amazing. By amazing, I mean she was

both warm and loving. Don’t get me wrong, she was by

no means perfect, and, at times, she drove me up a wall!

She always encouraged me to try at everything though.

I loved to perform and she got me on every stage she

possibly could. I made up silly dances and songs and

she would sit in her recliner any time I needed an

audience. She laughed so hard and would applaud

every time.

My mother was so sarcastic. When I would cry and get

whiney, she would come at me as if to comfort me, and

then start applauding announcing I had won the award

for best dramatic performance!

She had a lust for life, and I know that she was so

cheated by breast cancer. She had battled it on and off

for four years. She knew way before I did that this little

terror ist was going to win, but she stood strong

in silence.

A week before her passing, I found out through my step-

father, that she did not have much time left. I scurried to

buy a plane ticket from Iowa down to Georgia where she

lived. In transit, I wrote down as many memories as I

could think of between her and me. Some of them were

the stupidest jokes, but I did not want to forget a thing.

The day before she passed, I walked into her bedroom

where she lay in a semi-conscious state. She was heav-

ily sedated and the cancer had metastasized to her liver,

lungs, and brain. I sat in a chair by her bed and read her

all of the memories I had written down, trying hard to

enunciate through the ever-growing tears in my eyes that

caused my voice to quiver. When I was done reading

them, I kissed my mother’s hand and told her over and

over again how much I loved her. This wasn’t enough

though; I had to hug her. I carefully sat down on her bed

and as I leaned in to embrace her frail body, I saw a tear

from her eye. I knew seeing her tear I was going to lose

it completely and become hysterical. At the brink of this

happening, my mother became completely coherent,

opened her eyes wide and said, “And the award for best

dramatic performance goes to: Bwinny (her nickname

for me)!” She then laughed, gave me a look of “Oh

please,” and said, “Now get off the bed. There isn’tmuch room as it is!”

I took a step back and was stunned, but then began to

laugh uncontrollably at my mother’s comic relief in such

a sad moment as saying a final goodbye! There was my

mama, in all her glory, being a smart-ass just as if it was

any other day.

More than 4,000 breast cancer survivors and healthcare workers participated in the making of the Pink

Glove Dance sequel. During that time, we heard many powerful and inspiring stories of survivorship and hope.

Thank you to the survivors and their families for allowing us to share a few of their stories.

The following is a letter from a woman who saw the original Pink Glove Dance featured on the news and was inspired

to share the story of her mother's final few days battling breast cancer.

Special Feature




When I saw the brief [Pink Glove Dance] clip on ABC

World News, I smiled and shivers ran down my spine.“ ” When I saw the brief [Pink Glove Dance] clip on ABC

World News, I smiled and shivers ran down my spine. It

was the same feeling that came over me that day in my

mother’s bedroom. I quickly jumped on YouTube and

watched the video in its entirety. I cried the entire way

through, but tears of joy. And I laughed. As I laughed,

I looked up at the sky and said to my mama: I know you

are thinking this is hilarious!

The point of this letter was not to ramble on and on, but

to thank you for making such a funny video and for

everyone’s commitment to participating in something

that is sure to increase breast cancer awareness. The

choreography was like nothing I’ve ever seen, and I think

you have some future Broadway dancers on your

hands! You made me laugh in a time when Christmas is

around the corner and I begin missing my mother more

than ever. Most importantly, you provided me with a

laugh that I shared with my mother up in heaven and for

that, I am forever grateful because I just received the

best Christmas present ever!

Happy holidays to each and every one of you at that

hospital and keep donning those pink gloves because

they suit you all very well. I send the biggest hug to everystar in that video!

All my love,

Melinda Sara Crane

Wellman, Iowa




I am lucky thanks to early detection — without it, I would

still have breast cancer. Breast cancer runs in my family.

I have two sisters who were diagnosed and treated within

two years of each other. Their doctors suggested that they

be tested for the BRCA gene to see if that was going to be

an issue in the family. They were both tested and both werepositive for the BRCA-II gene. At that point, the doctors

suggested the family be tested. Let me tell you, I am one

of 12 children in my family. I tested positive for the BRCA-II

gene as well as five of five sisters tested. It was recom-

mended that I have a hysterectomy (full) to reduce my

chances of getting breast cancer from 80% to 40%. I got

the hysterectomy and two years later (almost to the day),

I was back on the table for a lumpectomy. It was biopsied

and was positive for cancer.

