healthy skin magazine - volume 9; issue 2

Improving Quality of Care Based on CMS Guidelines

What is an

ACO?

Get Set forBreast CancerAwareness Month

Free CE Inside!

Nurses LeadersRate PatientExperience

EnergizeYour Team

Wound Care PioneerDr. Katherine JeterBikes 3,100 Miles!Page 94

Volume 9, Issue 2

#1

Join the team!

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

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

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

Contact us at [email protected] to learn more!

HEALTHY SKIN

Content KeyWeʼve coded the articles and information in this magazine to indicate which national quality initiativesthey pertain to. Throughout the publication, when you see these icons youʼll know immediately thatthe subject matter on that page relates to one or more of the following national initiatives:• QIO – Utilization and Quality Control Peer Review Organization• Advancing Excellence in Americaʼs Nursing Homes

Weʼve tried to include content that clarifies the initiatives or gives you ideas and tools for implement-ing their recommendations. For a summary of each of the above initiatives, see Pages 6 and 7.

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Page 94

Page 12

Survey Readiness35 More than Just a Survey Tool61 A Guide to MDS 3.0 Section H

Prevention47 They’re Lurking in the Operating Room and Beyond!53 ERASE CAUTI Program Helps Hospitals Reduce Catheter Use by

20 Percent78 PRE-STAGE I: An Obvious, More Descriptive, and Clinically

Impactful Term than “Reactive Hyperemia” or “Blanchable Erythema”in Describing the State Before Stage I

80 12 Ways to Reduce Hospital Admissions

Treatment25 Effects of a Just-in-Time Educational Intervention Placed on Wound

Dressing Packages32 The Art of Wound Management38 Assessment and Management of Fungating Wounds

Special Features5 Medline’s Grant Program10 Patient Experience is #112 Transforming the Health Care Delivery System15 Answering Your Questions About Accountable Care Organizations18 The Path Forward for Quality Health Care23 2011 Nursing Leadership Priorities: The CNO’s Perspective92 Make Your Facility a Greener Place to Work94 Congratulations Dr. Jeter and WOCN!104 Countdown to Breast Cancer Awareness Month105 Medline Celebrates Six Years of Breast Cancer Awareness

Regular Features6 Two Important National Initiatives for Improving Quality of Care8 Breaking News72 Product Spotlight: Optilock87 Hotline Hot Topic: Assessing Lower Extremity Wounds

Caring for Yourself74 If Recent Attacks on Sunscreen Concern You96 How to Energize Your Team106 Recipe: Aunt Judy’s Tortilla Roll-Ups

Forms & Tools108 What Type of Wound Is It?110 One Needle, One Syringe, Only One Time111 National Diabetes Fact Sheet, 2011117 Spinal Injection Procedures Performed without a Facemask Pose Risk

for Bacterial Meningitis

HEALTHY SKIN

EditorSue MacInnes, RD, LD

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

Senior WriterCarla Esser Lake

Creative DirectorMichael A. Gotti

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

Lorri Downs, BSN, RN, MS, CIC

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

Joyce Norman, BSN, RN, CWOCN,DAPWCA

Kim Kehoe, BSN, RN, CWOCN, DAPWCA

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

Jackie Todd, RN, CWCN, DAPWCA

Wound Care Advisory BoardChristine Baker, MSN, RN, CWOCN, APN

Katherine A. Beam, DNP, RN, ACNS-BC

Patricia Rae Brooks, MSN, RN, ANP, CWOCN

Amparo Cano, MSN, CWON

Jill Cox, CWOCN

Sue Creehan, RN, CWOCN

Donna Crossland, MSN, RN, CWOCN

Barbara Delmore, PHD, RN, CWCN, AAPWCA

Karen Keaney Gluckman, MSN, FNP-BC, APN,CWOCN

Anita Prinz, RN, MSN, CWOCN, CFNC, COS-C

Mary Ransbury, RN, BSN, PHN, CWON

Denise Robinson, MPH, RN, CHWOCN

Diane Whitworth, RN, CWOCN

Improving Quality of Care Based on CMS Guidelines

Page 105

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

Improving Quality of Care Based on CMS Guidelines 3

©2011 Medline Industries, Inc. Healthy Skin is published by Medline Industries, Inc. One Medline Place, Mundelein, IL 60060. 1-800-MEDLINE.

One of these people is my daughter, Molly, a sophomoreat the University of Colorado. Last month, I watched herswim, bike and run alongside her teammates to win the2011 USA Triathlon Collegiate National Champi-onship…over 120 colleges and 1,600 athletes participated.School colors lined the transition area, teammatescheered and family and friends took pictures as theseincredibly talented athletes sped by. The spirit, teamworkand leadership were unbelievably motivating. I was soproud of her and inspired by her effort and determination.

Another person who inspires me is Dea Kent, CWOCN.She conducted and wrote the study you’ll find on page25, titled the “Effects of Just-in-Time Educational Inter-vention Placed on Wound Packages.” A few years ago,Dea was at a special launch presentation for Medline’snewly designed wound care packaging. The packagingwas unique because the design provided “just in timeeducation,” allowing the bedside nurse to correctly applyvarious wound dressing products. After the presenta-tion, Dea kept thinking that she would really like to testthe packaging to see if it made a difference in helpingthe non- wound care specialist in their confidence leveland technique in applying wound dressings. Dea had al-ways dreamed of doing a clinical study. But, not just anystudy, Dea wanted to be published in a peer reviewedmagazine. Wow, what a project…and one she had neverattempted before. She kept telling me, “You, know, I’mnot a PhD, but I know I can do this.”

From start to finish it took several years. But the resultwas a multi-centered randomized controlled study, whichwas accepted and published in the November/December2010 issue of the Journal of WOCN. The results were socompelling that she is also presenting the study at theupcoming WOCN conference in June in New Orleans.Dea had a vision and a goal…and she never let herselfwaiver regardless of the obstacles she faced alongthe way.

All of this leads me to Dr. Jeter’s story. Now this is a trulyinspiring story. At the age of 72, Dr. Jeter biked clearacross the country – 3,100 miles! Oh, and did I mentionthat she’s a breast cancer survivor? She achieved thisincredible feat, in partnership with the Wound, Ostomyand Continence Nurses Society (WOCN) to raise moneyto support the continuing education of WOC nurses.(See the full story on page 94.) How can you not beinspired by Dr. Jeter, her goal and her achievements?I’m in awe of her dedication and determination. But itmakes me want to set new goals for myself and achievethem. I hope it affects you the same way.

Best regards,

Sue MacInnes, RD, LDEditor

4 Healthy Skin

Healthy SkinLetter from the Editor

After looking at the photo on the cover of this issue of Healthy Skin, you might think you hadpicked up Bicycling Magazine. You didn’t. But there is a good reason Dr. Katherine Jeter is

our featured story. She is one of several people that come to mind who had a vision and a goal.A goal which at the time may have seemed unthinkable, yet through sheer perseverance,discipline and determination, they beat the odds. Whether the goal is related to a hobby, asport, or your professional career, it is has to be a glorious feeling to set a very hard goal andto make it!


Medline is committing up to $1 million over several years to stim-ulate the gathering of solid evidence that supports the adoptionof solutions into clinical practice. Review panel members thatrepresent a breadth of research and practice knowledge willselect grant recipients to be awarded up to $25,000 each forpilot grants and up to $100,000 each for an empirical study.

Objectives• To stimulate research that will lead to the development ofnew targeted interventions aimed at improving patient safetyand decreasing healthcare-acquired conditions

• To test the costs and effectiveness of interventions andprograms designed to improve the quality of care andincrease patient safety.

• To disseminate practical, evidence-based solutions withinand across healthcare facilities, leading to improvedpatient safety.

These awards are designed to assist healthcare providers indeveloping and testing creative solutions or interventions forreducing or preventing healthcare-acquired harms. Recipients ofgrant award will be paired with a research mentor/consultantthrough the grant program to develop methods and guide theconduct of the study, ensuring that a rigorous research processis followed. These studies can be small pilot studies aimed atdeveloping and testing the feasibility of new solutions or largerevaluation studies to more fully test the cots, effectiveness or dis-semination of evidence-based solutions. Please note that at thistime, the program is only accepting submissions from healthcareproviders based in the United States, Canada or Mexico.

Award Process1. In response to our request for applications (RFA), providerswill submit a letter (limited to 3 pages) of intent providing thefollowing information:• The patient safety event that the study will address• Whether the applicant is proposing a pilot study($25,000 limit) or empiric study ($100,000 limit)

• The proposed patient safety solution• The objective of the study• The proposed approach to the study (enough detail tounderstand how the patient safety solution will beimplemented and how the investigator plans to measurethe impact of the intervention)

• Expected output of the study• Plan for submission of institutional review board (IRB)approval of the proposed study or documentation toshow that the study is exempt IRB federal requirements

2. In addition, the applicant should submit the following withthe letter (not included in the 3-page limit):a. Brief biography about the individuals involved (limitedto one page each), which includes any experience aboutthe area of study focus.

b.Budget estimate (limited to one page), including the majorexpenditure categories.

3. Only one application from a healthcare provider will beconsidered. Institutions cannot submit more than oneapplication.

4. The review committee will review all LOIs received after theJune 30, 2011 deadline. Accepted letters will be assigned tothe most appropriate research mentor, who will contact theapplicant and work with him or her to develop the letter intoa full proposal of 5-7 pages in length, including a completebudget. Proposal and budget guidelines will be sent afterthe approval of the letter of intent.

Most of the projects that are chosen for full proposalsubmission will be funded; however, this process mayinvolve a subsequent resubmission a revised proposalso that the funded research plan is clear.

5. Pilot grants will generally be up to six months in duration witha budget of no more than $25,000. Empirical studies can beup to $100,000 and last up to a year in duration. Pilot studygrantees can go on to submit an empirical study grant at thesuccessful conclusion of the pilot project, or applicants canapply for a full empirical study grants based on their initialletter of intent if they have an existing practice with someevidence base that they wish to evaluate.

6. The final report for a pilot grant study should be a briefpaper written for a Medline publication (Healthy Skin, TheOR Connection or Infection Prevention Now) whether or notthe study is successful. The final report for an empirical studyis a paper to be submitted for publication in a peer-reviewedjournal.

E-mail your request for application to:[email protected]

MEDLINE’S GRANT PROGRAMSupporting the Adoption of Solutionsinto Everyday Practice2011 Submission Dates May 1- June 30, 2011

Special Feature

6 Healthy Skin

Two Important National Initiativesfor Improving Quality of Care

Achieving better outcomes starts with an understanding of current qualityof care initiatives. Hereʼs what you need to know about national projects andpolicies 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 will remain in effect through July , 2011.

Purpose: To carry out statutorily mandated review activities, such as:• Reviewing the quality of care provided to beneficiaries;• Reviewing beneficiary appeals of certain provider notices;• Reviewing potential anti-dumping cases; and• Implementing quality improvement activities as a result of case review activities.

Goal: In the 9th SOW, the QIO Program has been redesigned with a framework for accountability and also in content. Thecontent now consists of four themes with the goal to help providers, both in long-term care and acute-care facilities,prevent illness, decrease harm to patients and reduce waste in health care.Of note: QIOs will be required to help Medicare promote three overarching themes: adopt value-driven healthcare,support the adoption and use of health information technology and reduce health disparities in their communities.Under the direction of the Centers for Medicare & Medicaid Services (CMS), the QIO Program consists of a nationalnetwork of 53 QIOs located in each of the 50 U.S. states, the District of Columbia, Puerto Rico and the Virgin Islands.

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

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

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

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

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

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

Advancing Excellence in America’s Nursing Homes2

Stay tuned fordetails on 10th RoundStatement of WorkCOMING SOON


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 reviews2. Quality improvement activities (QIAs)3. Alternative dispute resolution (ADR)4. Sanction activities5. Physician acknowledgement monitoring6. Collaboration with other CMS contractors7. Promoting transparency through reporting8. Quality data reporting9. Communication (education and information)

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

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

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

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

homes in need

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

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

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

and rates9. Submitting plans to optimize performance at 18 months

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

Focus for the 9th Scope of Work– Move away from projects that are “siloed” in specific care settings– Focused activities for providers most in need– New emphasis on senior leadership (CEOs, BODs) involvementin facility quality improvement programs

The 9th Scope of Work Content Themes

Clinical Goals: Goal ActualGoal 1: Reducing high-risk pressure ulcers <10% 11%Goal 2: Reducing the use of daily < 5% 3%

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

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

short-stay, post-acute nursinghome residents

Operational/Process Goals: Goal ActualGoal 5: Establishing individual targets for > 90% 36.5%

improving qualityGoal 6: Assessing resident and family 22.5%

satisfaction with quality of careGoal 7: Increasing staff retention 13.9%Goal 8: Improving consistent assignment 26.6%

of nursing home staff so thatresidents receive care from thesame 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

8 Healthy Skin

BREAKING NEWS

HHS announces new patientsafety partnershipThe Department of Health and Human Services (HHS)recently introduced Partnership for Patients, a collaborationwith hospitals and others to reduce hospital-acquired condi-tions (HACs) and preventable hospital readmissions. Theinitiative will use $1 billion in Patient Protection and AffordableCare Act funding to test models of safer care delivery, pro-mote best practices and help Medicare patients at high riskfor readmission safely transition from the hospital to other caresettings. By 2014, participants hope to reduce HACs by 40percent and preventable readmissions by 20 percent to saveup to $35 billion across the health care system.

Medicare patients spending lesstime in the hospital at end of lifeMedicare beneficiaries with severe chronic illness spent fewerdays in the hospital at the end of life in 2007 than they did in2003, and were less likely to die in a hospital and more likelyto receive hospice care, according to a study released by theDartmouth Atlas Project. However, Medicare patients weremore likely to be treated by 10 or more doctors in the last sixmonths of life in 2007 (36.1 percent) than they were in 2003(30.8 percent), and the average number of intensive care daysfor these patients increased to 3.8 from 3.5.

AHRQ issues findings fromhospital culture of safety surveyThe Agency for Healthcare Research and Quality (AHRQ) justreleased the latest findings from its Hospital Survey onPatient Safety Culture, a tool to help hospitals evaluate theirefforts to create a culture of safety. The voluntary survey looksat 12 areas, including communication openness; handoffsand transitions; management support for patient safety;organizational learning/continuous improvement; staffing;supervisor/manager expectations and teamwork. The resultswere based on data from 1,032 U.S. hospitals.

Areas of strength:

• teamwork within units• supervisor/manager expectations

Areas for potential improvement:

• non-punitive response to mistakes• handoffs/transitions

BREAKING NEWS

Source: American Hospital Association

• Average reduction in facility-acquiredpressure ulcers: 70.5%

• Average annual savings: $306,000

How does it work?With a compelling combination of productsand education:1. Medline’s strategic product bundle, including

skin care and incontinence products2. Medline’s free educational program for

nurses and nursing assistants, including4 CE credits for nurses plus online,interactive competencies

©2011 Medline Industries, Inc. Medline is a registeredtrademark of Medline Industries, Inc.

1. Medline Industries, Inc. Data on file.

If you are interested in:

Implementing a program that allows youto achieve these results and sustain themover time

Reducing the incidence of pressure ulcersat your facility

Learning more about Medline’s PressureUlcer Prevention Program

Get results withMedline’s Pressure Ulcer Prevention Program

800 facilities have joined the program.Are you one of them?

Download a QR Code Reader app

Launch the QR app

Scan this QR Code or visithttp://www.medline.com/qr-code/jennie-edmundson/

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VIEW A PRESSURE ULCER PREVENTIONPROGRAM SUCCESS STORY

10 Healthy Skin

of nurse leaders confirmedthat their organization willbe part of an accountablecare organization withinthe next five years.

of nurse leaderssay that nursingresearch isbeing effectivelytranslated intopractice at thebedside.

39%

Patient experience is #1

When ranking the most importantfactors for providing high-qualitypatient care, nurse leaders reported:

#1 MOST IMPORTANTNurse-to-patient staffing ratio

#2 MOST IMPORTANTNurse experience level

#3 MOST IMPORTANTNurse education/certification level

According to the newlyreleased HealthLeadersMedia Industry Survey2011, nurse leaders aremost concerned about1. Patient experience/

patient satisfaction2. Quality/patient safety3. Cost reduction

With the advent of theHCAHPS (Hospital ConsumersAssessment of HealthcareProviders and Systems)survey and more governmentpay-for-performancerequirements, nurses aremaking the connection thatreimbursement will be tiedto patient satisfaction andquality of care, and patientsafety beginning next year.

53%

Nurse leaders rank priorities in national survey

Regarding handhygiene compliance,

of nurse leaders agreed thatthe primary reason behindfailure to achieve hand-washingcompliance is lack of spineto self-police and reportcolleagues’ violations.

Source: HealthLeaders Media Industry Survey 2011: Nurse Leaders. Available at: www.healthleadersmedia.com/intelligence

48%

Special Feature

of nurse leaders saidtheir organization plans toencourage more nursesto pursue bachelor’sdegrees over the nextthree years; 18 percentplan to encouragenurses to pursuemaster’s degrees.

73%

©2011 Medline Industries, Inc. NE1 is a trademark of Medline Industries, Inc.Medline is a registered trademark of Medline Industries, Inc. Patent pending.

Wound measurement made easyThe NE1 Wound Assessment Tool is a proven way toaccurately measure and record wound characteristics,featuring a unique right angle design to see length andwidth measurements at the same time. It also containsareas to record the type of wound, plus the date, timeand clinician’s name.

Key benefits• Increase accuracy of wound assessmentby more than 100 percent1

• Standardize wound documentation• Drive appropriate reimbursement dueto more accurate wound assessment

NE1™ Wound Assessment ToolAccurate identification, consistent documentation

Interactive training and online competencies availableon-demand at www.medlineuniversity.com

Winner ofNational HCAInnovatorsAward

Reference1. Young DL, Esocado N, Landers MR, Black J. A pilot study providing

evidence for the validity of a new tool to improve assignment of NPUAPstage to pressure ulcers. Advances in Skin & Wound Care. In press.

Camera not included.


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Transformingthe Health CareDelivery System

by Teresa Nguyen Clark, MPH, MBA

12 Healthy Skin

Special Feature

� �The Secretary shall establish a hospital value-based purchasing program under whichvalue-based incentive payments are made in a fiscal year to hospitals that meet theperformance standards...

H.R. 3590 Patient Protection and Affordable Care Act 2010Title III, Subtitle A, Part I

What is hospital value-based purchasing?Much talk exists in the media about value-based purchasing. Isit legislation? Is it a change in payment? Is it a new focus? It isall those things - legislation, payment, and focus. But what is itto you?

The recently enacted health care reform law — H.R. 3590Patient Protection and Affordable Care Act 2010— establisheda hospital value-based purchasing (VBP) program, which is anew payment system that will be implemented for the Medicareprogram by the Centers for Medicare & Medicaid Services(CMS) starting in October 2012. Under the Medicare VBP pro-gram, hospitals that do not surpass CMS-mandated perform-ance targets will be subject to reimbursement penalties.

The Medicare VBP program initially focuses on five clinical con-ditions:• Acute myocardial infarction (AMI)• Heart failure (HF)• Pneumonia (PN)• Surgeries, as measured by the Surgical CareImprovement Project (SCIP)

• Healthcare-associated infections (HAI)

In addition to these five clinical conditions, the Medicare VBPprogram also focuses on Hospital Consumer Assessment ofHealthcare Providers and Systems (HCAHPS), which is thepatient’s perspective on quality.

How is any of this different than today?Today, Medicare lets your hospital know ahead of time whatthe performance target for payment will be. Knowing this aheadof time, you can anticipate what your future reimbursementsmay be, based upon your performance relative to the pre-defined Medicare target. Then if you meet the performancetargets, you share in the savings with other hospitals.

Come 2012, in a hospital value-based purchasing environment,you no longer know what the performance target will be aheadof time. That is, Medicare will no longer pre-define the targetbefore the performance period. Instead, Medicare will set thetarget after the performance period, with the performance tar-get set at the national level.

This essentially means your hospital will now be in a nationalcompetition for Medicare dollars, regardless of hospital char-acteristics, such as size and teaching status. This also meansthat going into a performance period, your hospital no longerknows what the Medicare performance target will be.

How will this change what I do today?Although October 2012 seems far away, Medicare will be start-ing to look at your baseline performance this summer. Thisleaves you little time to make changes that ready you for work-ing in a value-based purchasing environment.

In addition to the timing of changes, value-based purchasingwill also affect your focus. Medicare has focused payment onclinical conditions and it will continue to do so under VBP.However, under VBP Medicare will now also focus on thepatient experience of care, as measured by the HCAHPS. TheHCAHPS will shift your focus from clinician and diseaseprocess-centric to patient-centric.

Okay then - Where do I start?With the upcoming changes, there are two places to startlooking:1. How do you compare to the national market,regardless of hospital characteristics?

2. From whose perspective is your patient experienceof care model based upon? Clinicians? Patients?

Title III focus on Medicare VBP dramatically alters the healthcare landscape. If not prepared, your hospital, clinicians, andleaders will be left in a precarious position when the MedicareVBP payment effects begin October 2012.

Teresa Nguyen Clark, MPH, MBA, is vice president of clinicalbusiness strategy and delivery for VHA, Inc., where she is respon-sible for developing business and implementation strategies forVHA’s clinical performance team to enhance the company’s effortsto drive sustainable quality improvement with its members. Beforejoining VHA in 2007, Teresa was the special assistant to the Cen-ters for Medicare and Medicaid Services (CMS) chief medical offi-cer and the director of the Office of Clinical Standards and Quality.


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

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An ACO is a network of doctors and hospitals that comes togethervoluntarily to share responsibility for providing care to patients. Theconcept is part of U.S. healthcare reform under the Affordable CareAct and primarily focuses on Medicare patients.1

Accountable Care OrganizationsAnswering Your Questions About

What is an accountable careorganization (ACO)?

The plan is set to be established by January 1, 2012.When will the ACO

program begin?

Special Feature

The goal of an ACO is to improve the safety and quality of patient careand make health care more affordable. Today more than half ofMedicare patients have five or more chronic conditions and oftenreceive care from multiple physicians and multiple facilities. Failure tocoordinate care can often lead to patients not receiving proper care,receiving duplicative care and being at an increased risk of sufferingthe effects of medical errors.1

What is the purposeof an ACO?

Doctors and hospitals are the only providers allowed to form an ACO;however, they will be responsible for incentivizing other healthcareorganizations, such as long-term care facilities and home health, towork together on behalf of the patient. ACOs must agree to manageall healthcare needs for a minimum of 5,000 Medicare beneficiariesfor at least five years.2

Who is eligible toform an ACO?

The benefit of forming an ACO lies in financial incentives fromMedicare for ACOs that demonstrate good quality care while keepingcosts down. The ACO concept was designed to make providersjointly accountable for the health of their patients, giving them strongincentives to cooperate with each other and save money. Financialbonuses will be awarded when ACOs keep costs down, meet specificquality benchmarks, and carefully manage patients with chronicdiseases. The goal is to avoid unnecessary tests, procedures andhospitalizations.1

Why would hospitals and doctorswant form an ACO?

• Nearly one in five Medicare patients dischargedfrom the hospital is readmitted within 30 days.This could be avoided if patient care outsidethe hospital was more aggressive and bettercoordinated – through an ACO.1

• ACOs could potentially save Medicare as muchas $960 million over three years.1

How ACOs Can Help

References1. Accountable Care Organizations: Improving Care Coordination for People with Medicare. U.S. Department of Health & Human Services website.

Available at http://healthcare.gov/news/factsheets/accountablecare03322011a.html. Accessed March 31, 2011.2. Gold J. Accountable care organizations, explained. Kaiser Health News. Available at http://www.npr.org/2011/01/18/132937232/accountable-care-

organizations-explained. Accessed March 23, 2011.

16 Healthy Skin

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Patient safety is in your hands

taintntainthe


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Also available in afoaming formulation.

©2011 Medline Industries, Inc. Medline and Epi-clenz are registered trademarks of Medline Industries, Inc.

The pathforwardfor qualityhealth careBy Lorri A. Downs BSN, MS, RN, CIC

18 Healthy Skin

Special Feature


The U.S. healthcare delivery system is fragmented. Care isdelivered at many locations leading to waste and duplication ofservices. To try to alleviate this problem, Congress has estab-lished the Medicare Shared Savings Program for AccountableCare Organizations (ACOs) under the Affordable Care Act. Howwill this program change healthcare delivery? How will it affectquality of care?

“Medicare Accountable Care Organizations (ACOs) are the firststep in reforming the American healthcare system. ACOs will bethe change in patient care delivery designed to accelerateprogress toward a three-part national goal:1

➢ Better care for individuals➢ Better health for populations➢ Slow the growth of costs with improvements in care

ACOs will assume responsibility for a defined population ofMedicare beneficiaries. If the ACO succeeds in both deliveringhigh quality care and cost savings, the organization will share inthe Medicare savings it achieves.2

On March 31, 2011 the Department of Health and HumanServices took the first step in forming accountable careorganizations (ACOs) by issuing the proposed rule for theseorganizations.1 The heart of this concept of care delivery is tobring providers and suppliers of Medicare covered servicestogether to coordinate care for Medicare beneficiaries.

Initially skilled nursing facilities, nursing homes and long-termcare hospitals are not specifically designated as eligible to formindependent ACOs.

ACOs will be required to provide the Centers for Medicare andMedicaid Services (CMS) with a plan documenting andaddressing the following key Quality Processes:➢ Promote evidence-based medicine➢ Patient engagement➢ Report on quality and cost metrics➢ Coordination of care

As ACOs begin to be defined, and the list of requirementsunfold, clearly quality will be at the core. The National QualityStrategy is a broad road map that will require the ongoingdevelopment of specific goals and agreed metrics for healthcarequality improvement. Efforts will focus on avoiding duplication ofservices, ensuring accountability, and streamlining qualityreporting.

1. Under the Affordable Care Act, existing guaranteedMedicare-covered benefits won’t be reduced or takenaway. Neither will the ability to choose your own doctor.

2. Nearly four million people with Medicare received costrelief during the healthcare reform law's first year.Medicare recipients with prescription drug coverage whohad to pay for drugs in the coverage gap known as the"donut hole," received a one-time, tax-free $250 rebatefrom Medicare to help pay for their prescriptions.

3. Medicare recipients with high prescription drug costs thatput them in the donut hole now get a 50% discount oncovered brand-name drugs. Between today and 2020,Medicare recipients will get continuous coverage forprescription drugs. The donut hole will be closedcompletely by 2020.

4. Medicare covers certain preventive services withoutcharging the Part B coinsurance or deductible.Recipients will also be offered a free annual wellness exam.

5. The life of the Medicare Trust fund will be extended to atleast 2029, a 12-year extension as a result of reducingwaste, fraud and abuse, and slowing cost growth inMedicare, which will provide recipients with future costsavings on premiums and coinsurance.

At the end of the day, we all must increased collaboration andcommunication between facilities to help reduce waste in ourhealthcare system. Partnering for Prevention has become criti-cally important. Teaching and supporting healthcare providersabout sustainable solutions across the continuum of care will helpprevent costly readmissions and hopefully translate into a health-ier population.

About the authorLorri Downs, BSN, MS, RN, CIC is a board-certified infection preventionist and vice presi-dent of infection prevention for MedlineIndustries, Inc. She has a diverse portfolio ofmore than 25 years in the nursing professions.Her expertise focuses on infection preventionsurveillance at large acute care organizations,

plus ambulatory and public health settings. Lorri has developed hos-pital infection control programs and local emergency preparednessplans, and she has lectured on various infection prevention topics.

Things to Know about Healthcare Reformand Medicare Benefit4

TOP 5

20 Healthy Skin

Priority

Goal:Eliminate preventable healthcare-acquired conditions

Opportunities for success:* Eliminate hospital-acquired infections* Reduce the number of serious adversemedication events

Illustrative measures:* Standardized infection ratio for centralline-associated blood stream infectionas reported by CDC’s NationalHealthcare Safety Network

* Incidence of serious adversemedication events

Goal:Create a delivery system that is lessfragmented and more coordinated,where handoffs are clear, and patientsand clinicians have the information theyneed to optimize the patient-clinicianpartnership

Opportunities for success:* Reduce preventable hospitaladmissions and readmissions

* Prevent and manage chronic illnessand disability

* Ensure secure information exchangeto facilitate efficient care delivery

Illustrative measures:* All-cause readmissions within 30 daysof discharge

* Percentage of providers who provide asummary record of care for transitionsand referrals

Initial Goals, Opportunities for Success,and Illustrative MeasuresNational Quality

Strategy Prioritiesand Goals,

with IllustrativeMeasures3

#1Safer Care

#2EffectiveCare

Coordination


Goal:Build a system that has the capacityto capture and act on patient-reportedinformation, including preferences,desired outcomes, and experienceswith health care

Opportunities for success:* Integrate patient feedback onpreferences, functional outcomes,and experiences of care into all caresettings and care delivery

* Increase use of EHRs that capture thevoice of the patient by integratingpatient-generated data in EHRs

* Routinely measure patient engagementand self-management, shareddecision-making, and patient-reportedoutcomes

Illustrative measures:* Percentage of patients askedfor feedback

Goal:Prevent and reduce the harmcaused by cardiovascular disease

Opportunities for success:* Increase blood pressure controlin adults

* Reduce high cholesterol levelsin adults

* Increase the use of aspirin to preventcardiovascular disease

* Decrease smoking among adultsand adolescents

Illustrative measures:* Percentage of patients ages 18 yearsand older with ischemic vasculardisease whose most recent bloodpressure during the measurementyear is <140/90 mm Hg

* Percentage of patients with ischemicvascular disease whose most recentlow-density cholesterol is <100

* Percentage of patients with ischemicvascular disease who havedocumentation of use of aspirin orother antithrombotic during the12-month measurement period

* Percentage of patients who receivedevidence-based smoking cessationservices (e.g., medications)

Goal:Support every U.S. community as itpursues its local health priorities

Opportunities for success:* Increase the provision of clinicalpreventive services for children andadults

* Increase the adoption ofevidence-based interventions toimprove health

Illustrative measures:* Percentage of children and adultsscreened for depression and receivinga documented follow-up plan

* Percentage of adults screened for riskyalcohol use and if positive, receivedbrief counseling

* Percentage of children and adults whouse the oral health care system eachyear

* Proportion of U.S. population servedby community water systems withoptimally fluoridated water

Goal:Identify and apply measures that canserve as effective indicators of progressin reducing costs

Opportunities for success:* Build cost and resource usemeasurement into payment reforms

* Establish common measures to assessthe cost impacts of new programs andpayment systems

* Reduce amount of health carespendingthat goes to administrative burden

* Make costs and quality moretransparent to consumers

Illustrative measures:* To be developed

U.S. Department of Health and Human ServicesMarch 2011

Initial Goals, Opportunities for Success,and Illustrative Measures

Priority Initial Goals, Opportunities for Success,and Illustrative Measures

Priority

#4Prevention

and Treatmentof LeadingCauses ofMortality

#5Supporting

BetterHealth in

Communities

#6Making

Care MoreAffordable

#3Person-

and Family-CenteredCare

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The top priorities for organizations in 2011 are very simplystated, but not easily executed. Here are the most importantareas of focus:

• Staff engagement and loyalty (HCAHPS)

• Nursing and physician engagement and collaboration(HCAHPS)

• Excellence with delivering the patient experience(HCAHPS)

• Reliable care that is founded on best practice qualityand safety practices (Pay for Performance -Value Based Purchasing - Core Measures / SCIP /Hospital-Acquired Conditions)

• Nursing staff at the forefront of designing, developingand implementing solid EMRs (“Meaningful Use”-Patient Protection Accountability Care Act-PPACA)

• Excellent, system-focused leaders who care andengage all staff on their excellence journey

• An environment that fosters and supports theSTEEEP aims of Lean/Six Sigma (Safe-Timely-Effective-Equitable-Efficient-Patient-Centered Care)

Building strong partnerships internally and externally is a neces-sity for a successful health system. Interdisciplinary teams thatinclude: nurses, materials managers, purchasing, CWOCNs,infection control preventionists, physicians, chief medical officersand chief nursing officers must come together to evaluate currentclinical and service excellence delivery. Innovation and changemanagement will be a necessary core competency of staff andleaders in positions to influence excellence.

The ideal state for CNOs and clinical leaders is to have collabo-ration and standards in practice, processes, and leadershipacross our nation. Remember, if excellence was that easy, wewould have nailed this years ago. Our dear leader, FlorenceNightingale, instructed us, “First Do No Harm.” Let’s continue tolearn from one another and provide our staff, physicians andpatients with excellence, and of course, eliminate harm.

2011 Nursing Leadership Priorities:The CNO’s Perspectiveby Candace S. Smith, MPA, RN, NEA-BC

CNOs can truly drive excellence with good teamwork in supporting the efforts of hospital staff and leaders. Providingthe front line with the tools to do their jobs is paramount, and CNOs can certainly influence their efforts.

“

“

First Do No Harm.

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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.

MEDLINE’S REVOLUTIONARY SHOW-AND-TELL PACKAGING


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Effects of a Just-in-Time Educational InterventionPlaced on Wound Dressing Packages

A Multicenter Randomized Controlled Trial

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

Purpose: I compared the effects of a just-in-time educationalintervention (educational materials for dressing application at-tached to the manufacturer’s dressing package) to traditionalwound care education on reported confidence and dressingapplication in a simulated model.

Subjects and Settings: Nurses from a variety of backgroundswere recruited for this study. The nurses possessed all levelsof education ranging from licensed practical nurse to masterof science in nursing. Both novice and seasoned nurses wereincluded, with no stipulations regarding years of nursingexperience. Exclusion criteria included nurses who spent lessthan 50% of their time in direct patient care and nurses withadvanced wound care training and/or certification (CWOCN,CWON). Study settings included community-based acutecare facilities, critical access hospitals, long-term care facili-ties, long-term acute care facilities, and home care agencies.No Level I trauma centers were included in the study forgeographical reasons.

Methods: Participants were randomly allocated to control orintervention groups. Each participant completed the KentDressing Confidence Assessment tool. Subjects were thenasked to apply the dressing to a wound model under theobservation of either the principal investigator or a trainedobserver, who scored the accuracy of dressing applicationaccording to established criteria.

Results: None of the 139 nurses who received traditionaldressing packaging were able to apply the dressing to awound model correctly. In contrast, 88% of the nurses whoreceived the package with the educational guide attached toit were able to apply the dressing to a wound model correctly

(x2 = 107.22, df = 1, P = .0001). Nurses who received thedressing package with the attached educational guide agreedthat this feature gave them confidence to correctly apply thedressing (88%), while no nurse agreed that the traditionalpackage gave him or her the confidence to apply the dress-ing correctly (x2 = 147.47, df = 4, P < .0001).

Conclusions: A just-in-time education intervention improvednurses’ confidence when applying an unfamiliar dressing andaccuracy of application when applying the dressing to a sim-ulated model compared to traditional wound care education.

IntroductionAppropriate wound care, which includes accurate selectionand application of a variety of wound care products, is a keyresponsibility for the individual wound care clinician and healthcare facility. Wound care is especially challenging when pro-vided by multiple caregivers with varied educational andexperiential backgrounds. Educating multiple persons todeliver competent wound care may appear especially over-whelming for agencies that lack a wound care specialistto ensure adequate education for all involved staff or lay careproviders.

Seaman and colleagues1 suggest that innovative dressingsmay help caregivers improve wound-healing outcomes. How-ever, this is true only when dressings are selected andapplied appropriately. Ayello and colleagues2 demonstrated aneed for increasing both the quality and quantity of educa-tion related to wound care. Nevertheless, little research hasbeen completed that evaluates the efficacy of educationalstrategies to promote appropriate selection and applicationof wound care products.


Treatment

26 Healthy Skin

Clinical decision making is a complex process that involvesthe intersection of a number of factors, including knowledgeof wound healing, local and systemic factors that influencewound healing, specific wound care interventions, and pastexperience.3 Nurses must make multiple decisions when car-ing for an individual patient and that influence patient out-comes such as wound healing.4 Rycroft-Malone andassociates5 found that protocol-based care increased nurses’independence and autonomy. Verdu6 found that decisiontrees assist nurses to make complex clinical decisions,including the selection of appropriate wound dressings.

Educational intervention. Advances in the application ofinformatics in health care have led to a teaching techniquecommonly labeled “just-in-time” education.7 This model isadapted from the business world and is based on the con-cept that learning is facilitated when the education is providedin a time-sensitive manner (i.e., education delivered at themoment it is most needed). This approach to educationallows for customization of content8 and provides the learnerwith tools that enhance their ability to provide effective care.Just-in-time education also allows the learner to be more self-directed.9 There are many examples of “just-in-time” educa-tion in the everyday world, such as reading directions for anover-the-counter medication at the time of purchase. Woundcare specialists have developed a variety of tools, includingdecision trees for selection of appropriate pressure redistributionsurfaces and algorithms for selecting an appropriate dressing,that have proved useful for assisting generalists managewounds. Just-in-time education may prove useful for woundcare if it can be made available when a dressing is applied.

One company that manufactures dressings (Medline Industries,Inc, Mundelein, Illinois) has developed a packaging systembased on the concept of “just-in-time” education (Figure 1).Instructions for appropriate dressing use are attached to eachpackage. This study was undertaken to assess the effects ofthis educational resource. Specifically, I examined nurses’reported confidence in their ability to provide appropriate careusing an unfamiliar dressing and an objective assessment ofnurses’ ability to apply the dressing correctly to a woundmodel.