Participating in the Pink Glove Dance was AWESOME! It

was a great day and it felt wonderful to be with so many

others who had similar stories and the people who helped

us (the patients) through it all. When the healthcare work-

ers were dancing with us, we were high-fiving them and

thanking them for everything they do. I am so lucky to haveknown about the breast cancer early and to be working

at Medline.

Helen Franklin

Medline Information Services

Mundelein, Illinois

Below is an e-mail from a Medline employee in the Information Services department. She and her five sisters tested positive for

the breast cancer gene and each underwent treatment. She danced in Chicago for the sequel.




Want to fight the effects of aging? Add these powerful foods to your diet!

1. Fatty fish. Mackerel, bluefish,

salmon and tuna are rich sources of

omega-3 fatty acids, which improve

circulation, reduce inflammation and

reduce the risk of heart disease.

2. Whole grains. Pass up the

white bread, and fill your plate with

whole grains, an excellent source

of B-complex vitamins, including

riboflavin and niacin, which are

essential for optimal energymetabolism.

3. Low-fat dairy products.

Drink your skim milk, and eat

plenty of yogurt to receive the

anti-aging benefits of calcium

and vitamin D. Not only are they

good for your bones, calcium

also helps boost your metabolic

rate, and vitamin D exhibits

anti-cancer activity.

4. Green leafy vegetables.

Never underestimate the power of

spinach and salad greens. Green

leafy vegetables are terrific sources

of fiber, calcium and beta-carotene,

an important antioxidant that pro-

tects the skin from the effects

of ultraviolet radiation.

5. Berries. Try them all –

strawberries, blueberries,

raspberries. They are rich

in flavonoids, which have

been shown to help reduce

the risk of heart disease,

cancer and diabetes.

6. Green tea. This traditional Asian

drink has been shown to have anti-can

cer properties. It also contains theanine

an amino acid known for its relaxation

benefits.

7. Mangosteen. Never heard of it?

Never mind. Just give it a try. This small,

purplish fruit from Southeast Asia contains

anti-inflammatory compounds known as

xanthones, which have been shown to

improve gastrointestinal function, controlpain and reduce markers of inflammation

in the blood, such as C-reactive protein.

The mangosteen is best in juice form.

8. Exotic spices. Jazz up your recipes

with turmeric, curry, cumin and ginger,

which have profound anti-cancer proper-

ties. Used in Indian and Thai cuisine, each

of these spices has been linked with

prevention and accelerated healing of

cancers of the mouth, throat andgastrointestinal tract.

9. Citrus fruits. Whether it’s oranges,

lemons, limes, grapefruit or tangerines,

citrus fruits are a rich source of vitamin C.

Plus, the white underside of the peels is

a source of specialized flavanoids known

as poly-methoxylated-flavones (PMFs),

which have been shown to reduce stress

hormones and cholesterol levels.

10. Red wine. Sip a glass of your

favorite Merlot, and reap the benefits of

resveratrol, a flavanoid found in the skins

of red grapes. Animal studies have shown

that diets high in resveratrol are associate

with a unique set of anti-aging benefits.

Studies of resveratrol’s effects on humans

are underway.Source: Talbott S. Anti-aging power foods slideshow. HealthyAging.

Available at http://healthy-aging.advanceweb.com. Accessed May 16, 2010.

Caring for Yourself



94 Healthy Skin

Healthy Eating

• 1 teaspoon olive oil

• 1 clove garlic, minced

• 2 cups (1-inch cubes) country style

bread (only hearty dense bread will do)

• 3 pounds ripe tomatoes, cut into

quarters

• ¼ cup loosely packed fresh basil

leaves, chopped

• 1 teaspoon sugar

• ¼ teaspoon salt

Directions:

In a small skillet, heat oil on medium heat until hot. Add garlic and

cook for one minute – stirring constantly. Remove from heat.

In a food processor with knife blade attached, pulse bread until

coarsely chopped. Add tomatoes and garlic. Pulse until mixture

is almost a puree. Pour soup into a bowl and stir in chopped

basil, sugar and salt. Serve warm or chilled.

Operations analyst Mary Lanciloti, who

works at Medline’s Vernon Hills, Ill. office,

won a bronze medal for this recipe in the

International Cookoff during Employee

Appreciation Week.