MethodsThis randomized controlled trial compared self-reported confi-dence levels in providing wound care and applying a dressingto a model in 2 groups of nurses. Study procedures werereviewed and approved by my facility’s institutional review

board, and all participants gave informed consent. Nurseswere recruited through informal announcements made onvarious units including medical/surgical units, emergencydepartments, surgery, day surgery, and long term acuterehabilitation unit, home health care agencies, and long termcare facilities. Nurses with wound care certification (CWOCN,CWON, and CWCN) and advanced practice nurses were ex-cluded from participation. In addition, nurses who spent lessthan 50% of their time in direct patient care were excluded.I excluded these nurses since direct patient care is not thefocus of their routine responsibilities and their participationmay have introduced confounding variables into the study.

FIGURE 1. Educational guide attachment on dressing package

Nurses were randomly allocated to a control group receivingtraditional wound education, or the intervention group receiv-ing just-in-time education. Simple random allocation wascompleted by allowing each nurse to choose a colored card.Cards were 1 of 2 colors; selection of 1 color led to allocationto the control group, and selection of the other color resultedin allocation to the intervention group. Participants had noknowledge of which dressing the colored cards represented.No compensation was provided to participants, and the com-pany who designed the innovation had no input into the de-sign, concept, or implementation of the study. However, thecompany did supply dressings, free of charge, needed toconduct the study.

Study setting. The study was conducted at 8 facilities incentral Indiana, including community hospitals, critical accesshospitals, long-term acute care units, long-term care facili-ties, and home health agencies. The long-term acute careunits and home health agencies were used in the pilot studyonly, due to staff availability. Facilities were selected that weregeographically near the principal investigator. Each facility was

contacted and the appropriate administrator was approachedabout allowing me to solicit involvement in the study. Oncemanagement approval was given, site visits for the recruit-ment of subjects were completed.

Instruments. Data were collected using 2 tools: (1) the KentDressing Confidence Assessment, a rating scale/question-naire to assess the nurses’ feeling of confidence in dressingapplication; and (2) a structured criteria form to be used toevaluate each nurse’s ability to accurately apply the dressingto the wound model (Figures 2 and 3).

The Kent Dressing Confidence Assessment is a questionnaireused to measure nurses’ confidence in wound dressingapplication; I developed the tool prior to data collection. It wasevaluated by a panel of researchers, with expertise in woundcare and instrument development, and professional educa-

tors. The tool was then revised in orderto obtain consensus as to measure-ment criteria, wording, and generalpresentation. Following content valida-tion by the panel, the tool was furtherevaluated in a pilot study involving 34nurses. Each nurse randomly selected1 of the test dressings and completedthe questionnaire. Demographic infor-mation was collected on the nursesinvolved in the pilot study, and they wereinterviewed to determine if they foundthe questionnaire clear and under-standable. They were also asked to pro-vide suggestions for improving wordingof any items they found confusing. Allparticipants indicated they found instru-ment items clear, concise, easy to read,easy to complete, and easy to under-stand. The Kent Dressing ConfidenceAssessment contains 10 questions;each item is answered via a 5-pointscale, “strongly agree,” “agree,” “neu-tral,” “disagree,” or “strongly disagree.”Each item is scored individually. I thendeveloped a form using informationfrom the educational packaging thatspecified correct criteria for dressingapplication. This form contained 4application criteria; each of the criteriahad to be demonstrated by the nurse in

order for the dressing application to be scored as “correctlyapplied” (Figure 3).

Study procedures. I selected a dressing that was not famil-iar to study participants in order to enable a more accurateassessment of the effect of the educational intervention onapplication and self-reported confidence with application. Thecontrol group received the unfamiliar dressing in a “standard”package with instructions to actually apply the dressing to thewound model. Scissors and gauze were made available foruse, and the participants were told they could use any itemthey thought necessary to apply the dressing. The nurseswere not asked to secure any secondary dressing in place.Rather, they were instructed to apply the secondary dressingaccording to package instructions. Participants were allowedto ask questions, but no information about how to apply thedressing was given by the principal investigator (D.K.) or


Figure 2. Kent Dressing Confidence Assessment.

The package Strongly Somewhat Neutral Somewhat Stronglydirections on the Agree Agree Disagree Disagreewound dressingpackage:

1. Provides directionsabout use of thedressing.

2. Defines one or moreuses of the dressing.

3. Indicates instructions forapplication of the dressing.

4. Indicates the method forremoving the dressing.

5. Explains how to applythe dressing correctly.

6. Defines the changefrequency of the dressing.

7. Allows me to applythe dressing safely.

8. Educates me aboutspecific precautions inrelation to the dressing.

9. Gives me confidencethat I can correctly applythe dressing.

10.Will change my nursingpractice in relation toapplication of wounddressings.

Please place an “x” in the category that best represents your answer

28 Healthy Skin

trained observer. The intervention group wasmanaged in an identical fashion, but they re-ceived the unfamiliar dressing in a packagewith an attached instruction sheet (Figure 1).

Each participant completed the Kent DressingConfidence Assessment tool (Figure 2). Sub-jects were then asked to apply the dressing toa wound model under the observation ofeither the principal investigator (D.K.) or atrained observer, who scored the accuracy ofdressing application according to establishedcriteria (Figure 3). The trained observer was anurse trained in providing wound care anddressing application. I taught the observer toscore the subject based on the 4 criteria forcorrect dressing application and on how tointeract with subjects during data collection.I evaluated training by direct observation ofthe data collector prior to data collection. Inorder to avoid education among participants,I allowed only 1 participant in the study roomat any time. Subjects were asked to not tospeak of any part of their experience in thestudy room until all data were collected at thatfacility. Was dressing applied correctly

Data analysis. Proportions and chi-square analysis wereused to determine whether the educational interventionaffected nurses’ reported confidence when applying a noveldressing and their observed performance when applying thedressing to a model. Chi-square findings were validated withthe Fisher exact test.

ResultsOne hundred seventy-three nurses participated in the study.Among the control and intervention groups, there were 43

licensed practical nurses and 130 RNs, including diploma (n= 7), associate degree (n = 65), bachelor’s degree (n = 55),and master’s degree (n = 3) RNs. The most common cate-gory of work experience was category B (2-5 years) amongthe nurses. Forty-one nurses worked in a long-term carefacility, 13 worked in home health care, 18 worked in long-term acute care, and the remaining 101 nurses worked in theacute care hospital (Table 1). No statistically significant differ-ences were found when groups were compared based oneducational preparation, care setting worked, or years ofexperience.

Confidence with dressing application. Dressing applica-tion confidence was evaluated via 3 items from the KentDressing Confidence Assessment: (1) item 5 that queried cor-rect dressing application; (2) item 7 that queried safe appli-cation of the dressing; and (3) item 9 that queried confidencewhen correctly applying the dressing. Significantly, fewer con-trol group subjects agreed that they could correctly apply thedressing (item 5) (4% vs 100%, x2 = 173.00, df = 4, P =.0001). Significantly, fewer control group subjects agreed thatthey could safely apply the dressing as compared to subjectsreceiving just-in-time education (item 7) (4% vs 91%, x2 =

Figure 3. Criteria for dressing application. Yes No

1. Must trim dressing with scissors to fit the wound

2. Must remove the blue protective packaging from thedressing prior to placing it into the wound

3. Must pack the dressing loosely into the wound bed,filling it only 2/3 full.

4. Must cover with a secondary dressing

Must score “yes” in all categories to correctly apply dressing to the wound model.

Was dressing applied correctly Yes No

Table 1. Demographic Information

Control Intervention Group TotalGroup, N Group, N Comparison

Licensure x2 = 0.1549 N = 173LPN 21 22 df = 1RN 59 71 P = .69

Education x2 = 1.6162 N = 173LPN 21 22 df = 1Diploma RN 4 3 P = .20ADN RN 33 32BSN RN 21 34MSN RN 1 2

Experience, y x2 = 0.1274 N = 173<1 12 8 df = 12-5 20 22 P = .726-10 13 1711-15 9 2316-20 19 1921-25 4 3≥26 3 1

Care setting x2 = 2.8728 N = 173Acute care 46 55 df = 3ECF 4 22 P = .41Home care 19 9Long-term acute care 11 7

Abbreviations: ADN, advance degree nurse; ECF, extended care facility; LPN, licensed practical nurse


160.07, df = 4, P < .0001). Fewer nurses in the control groupagreed that they felt confident with dressing application whencompared to nurses in the intervention group (item 9) (19% vs88%, x2 = 147.47, df = 4, P < .0001) (Table 2).

Dressing application. None of the 62 nurses in the controlgroup were able to apply the dressing to the wound modelcorrectly as compared to 68 of 77 nurses (88%) in the inter-vention group who were able to apply the dressing correctly(x2 = 100.694, df = 1, P < .0001) (Figures 4 and 5). The mostcommon dressing errors were as follows: (1) failure to trim thedressing to fill the wound cavity two-thirds full (100%);(2) failure to remove the blue cover (carrier sheet) on thedressing (68%); and (3) overpacking the wound by scrunch-ing the entire dressing up in the wound bed (100%). Reporteddata does not include pilot study groups.

DiscussionFindings from this study provide evidence that use of a just-in-time educational intervention (placement of an instructionalguide for application in the individual dressing packages)enhances application technique and reported confidencewhen applying a previously unfamiliar dressing. More subjectsin the intervention group reported confidence that they couldsafely and correctly apply the dressing than did control groupsubjects, and this perception was validated when subjectswere asked to apply the dressing to a model.

I reviewed the literature and found no other studies demon-strating the efficacy of the just-in-time educational techniquein wound care. Poskus10 reported that a just-in-time inter-

vention improved accuracy of a swallowing protocol. Simi-larly, Grasso and colleagues11 found that personal digital as-sistants (an electronic device designed to deliver just-in-timeeducation) that accessed a drug database significantly re-duced the rate of medication errors in 1 facility. Al-Saleh andWilliamson12 also found that personal digital assistants pro-vide the ability to find information quickly and promote safepatient care, as well as confidence in undergraduate nursingstudent.

Although this study did not directly measure dressing appli-cation in a clinical practice setting, more subjects receivingthe intervention were able to accurately apply an unfamiliardressing accurately to a model than were subjects given tra-ditional education. In addition, 71% of nurses who receivedthe just-in-time educational intervention reported they wouldchange their practice based on the package insert. It is notknown why the remaining 29% responded that they did notfeel that the intervention would prompt them to change theirpractice. Some participants stated that they frequently pro-vide wound care based on physician orders, without reallythinking about the purpose of a particular dressing. Othersexpressed that dressing application is relatively intuitive, andthey simply glanced through the educational guide instead ofreading it, as observed by the investigator. However, sinceaccurate application of this type of dressing falls within thescope of nursing practice, this response presents a challengeto wound care nurses when educating peers about wound care.

I attributed application failures in the control group to a lackof knowledge about dressing application, since no information

was available on thedressing packageitself. Factors con-tributing to dressingapplication failures forintervention groupsubjects may includean assumption thatthey could apply thedressing correctlywithout consultingdirections, or a historyof topical dressingpackages withoutjust-in-time informa-tion aiding accurateapplication.

The package directions on the wound dressing package:

1. Provides directions about use of the dressing. 0 100

2. Defines one or more uses of the dressing. 0 100

3. Indicates instructions for application of the dressing. 0 100

4. Indicates the method for removing the dressing. 0 100

5. Explains how to apply the dressing correctly. 0 100

6. Defines the change frequency of the dressing. 0 100

7. Allows me to apply the dressing safely. 0 90

8. Educates me about specific precautions in 0 96relation to the dressing.

9. Gives me confidence that I can correctly apply 0 88the dressing.

10.Will change my nursing practice in relation to 0 71my application of wound dressings.

% Agree

Table 2. Questionaire Results

Kent Dressing Confidence Assessment Plain Package Package With Instructions(n=80) (n=93)

30 Healthy Skin

LimitationsStudy limitations include using a model for dressing applica-tion rather than direct observation in clinical practice. In addi-tion, although subjects were instructed not to discussdressing application with other study participants, it was notpossible to ensure that subjects did not discuss applicationoutside the research setting. I did not include pilot studydressing application data in the overall results. The outcomeswere similar for this portion of the study, but the focus was onvalidation of the Confidence Assessment Tool and the studyprocedures.

ConclusionsJust-in-time education, in the form of education on a dress-ing package, improved both nurses’ confidence in applica-tion of an unfamiliar dressing and their accuracy whenapplying the dressing to a simulated model. Study findingsprovide evidence that manufacturers of wound dressingsshould apply just-in-time educational techniques by placingan educational guide on all dressing packages in order toenhance the accuracy and safety of application and,ultimately, its efficacy in wound healing.

KEY POINTS✔Just-in-time education in the form of an educationalguide on wound dressing packages led to increasednursing confidence in a broad sample of nurses withvarying educational backgrounds and numbers ofyears of experience.

✔Just-in-time education in the form of an educationalguide on wound dressing packages led to increasedsafety and accuracy when applying an unfamiliardressing in a simulated model.

✔ More than 70% of nurses reported that placement ofan educational guide on wound dressing packageswould change their practice when delivering wound care.

AcknowledgmentsThe author thanks Medline Industries for supply of dress-ings/packaging for the study. The author also thanks St.Joseph Hospital, Kokomo, Indiana, for supporting this studyas well as Mark Smith, St. Vincent Hospital, Indianapolis,Indiana, for statistical analysis of the data.

Dea J. Kent, MSN, RN, NP-C, CWOCN, Manager, WoundOstomy Clinic, Riverview Hospital, Noblesville, Indiana.Correspondence: Dea J. Kent, MSN, RN, NP-C, CWOCN,PO Box 386, Sharpsville, IN 46068 ([email protected]).

References1. Seaman S, Herbster S, Muglia J, Murray M, Rick C. Simplifying modern wound

management for nonprofessional caregivers. Ostomy Wound Manag. 2000;46:18-27.2. Ayello E, Baranoski S, Salati D. Wound care survey report. Nursing. 2005;35:36-45.3. Banning M. A review of clinical decision making: models and current research.

J Clin Nurs. 2007;17:187-195.4. Twycoss A, Powls L. How do children’s nurses make clinic decisions? Two preliminary

studies. J Clin Nurs. 2006;15:1324¬1335.5. Rycroft-Malone J, Fontenla M, Bick D, Seers K. Protocol-based care: impact on roles

and service delivery. J Eval Clin Pract. 2008;14:867-873.6. Verdu J. Can a decision tree help nurses to grade and treat pressure ulcers? J Wound

Care. 2003;12:45-50.7. Yensen J. Just-in-time resources on demand. http://www.langara.

bc.ca/vnc/ksu/ksu.htm#_TOC11. Accessed May 25, 2008.8. Barr R, Tagg J. Just-in-time education: learning in the global information age.

http://knowledge.wharton.upenn.edu/. Published December 2002.Accessed June 5, 2008.

9. Bongiorni B, Spicknall M, Horsmon A, Cohen P. On-demand education to meet marineindustry professional development needs. J Ship Prod. 1999;15:164-178.

10.Poskus K. Triumphs and challenges of implementing a nursing bedside swallowscreening tool: a stroke coordinator’s perspective. Perspect Swallowing SwallowingDisord (Dysphagia). 2009;18: 129-133.

11.Grasso B, Genest R, Yung K, Arnold C. Reducing errors in discharge medication listsby using personal digital assistants. Psychiatr Serv. 2002;53:1325-1326.

12.Al-Saleh M, Williamson K. EBP and patient safety: using PDAs in nursing educationclasses. Paper presented at: Summer Institute on Evidence-Based Practice; 2009.http://www. acestar.uthscsa.edu/institute/su09/documents/Al-Saleh_000.pdf.Accessed January 29, 2010.

Published with permission from the Journal of Wound, Ostomy and Continence Nursing.November/December 2010; 37(6):609-614.

706050403020100

Control Group 0Intervention Group 68

706050403020100

Control Group 62Intervention Group 9

Figure 4. Successfuldressing applicationresults, n = 68.

Figure 5. Dressingapplication failures,n = 71.


The Wound,Ostomy andContinenceNurses Society43rd WOCNAnnual Conference

June 4-8, 2011, New Orleans, LA

GENERAL SESSIONS

June 5, 201110:00-11:00 am“The Healing Power of Humor”Stuart Robertshaw, EdD, JD

11:30 am-12:30 pm“Lawsuits, Technology and Wounds:How Electronic Records Change your Practice”Kevin W. Yankowsky, JD

2:15-3:45 pmOral Paper Presentationsincluding “Effects of Just-in-Time EducationIntervention Placed on Wound Dressing Packages”Dea J. Kent, MSN, RN, NP-C, CWOCN

June 6, 20119:15-10:15 am“Preparing for the Future: Professional Opportunitiesfor the WOC Nurse”Janice Colwell, MS, RN, CWOCN, FAAN andLaurie McNichol, MSN, RN, GNP, CWOCN

June 7, 20112:15-3:15 pm“Palliative Care”Jay Horton, ACHPN, FNP-BC, MPH

June 8, 201110:30 -11:30 am“Touch, Tenderness, and Time: From MotherTeresa’s Calcutta to the Modern Bedside”Anne Ryder

All general sessions will be availablevia live webcast Eastern Time.To view, go to http://www.prolibraries.com/-wocns/?select=sessionlist&conferenceID=6

By Dionie Bibat, BSN, RN, WOC NurseIt was a Tuesday morning in late July, and retiredWOCNs Dora andNancy were having breakfast at an outdoor café. They were wait-ing for Sara to join them. The sun was warm, and the two womensipped coffee and reminisced about the past. They first met yearsago at ET school.

Dora, the older of the two, said, “I remember the days when weused Maalox® and heat lamps for wounds. The faster the wounddried the better.”

Nancy, who was the entrepreneur of the group replied, “Yeah, I usedto add sugar to theMaalox, and then do the heat lamp, and the onlything I was really concerned about was to make sure the patientdid not get burned by the heat lamp.”

Sara, the youngest of the group finally arrived and sat to join them.Not missing a beat, she replied, “Gosh, how on earth did you getany wounds to heal with that kind of treatment?” The rest of theconversation progressed to the more modern concepts of woundmanagement.

Research shows that as early as 3000 BC, healers implementedthe importance of nutrition in wound care1 and years later, in 1962,evidence of moist wound healing was documented.2 Despite thegrowing knowledge that healing occurs when proper conditions are

appropriate, such as nutrition, moisture and health of the patient, cli-nicians in the last 26 years were still using treatments such asMaalox and heat lamps for wounds. Fortunately, with more aware-ness, this type of treatment is no longer popular.

Wound healing is multidisciplinary; it is a collaborative approachbetween the patient, nutritionist, wound nurse, physician and otherclinicians. Treatment of wounds not only involves assessing thewound; it must be a holistic approach.

Factors to considerHowdid thewound develop?What is the etiology? An excellentpatient history will help the clinician determine the cause of thewound. There are “typical” characteristics of the most commontypes of wounds, such as pressure ulcers, vascular wounds,(including venous insufficiency and arterial disease) and neuro-pathic/diabetic wounds. In some cases, it may be difficult to deter-mine the origin of the wound, and diagnostic tests are necessary.Consider a biopsy in a wound that is uncharacteristic or has an un-familiar presentation.

Systemic support. The old saying “focus on the whole of thepatient, not the hole in the patient” is so true today. Assess thepatient’s entire system, such as evaluating their nutritional status bytaking a dietary history. Blood work, such as protein levels, pre-albumin and blood glucose levels, may divulge more needed infor-

The Art of WoundManagement


Treatment

34 Healthy Skin

mation.3 Evaluating the circulatory status and blood oxygenationare important factors to address. What medications does thepatient currently take? Look at both prescribed and over-the-counter medications, as well as herbal supplements. Are there otherchronic conditions that could affect the ability to heal? Look formobility issues or impairments that could contribute to mechanicalstressors such as friction, shear and pressure. Supporting thepatient also includes educating the patient and family on the pre-vention, etiology and treatment involved in wound healing.3

Topical treatment of the wound. ”The Five Principles of WoundHealing” uses the acronym WOUND. The key is to understandthese principles of wound healing and to apply them when choos-ing an appropriate topical product.4

W- is the wound healing?

O- optimal moisture

U - understand the periwound skin

N- necrotic or viable tissue

D - depth or dead space

With hundreds of dressings to choose from, new clinicians like Saramay have difficulty finding the appropriate one. To add to the con-fusion, economic factors also play a role in making these decisions.It is extremely important to stay current with the latest trends inwound care. Valuable information is readily available via woundjournals, peer discussions, conferences and education fairs. Hereare a few valuable resources:• Educare Hotline 888-701-SKIN (7546)• Wound Ostomy and Continence Nurses Society

www.wocn.org• National Pressure Ulcer Advisory Panel

(NPUAP), www.npuap.org• Joint Commission on Accreditation of Healthcare

Organizations (Joint Commission) www.jointcommission.org• Wound Healing Society (WHS) www.woundheal.org

About the author

Dionie Bibat BSN, RN, WOC Nurse, is Vice President of ClinicalServices at Medline Industries, Inc. Prior to joining Medline, Dionieworked for a major wound company as a Clinical Resource Specialistand has 14 years experience as a sales representative. As a CWOCNat Evanston Hospital in Evanston, IL, she created and revised protocolsregarding wound and ostomy care. She also developed and headedthe wound team at Evanston and participated in the productscommittee.

References1. Patel GK. The role of nutrition in the management of lower extremity wounds. Int J Low

Extrem Wounds. 2005;4(1):12-22.2. Mulder G. Section Editor's Message: Genomic, Cellular, and Recombinant Technologies

in Tissue Repair. Wounds. 2008. Available at: www.woundsresearch.com/article/2268http://www.woundsresearch.com/article/2268. Accessed May 2, 2011.

3. Bryant RA, Nix DP. Acute & Chronic Wounds Current Management Concepts. 3rd ed.St. Louis, MO: Mosby; 2007.

4. The Wound Care Handbook. 2nd ed. Mundelein, IL: Medline Industries, Inc., 2008.


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Assessmentand

Managementof FungatingWounds

38 Healthy Skin

By Kelli J. Bergstrom,

BSN, RN, ET, CWOCN


AbstractA fungating wound is a malignant lesion that infiltrates the skinand its supporting blood and lymph vessels. They tend todevelop in the last few months of a patient's life, and oftenimpair psychosocial well-being. Fungating wounds presentunique challenges for WOC nursing management, includingprevention or management of bleeding and control of exudateand odor. Our knowledge of the epidemiology, etiology,assessment, and management of these lesions is limited. Thisarticle provides an overview of the epidemiology of fungatingwounds, their assessment and options for management,focusing on local wound management, control of associatedsymptoms, and psychosocial support for patient and family.

IntroductionA cancer diagnosis can be devastating for any patient, espe-cially when complicated by a fungating wound. A fungatingwound can be present for years, but they usually develop in thelast few months of a patient's life. Although fungating woundspose a challenge for patients and caregivers, Clark1 reports thatonly 90 research articles have been published on the topic inthe past 30 years. Approximately 5% of patients with cancerand 10% of those with metastatic disease will develop afungating wound.2,3 Although they can arise from any type ofunderlying malignant tumor, the majority of metastatic cuta-neous lesions arise from primary tumor sites involving thebreast, lungs, skin, and gastrointestinal tract.4 Fungatingwounds require additional research focusing on their etiologyand presentation, physical and social impact, and management,especially as patients approach end of life,5 and WOC nursesshould both initiate and participate in interdisciplinary studiesaddressing these challenging wounds.

Etiology and PresentationA fungating wound, also known as a malignant lesion, isdefined as the infiltration and proliferation of malignant cells into the skin and its supporting blood and lymph vessels.6 It mayevolve from the site of the primary cancerous lesion or from asecondary lesion.7 Fungating malignant wounds may be locallyadvanced, metastatic, or recurrent.8 Metastatic spread tends tooccur along pathways of minimal resistance, such as tissueplanes, blood or lymph vessels of the skin, or through implan-tation of tumor cells through a surgical incision.9 They frequentlyoccur in patients between the ages of 60 and 70 years andoften develop during the last 6 months of life.10 Diagnosis isbased on histological assessment and cultures from thesurface of the wound to confirm the presence of anaerobicorganisms that flourish on the necrotic tissue. If these organ-isms are not accurately identified, inappropriate treatments canlead to the production of by-products that can interact withwound drainage resulting in periwound maceration.7

Fungating wounds have a tendency to expand rapidly, and theyshow a propensity to become locally invasive, or form shallowcraters.7 Initially, they present as multiple nontender nodules thatare skin-toned, pink, violet-blue, or black-brown in color, butthey go on to develop in to papillary lesions (resembling a cau-liflower stalk) that may be complicated by an ulcer, sinus tract,or fistula.8 The most common location for a fungating malignanttumor is the breast; these lesions represent 62% of fungatingwounds. Head and neck lesions account for 24%, the groin,genitals and back account for approximately 3%, and all otherregions account for 8% of all fungating wounds.10 As theselesions expand, they tend to disrupt the local blood supply,resulting in necrosis of the malignant tumor and underlying

Fungatingwounds presentunique challenges,

including prevention ormanagement of bleedingand control of exudate

and odor.

Treatment

tissue. Anaerobic organisms readily grow and proliferate in thiswarm, moist, and oxygen-poor environment. It is the prolifera-tion of these anaerobic organisms that create their characteristicexudate and malodor. Tumor infiltration of the local lymphaticvessels can also affect interstitial tissue drainage resulting inlymphedema of the affected region.7

AssessmentAssessment is an ongoing process due to the progressivenature of the wound, and the evolving condition of thepatient.10 It is necessary for the WOC nurse to take a holisticapproach in assessing the interrelationship between patient andthe wound.7 In addition to assessing local wound factors, theWOC nurse should consider the cause and stage of the under-lying cancer, previous and current treatment, the patient’sunderstanding of the diagnosis, nutritional status, impact of themalignancy and wound on the patient's and caregivers’ psy-chosocial status and quality of life. Assessment should alsoevaluate availability of resources and social support networks.9

Local wound assessment includes evaluation of its location,dimensions, depth, percentage of devitalized tissue, degree oftissue adherence of the wound surface, volume and character-istics of exudate, odor, history of bleeding, quality and intensityof pain, signs of fistula or sinus formation, and condition of theperiwound skin.9 Assessment data are then used to develop amanagement plan, taking care to ensure that the plannedinterventions are consistent with the patient's goals and priori-ties and do not adversely interact with other components of themanagement plan.7

TreatmentThe management goals of a fungating tumor vary, depending onthe stage of the underlying cancer, the patient's prognosis, andthe individual's own goals and wishes. In some cases, the goalis to arrest tumor growth. In these cases, a multidisciplinaryapproach is required that may include radiotherapy, chemother-apy, surgery, hormone manipulation, neutron therapy, and lowintensity laser therapy.10 In other situations fungating tumorsoccur at the end of life, and treatment is completed in a pallia-tive care setting that focuses on comfort and maintenance ofthe best possible quality of life for the patient and family.11 Ineither case, it is important to remember that the symptoms pro-duced by a fungating wound are often as distressing as thewound itself. Therefore, management focuses on alleviation ofbothersome symptoms including pain, cutaneous irritation,exudate, bleeding, odor, and psychosocial support, regardlessof whether treatment is delivered in a palliative or aggressivecare context.

PainPain is a subjective symptom impacted by the underlying con-dition, the wound itself, and dressing changes.10 Assessmentincludes location, nature, duration, onset, frequency, intensity,impact on activities of daily living, aggravating and alleviatingfactors, current analgesia use, and effects of treatment. Stan-dardized pain scales are used to assess intensity. Evaluationshould also differentiate nociceptive pain (caused by stimula-tion of nerve endings when provoked by inflammatory media-tors) from neuropathic pain (caused by nerve damage anddysfunction) because treatment differs depending on the type ofpain. Analgesics, including opioids and nonopioid agents, areused for nociceptive pain, while adjuvant agents, such asamitriptyline and carbamazepine, are more effective for neuro-pathic pain. Analgesics and adjuvant agents may be prescribedseparately or concurrently to achieve a combined effect.According to recent case studies, topical opioids applied to thewound surface can provide immediate local analgesia and workindirectly to diminish the inflammatory process.10,12 When man-aging pain associated with dressing changes, several interven-tions may be implemented, such as a “booster” dose ofanalgesia prior to dressing changes, use of nonadherent softsilicone dressings, gentle care techniques, and reducedfrequency of dressing changes.

40 Healthy SkinContinued on page 42

Assessment is an ongoing process due tothe progressive nature of the wound, andthe evolving condition of the patient.10

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42 Healthy Skin

Periwound Skin IrritationPatients with fungating wounds often experience a creeping,intense itching sensation attributed to the activity of the tumor.Because of its invasiveness, the tumor causes severe damageto the patient's peripheral nerve supply, which is responsible fortransmitting pruritic sensations. Typical inflammatory mediatorsare not involved; therefore, intense itching is normally notresponsive to traditional antihistamines. Alternative options fortreatment include cancer specific hormone therapy, chemother-apy, tricyclic antidepressants, or Transcutaneous ElectricalNerve Stimulation.13

ExudateFungating wounds may produce large amounts of exudateresulting in discomfort and embarrassment for the patient.Exudate also may lead to periwound maceration, increasing therisk of infection.10 Several types of dressings may be used tomanage high-volume exudate, and WOC nurses are a valuableresource when selecting an appropriate dressing. The optimaldressing should be nonadherent to the tumor to reduce painand trauma associated with dressing changes. It should effec-tively absorb exudate and toxins while maintaining a moist sur-face that supports autolytic debridement of necrotic tissue. Ifthe wound is friable and bleeds easily, a dressing with hemo-static properties is beneficial. Control of odor and restoration ofbody symmetry and cosmetic acceptability with the use of lessbulky dressings are also important principles to consider for thepatient's self-image.7 The categories of dressings normally rec-ommended include activated charcoal dressings for odor con-trol, alginates for bleeding wounds, foam/hydropolymerdressings for exuding wounds, hydrocolloid sheets for lightlyexuding wounds or protection of surrounding skin, hydrofiberdressings for heavily exuding wounds, and semipermeable filmmembranes for protection of intact skin. If the volume of woundexudate is too high even for highly absorbent dressings andrequires more than 2 to 3 dressing changes per day, a woundmanager pouchmay be necessary to collect drainage and protectsurrounding skin.9 Ointment based skin protectants or liquidpolymer acrylate barrier films should be considered for patientswith exudate that compromises intact skin.10

Not only is the selection of the most effective dressing a chal-lenge; determining the best way to secure the dressing is oftendifficult. Some dressings are self-adhesive, but most require aseparate product. Depending on the location and size of thewound, traditional adhesives, such as a tape, may not beappropriate. In addition, the patient may be more vulnerable to

skin tears and breakdown due to the underlying malignancy andits impact on nutritional status. In some cases, standard adhe-sive products may potentiate problems and a cling dressingwrap or a tubular net bandage may be used to secure dressingswithout resorting to an adhesive secondary cover.

BleedingBecause blood vessels can be disrupted by the infiltration oftumor cells, bleeding at the wound site is common in patientswith fungating wounds.10 There are several treatment optionsto control spontaneous bleeding, including oral antifibrinolytics,such as tranexamic acid, and radiotherapy.8 In situations wherethe bleeding is associated with dressing changes, interventionsto prevent bleeding include gentle technique for application andremoval of dressings, maintaining a moist wound and dressinginterface, gentle cleansing techniques, and use of nonfibrous,nonadherent dressing materials. Certain dressings, such as cal-cium alginates, have hemostatic properties that exchangesodium ions for calcium ions, promoting the clotting cascadewithin the wound bed.5 It is important for the WOC nurse tomonitor the patient's hemoglobin levels because if the patientbecomes anemic, a blood transfusion or iron tablets may berequired.10

OdorThe presence and severity of odor is subjective and influencedby multiple factors such as the patient's ability to perceive odor,along with the perceptions of caregivers and family members.14

This symptom can be one of the most devastating aspects ofa fungating wound.15 As noted previously, wound odor isassociated with necrotic tissue that supports the growth ofanaerobic bacteria, and the presence of volatile fatty acids inthe wound. Stagnant exudate, infection, and fistula formationare also contributing factors.1

Treatment for odor encompasses multiple aspects of woundcare. Systemic antibiotics may be appropriate if there is evi-dence of clinical infection. However, excessive use of antimi-crobial agents should be avoided because it can lead toovergrowth of resistant organisms such as methicillin-resistantStaphylococcus aureus and vancomycin-resistant enterococcus,and some antibiotics increase the risk of nausea and vomiting.10

Metronidazole has been evaluated for use as a topical agent forreducing wound odor.16 It is a synthetic antimicrobial drug,which works against anaerobic bacteria and protozoa; however,it can take up to 2 to 3 days before odor is reduced.15 The


wound should be cleansed with normal saline and the metron-idazole applied liberally and covered with a secondary dress-ing. For heavily exudative wounds, consider the use of crushedmetronidazole tablets sprinkled over the wound surface andcovered with a petroleum-jelly-coated dressing. For drywounds, the gel form of metronidazole is more appropriate.17

Metronidazole should not be used in conjunction with any othertopical creams, gels, or ointments because its effectiveness andantimicrobial activity could be potentially diluted.7 Although ithas been shown to be effective in many odorous wounds, it isineffective in wounds that are too moist or dry.15

Charcoal dressings also may be used to alleviate odor. Becausethe molecules that are responsible for the malodor are attractedto the carbon surface, the activated charcoal dressing acts asa filter to absorb these molecules, preventing them from beingreleased into the air.14 In order to be effective, a charcoal dress-ing must be fitted as a sealed unit directly on to the wound.10

There are limitations for application on charcoal dressings in fun-gating wounds because the dressing is effective only in woundsthat produce minimal exudate.15 Silver dressings may alsoreduce wound odor because of its antimicrobial effect againsta wide range of organisms including methicillin-resistant Staphy-lococcus aureus and vancomycin-resistant enterococcus, thusinhibiting bacterial growth and preventing colonization; however,they tend to be expensive especially when frequent dressingchanges are needed.14

Alternative topical agents sometimes used to control odorinclude sugar paste, medical honey, and yogurt.15 There are

several controlled trials and case studies supporting the bene-fits of sugar paste and honey in wound care,16 but the evidencefor yogurt is limited to anecdotal reports. Because sugar pasteis not commercially available in the United States, a specificcombination of caster sugar, icing sugar, polyethylene glycol,and hydrogen peroxide is recommended in the literature. Thispaste is prepared in both thick and thin consistencies in thehospital pharmacy and stored in a screw-top plastic containerfor up to 6 months. The table shows the formula for sugarpaste.18 Sugar paste has the ability to absorb fluid due to itshigh osmolality, thereby starving bacteria of fluid and inhibitingtheir growth. On contact with the wound, sugar paste liquefies,and prevents dehydration of normal cells. It also enablessloughing of necrotic cells and promotes granulation tissue for-mation.19 Some studies have shown it to be effective againstStaphylococcus aureus, Streptococcus faecalis, Escherichiacoli, and Candida albicans.18 Although it can be useful forpatients with fungating wounds, the effect wears off over timeso it is necessary to apply a thick layer to the surface of thewound and secure with a petroleum-jelly-coated dressing twiceor more a day.15,19

Honey has been used as a dressing since ancient times, butdue to the emergence of antibiotic-resistant strains of microor-ganisms, there is an increased interest in its wound healingproperties. Medical grade honey derived from the Leptosper-mum species found in the manuka flower of Australia and NewZealand, inhibits bacterial growth in several ways, including itsacidic pH, which prevents biofilm formation, the slow release ofhydrogen peroxide, which is toxic to microbes, and highosmolality, which inhibits bacterial growth.20 Honey also acts asa debriding agent with several mechanisms of action. Itencourages autolytic debridement due to its strong osmoticaction of pulling fluid from the wound and washing the base toremove debris and slough.21 The production of hydrogen per-oxide contributes to debridement by activating proteases tobreakdown unwanted tissue.20 Odor control is attributed toinhibition of bacterial growth and removal of necrotic tissue fromthe wound base.21 However, topical honey may be difficult toapply and requires the use of an absorbant secondary dressing.Therefore, it may not be an option for wounds that are toomoist. Advances in technology have provided several forms ofhoney-impregnated dressings, including alginates and hydro-colloids that may be more effective in the management of fun-gating wounds. These dressings received US Federal DrugAdministration approval in 2007 and are manufactured throughMedihoney, Derma Sciences, Canada.20

Because blood vesselscan be disrupted by theinfiltration of tumor cells,bleeding at the wound siteis common in patients withfungating wounds

44 Healthy Skin

other studies could be found to support its use. Maggots arehighly effective in debriding necrotic tissue and removing bac-teria through ingestion; however, there is a great potential forbleeding and patient acceptance may be difficult.5

Psychosocial SupportFungating wounds are an ongoing reminder of the underlyingdisease that frequently provoke a wide range of negative emo-tions such as guilt, shame, confusion, frustration, loss of power,and denial.25 Fungating wounds are often disfiguring and mal-odorous, which can profoundly impair a patient's self-image.26

Because the location, appearance, and odor of a wound maybe a source of embarrassment and distress for both the patientand family, all are at risk for social isolation, depression, dimin-ished sexual expression, and difficulty maintaining relationshipswith family and friends.27 The WOC nurse should evaluate theindividual's coping mechanisms and social support networksto determine the impact of the wound on psychosocial statusand social support networks.28 Patients and families affectedby fungating wounds may require additional support and coun-seling from psychologists, social workers, bereavement coun-selors, as well as hospice and other professionals. Patients andfamily members should play an active role in determining woundcare, and treatments should be chosen to minimize thewound's impact on the patient and family, provide adequatecontrol of symptoms, and allow for the potential of intimacy. Thetreatment plan should also provide comfort as well asindependence.29

ConclusionFungating wounds are a devastating complication of malignan-cies. WOC nurses should take an active role in assessment andmanagement of the fungating malignant wound, focusing onmanagement of distressing symptoms such as pain, excessiveexudate, odor, and bleeding. The WOC nurse is ideally suited tomake recommendations for care, assure that appropriate inter-ventions are being carried out, provide education to the patientand caregivers, and offer solutions to existing and future prob-lems. The WOC nurse should also act as an advocate forpatients with fungating wounds by providing support andencouragement, and helping assist the patient to maintain dignityand maximize comfort during the end of life. WOC nursesshould generate and participate in further research aboutfungating wounds, including the search for the most effectivemethods for controlling odor and exudate.