She subscribes to lots of different magazines, and always scans

them for new recipes to try. This one caught her eye because

it’s quick, easy and nutritious. She also noted that it’s perfect for

anyone who is trying to drop a few pounds because it’s low in

calories and very filling.

“I’m a big gardener, so this recipe gives me a chance to use

fresh tomatoes and basil from my own garden,” Mary said. “Of course, you can always find good summer tomatoes at the local

farm stand or supermarket, too.”

Mary shared that she likes to cook and loves to bake. She took

it up based on her grandmother’s advice that if you like to cook

and bake and sew, you’ll land yourself a good husband.

“I guess it wasn’t the greatest advice,” Mary said. “Because I’ve

always been single! Oh, well.”

Tuscan Tomato Soup (6 servings)

Nutrition

Information

Servings: 6

Calories: 271

Fat: 3.38 g

Sodium: 579 mg

Fiber: 4.9 g




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

FORMS & TOOLS

Pressure Ulcer PreventionOnline Skin & Risk Assessment Competency ................96

SKINSAVERS Initiative: A Pressure Ulcer

Prevention Tool ................................................................98

Healthcare ReformImpact of Healthcare Reform on Home Health ............103

Patient Handout: Medicare and the New Health

Care Law – What it Means for You ..............................105

Palliative CareA National Framework and Preferred Practices for

Palliative and Hospice Care Quality ............................109

Infection ControlTen Tips for Cleaning and Disinfecting Shared

Medical Equipment ......................................................111

Some Things Should Not be Reused ..........................114

CDC Clinical Reminder: Use of

Fingerstick Devices ......................................................115



96 Healthy Skin

Announcing New Online Skin &

Risk Assessment Competency

The Latest Addition to Medline’s

Pressure Ulcer Prevention Program

Medline’s Pressure Ulcer Prevention Program –

an educational initiative aimed at reducing the inci-

dence of pressure ulcers – has added an interactive

online competency to allow nurses to demonstrate

what they’ve learned in a virtual clinical setting.

This approach provides consistency, as each

learner 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 hand

sanitizer at the wall unit to pulling back the

bed linens and patient gown, performing

assessments on three separate patients.

An illustrated hand replaces the usual

mouse arrow on the screen.




At the end of each skin assessment, the

learner completes the Braden Scale to

determine the patient’s level of risk for

pressure ulcers.

Sarah is in a coma with a naso-gastric

feeding tube. She has a visible wound

on her right arm.

When the learner clicks on Sarah’s

arm, a close-up photograph of her

wound and a related multiple choice

question appear on the screen.

The only way to access the Skin and Risk

Assessment Competency is by joining the

Pressure Ulcer Prevention Program. Visit

www.medline.com/PUPP-webinar to sign up

for an informational webinar to learn more.

(See back cover for webinar dates.)

Prevention



98 Healthy Skin

Forms & Tools SKINSAVERS Initiative

A pressure ulcer prevention toolSKINSAVERS Initiative

Pressure ulcers are a great health concern with considerable financial implications and ability

to cause considerable pain and suffering. Accordingly, the SKINSAVERS initiative was put into

place at Lutheran Medical Center in Brooklyn, NY, and includes the following:

• WOCN consultation of all patients with pressure ulcers stage II and greater

• Standardization of skin and advanced wound products

• Staff education on skin and wound product utilization

• Braden Scale risk assessment performed on admission and daily

• Recruitment, training, empowerment of SKINSAVERS RN unit champions

• Implementation of SKINSAVERS bundle for pressure ulcer prevention

SKINSAVERS Bundle

S – Side lying positioning at 30-degrees

K – Keep HOB at 30 degrees

I – Inspect skin daily & at every turn

N – Nutrition & hydration improvement/nutrition consult

S – Suspend heels

A – Apply moisture barrier after incontinence episodes

V– Vigilant skin care & moisturizer

E – Encourage mobility

R – Reposition at least every 2 hours

S – Support surfaces: bed & chair

Since its implementation the initiative has shown considerable reduction in the incidence of

pressure ulcers. Ongoing staff education is an essential part of the program. With increased

knowledge comes increased compliance and subsequently improved patient outcomes.

© 2010 Feddy S. Emmanuel. Printed with permission.

About the author

Feddy S. Emmanuel, RN, MSN, FNP-BC, CWOCN is a practicing WOC

Nurse Practitioner at Lutheran Medical Center in Brooklyn, NY. She earned

her Master of Science degree and Family Nurse Practitioner certificate in 2008

from SUNY Downstate Medical Center in Brooklyn, NY, and is board certi-

fied by the ANCC. She obtained her WOCN certificate from Albany Medical

Center WOCNEP in 1998, has been board certified by the WOCNB for 11

years and holds a certificate in HBOT. She has been a registered nurse for

over 30 years with experience in acute care, critical care, long-term care, home

health and outpatient services.

By Feddy S. Emmanuel, RN, MSN, FNP-BC, CWOCN



BioCon™- 500Bladder ScannerSafely Measures

Bladder VolumeMinimize unnecessary catheterization

Research has shown that 80 percent of urinary tract

infections acquired at healthcare facilities are associated

with an indwelling urethral catheter.1 This type of infection

is known as CAUTI, or catheter-associated urinary

tract infection.

Avoiding unnecessary catheter use is a primary strategy

for preventing CAUTI, and clinical guidelines recommend

the consideration of alternatives to catheterization.2

Bladder scanners accurately assess bladder volumes,

and many urinary 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 aboutCAUTI prevention, visit

www.medline.com/erase

or contact your Medline

sales representative.



What did we do after designing a revolutionary

new catheter tray system?

We found THREE more waysto make it even better.

We’re obsessed with engineering new and better

technology for healthcare workers. So after we

revolutionized the outdated Foley catheter tray witha unique, one-layer system design, we immediately

turned our attention to addressing how we could

make 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 redesign

and comprehensive ERASE CAUTI education, these

three new features help to improve patient safety andquality, while reducing avoidable costs associated with

waste and urinary tract infections.

To learn about the ERASE CAUTI system, as well as

other strategies for minimizing the risk of CAUTI, sign

up for a free Innovation in the Prevention of CAUTI

webinar at www.medline.com/erase/webinar.




A checklist that fits better

in the medical record

The reformatted checklist is smaller, making

it easier to fit in the patient chart or medical

record. It is also available as an attachment

for electronic documentation.

Education you’ll want to present

to your patient

There’s nothing like the new Patient

Education Care Card. Designed to look

and feel like a “Get Well Soon” card, it

tells patients about catheterization so

they know you are providing them the

best care possible.

1

2

3

Real photography on the outside –

so you know exactly what’s inside

A photo on the package helps identify the

contents of the kit, serves as an educationaltool for the clinician and can be used to

discuss the procedure with the patient.

Also, the label opens up to a booklet with

step-by-step instructions and helpful tips

for the clinician.



Tip Sheet

Impact of Health Care Reform(The Patient Protection & Affordable Care Act) on

Home Health Care Agencies and Nurses

Joan M. Marren, RN, MA, MEd,Chief Operating Officer, Visiting Nurse Service of New York /

President, VNSNY Home Care

Payment Changes

Reduces reimbursement to home care by $39.7 billion over 10 years beginning in2011. Home health agencies will be under great pressure to manage costs,including nursing costs, case mix and utilization closely. This raises concernsabout the potential impact on access to and quality of home care.

Mandates two studies - first (due 1/2015) to assess the impact of home carereductions on access, quality and number of agencies and types; second (due3/2014) to evaluate costs to serve low income, complex care patients and their

patterns of admission to home health care. The Act authorizes up to $500million, based on study findings, for demonstrations to see if changes to PPSreimbursement will improve access for high need patients.

Take Away Message: Home health agencies, and their nurses in particular, serving

high cost, complex care patients have a unique opportunity to articulate the

characteristics and needs of these patients and to participate in demonstrations to

assure their access to care.

Quality Reporting & Incentives/Value Based Purchasing

Requires development of a national strategy and action plan to improve healthservice delivery, outcomes and population health with emphasis on managing

high cost chronic illness, reducing preventable hospital admissions and decreasinghealth disparities

Implements value based purchasing/pay for performanceTake Away Message: A national health care improvement strategy can raise

awareness of the role and contributions of home health nurses to management of

chronic illness and avoidance of hospitalization. Success in a value based purchasing

model will highlight the impact of home care nurses on quality of care but nurses

must be sure that measures are properly risk adjusted and within the home care

agencies’ and nurses’ control.

Chronic Care Coordination & Service Innovation


Impact of Health Care Reform on Home Health Forms & Tools



104 Healthy Skin

Forms & Tools Impact of Health Care Reform on Home Health

Establishes Federal Coordinated Health Care Office and creates a Center for Medicare and Medicaid Innovation to better integrate Medicare/Medicaid strategy

at the federal and state level and to test new payment and service delivery models

for elderly and chronically ill.