Yogurt has also been used to control odor in fungating wounds.Evidence is insufficient to confirm or refute its efficacy, but clin-ical experience and anecdotal reports in the literature suggestit is effective in some cases.9 Most manufactured yogurts con-tain the active culture, lactobacillus, which produces lactic acidlowering the pH in the wound bed and inhibiting growth of odor-producing organisms.22 At least 1 newer yogurt preparation alsocontains Bifidobacterium culture; it is described as helping reg-ulate the digestive tract, and its effect on malodorous fungatingwounds is not known. Room temperature plain yogurt shouldbe applied to the wound surface and covered with a petro-leum-jelly-coated dressing.23 Treatment should be repeated 4times a day for 2 to 3 days until odor is resolved.

Aromatherapy is another option for odor management. Essen-tial oils of lavender, lemon, citrus, or tea can be used on thebandage or secondary dressing, but not directly on the woundbed itself. Scented candles and burning oils, as well as kitty lit-ter and coffee grounds placed throughout the patient's homemay help to mask the odor.15 Frequent dressing changes andproper disposal of waste products is also recommended sincesaturated dressings can harbor odor.5

Debridement is useful in fungating wounds with large amountsof necrotic tissue. Sharp wound debridement is contraindicatedbecause of the risk for potential bleeding and malignant cellseeding. Autolytic debridement is preferred because it avoidsthe risk for bleeding and it can be promoted with any dressingregimen that maintains a moist wound surface. Autolytic de-bridement may occur naturally where devitalized tissue eventu-ally separates on its own.14 Larval therapy has been suggestedfor use in fungating wounds by Thomas and colleagues24 but no

Aromatherapy is another optionfor odor management.


Key Points• As a WOC nurse, it is necessary to understand the etiologyand presentation of fungating wounds so that they canbe accurately assessed and managed.

• Management of fungating wounds focuses on controllingpain, cutaneous irritation, exudate, bleeding, odor, andpsychosocial issues.

• There is a need for further research by WOC nurses so thatpatients can be managed more effectively.

Correspondence: Kelli J. Bergstrom, BSN, RN, ET, CWOCN,The James Cancer Hospital and Solove Research Institute,300 W 10th St, Starling Loving Hall Rm M200, Columbus,OH 43210 ([email protected]).

References1. Clark J. Metronidazole gel in managing malodorous fungating wounds.

Br J Nurs. 2002; 11(6):54–60.2. Lookingbill DP, Spangler N, Helm KF. Cutaneous metastases in patients with

metastatic carcinoma: a retrospective study of 4020 patients. J Am AcadDermatol. 1993; 29:228–236.

3. Lookingbill DP, Spangler N, Sexton FM. Skin involvement as the presenting signof internal carcinoma. J Am Acad Dermatol. 1990; 22:19–26.

4. Seaman S. Management of fungating wounds in advanced cancer. Semin OncolNurs. 2006; 22(3):185–193.

5. Hampton S. Managing symptoms of fungating wounds. J Community Nurs.2004; 18(10):20–28.

6. Grocott P. Palliative management of fungating wounds. J Wound Care. 1995;4(5):240–242.

7. Collier M. Management of patients with fungating wounds. Nurs Stand. 2000;15(11):46–52.

8. Grocott P. Care of patients with fungating malignant wounds. Nurs Stand. 2007;21(24):57–58, 60, 62.

9. Wilson V. Assessment and management of fungating wounds: a review. Br JCommunity Nurs. 2005; 10(3):S28–S34.

10. Dowsett C. Malignant fungating wounds: assessment and management.Br J Community Nurs. 2002; 7(8):394–400.

11. Burns J, Stephens M. Palliative wound management: the use of a glycerinehydrogel. Br J Nurs. 2003; 12(6):S14–S18.

12. Krajnik M, Zbigniew Z, Finlay I, Luczak J, Van Sorge AA. Potential uses of topicalopioids in palliative care- report of 6 cases. Int Assoc Stud Pain. 1999; 80(1-2):121–125.

13. Grocott P. The Palliative Management of Fungating Malignant Wounds. Paperpresented at the meeting hosted by SAWMA and ASTN at the Queen ElizabethHospital; 2003.

14. Draper C. The management of malodor and exudate in fungating wounds.Br J Nurs. 2005; 14(11):S4–S12.

15. Nazarko L. Malignant fungating wounds. Nurs Res Care. 2006; 8(9):402–406.16. Adderley UJ, Smith R. Topical agents and dressings for fungating wounds.

Cochrane Database Syst Rev. 2007;(2):CD003948. DOI:10.1002(14651858.CD003948.pub2.17. Bauer C, Geriach MA, Doughty D. Care of metastatic skin lesions. J Wound,Ostomy, Continence Nurs. 2000; 27(4):247–251.

18. Tanner AG, Owen ERTC, Seal DV. Successful treatment of chronically infectedwounds with sugar paste. Eur J Clin Microbiol Infect Dis. 1988; 7:524–525.

19. Newton H. Using sugar paste to heal postoperative wounds. Nurs Times. 2000;96(36):15–16.

20. Pieper B. Honey-based dressings and wound care: an option for care in the UnitedStates. J Wound, Ostomy, Continence Nurs. 2009; 36(1):60–68.

21. Blair SE, Coccetin NN, Harry EJ, Carter DA. The unusual antibacterial activity ofmedical-grade leptospermum honey: antibacterial spectrum, resistance andtranscriptome analysis. Eur J Clin Microbiol Infect Dis. 2009; 28(10):1199–1208.

22. Gribbons CA, Aliapoulios MA. Treatment for advanced breast carcinoma. Am J Nurs.1972; 72(4):678–682.

23. Welch LB. Simple new remedy for the odor of open lesions. RN. 1981; 44(2):42–43.24. Jones M, Andrews A, Thomas S. A case history describing the use of sterile larvae

(maggots) in a malignant wound. World Wide Wounds [serial online]. February 14,1998; Available from: CINAHL Plus with Full Text.

25. Lund-Nielsen B, Muller K, Adamsen L. Malignant wounds in women with breast cancer:feminine and sexual perspectives. J Clin Nurs. 2005; 14:56–64.

26. Lo SF, Hu WY, Hayter M, Chang SC, Hsu MY, Wu LY. Experiences of living with amalignant fungating wound: a qualitative study. J Clin Nurs. 2008; 17(20):2699–2708.

27. McDonald A, Lesage P. Palliative management of pressure ulcers and malignant woundsin patients with advanced illness. J Palliat Med. 2006; 9(2):285–295.

28. Laverty D. Fungating wounds: informing practice through knowledge/theory. Br J Nurs.2003; 12(15):S29–S40.

29. Kirsner R. Malignant wounds. Wound healing perspectives: a clinical pathway tosuccess. 2007;4(1):1–8.

Printed with permission from the Journal of Wound, Ostomy & Continence Nursing.January/February 2011; 38(1):31–37.

Medline’s Pressure Ulcer Prevention Program now has acomponent designed specifically for the perioperative services.The easy-to-use interactive CD addresses the following:

• Hospital-acquired conditions• CMS reimbursement changes• Best practices for pressure ulcer prevention• Perioperative assessment tools• Critical patient and equipment risk factors

MORE IMPORTANT THAN EVER BEFORE

PerioperativePressure UlcerEducation

©2011 Medline Industries, Inc.Medline is a registered trademark of Medline Industries, Inc.


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They’re lurking in ...

Remember the old riddle, “Where do most pressure ulcersoccur?” The answer is — in the ambulance!

Well, the truth is pressure ulcers do occur in the ambulance — and lots of other places youmight not even think about, including the operating room (OR). In fact, the pressure ulcerincidence rate as a result of surgery may be as high as 66 percent1 and 42 percent of allhospital-acquired pressure ulcers are occurring in surgical patients.2

Here are some more daunting facts:• 37 percent of patients undergoing head or neck surgery develop sacral ulcers3

• Cardiac, general vascular and open heart surgeries have a high incidence of occiputand heel ulcers

• 72 percent of perioperative pressure ulcers occur on heels4

The following types of surgical patients are at greater riskfor pressure ulcers:• Neonates• Elderly• Malnourished• Morbidly obese• Patients with chronic diseases• Patients with existing pressure ulcers

by Cynthia A. Fleck, RN, BSN, MBA,ET/WOCN, CWS, DWC, CFCN

Prevention

The Operating Room

and Beyond!


48 Healthy Skin

Perioperative risk factors forpressure ulcer developmentCertain conditions specific to the surgical experience canalso contribute to the risk of pressure ulcers. Some ofthese conditions include blood volume loss, temperature,time and moisture.

Blood volume loss. Blood volume loss and shunting canincrease the hazard of pressure ulcers and lack of bloodflow to the lower extremities.5,6

Temperature. Another consideration is the cold OR envi-ronment. The body will likely shunt blood away from theskin into the trunk of the body to protect the vital organs,which can be dangerous to the skin. The use of warmingblankets tends to occur in lengthy procedures. These canbe helpful to prevent cooling of the body, which can con-tribute to pressure ulcers, however, the blanket should becovered with a sheet.

Time. Increased time in the OR is associated withincreased pressure ulcer development as well.7 Surgerieslasting between three and four hours had pressure ulcerincidence rates of 5.8 percent; seven or more hours hadincident rates of 13.3 percent,8 and there is a significantincrease in pressure ulcer incidence for operations lastinglonger than eight hours.9

Moisture. We all know moisture can wreak havoc on theskin and predispose individuals to pressure ulcers, so it isrecommended that pooling of any fluid or blood be moni-tored intraoperatively. It is suggested that the OR surfacehave minimal linens or layering. There are also novel ORproducts available (modern-day “chux” that are superabsorbent) that can actually absorb large volumes of fluidand remain dry to the touch, thus protecting the patient’s skin.

Evaluating surgical surfacesAlways remember that no matter where a patient’s bodyresides, pressure ulcers can develop rapidly. OR surfacesshould be evaluated before each case, and the Associationof periOperative Registered Nurses (AORN) guidelinesrecommend using pressure redistribution surfaces forsurgeries lasting longer than two-and-a-half hours.

In fact, I recently had foot surgery, and my surgeon origi-nally thought it would last only a couple of hours. Lo andbehold, it lasted three hours and 45 minutes, and althoughI am a fairly young, well-nourished and healthy individual,I succumbed to a Stage II perioperative pressure ulcer. The

Perioperative tips for avoiding pressure ulcers• Assure that the OR table or surface is of

sufficient size to support the patient –especially important for obese patients whosebodies may be larger than the average sizeOR surface

• Lift – do not drag – the patient from surfaceto surface.

• Monitor pressure points when possible during“time outs”

Post-operative considerations for avoidingpressure ulcers

• Be aware of a possible delay in visualizationdue to bandages and other monitoringequipment

• Prolonged immobility or confinement to a bedor chair increases pressure ulcer risk10


lesson to be learned: because there is no guarantee howlong a surgery will take, a pressure redistribution surfaceshould be available in every operating room.

There are high-quality surfaces that self-adjust (Figure 1),provide a stable environment for the surgeon and OR staffto work and conform to the patient’s body. Some of thesesurfaces contain the same type of visco or viscoelasticmemory foam many of us sleep on in our own bedrooms.When evaluating various surfaces, ask the vendor aboutthe warranty, weight limits, cleaning instructions and com-parative data such as pressure mapping. This will help youmake an educated decision regarding your purchase.

Important steps to take after surgeryAt the hand-off to the post-anesthesia care unit (PACU) itis advisable to:• Clean and dry the patient’s skin• Conduct a post-op skin assessment, noting:

- Skin irritation- Discoloration- Bruising- Swelling

• Provide a thorough report including:- Results of pre-surgery risk factors and potential

new risks that developed during surgery- Results and skin assessment performed before,

during and after surgery- How long the surgery lasted

Pressure ulcer risk in ancillary servicesThere is also high risk for pressure ulcers in ancillaryservices:• Radiology• Renal dialysis• Cardiac and vascular procedure laboratories

The problem is that until awareness is increased, we willcontinue doing what we always did, and patients will con-tinue to develop pressure ulcers.

Patients undergoing lengthy radiology procedures have a53.8 percent incidence of pressure ulcers. Emergencydepartments are another area of risk, with 40 percent ofpatients admitted through the emergency department atrisk for pressure ulcer development.11

The average emergency department patient waits six toeight hours lying on a stretcher that usually consists of twoto three inches of open-celled foam and an uncomfortablenon-conformable cover that can contribute to the devel-opment of pressure ulcers.

This is especially important now that acute care facilitiesare financially responsible for acquired pressure ulcers –which can be quite costly. Many hospitals have instituteda comprehensive program to prevent pressure ulcersacross the continuum, including the OR, ED and ancillaryareas. Introducing a tool kit on average can reduce a facility’s

Figure 1

AORN guidelines recommend usingpressure redistribution surfaces forsurgeries lasting longer than 21/2 hours.

50 Healthy Skin

pressure ulcers by 70 percent while substantially increas-ing the knowledge of licensed staff and nurse assistants.12

Take your knowledge and pass it onConsider sharing this article with the emergency depart-ment, ancillary areas such as the cath lab, dialysis andother high-risk area personnel, and of course with theambulance companies where your patients could be atrisk. If you are on a skin care committee, get the othermembers involved, as these care areas present jeopardy thatcan be easily mitigated.

When we ask ourselves the age-old question of whereall the pressure ulcers are occurring, now we have moreammunition to fight the battle. And yes, the ambulance,with its tiny vinyl-covered two-inch, foam mattress maybe part of the problem. The good news is that we haveanswers and products that can make positive changehappen.

About the author

Cynthia Ann Fleck, RN, BSN, MBA,CWS, DNC, CFCN is a certified wound spe-cialist, dermatology advanced practicenurse, certified foot and nail care nurse,writer, speaker, a past president and chair-man of the board for the American Acad-emy of Wound Management (AAWM), pastdirector for the Association for the Ad-

vancement of Wound Care (AAWC), and Vice President, ClinicalMarketing for Medline Industries, Inc. Cynthia can be reached [email protected].

References1. Recommended practices for positioning the patient in the perioperative

practice setting. In: Perioperative Standards and Recommended Practices.Denver, CO: AORN, Inc; 2010.

2. Beckrich K, Aronovitch SA. Hospital-acquired pressure ulcers: a comparisonof costs in medical vs. surgical patients. Nursing Economics. 1999;17(5):263-271

3. Recommended practices for positioning the patient in the perioperativepractice setting. In: Perioperative Standards and Recommended Practices.Denver, CO: AORN, Inc; 2010.

4. Recommended practices for positioning the patient in the perioperativepractice setting. In: Perioperative Standards and Recommended Practices.Denver, CO: AORN, Inc; 2010.

5. Keller C. The obese patient as a surgical risk. Seminars in PerioperativeNursing. 1999; 8(3):109-117.

6. McEwen DR. Intraoperative positioning of surgical patients. AORN Journal.1996; 63(6):1058-1063, 1066-1075, 1077-1082.

7. Papantonio C, Wallop J, Koldner K. Sacral ulcers following cardiac surgery:incidence and risks. Adv in Wound Care. 1994;7(2):24-36.

8. Aronovitch S. Intraoperatively acquired pressure ulcer prevalence: a nationalstudy. J Wound Ostomy Continence Nursing. 1999;26(3):130-136.

9. Ratliff C, Rodeheaver G. Prospective study of the incidence of OR-inducedpressure ulcers in elderly patients undergoing lengthy surgical procedures.Adv Skin Wound Care. 1998;11(suppl 3):10.

10. Allman RM, Goode PS, Burst N, Bartolluci AA, Thomas DR. Pressure ulcerhospital complications and disease severity: impact on hospital costs andlength of stay. Advances in Skin & Wound Care, 1999;12(1):22-30.

11. Tarpey A, Gould D, Fox C, Davies P, Cocking M. Evaluating support surfacesfor patients in transit through the accident and emergency department.J Clin Nurs. 2000;9(2):189-198.

12. Armstrong DG, Ayello EA, Capitulo KL, Fowler E, Krasner DL, Levine JM, etal. New opportunities to improve pressure ulcer prevention and treatment:implications of the CMS inpatient hospital care present on admission (POA)indicators/hospital-acquired conditions policy. J Wound Ostomy ContinenceNurs. 2008. 35(5):485-492.


ERASE CAUTI®

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52 Healthy Skin

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Urinary tract infections (UTIs) are the most common HAIs;80 percent of these infections are attributable to anindwelling urethral catheter.1 The ERASE CAUTI Foleycatheter management system helps providers reduce therisk of infection by combining evidence-based principles andtraining with an innovative one-layer tray design.

Arkansas Methodist Medical CenterClinicians at Arkansas Methodist Medical Center (AMMC), oneof the first hospitals to implement the ERASE CAUTI system,are using the program to change the way they assess andperform urinary catheter insertions. Since implementing theprogram a year ago, the Paragould, Ark., hospital has seen a21 percent reduction in catheterizations and CAUTIs.

Medline’s ERASE CAUTI Foley catheter management system, featuring a revolutionaryone-layer tray design, is helping hospitals “Get to Zero” – reducing hospital-acquired infections(HAIs) through improved education about evidence-based practices. Launched just 18 monthsago, the ERASE CAUTI program is used by more than 250 hospitals across the country,helping to significantly reduce the risk of catheter-associated urinary tract infections (CAUTIs)and cut Foley catheter use and related costs by an average of 20 percent.

ERASE CAUTI Program HelpsHospitals Reduce Catheter

Use by 20 PercentRevolutionary Foley Catheter Tray

Education Helps Improve Patient Safety

"The one-layer tray design is labeled in a specific sequencethat helps guide our nurses during the catheterizationprocess to adhere to current CDC recommendations,including aseptic technique," said Lisa Bridges, RN, infec-tion preventionist for AMMC. "To help us reduce catheteri-zations, we are requiring our entire nursing staff to take theprogram education on the alternatives to catheterization.Plus, the new tray has a checklist to help the nurse make adecision on whether catheterization is appropriate for thepatient and to assure the education transfers into everydayclinical practice."

As measured by the number of catheterizations performed inMarch and April 2009 versus the same time in period in


Prevention

54 Healthy Skin

2010, AMMC reduced the number of catheterizations from192 to 151, a 21 percent drop (based on adjusted patientday). This decrease contributed to the hospital achievingzero CAUTIs in April 2010, compared to three in April 2009,according to Bridges.