Proposes demonstration programs to reduce cost and improve coordination and

quality for the chronically ill by expanding medical and health care homes

(Independence at Home/Medicaid “health homes”), developing new models and

incentives for improved cross continuum collaboration (Community Care

Transitions Program and “bundled payment”), and sharing savings with

accountable, collaborative, multi-provider organizations (Accountable Care

Organizations).

Take Away Message: Proposed initiatives present many opportunities for home

health care nurses and nurse practitioners, as lead providers and in partnershipwith others, to play a greater role in the care management of chronic illness patients

in the community.

The CLASS Act

Creates a new federally administered, voluntary insurance program that supports

community living for beneficiaries with long term cognitive or functional

impairments

Provides a modest benefit to cover non medical ADL services and support.

Take Away Message: Program could expand the market for community based

assessment, care management and direct care services provided or supervised by

home health care nurses.

Expansion of Medicaid & Long Term Care Home and Community Based Services

Proposes various models and incentives that expand Medicaid coverage and

promote community based care in lieu of nursing home placement.

Take Away Message: More insured individuals and emphasis on access to

community care options will probably create greater demand for home care

services. This will drive demand for skilled home care nurses to deliver services and

to train and oversee paraprofessional home care workers.

Workforce Development

Authorizes grants and training programs for “community health workers”,

“community based long term care entities” and health professionals who providedirect care

Focuses particular emphasis on targeting training programs to serve underserved,

high risk communities and populations.

Take Away Message: Access to increased numbers of well prepared home care

nurses and paraprofessional staff will be essential to meet anticipated demand from

demographic changes in the population and from health care reform’s emphasis on

building community care options and capacity.



MAY 2010

C E N T E R S F O R M E D I C A R E & M E D I C A I D S E R V I C E S

Medicare and the NewHealth Care Law—

What it Means for You

AMessage fromKathleen Sebelius,

Secretary of Health & Human Services

e Aordable Care Act passed by Congress and signed by PresidentObama this year will provide you and your family greater savings and

increased quality health care. It will also ensure accountability throughout the health care system so that you, your family, andyour doctor—not insurance companies—have greater controlover your care.

ese are needed improvements that will keep Medicarestrong and solvent. Your guaranteed Medicare benets won’tchange—whether you get them through Original Medicare or

a Medicare Advantage plan. Instead, you will see new benetsand cost savings, and an increased focus on quality to ensurethat you get the care you need.

is brochure provides you with accurate information aboutthe new services and benets to help you and your family nowand in the future.

e Centers for Medicare & Medicaid Services (the federalagency that runs the Medicare, Medicaid, and Children’s HealthInsurance Program) will continue to provide you with up-to-dateinformation about these new benets and will ensure that your personal

information is safe.

Remember—rely on your trusted sources of information when it comesto accurate information about Medicare, and don’t hesitate to call1-800-MEDICARE or go on-line at Medicare.gov if you have questionsor concerns. Don’t give your personal Medicare information to anyonewho isn’t a trusted source.


Medicare and Health Care Reform – Patient Handout Forms & Tools



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HEALTH CARE LAW

What Stays the Same

The guaranteed Medicare benefits you currently receive will remain the same. During open enrollmentthis fall, you will continue to have a choice between Original Medicare and a Medicare Advantage plan.Medicare will continue to cover your health costs the way it always has, and there are no changes ineligibility. But, there are some important benefits that you and your family can take advantage of starting

this year. Look for more details in your Medicare andYouHandbook coming this fall.

Improvements inMedicare You Will See Right Away

More Affordable Prescription Drugs

• If you enter the Part D “donut hole” this year, you will receive a one-time, $250 rebate check if youare not already receiving Medicare Extra Help. These checks will begin mailing in mid-June, and willcontinue monthly throughout the year as beneficiaries enter thecoverage gap.

• Next year, if you reach the coverage gap, you will receive a 50%discount when buying Part D-covered brand-name prescription drugs.

• Over the next ten years, you will receive additional savings until the

coverage gap is closed in 2020.

Important New Benefits to Help you Stay Healthy

• Next year you can get free preventive care services like colorectalcancer screening and mammograms. You can also get a free annualphysical to develop and update your personal prevention plan based

on current health needs.

Improvements to Medicare Advantage

• Today, Medicare pays Medicare Advantage insurance companies over$1,000 more per person on average than Original Medicare. These

additional payments are paid for in part by increased premiums by allMedicare beneficiaries—including the 77% of seniors not enrolled in aMedicare Advantage plan.

• The new law levels the playing field by gradually eliminating MedicareAdvantage overpayments to insurance companies.

• If you are in a Medicare Advantage plan, you will still receive guaranteed Medicare benefits.

• Beginning in 2014, the new law protects Medicare Advantage members by taking strong steps to ensurethat at least 85% of every dollar these plans receive is spent on health care, rather than administrative costsand insurance company profits.

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Forms & Tools Medicare and Health Care Reform – Patient Handout



HEALTH CARE LAW

Improvements in Medicare You Will See Soon

Better Access to Care• Your choice of doctor will be preserved.

• The law increases the number of primary care doctors, nurses, and physician assistants to provide betteraccess to care through expanded training opportunities, student loan forgiveness, and bonus payments.

• Support for community health centers will increase, allowing them to serve some 20 million new patients.

Better Chronic Care• Community health teams will provide patient-centered care so you won’t have to see multiple

doctors who don’t work together.• If you’re hospitalized, the new law also helps you return home successfully—and avoid going back—by

helping to coordinate your care and connecting you to services and supports in your community.

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Improvements Beyond Medicare That You and Your Family Can Count On

Improves Long-Term Care Choices• New tools and resources in the Elder Justice Act, which was included in

the new law, will help prevent and combat elder abuse and neglect, and

improve nursing home quality.• The new law creates a new voluntary insurance program called CLASS

to help pay for long-term care and support at home.

• Individuals on Medicaid will receive improved home- and community-based care options, and spouses of people receiving home- and community-based services through Medicaid will no longer be forced into poverty.

Helps Early Retirees• To help offset the cost of employer-based retiree health plans, the new law creates a program to preserve

those plans and help people who retire before age 65 get the affordable care they need.

Helps People with Pre-existing Conditions• The new law provides affordable health insurance through a transitional high-risk pool program for

people without insurance due to a pre-existing condition.

• Insurance companies will be prohibited from denying coverage due to a pre-existing condition forchildren starting in September, and for adults in 2014.

• Insurance companies will be banned from establishing lifetime limits on your coverage, and use of annual limits will be limited starting in September.

Expands Health Coverage for Young People• Young people up to age 26 can remain on their parents’ health insurance policy starting in September.




HEALTH CARE LAW

For More Information

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CMS Product No. 11467

The New Law Preserves and Strengthens Medicare

New Tools to Fight Fraud and Protect Your

Medicare Benefits

• The new law contains important new tools to helpcrack down on criminals seeking to scam seniorsand steal taxpayer dollars.

• It reduces payment errors, waste, fraud, andabuse to make Medicare more efficient and return

savings to the Trust Fund to strengthen Medicarefor years to come.

• You are an important resource in the fight againstfraud. Be vigilant and rely only on your trustedsources of information about your Medicarebenefits.

• Call 1-800-MEDICARE if you have any questionsor want to report something that seems like fraud.

Keeps Medicare Strong and Solvent

• Over the next 20 years, Medicare spending willcontinue to grow, but at a slightly slower rate asa result of reductions in waste, fraud, and abuse.This will extend the life of the Medicare TrustFund by 12 years and provide cost savings tothose on Medicare.

• In 2018, seniors can expect to save on averagealmost $200 per year in premiums and over $200per year in co-insurance compared to what they would have paid without the new law.

• Upper-income beneficiaries ($85,000 of annualincome for individuals or $170,000 for marriedcouples filing jointly) will pay higher premiums.This will impact about 2% of Medicarebeneficiaries.

For more information about the new health care law now, visit

www.medicare.gov. If you have any questions, call 1-800-MEDICARE

(1-800-633-4227) or your State Health Insurance Assistance Program (SHIP).

Visit www.medicare.gov or call 1-800-MEDICARE to get their telephone

number. TTY users should call 1-877-486-2048. If you need help in a language other than English or

Spanish, say “Agent” at any time to talk to a customer service representative.

Visit the Eldercare Locator at www.eldercare.gov to find out how to access home- and community-based services and benefits counseling, transportation, meals, home care, and caregiver support services.

You can also call 1-800-677-1116. The Eldercare Locator, a public service of the U.S. Administration on

Aging, is your first step for finding local agencies in every U.S. community.