Another leading factor causing CAUTI is leaving a catheter inplace for more than two days after surgery.2 The SurgicalCare Improvement Project (SCIP) recommends removal ofcatheters within 24-48 hours post-operatively. In the firstquarter of 2009, only 20 percent of the catheters AMMCplaced in the O.R. were being removed within two days. Withthe implementation of the ERASE CAUTI program, theremoval rate increased to 50 percent in the first quarterof 2010.

"With the Foley InserTag and checklist sticker placed on thepatient's chart, nurses and physicians knew exactly whenthe catheters had been placed," said Bridges, "and wereable to remove them in the necessary 24-48 hoursafter surgery."

Also, included in the tray is a patient education care card thatlooks like an actual get well card. According to Bridges, thecard is a more effective way to educate patients about theprocedure, including the risks and complications associatedwith closed system Foley catheters.

"Before, we had to print our education from the computer,and it was not something the patient or the clinician normally

took time to review," said Bridges. "The patient care cardhas significantly improved our ability to provide patients andfamilies with a tool to help them better understand the propercare and maintenance of the catheter, signs and symptomsof CAUTI and how they can help reduce the chances ofdeveloping CAUTI."

Floyd Medical CenterTo help reduce its CAUTI rates, Georgia-based Floyd Med-ical Center is utilizing the innovative tray, along with facility-wide physician and nurse education on the appropriate useof catheters and the importance of avoiding catheters whennot medically necessary. The initiative has led to an 83 per-cent reduction in CAUTIs and a 23 percent decline in thenumber of catheterizations performed at the hospital. Inrecognition of its accomplishments, the 304-bed non-profitteaching hospital in Athens, GA., earned first place in VHAGeorgia’s 2010 Clinical Excellence award category.

“We forged a hospital-wide initiative focused on reducingcatheter use and related urinary tract infections,” said DarrellDean, D.O., M.P.H., medical director for clinical and operationalperformance improvement at Floyd Medical Center. “TheMedline tray has many design elements and productenhancements that were integral in our program to reducevariation in practice and achieve our goal of reducingCAUTI.”

Dr. Dean cited the kit’s larger sterile barrier drape and one-layertray design (versus the industry standard two-layer tray) asimportant factors to helping the nursing staff maintain aseptictechnique. He also pointed to the tray’s checklists as vitaltools to CAUTI prevention – one that helps document a validclinical reason for inserting a catheter and another thatreviews the proper steps to catheter insertion. Uponcompletion, the checklists are then added to the patient’schart for proper documentation of insertion.

Unity HospitalUnity Hospital, a 340-bed nonprofit facility in Rochester, NewYork, is experiencing similar results with the ERASE CAUTIprogram. According to data from the hospital, the facilityreduced its urine nosocomial infection markers (NIMs) 32

“To help us reducecatheterizations, weare requiring our entirenursing staff to takethe program educationon the alternativesto catheterization.


“ “

We forged a hospital-wide initiative focusedon reducing catheteruse and related urinarytract infections...

percent in August 2010 compared to the same time periodin 2009. The associated cost for each urine NIM marker is$3,637, which demonstrates a significant cost-avoidancefollowing the introduction of the ERASE CAUTI program,according to Unity Hospital. Urine NIMs are an electronicmarker that uses sophisticated algorithms to analyze existingmicrobiology laboratory and patient census data to identifyhospital-acquired infections.

Although we had a low CAUTI rate in 2009, after imple-menting the ERASE CAUTI program, rates continue to trenddownward,” said Erica Perez, Unity’s clinical educator. “Theprogram ties in education, nursing power and a new indus-try product that promotes best processes by reinforcing theCDC guidelines to decrease the opportunity for a CAUTI todevelop.”

According to Perez, the hospital began using the ERASECAUTI program because it identified gaps in standardizationand knowledge regarding the proper insertion technique andclinical indications for using a Foley catheter.

“The Medline program offered the tools to reduce the incon-sistencies we observed in the technique nurses used toinsert catheters due to differing protocols at previous facili-ties where nurses have practiced, variance in how nurseswere initially taught the procedure and different types of Foleytrays nurses have used in the past," Perez said.

Perez emphasized that Medline’s one-layer tray presents theprocedure components in an intuitive manner, guiding thenurse through the procedure from left to right. The innovativetray also makes it easier to maintain aseptic technique sinceall the components are in one tray versus the traditionaltwo layers.

The hospital staff also took advantage of the program’sonline education, which reinforced aseptic technique throughlearning modules and an interactive competency tool theclinicians used to demonstrate knowledge of proper Foleyinsertion technique. To date, more than 500 nurses at Unityhave completed the education classes via Medline’s e-learn-ing site Medline University – www.medlineuniversity.com.These online modules have been added to the hospital’sclinical orientation as a mandatory core competency for newnursing staff.

Following a successful trial period last summer, the programwas rolled out facility-wide to all acute care units in August2010.

“The implementation of the ERASE CAUTI program hashelped us improve the standard of care for patients receiv-ing a Foley catheter and has reduced the risk of CAUTI,” saidPerez. “The reduction in urine NIMs indicates fewer patientsmay be at risk for developing a CAUTI.”

References1 Lo E, Nicolle L, Classen D, Arias A, Podgorny K, Anderson DJ, et al. SHEA/IDSApractice recommendation: strategies to prevent catheter-associated urinary tractinfections in acute care hospitals. Infect Control Hosp Epidemiol. 2008;29:S41–S50.

2Wald HL, Ma A, Bratzler DW, Kramer AM. Indwelling urinary catheter use in thepostoperative period: analysis of the national surgical infection prevent project data.Arch Surg. 2008; 143:551-557.

What did we do afterdesigning a revolutionarynew catheter tray system?

We found THREE more waysto make it even better.

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

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



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A checklist that fits betterin the medical recordThe reformatted checklist is smaller, makingit easier to place in the paper chart orattach to the electronic medical record.

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

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

SAFER CATHETERIZATIONFOR KIDS

Sometimes, you just need a buddy. Buddythe Brave lion cub is here to help your youngestcatheter patients. Along with some serious patient(and parent) education resources, you’ll find someupbeat fun and even a bravery award sticker inevery tray.

But it’s more than just fun. There’s published evidencethat distraction helps children tolerate unpleasantprocedures better than adult reassurance does.

You trust Medline for clinical innovations, such as ourindustry-leading catheter tray design. Now, we can beyour patient’s buddy, too.

Introducing Medline’s newPediatric Catheter Tray. Thelatest addition to the innovativeERASE CAUTI product line.

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“

Visit www.medlineuniversity.com for24 nursing home administrator courses.

Topics include:• QIS• Diabetes• Infection Control• Pressure Ulcer Prevention• Spend Management• Wound and Skin Care

©2011 Medline Industries, Inc.Medline and Medline University are registeredtrademarks of Medline Industries, Inc.

50 FREE NAB-approvedcredits now available atMedline University.

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A Guide toMDS 3.0 Section H

by Amin Setoodeh, BSN, RN

Objectives:• List the changes in section H from MDS 2.0 to 3.0• State the intent of section H• Describe how to conduct the assessment for urinaryincontinence

• Describe how to conduct the assessment for bowelincontinence

Now that facilities across the U.S. have put the first six monthsof the transition from MDS 2.0 to MDS 3.0 behind them, it maybe time to evaluate systems for what is working or what mightneed improvement. Although we may use the word “coding”when we talk about the MDS, it is important to remember thatwhat we are actually doing is an assessment. The MDS is notmeant to be a comprehensive assessment, but to identifypotential problems that lead to further investigation, assessment,care planning and treatment. In addition, MDS 3.0 lies at thecenter of regulatory reporting and RUG reimbursement. All of thismakes accurate completion critical. Regular education of everyoneon the interdisciplinary team can help with accuracy, speed, andregulatory compliance in addition to the benefits of better care.This article covers MDS 3.0 Section H, Bladder & Bowel, andcan be used for ongoing training as well as ideas for improve-ment of this important aspect of care.

As with other sections of the MDS, the change from 2.0 to 3.0for Bladder & Bowel (Section H) reflects the focus on individual-ized resident care and clinical relevance. Management of incon-tinence in long-term care facilities has a major impact on theemotional and physical well-being of the resident; and few willargue that it is not challenging for staff. With new questionssurrounding toileting plans, CMS, through the new MDS,supports a focus on promoting continence, rather thansimply managing the incontinence. In order to improve thecontinence of your residents, you must proactively increaseawareness of causes and treatments of incontinence with staff,residents and families. Team members with longevity in long-term care may need encouragement to embrace newapproaches to continence management that reflect a changein the culture of long-term care as well as clinical evidenceand research.

Note: Your main source of information for completing the resi-dent assessment instrument is the Long-Term Care Facility Res-ident Assessment Instrument* User’s Manual for MDS 3.0. Youshould have a copy of the manual handy and read the instruc-tions for Section H before attempting to complete the section.Furthermore, you may download the RAI user’s manual at theCMS MDS 3.0 training website. Please keep in mind, it is yourresponsibility to check CMS website for any updates or revisionsto the RAI User’s Manual.

CE ARTICLE


Continued on page 63

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LEARN MORE ABOUT THE ONLY INTEGRATED SOLUTIONFOR SURVEY READINESS IN NURSING HOMES

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

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

quality improvement

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

prioritization and focusing of interventions for maximum impact

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

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

Now with the new Stage 2 module featuring:• A dashboard view of triggered care areas based on data collectedusing abaqis® Stage 1 Suite

• Investigative tools to determine deficiencies in triggered care areas

Quality AssuranceSystem Webinar


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EXPERIENCE THE ABAQIS DEMO


Changes from 2.0 to 3.0 – A review

There are several significant changes in the MDS Section H:• MDS 3.0 calls for a 7-day look-back period for the actualcoding of continence versus MDS 2.0’s 14-daylook-back period

• Now includes trial toileting programs for individuals whoare identified to be incontinent or at risk to becomeincontinent. This may be a major change and challengefor your facility if you do not have a well-defined system forimplementing a toileting program

• Urinary incontinence and fecal incontinence toileting programsare addressed separately

• A resident’s response to the toileting program is captured,allowing CMS to collect and perhaps report data on thesuccess of toileting plans across the nation’s nursing facilities

• Questions concerning urinary toileting programs (H0200)should use a look-back period to the most recentadmission/readmission assessment, the most recent priorassessment, or to when incontinence was first noted

• MDS 3.0 clears up the confusion about the wordingof continence items such as coding residents with ancatheter indwelling as “continent”

• Fecal impaction was dropped as a specific item from SectionH and constipation is addressed with a yes or no response

There are two main goals for MDS 3.0 Section H

• The first goal is to gather the specifics of a resident’scontinence status: including use of bowel and bladderappliances, degree of urinary and fecal continence, use ofand response to urinary toileting programs and bowel patterns

• The second goal is that each resident who is incontinent orat risk of developing incontinence is identified, assessed,and provided with an individualized treatment plan. Theseinterventions may include medication, behavioral treatments,containment devices and services to achieve or maintainas normal elimination function as possible1

Facilities across the nation have delved deeply into their systems,processes, procedures and protocols to prepare for 3.0. Thisanalysis is a great opportunity to embrace a different approachfor the management of incontinence. The goal should be to identifythe specific root of the issue in order to develop an individualizednursing intervention with focus on promoting normal bladder andbowel function.

Is this occurring in your facility? Look at your current incontinencemanagement program and establish:

• Do you have a clear protocol to collect the requiredinformation necessary for completion of section H?

• Do you have a continence management team?• Do you have a specific toileting protocol with a focus onpromoting normal bowel and bladder function?

• Are you able to conduct a complete bowel and bladderassessment to identify the specific type of incontinence?

• Are you considering the resident’s elimination patterns todevelop an individualized nursing intervention for toileting?

• Does the staff understand the differences between thedifferent types of urinary incontinence?

If the answer to any of the above questions is no or maybe, thereis an opportunity to modify your current incontinence manage-ment program to promote compliance with the intent of CMSF315 and the MDS 3.0.

Completion of MDS 3.0 Section H

Section H0100 Appliances

It is important to know what appliances are in use and the historyand rationale for such use. Item H0100 records the appliancesthat were in use during the standard 7-day look-back period byasking you to check all that apply.

64 Healthy Skin

To determine the urinary or bowel appliances used in the look-back period, examine the resident to note the presence of anyurinary or bowel appliances. Furthermore, review the medicalrecord for current or past use of urinary or bowel appliances.

Some areas of potential confusion are spelled out in the RAImanual:• Suprapubic catheters and nephrostomy tubes are indwellingcatheters and should not be coded mistakenly as an ostomy.

• Even if used occasionally (e.g. daytime only), condomcatheters (men) and external urinary pouches (women) shouldbe coded properly as external catheters.

• Ostomies used for feeding, such as gastrostomy, should notbe coded in section H which is strictly for elimination ostomies.

The MDS is designed to collect information to assist your clinicalteam to develop resident-centered care plans. When developingcare plans for urinary and bowel appliances, consider interven-tions that are consistent with the resident’s goals and minimize

complications associated with the use of the appliances. Everyeffort should be taken to assure the appliances fit well, are com-fortable and promote the resident’s dignity.

External catheter – Make sure the catheter fits well and it iscomfortable; look for leakage and implement your facility guide-lines to promote and maintain skin integrity. This is particularlyimportant when the product involves adhesive. As always, besure you are promoting resident dignity by explaining the ration-ale for use of the appliance and making sure the device is con-cealed properly.

Indwelling catheter – Verify there is a valid medical justificationfor use of the indwelling catheter and consider the risk and ben-efits of use as well as the duration of use. Furthermore, considerthe potential complications resulting from the use of an indwellingcatheter such as:• Increased risk of urinary tract infection• Blockage of the catheter with associated bypassing of urine• Pain / discomfort• Damage to the urethra

Mitigate the potential complications by including interventions inthe resident’s care plan such as the CDC’s recommended guide-lines for securement of the catheter to the skin and maintainingunobstructed urine flow.

Ostomy – Inspect the peristomal skin for redness, tenderness,denudation and skin breakdown and monitor the site routinely.If possible, ask the resident to report any discomfort.

Section H200 Urinary Toileting Program

The questions in H0200, Urinary Toileting Program, capture threeaspects of a resident’s toileting program:A. Whether a toileting program has been attempted for this

resident since urinary incontinence was noted in this facilityB. The resident’s response to the trial program (improvement

or otherwise)C. Whether a toileting program is currently being used to

manage a resident’s urinary incontinence

Why the focus on toileting programs? According to the CMS, anindividualized, resident-centered toileting program may decreaseor prevent urinary incontinence, minimizing or avoiding the neg-ative consequences of incontinence. In fact, research hasshown that anywhere from one quarter to one third of residentsparticipating in an active individualized toileting program willregain normal bladder function or will experience a reduction

Appliances and Definitions from the RAI Manual

• Indwelling Catheter - A catheter that is maintained withinthe bladder for the purpose of continuous drainage of urine.

• External Catheter – A device attached to the shaft ofthe penis like a condom for males or a receptacle pouchthat fits around the labia majora for females. It connects toa drainage bag

• Intermittent Catheterization - Insertion and removalof a catheter through the urethra for bladder drainage. (Note:Please keep in mind that a one-time catheterization to obtaina urine specimen during the look-back period does notqualify as intermittent catheterization).

• Suprapubic Catheter - An indwelling catheter that is placedby a urologist directly into the bladder through the abdomen

• Nephrostomy Tube - A catheter inserted through the skin intothe kidney in individuals with an abnormality of the ureter orthe bladder

• Ostomy - Any type of surgically created opening of thegastrointestinal or genitourinary tract for discharge ofbody waste

• Urostomy - A stoma for the urinary system used in caseswhere long-term drainage of urine through the bladder andurethra is not possible

• Ileostomy - A stoma that has been constructed by bringingthe end or loop of small intestine out onto the surface ofthe skin

• Colostomy - A stoma that has been constructed byconnecting a part of the colon onto the anterior abdominal wall


in the episodes of incontinence, which may improve quality oflife, lower cost and reduce the required time of care.

Despite myths to the contrary, many incontinent residents willrespond positively to a toileting program as long as the programis developed based on the individual’s specific type of inconti-nence, voiding pattern and cognitive ability. Although staff mayexpect toileting programs to be more successful with residentswho do not have cognitive impairment, cognitive status has notbeen shown to be a predictor of success with a prompted void-ing program. [What is a predictor of success? A positive re-sponse to a short (usually 3-day) trial of prompted voiding!Those residents who successfully urinate in the toilet for 66 per-cent or more of the prompts by nursing staff will often continueto be continent during an active prompted voiding program.]

Also note that a toileting program should not be dismissedbecause it is only effective during the day. Daytime continence iscertainly a “win,” and the program should continue even thoughthere are barriers to continence during the night.

CMS DefinitionsThe following toileting interventions may be used to promoteas much normal elimination possible or reduce the episodesof incontinence:• Habit Training/Scheduled Voiding - A behavior techniquethat calls for scheduled toileting at regular intervals ona planned basis to match the resident’s voiding habitsor needs.

• Bladder Rehabilitation/Bladder Retraining - A behavioraltechnique that requires the resident to resist or inhibit thesensation of urgency (“the strong desire to urinate”), topostpone or delay voiding, and to urinate according toa timetable rather than to the urge to void.

• Prompted voiding - Regular monitoring with encouragementto report continence status using a schedule and promotingthe resident to toilet. Provide positive feedback when theresident is continent and attempts to toilet.

In order to develop effective toileting programs for your residents,establish an assessment process in your facility that includes afocus on determining the specific type of urinary incontinence.This information not only is required as per F-Tag 315 regulatoryguidelines, but it is also necessary to help the staff provide anindividualized program. For example, bladder retraining might be

the first program considered for urge incontinence; similarly,scheduled voiding may be the intervention of choice for over-flow incontinence. Although “type of incontinence” is not askedfor on the MDS instrument, it plays a critical role in developmentof the toileting program and overall continence management.

What qualifies as a toileting program?RAI 3.0 Manual refers to a toileting program as• Organized, planned, documented, monitored, and evaluated• Consistent with the nursing home’s policies and proceduresand current standards of practice

As such, the toileting program needs to be documented in themedical record and must be based on each resident’s specificassessment and voiding pattern. The nursing interventions mustbe resident-specific and communicated to the staff for imple-mentation. The response to the treatment must be documented.

CMS makes it clear that the following are not toileting programs:• Simply tracking continence status with a voiding record• Changing pads or wet garments• Assistance with toileting or hygiene without a resident-specific,documented and communicated plan

Coding H200A for Urinary Toileting Program Trial

When assessing for a toileting program trial (H200A), review themedical record for evidence of a trial of an individualized, resi-dent-centered toileting program such as bladder retraining,prompted voiding, habit training/scheduled voiding (see box forthose behavioral programs defined in the RAI manual). A propertoileting trial should include observations of at least three days oftoileting patterns with prompting to toilet and documentation ofthe results in a bladder record or voiding diary. In MDS 2.0, pres-ence of a toileting program was often checked without evidenceof a real program. MDS 2.0 also failed to account for and reporton those residents who had an unsuccessful trial. MDS 3.0 waswritten to correct these issues as well as separate toileting pro-grams from appliances.