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Forms & Tools Medicare and Health Care Reform – Patient Handout




Preferred Practices…

1. Provide palliative and hospice care by an interdisciplinary team of skilled palliative care professionals, including,

for example, physicians, nurses, social workers, pharmacists, spiritual care counselors, and others who collaborate

with primary healthcare professional(s).

2. Provide access to palliative and hospice care that is responsive to the patient and family 24 hours a day,

7 days a week.

3. Provide continuing education to all healthcare professionals on the domains of palliative care and hospice care.

4. Provide adequate training and clinical support to assure that professional staff is confident in their ability to

provide palliative care for patients.

5. Hospice care and specialized palliative care professionals should be appropriately trained, credentialed, and/or

certified in their area of expertise.

6. Formulate, utilize, and regularly review a timely care plan based on a comprehensive interdisciplinary assessment

of the values, preferences, goals, and needs of the patient and family and, to the extent that existing privacy laws

permit, ensure that the plan is broadly disseminated, both internally and externally, to all professionals involved in

the patient's care.

7. Ensure that upon transfer between healthcare settings, there is timely and thorough communication of the patient'sgoals, preferences, values, and clinical information so that continuity of care and seamless follow-up are

assured.

8. Healthcare professionals should present hospice as an option to all patients and families when death within a

year would not be surprising and should reintroduce the hospice option as the patient declines.

9. Patients and caregivers should be asked by palliative and hospice care programs to assess physicians'/healthcare

professionals' ability to discuss hospice as an option.

10. Enable patients to make informed decisions about their care by educating them on the process of their

disease, prognosis, and the benefits and burdens of potential interventions.

A National Framework and

Preferred Practices for Palliative

and Hospice Care Quality A National Quality Forum (NQF) Consensus Report

The National Quality Forum has recently identified palliative care and hospice care as national

priority areas for healthcare quality improvement. The highly influential NQF report provides

a framework and set of NQF-endorsedTM preferred practices that focus on improving palliative

care and hospice care across the Institute of Medicine’s six dimensions of quality – safe,

effective, timely, patient-centered, efficient, and equitable. The preferred practices mark acrucial step in the standardization of palliative care and hospice.

Center to Advance

Palliative Care

1255 FifthAvenue,Suite C-2

New York, NY 10029

Phone 212.201.2670

Fax 212.426.1369

www.capc.org

Preferred Practices – Palliative & Hospice Care Quality Forms & Tools



110 Healthy Skin

11. Provide education and support to families and unlicensed caregivers based on the patient's individualizedcare plan to assure safe and appropriate care for the patient.

12. Measure and document pain,dyspnea, constipation, and other symptoms using available standardized

scales.

13.Assess and manage symptoms and side effects in a timely, safe, and effective manner to a level that is

acceptable to the patient and family.

14. Measure and document anxiety, depression, delirium,behavioral disturbances, and other common

psychological symptoms using available standardized scales.

15. Manage anxiety, depression, delirium, behavioral disturbances, and other common psychological

symptoms in a timely, safe, and effective manner to a level that is acceptable to the patient and family.

16.Assess and manage the psychological reactions of patients and families (including stress, anticipatory grief,

and coping) in a regular, ongoing fashion in order to address emotional and functional impairment and loss.

17. Develop and offer a grief and bereavement care plan to provide services to patients and families prior to

and for at least 13 months after the death of the patient.

18. Conduct regular patient and family care conferences with physicians and other appropriate members of the

interdisciplinary team to provide information, to discuss goals of care, disease prognosis, and advance care

planning, and to offer support.

19. Develop and implement a comprehensive social care plan that addresses the social, practical, and legal needs of

the patient and caregivers, including but not limited to relationships, communication, existing social and culturalnetworks, decision making, work and school settings, finances, sexuality/intimacy, caregiver availability/stress, and

access to medicines and equipment.

20. Develop and document a plan based on an assessment of religious, spiritual, and existential concerns using

a structured instrument, and integrate the information obtained from the assessment into the palliative care plan.

21. Provide information about the availability of spiritual care services, and make spiritual care available either

through organizational spiritual care counseling or through the patient's own clergy relationships.

22. Specialized palliative and hospice care teams should include spiritual care professionals appropriately trained

and certified in palliative care.

23. Specialized palliative and hospice spiritual care professionals should build partnerships with community

clergy and provide education and counseling related to end-of-life care.

24. Incorporate cultural assessment as a component of comprehensive palliative and hospice care assessment,

including but not limited to locus of decision making, preferences regarding disclosure of information, truth telling

and decision making, dietary preferences, language, family communication, desire for support measures such as

palliative therapies and complementary and alternative medicine, perspectives on death, suffering, and grieving,

and funeral/burial rituals.

25. Provide professional interpreter services and culturally sensitive materials in the patient's and family's

preferred language.

A National Framework and Preferred Practicesfor Palliative and Hospice Care Quality (continued)

continued on next page

Forms & Tools Preferred Practices – Palliative & Hospice Care Quality



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 can

help prepare for both the traditional and QIS survey processes. This demonstration also

highlights 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




Some things should not be reused

www.ONEandONLYcampaign.org

disease transmission from the misuse of needles,

syringes, and medication vials in outpatient

settings. While the campaign will be initially

rolled out in targeted locations, the vision is

to develop a concept that can be replicated

nationwide. For more information, please visit:

www.ONEandONLYcampaign.org.

Safe Injection Practices Coalition partners include

the following organizations: Accreditation

Association for Ambulatory Health Care (AAAHC),

American Association of Nurse Anesthetists (AANA),

Ambulatory Surgery Foundation, Association for

Professionals in Infection Control and Epidemiology,

Inc (APIC), BD (Becton, Dickinson and Company),

Centers for Disease Control and Prevention (CDC),

CDC Foundation, HONOReform Foundation,

Nebraska Medical Association (NMA), Nevada

State Medical Association (NSMA), and Premier

Safety Institute.

About the One& Only CampaignThe goal of the One & Only Campaign is to improve

safe injection practices across healthcare settings.

The practices within an organization are highly

influenced by its culture or are an expression of its

culture. Thus, through education, outreach, and

grassroots initiatives, the One & Only Campaign

will seek to influence the culture of patient safety.

The One & Only Campaign is an education and

awareness campaign aimed at both healthcare

providers and the public to increase proper

adherence to safe injection practices to prevent



The shared use of fingerstick devices is one of the common root causes of exposure and infection in settings suchas long-term care (LTC) facilities, where multiple persons require assistance with blood glucose monitoring. Riskfor transmission of bloodborne pathogens is not limited to LTC settings but can exist anywhere multiple persons

are undergoing fingerstick procedures for blood sampling. For example, at a health fair in New Mexico earlier thisyear, dozens of attendees were potentially exposed to bloodborne pathogens when fingerstick devices werereused to conduct diabetes screening.

CDC CLINICAL REMINDER

Use of Fingerstick Devices on More than One Person PosesRisk for Transmitting Bloodborne Pathogens

Summary: The Centers for Disease Control and Prevention (CDC) has become increasingly concerned about the

risks for transmitting hepatitis B virus (HBV) and other bloodborne pathogens to persons undergoing fingerstickprocedures for blood sampling -- for instance, persons with diabetes who require assistance monitoring their blood

glucose levels. Reports of HBV infection outbreaks linked to diabetes care have been increasing1,2,3

. This noticeserves as a reminder that fingerstick devices should never be used for more than one person.

Background

Fingerstick devices are devices that are used to prick the skin and obtain drops of blood for testing. There are twomain types of fingerstick devices: those that are designed for reuse on a single person and those that aredisposable and for single-use.

Figure 2: Single-use, disposable

fingerstick devices*

National Center for Emerging and Zoonotic Infectious Diseases

Division of Healthcare Quality Promotion (DHQP)

Reusable Devices: These devices often resemble a pen and have the

means to remove and replace the lancet after each use, allowing the deviceto be used more than once (see Figure 1). Due to difficulties with cleaning

and disinfection after use and their link to numerous outbreaks, CDCrecommends that these devices never be used for more than one person. If

these devices are used, it should only be by individual persons using thesedevices for self-monitoring of blood glucose.

Figure 1: Reusable

fingerstick devices*

Single-use, auto-disabling fingerstickdevices: These are devices that are

disposable and prevent reuse through an

auto-disabling feature (see Figure 2). In

settings where assisted monitoring of blood

glucose is performed, single-use, auto-

disabling fingerstick devices should be used.



he dance sensation spreads

cross North America!

––––––––––––––––––––––––

· New York City · Chicago, IL ·

healthy skin magazine - volume 8; issue 3

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