Code 0 (No) if the resident did not undergo a toileting trial. Thisincludes residents who are continent of urine on their own as wellas those who are continent with assistance. You will also code 0(No) for residents who use a permanent catheter or ostomy aswell as residents who prefer not to participate in a trial.

66 Healthy Skin

Code 1 (Yes) for those residents who did partake in a toiletingprogram trial at least once since admission, readmission, priorassessment or when urinary incontinence was first noted in yourfacility.

Code 9 (Unable to determine) if records cannot be obtained todetermine if a trial toileting program has been attempted. If 9 iscoded here, you’ll skip H0200B and go to H0200C, where youwill be asked about whether a current toileting program or trial isin process.

Section H0200B Response to Toileting Program

You found information in the resident’s record regarding a toilet-ing program trial – so, what was the outcome of that trial?H0200B asks for the resident’s response – whether there wasimprovement in continence. To assess the outcome of the toi-leting trial, review the resident’s responses as recorded duringthe trial. Note any changes in the number of incontinenceepisodes and degree of wetness the resident experiences. Yourlook-back period for H0200B should be based on the mostrecent admission/readmission assessment, the most recent priorassessment or when incontinence was first noted. While there isno clear definition of what is considered improvement, the RAIManual suggests that one less incontinent episode per day couldbe considered a success.

Tracking Elimination Patterns

If your facility does not have a comprehensive continence man-agement program that includes successful toileting programinterventions, one of the most important improvements to pro-mote toileting should start with tracking and recording voidingpatterns. Voiding patterns are important in assessment, devel-opment of individualized care plans and ongoing monitoring oftoileting programs. Without one it would be difficult for the stafffilling out the MDS H0200B regarding the response to a resi-dent’s toileting trial. Voiding records may help detect urinary pat-terns or intervals between incontinence episodes while allowingthe clinical team to help the resident avoid or reduce the fre-quency of episodes. If regular and consistent documentation ofelimination is a standard aspect of care in your facility rather thana rare occurrence; complete and accurate voiding diaries willbecome the norm.

When implementing a new voiding record system, meet with allthe staff involved in the process. Clearly highlight the expecta-tion and how the staff should document and communicate witheach other. Voiding records will be used for several reasons – soconsider a process that makes it easy for assessment, care plan-ning, and MDS completion. Because the records are instrumen-tal in developing individualized care, educate the clinical team onhow to use the information gathered. Start with a few residentsat time and designate a staff member to document and report allfindings by end of the shift. To encourage proper documenta-tion, use a new copy of the form for each shift.

When Coding Section H0200BCode 0 (No improvement) if the frequency of the resident’s uri-nary incontinence did not decrease during the toileting trial.

Code 1 (Decreased wetness) if the resident’s urinary inconti-nence frequency decreased, but the resident remained inconti-nent. Keep in mind there is no quantitative definition ofimprovement. However the improvement should be clinicallymeaningful, such as reduction of at least one less incontinentvoid per day than before the toileting program was implemented.

Code 2 (Completely dry) if the resident becomes completelycontinent of urine, with no episodes of urinary incontinence dur-ing the toileting trial. For residents who have undergone morethan one toileting program trial during their stay, use the mostrecent trial to complete this item.

Code 9 (Unable to determine or trial in progress) if theresponse to the toileting trial cannot be determined becauseinformation cannot be found or because the trial is still in progress

Section H200C – Current Toileting Program

This final question in the toileting program section asks for cur-rent toileting program information about the resident. Here, thelook-back period is seven days and specifically uses four days asthe determinant for whether the coding is Yes or No. If an indi-vidualized toilet plan was used more than four days out of thelast seven, then you would code yes.

C. Current toileting program or trial - Is a toileting program (e.g., scheduled toileting, prompted voiding, or bladder training) currentlybeing used to manage the resident's urinary continence?0. No...1. Yes.

Enter Code


Make sure to review the medical record for evidence of a resi-dent-specific toileting program being used to manage inconti-nence during the 7-day look-back period. Note the number ofdays that the toileting program was carried out during the look-back period. Remember that a successful individualized toilet-ing program could be a daytime toileting plan with a residentpreference to treat nighttime incontinence with incontinenceproducts or pads.

A final note on Toileting Programs – consider reevaluating a res-ident whenever there is a change in cognition, physical ability orurinary tract function.

Section H0300 Urinary Continence

This segment of MDS 3.0 documents a resident’s urinary incon-tinence status. Although the majority of residents admitted tolong-term care facilities may experience urinary incontinence,caregivers need to remember how much incontinence can im-pact the quality of life for an individual. That is why, in 1995, theoriginal MDS 2.0 included information regarding the resident’scontinence status to trigger one of 16 Resident Assessment Pro-tocols (RAPs) the goal of which was to develop a complete andindividualized care plan for incontinence management. Unfortu-nately, 15 years later, far too many residents in the United Stateshave a canned continence care plan of “check and change.”

CMS recognizes the following negative effects of incontinence:• Increased risk of long-term institutionalization• Increased risk of repeated urinary tract infections• Interference with participation in activities• Social embarrassment• Increased feelings of dependency and depression• Increased risk of falls and injuries resulting from attemptsto reach a toilet unassisted

Part of the education of your staff should be what constitutesincontinence versus continence. Caregivers should understandthat any voluntary void into a toilet, commode, urinal or bedpanis considered a continent episode. This is true even if assisted bynursing staff or as the result of a toileting program. The key hereis voluntary. Urinary incontinence, on the other hand, is anyinvoluntary loss of urine.

To code section H0300, begin with reviewing the medical recordsuch as physician history, physical examination, nursing assess-

ments, progress notes, bladder records or flow sheets for doc-umentation of incontinence during the 7 day look-back period.Consult with the responsible nursing staff regarding the resident’sincontinent incidents. Interview the resident, if able, regardinghis/her continence or with family members if the resident isunable to share this history.

MDS coding makes a distinction between occasionally inconti-nent, frequently incontinent and always incontinent. The newMDS 3.0 definitions of these three for coding purposes havechanged from 2.0’s definitions as well as dropping a fourth 2.0“usually continent” category altogether. Confusion about whetherto code an individual with an indwelling catheter as continent hasbeen eliminated. Instructions for coding intermittent catheteriza-tion are included in the RAI manual: you will want to code conti-nence level based on continence between those intermittentcatheterizations.

Code 0 (Always continent) if throughout the 7 day look-backperiod the resident has been continent of urine without anyepisodes of incontinence

Code 1 (Occasionally incontinent) if during the 7-day look-back period the resident was incontinent less than 7 episodes

Code 2 (Frequently incontinent) if during the 7-day look-backperiod the resident was incontinent of urine 7 or more episodes,but had at least one continent void. This includes incontinence ofany amount of urine – daytime or nighttime

Code 3 (Always incontinent) if during the 7 day look-backperiod, the resident had no continent voids

Code 9 (Not rated) if during the 7-day look-back period the res-ident had an indwelling bladder catheter, condom catheter,ostomy, or no urine output. This includes residents on chronicdialysis with no urine output for the entire 7 days.

H0400 Bowel Continence

Fecal incontinence also has a major impact on quality of life, verysimilar to urinary incontinence. Bowel incontinence may inter-fere with participation in activities; it may be embarrassing andcan lead to increased feelings of dependency and defeatism.Furthermore, bowel incontinence may increase the risk of long-term institutionalization and skin breakdown.

68 Healthy Skin

To conduct a complete bowel assessment, start by reviewing themedical record, including physician notes, physical examination,nursing assessments, progress notes and bowel records/incon-tinence flow sheets. Interview residents if they are capable of dis-cussing their bowel habits. Speak to the family members if theresident is unable to report on continence. The nursing assis-tants who care routinely for that resident are another source of in-formation. For coding purposes, even a temporary bowelincontinence precipitated by loose stools or diarrhea from anycause including a stomach ailment, laxatives or other medica-tions would count as incontinence. This is another point to stressto those charged with completing bowel and bladder records.

To complete the coding of H0400:Code 0 (Always continent) If throughout the 7-day look-backperiod the resident has been continent of bowel on all occasionsof bowel movements, without any episodes of incontinence

Code 1 (Occasionally incontinent) If during the 7-day look-back period the resident was incontinent of stool once. Thisincludes bowel incontinence of any amount during the day or night

Code 2 (Frequently incontinent) If during the 7-day look-backperiod the resident was incontinent of bowel more than once buthad at least once continent bowel movement. This includesincontinence of any amount of stool day or night

Code 3 (Always incontinent) If during the 7-day look-backperiod the resident was incontinent of bowel for all bowel move-ments and had no continent bowel movements

Code 9 (Not rated) If during the 7-day look-back period the res-ident had an ostomy or did not have a bowel movement for theentire 7 days

H0500 Bowel Toileting Program

Item H0500 documents whether a toileting program is beingused to manage a resident’s fecal incontinence. There has beensignificantly more research on the impact of toileting programs onurinary incontinence than for fecal incontinence. What few stud-

ies have been done suggest some of the following items to con-sider when creating your continence program:• Many residents take medications that cause constipation• Many treatments for constipation cause or contribute tofecal incontinence

• The severe straining resulting from constipation may causesphincter dysfunctions contributing to fecal incontinence

• The task of toileting residents with constipation averaged overseven minutes, which may explain why direct care staff maynot prompt or assist in toileting6

• Nursing home staff under-detects and thus under-reportssymptoms of constipation

• Prompted toileting programs, along with dietary changes, mayincrease the number of bowel movements and the number ofbowel movements in the toilet, but seem to have little effecton number of fecal incontinence episodes

Despite these factors, a systematically implemented bowel toi-leting program may decrease or prevent bowel incontinence andminimize or avoid the negative consequences of fecal inconti-nence. Many incontinent residents respond to a bowel toiletingprogram that is modeled after their voiding pattern.

Coding for H0500Similar to the urinary incontinence program, you should reviewthe medical record for evidence of a bowel toileting program tocomplete item H0500. Look for implementation of an individual-ized, resident- specific toileting program based on an assess-ment of the resident’s unique bowel pattern.

You should find evidence that the individualized program wascommunicated orally to staff and the resident. The resident’sresponse to the toileting program and subsequent evaluationsshould also be documented in the medical record.

Code 0 (No) If the resident is not currently on a toileting programtargeted specifically at managing bowel continence

Code 1 (Yes) If the resident is currently on a toileting programtargeted specifically at managing bowel continence


H0600 Bowel Patterns

Item H0600 documents whether a resident has experienced anyproblems with constipation during the 7- day look-back period.Whether a resident suffers from constipation is now a yes/noquestion in order to highlight this very common problem for res-idents in long-term care facilities. As noted above, constipationis a side effect of many medications as well as a consequence ofimmobility. The focus of constipation, through the MDS, can helpfacilities to detect possible dehydration as well as decrease therisk of fecal impaction.

Fecal impaction, as a separate question, was eliminated from thenew MDS. The MDS 3.0 validation panel did not consider theMDS 2.0 question of fecal impaction as reflecting the real inci-dence of fecal impaction.* Since there was no evidence that this2.0 question improved reporting or prevention; the MDS turnsits focus on constipation which prompts detection and manage-ment of constipation, thereby reducing potential of impaction.

Besides leading to fecal impaction, severe constipation maycause:• Abdominal pain• Anorexia• Vomiting• Bowel incontinence• Delirium• Urinary incontinence

Sometimes fecal impaction manifests as fecal incontinence withwatery stool from higher in the bowel (or irritation from theimpaction) moving around the impacted mass, causing soiling.Education of your staff should include this detail, as it is coun-terintuitive to look for impaction if there is some, albeit liquid,incontinence.

The RAI Manual Definitions:Fecal Impaction: A large mass of dry, hard stool that candevelop in the rectum due to chronic constipation. This massmay be so hard that the resident is unable to move it from therectum.

Constipation: If the resident has two or fewer bowel movementsduring the 7 day look-back period or if most bowel movementsconsist of hard stool that is difficult to pass.

To begin the assessment for bowel patterns, review the medicalrecord including physician history, physical assessment, nursingnotes and bowel records for evidence of constipation. Interviewthe resident if possible or speak to the family members. Ask thedirect care staff about problems with constipation.

Code H0600 as follows:Code 0 (No) If the resident shows no signs of constipation dur-ing the 7-day look-back period

Code 1 (Yes) If the resident shows signs of constipation duringthe 7-day look-back period code (such as two or less bowelmovements or difficult to pass hard stools)

ConclusionThis completes Section H of the MDS. As you have learned, itgives a snapshot of the resident’s continence status. Because itis so comprehensive, section H of the MDS truly requires yourfacility to develop systems that facilitate the collection and doc-umentation of bladder and bowel assessment and interventions.Your interdisciplinary MDS team should analyze the currentprocess flow and systems to optimize capturing this informationand reduce duplication of efforts and documentation.

An overall goal of the update to the MDS is to increase the rele-vance of the clinical items, and section H certainly reflects this.CMS makes it clear that it is important for U.S. nursing homeresidents to obtain the highest level of bowel and bladder func-tion possible. Section H will help you capture those efforts.

* Also, fecal impaction is an incident/event; the MDS attempts to capturethe general condition of the resident.

1. A major change from MDS 2.0 to 3.0 is:a. 3.0 has a 14-day look-back period for section Hb. 3.0 requires completion of a voiding diary within 30 daysc. 3.0 calls for 7-day look-back period for section Hd. 3.0 has a look-back period of 3 days for voiding diaries

2. Which of the following is not considered atoileting program?a. Elimination Recordingb. Habit trainingc. Bladder retrainingd. Prompted voiding

3. Residents with catheters should be codedas continenta. Tb. F

4. Which of the following should not be coded as anappliance in Section H?a. Urostomyb. Colostomyc. Ileostomyd. Gastrostomy

5. Residents should be reevaluated for individualizedcontinence care plan when there isa. Change of cognitionb. Change to urinary tract functionc. Change of physical abilityd. All of the above

6. Which of the following is considered an example ofa toileting program by RAI Manual?a. Toileting according to the residents voiding patternb. Changing incontinence product and performing perineal

care when requested by residentc. Observation and tracking of resident’s bowel and

bladder activityd. Changing pad or garment every two hours

7. Voiding records cana. Give the date of first urinary incontinence episodeb. Help detect urinary or fecal voiding patternsc. Determine Urge Incontinenced. Report urinary tract infections

8. Residents with dementia are not candidates for atoileting programa. Tb. F

9. If a resident has watery stool or some fecalincontinence, it is impossible for them to havefecal impaction.a. Tb. F

10. The following are all risks of incontinence except:a. Increased risk of long-term institutionalizationb. Increased risk of repeated urinary tract infectionsc. Reduction of participation in activitiesd. Congestive heart failuree. Increased feelings of dependency and depression

CE TEST

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A Guide to MDS 3.0 Section H

Visit www.medlineuniversity.com and login or create an account.Choose your course to take the test and receive 1 FREE CE CREDIT.

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Visit today to learn more about:• Hand hygiene• Incontinence• Skin care• Long-term care• Pressure ulcers

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74 Healthy Skin

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76 Healthy Skin

Here, the Photobiology Committee responds to the criticismsand explains why sunscreen remains an essential part of any-one’s daily sun safety program.

As sunscreen use has gone up in the past 30 years, so hasmelanoma incidence. Systematic review of all studies from 1966to 2003 shows no evidence to support the relationship betweensunscreen use and increased risk of melanoma, the deadliestform of skin cancer. Actually, some important epidemiological re-search has indicated that population groups using sunscreenhave reduced their melanoma incidence.

The use of excessive SPFs and terms such as “broad-spectrumprotection” or “multispectrum protection” on sunscreen labelsmislead us into a false sense of security, when sunscreensreally do not protect adequately against UVA radiation.

Because both ultraviolet A (UVA) and ultraviolet B (UVB) areharmful, you need protection from both kinds of rays. “Broad-spectrum protection” and “multispectrum protection” meanonly that a sunscreen offers protection against parts of boththe UVA and the UVB spectrum. It does not mean completeprotection. Because there is no consensus on how much pro-tection the terms indicate, they may not be entirely meaningful.SPF refers specifically to how much protection is offeredagainst UVB rays, but to date in the United States, we have noequivalent measurement to represent the degree of UVA pro-tection in a sunscreen. Nonetheless, UVA protection in sun-screen has greatly improved in recent years. To make sure youare getting effective UVA as well as UVB coverage, look for asunscreen with an SPF of 15 or higher, plus some combinationof the following UVA-screening ingredients: stabilized avoben-zone, ecamsule (also known as Mexoryl), oxybenzone, titaniumdioxide, and/or zinc oxide.

For everyday use, an SPF of 15 or higher is generally adequate,while SPFs of 30 or higher are appropriate for active, extendedoutdoor activity. [BOLD]

An SPF 15 sunscreen screens out 93% of the sun's UVB rays,whereas SPF 30 protects against 97% and SPF 50 against 98%.The Skin Cancer Foundation agrees that in most cases, SPFsbeyond 50 are unnecessary.

Sunscreen blocks vitamin D.

Although solar UVB is one source of vitamin D, the benefits ofexposure to UVB cannot be separated from the harmful effectsof sun exposure: skin cancer, cataracts, immune system sup-pression, and premature aging. In addition, excessive exposureto the sun actually depletes our body's supply of vitamin D. Thesafest way to obtain vitamin D is through a combination of dietand vitamin D supplements. The Skin Cancer Foundation rec-ommends increasing your intake of vitamin D to 1,000 mg daily.

The sunscreen ingredient oxybenzone may be a carcinogen.

Old research on rodents suggested that oxybenzone, a syn-thetic estrogen, can penetrate the skin, may cause allergic re-actions, and may disrupt the body’s hormones, producingharmful free radicals that may contribute to melanoma. How-ever, there has never been any evidence that oxybenzone,which has been available for 20 years, has any adverse healtheffect in humans. The ingredient is approved by the Food andDrug Administration (FDA) for human use on the basis of ex-haustive review. The Photobiology Committee reviewed thestudies on oxybenzone and found no basis for concern.

Retinyl palmitate, a form of vitamin A and an ingredient in 41%of sunscreens, speeds up growth of tumors and other lesionswhen exposed to the sun.

The EWG cites an FDA study for these data and faults the FDAfor not releasing the study. However, the FDA is yet to release thestudy precisely because it has not gone through proper peer re-view. Thus, the EWG based its criticisms on an unapproved 10-year-old study of mice that has never been published in any


journal. To date, there is no scientific evidence that vitamin A isa carcinogen in humans. What's more, only trace amounts ofretinyl palmitate appear in sunscreens, and some evidence sug-gests that it is actually protective against cancer.

Nanoparticles in micronized zinc oxide and titanium dioxidemay be more harmful than larger forms of these chemicals,crossing the placenta and affecting the developing fetus, orcausing DNA damage linked to cancer.

Micronized versions of zinc oxide and titanium dioxide were de-signed to improve them cosmetically so that they no longer lefta tell-tale splotch of white on the skin. This improvement greatlyincreased the use of sunscreens containing these ingredients,which is a good thing because they are the two most effectiveingredients to date in sunscreens against the entire UV spec-trum. Multiple studies have demonstrated that the nanoparti-cles in these ingredients do not penetrate the skin, and there isfurthermore no strong evidence of their toxicity. The general sci-entific consensus (which even the EWG now admits) is that theypose no risk to human health.

Criticisms have also been leveled against the Skin CancerFoundation’s Seal of Recommendation program, saying thatsunscreen companies simply pay for use of the Seal.

In actuality, manufacturers must provide scientific data on theirsun protection product showing that it sufficiently and safely aidsin the prevention of sun-induced damage to the skin. The dataare reviewed by an independent volunteer team of photobiolo-gists-experts in the study of the interaction between ultravioletradiation and the skin. Every sunscreen product awarded theSeal is monitored annually to ensure that it continues to meetthe criteria. The Seal of Recommendation requirements include:• an SPF of 15 or greater,

• validation of the SPF number by testing on 20 people,

• substantiated data that the product does not cause pho-totoxic reactions or contact irritation, and

• substantiation for any claims that a sunscreen is watersweat resistant.

The Skin Cancer Foundation also awards the Seal to other sunprotection products, such as clothing, window film, awnings,hats, and sunglasses.

Consumers should rest assured that sunscreen products aresafe and effective when used as directed and should be con-sidered a vital part of a comprehensive sun protection programthat includes the following sun safety strategies:• Seek the shade, especially between 10:00 a.m.

and 4:00 p.m.

• Do not burn. Wear a sunscreen with an SPF of 15 orhigher every day.

• Apply 1 oz (2 tbsp) of sunscreen to your entire body 30minutes before going outside. Reapply every 2 hours orafter swimming or excessive sweating.

• Cover up with clothing, including a broad-brimmed hatand UV-blocking sunglasses.

• Keep newborns out of the sun. Sunscreens should beused on babies over the age of 6 months.

• Examine your skin from head to toe once every month.

• See your doctor every year for a professional skinexamination.

• Avoid tanning and UV tanning salons.

Printed with permission from the Journal of the Dermatology Nurses’ Association. Sep-tember/October 2010; 2(5):228-229.

78 Healthy Skin

INTRODUCTIONDiagnosis and staging of pressure ulcers is an important aspectof clinical practice in healthcare settings, having an enormousimpact on patient health, caregiver utilization effectiveness,reduction of pain and suffering, and health economic issues.Major benefits to the patient and the healthcare system canresult if the skin condition is accurately diagnosed and appropriateactions taken commensurate with the nature of the diagnosis.

The NPUAP Pressure Ulcer Classification System lists four dif-ferent stages of pressure ulcers and two additional descriptions.In addition, because the breach of skin to Stage I is preceded bycertain signals, it is of enormous and disproportionate benefit foractive and urgent intervention as soon as these signals are rec-ognized. Those signals could include a reddened discolorationon a Caucasian that is blanchable.

Training of nursing and other clinical staff is critical so that thesesignals do not go unnoticed. Even if they are noticed, the wordsthat describe these conditions matter. The use of the right wordsto describe these imminently dangerous conditions of skin cancall the nursing staff into action because some well chosenwords, by themselves, can potentially convey a sense of urgencyand provide a call for urgent action.

RATIONALEA Stage I pressure ulcer has been described as “non-blanchableerythema”. Pressure ulcer development actually occurs before apressure ulcer is actually noted; the physiologic changes areoften non-visible to the naked eye and include temperaturechanges and itching. (3) Pressure and shear that are causing thistissue damage must be recognized and considered an alarm toinstitute or upgrade prevention measures. (8) Several terms havebeen used in clinical literature to describe the condition of skinimmediately before it before it becomes a Stage I (NPUAP) pres-sure ulcer. The terms “blanchable erythema” (6) or “reactivehyperemia” (7) have been used to describe this condition. How-ever, a less frequently used term “Pre-Stage I” has been usedpreviously and it is the authors’ view that this concept is moredescriptive of the skin condition, and perhaps, a call to urgentaction if such a diagnosis is indeed reached.

This study describes a survey of clinicians whose opinions weresought about which of a set of three descriptions would bedeemed the most effective call to action steps to prevent furtherdamage.

OBJECTIVEThe objective of this study is the identification of the rightterms to be used for the description of the skin health thatexists just prior to the creation of a Stage I pressure ulcer.Such a well chosen and “call to action” term to describe acommon condition in clinical settings is appropriate for inclu-sion, for example, in a skin/wound assessment tool that hasbeen developed to assist non-expert clinicians in staging andassessment.

METHODS19 nurses and 11 CNAs in a 30 bed hospital rehabilitationunit, none of whom would be deemed an expert in woundassessment and staging, were asked which of the followingterms were more likely to result in immediate preventiveaction. Immediate interventions are described as off-loadingheels, turning, and communicating the problem to others.

QUESTION:Which term gives you the best understanding ofa problem that required an immediate active intervention?

Term choices: Blanchable Erythema, Pre-Stage I, ReactiveHyperemia.

RESULTS90% of those subjects surveyed felt that the term “Pre-StageI” wound result in preventative action.

Following this survey, the lead author who is a practicingclinician observed that when “reactive hyperemia” or “blanch-able erythema” were diagnosed by her in patient documen-tation, there was less proactive action taken by the subjectsof the survey. Diagnosis described as “Pre-Stage I” resultedin a far higher frequency of proactive steps such as offload-ing and patient turning. Quantitative data to support thisobservation was not gathered.

DISCUSSION AND CONCLUSIONThe choice of the right term to describe an emergent condi-tion on the skin is important, because this can be a “call toaction” by its very nature. It appears from literature that manyterms have been used to describe the reddening of skin thatis known to precede the formation of the Stage I PressureUlcer. It is felt that all possible steps are worth considering inpreventing this crucial first stage of damage to skin.

CASE STUDY

PRE-STAGE I: An obvious, more descriptive, and clinicallyimpactful term than “Reactive Hyperemia” or “BlanchableErythema” in describing the state before Stage I


From this survey based research, it appears that the respon-dents strongly felt that the use of the term “Pre-Stage I” isappropriate for the typical reddening of the skin that precedesa Stage I pressure ulcer. Other terms used clinically to de-scribe the same condition did not seem to have the samecall-to-action urgency that the use of the term “Pre-Stage I”had in the opinion of the respondents.

Though quantitative data on the observation was not col-lected, actual diagnosis as Pre-Stage I skin conditions led toa higher level of proactive steps being taken to prevent furtherdeterioration, compared to the diagnosis as either “blanch-able erythema” or “reactive hyperemia.”

Based on the findings of this study, the authors recommendthat the term “Pre-Stage I” is most appropriate in clinical sit-uations and for inclusion in any staging tool that is created toaugment the current state of the art in wound assessmentand staging.

References1 www.npuap.org National Pressure Ulcer Advisory Panel and European Pressure Ulcer

Advisory Panel. Prevention and treatment of pressure ulcers: clinical practice guideline.Washington DC: National Pressure Ulcer Advisory Panel; 2009.

2 Bhattacharya SB. Pressure Ulcers –Kansas Reynolds Program in Aging. KansasUniversity School of Medicine. www2.kumc.edu/coa/education/FacDevPowerPoint.

3 Sharp CA and McLaws M-L, A discourse on pressure ulcer physiology: the implicationsof repositioning and staging. World Wide Wounds 2005. www.worldwidewounds.com.

4 Porter A, Cooter R. Surgical management of pressure ulcers. Primary Intention1999;7(4):151-155.

5 Kosiak M. Etiology and pathology of ischemic ulcers. Arch Phys Med Rehabil 1959;40(2): 62-9.

6 Edlich RF, Winters KL, Woodard CR, Buschbacher RM, Long WB, Gebhart JH, and MaEK. Pressure Ulcer Prevention. Journal of Long Term Effects of Medical Implants.2004;12(4):285-304.

7 Sanders W, Allen RD. Pressure Management in the Operating Room: Problems andSolutions. Managing Infection Control 2006;6(9):63-72.

8 Defloor T, Schoonhoven L, Fletcher J, Furtado K, Heyman H, Lubbers M, Lyder C andWitherow A. Pressure Ulcer Classification Differentiation Between Pressure Ulcers andMoisture Lesions. EPUAP Statement. NPUAP.org accessed 2-10-2011.

Prevention

Nancy Estocado, PT, CWS1

Margaret Falconio West BSN, RN, APN/CNS, CWOCN2

Debashish Chakravarthy, PhD2

1Sunrise Hospital, Las Vegas, NV2Medline Industries, Inc. Mundelein, IL

Patient A1 – smallarea of discoloration(redness) noted onthe heel

Patient A2 – using aclear disk to assessthe area, note theblanching or lighteningof the red area

Patient B1 –reddened area onthe heel

Patient B2 – usingthe clinician’s finger,note the blanching ofthe area

80 Healthy Skin

12


Time flies. In just 21 months, the federal government will startpenalizing hospitals with higher than expected readmission rates.And even though much about the regulations-to come remainsunclear, clinicians along the care continuum are scrambling toget ready.

Or they should be. It’s not just important for a hospital’s bottomline. It’s important for the patient.

We’ve been talking with some of the nation’s experts on the sub-ject, including Stephen F. Jencks, M.D., whose April 2009 articlein the New England Journal of Medicine set the tone for today’sreadmission prevention energy. His review of nearly 12 millionbeneficiaries discharged from hospitals between 2003 and 2004found that nearly 21 percent, or one in five, were re-hospitalizedwithin 30 days and 34 percent were readmitted within 90 days.

We also spoke with Amy Boutwell, MD, an internist at Newton-Wellesley Hospital in Newton, MA and Director of Health PolicyStrategy for the Institute for Healthcare Improvement; TimothyFerris, MD, medical director of the Massachusetts General Physi-cians Organization, and Estee Neuhirth, director of field studiesat Kaiser Permanente in California.

Some of these strategies aren’t yet proven to work in all settings,of course. And many are still in the demonstrations phase. Butwith national readmission rates as high one in five, and higher forcertain diseases, many providers are trying anything that soundsplausible.

Here are some of the prevention strategies that these and otherexperts think might be worth a shot. Many involve—to a greateror lesser degree —following the patient out of the hospital,

Ways toReduce HospitalReadmissions

By Cheryl Clarkfor HealthLeaders MediaDecember 27, 2010


Prevention

©2011 Medline Industries, Inc.Medline is a registered trademarkof Medline Industries, Inc.


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either in-person, electronically, or by phone, but others involveupside-down introspection and re-evaluation by providers alongthe care continuum.

1. Discharge SummariesDictate discharge summaries within 24 hours of discharge.Boutwell says that standard practice and policy at most hospi-tals is that discharge summaries are completed within 30 daysof the discharge. “I was trained that the summary is a retro-spective report of what happened in hospitalization. But what weneed today is anticipatory guidance. Patients get discharged andgo home. They can’t fill their meds, insurance doesn’t cover themed or they have questions. They’re nervous and worried. Theycall their primary care provider, who didn’t even know they wereadmitted.

Boutwell says that 30-day-discharge summary policies “mighthave sufficed in a time gone by. But that doesn’t work anymore.Information needs to be available at the time of discharge.There’s a growing recognition of this need, but staff bylawshaven’t changed.”

2. Lengthen the Handoff ProcessAt every juncture in patient care process, especially discharge,have teams talk to each other about the patient. And by the way,don’t call them discharges. Call them “transitions.” Standardizethem for a variety of providers, from hospital to rehabilitationfacility to skilled nursing facility to home and back.

Boutwell says that “taking this person-centered approach shiftsthe concept from discharge, which is a moment in time andyou’re done with it, to a transition—a shared accountability. Weneed to make sure the receiving providers understand who thispatient is, with a 360-degree view.

Jencks adds that “senders and receivers, for example hospitaldischarge planners and skilled nursing facility staff and homehealth” meet often enough so they can learn about the realitiesof the transitions they initiate and receive.

3. Provide Medication on DischargeSend the patient home with a 30-day medication supply,wrapped in packaging that clearly explains timing, dosage,frequency, etc. Some health centers with Medicaid patients maybe trying this strategy, which is difficult for hospitals to do withMedicare patients because of distinctions between Part A andPart B payment. Still, for some high-risk populations, such aspatients with congestive heart failure and those who have beenreadmitted before, it might be worth it for the hospital to absorbthe cost.

4.Make a Follow-up Plan Before DischargeHave hospital staff make follow-up appointments with patient’sphysician and don’t discharge patient until this schedule is setup. A key is to make sure the patient has transportation to thephysician’s office, understands the importance of meeting thattime frame, and following up with a phone call to the physicianto assure that the visit was completed.

5. TelehealthWe couldn’t find anyone using video monitors to communicateon a daily basis with the use of such software as Skype, forexample, but some readmission experts say it’s an interestingapproach to keep up visual as well as verbal communication withpatients, especially those that are high risk for readmission.

On a more practical scale, Home Healthcare Partners in Dallasuses health coaches, intensive care clinicians, and wireless tech-nology to record vital signs on a daily basis for about 2,100discharged Medicare fee-for-service beneficiaries for between

84 Healthy Skin

60 to 120 days. So far, they have done this for about 7,000unduplicated patients in the last two years, for several hundredhospitals in Dallas and Louisiana, says HHP’s CEO,Wayne Bazzle.

The target population for intense monitoring includes those withfour or five co-morbidities and who have a primary diagnosis ofcongestive heart failure, chronic obstructive pulmonary disease,diabetes, Alzheimer’s and hypertension.

Bazzle says that the effort involves phone calls of between fiveand 15 minutes, and is frequent enough with the same team “sowe have their trust. We can help them stay out of the hospital ifthey'’re more truthful with us about what’s going on, and if wesee some deterioration, we can help them cope. Normally it’s amedication management issue, or they’ve become a little toorelaxed with their diet.”

6. Identify Frequent FlyersCustomize your hospita’s admission and re-admission rates fordemographic and disease characteristics to identify those athighest risk, and expend extra resources on their care needs.This may involve special programs for homeless patients, suchas the one effort by a cohort of Los Angeles hospitals who grap-pled with how to safely discharge homeless patients withoutviolating city laws.

The Los Angeles project now discharges homeless patients whomeet certain criteria to a half-way type of house in nearby Bell,and saved $3 million for hospitals in its first few months. Expan-sions in other parts of Southern California are underway.

7. Understand What's Happening After DischargeKaiser Permanente is using video cameras to chronicle homesettings and the entire care process to determine what’shappening to the patient after discharge that provoked areadmission.

The team is also using video of the care team, from the phar-macist, home care providers, nurses, and physicians about theircare of that patient, to highlight wrinkles and cracks in thesystem that brought the patient back to the hospital.

So far, Kaiser officials say that the video project has contributedto a reduction in readmission rates at some hospitals where ithas been tried, such as from 15.7 percent to 9 percent atKaiser’s South Bay Medical Center near Los Angeles, becauseit gave the team information to streamline care, says Kaiser’sNeuwirth.

8. Provide Home Care on WheelsJust like Meals-on-Wheels can be scheduled in advance, so cancase management, housekeeping services, transportation to thepharmacy and physician’s office. At Piedmont Hospital in Atlanta,in collaboration with the Area Agency on Aging, patients havingelective knee surgery get coupons and prescheduling, “so thatby the time you get out of the hospital, it’s waiting there for you,”Boutwell says. She adds that this kind of a pre-arrangement forpost-transition care is “spreading like wildfire” among a numberof hospitals, but so far it’s mainly being tried with electivepatients.

Many strategies involve—to a greater or lesserdegree —following the patient out of the hospital,either in-person, electronically, or by phone.


9. Consider Physician Medication ReconciliationA recent paper in the New England Journal of Medicine by Yut-ing Zhang of the University of Pittsburgh noted the wide geo-graphic variation among physicians’ prescribing practices withmedications that should be avoided in patients over age 65. Shealso noted variation in prescribing practices for drugs that havea high risk for negative drug-disease interaction.

Jencks says that Zhang and colleagues “are pointing us to arather important gap in the most common thinking about transi-tions—that we are to make sure that patients are able to get andtake medications, get recommended follow-up, and generally doas they are told. But we know that medication plans can be inlife-threatening error, that physicians often recommend a time-to-follow-up that is too long, that discharge plans are often writtenin ignorance of the patient’s pre-admission history and experi-ence. In general, we need to be much more critical of the planspatients get.”

10. Make Sure Patients UnderstandPatients may nod, and say they understand what they’re sup-posed to do after they leave the hospital. But “teach back,” inwhich they and their caregivers repeat back those instructions,even to more than one hospital caregiver, needs to be constantlyreinforced, readmission experts say. Jencks says that caregiversneed to understand that their patients are often heavily med-icated, stressed, groggy and confused. And that their diseasestate may impair their ability to understand what they are beingtold, much less remember it two days later.

11. Focus on Highest-risk PatientsExamine the readmission patterns at your hospital and see whichpatients, with which conditions, diseases or procedures, havethe most readmissions. If resources are limited as they are atmost hospitals, push them toward a select group of patients ina more intense way to see if increased effort makes a difference.

For example, in his New England Journal of Medicine paper,Jencks showed that for certain diseases or conditions, and incertain parts of the country, readmission rates are even higherthan the national average of one in five. For example, for med-ical patients, the readmission rate for heart failure patients was27 percent; for those with psychoses, 24.6 percent; chronicobstructive pulmonary disease, 22.6 percent. Patients withpneumonia and gastrointestinal problems were re-hospitalizedat rates of 21 percent and 19.2 percent respectively.

For surgical patients, those with vascular surgery had the high-est readmission rate, 23.9 percent, followed by those with hip orfemur surgery, 17.9 percent. Perhaps these are the places wherereadmissions can be most quickly reduced.

States with the Highest Hospital Readmission Rates

Washington, D.C. 23.2%

Maryland 22%

Louisiana 21.9%

New Jersey 21.9%

Illinois 21.7%

West Virginia 21.3%

Kentucky 21.2%

Mississippi 21.1%

Missouri 20.8%

New York 20.7%

Massachusetts 20.2%

Oklahoma 20.1%

12. Listen to the PatientInvolve the emergency room, hospice or home health providersto make sure patients don’t come to the emergency room fornon-emergent end-of-life care issues. Providing patients andtheir family members with informed choices, opportunities foradvance directives, and counseling in the emergency room settingmay avert painful, unnecessary admissions. Look for this to bea major expansion of palliative care professionals inside the ED.

“There really needs to be a care plan that reflects the patient’swishes,” Jencks says. “This is quite different from either a med-ical power of attorney or what is often called a living will becauseit lays out the goals of treatment.

“Cure? Palliation? Functional independence? Playing dominoeswith friends? Hospice? This kind of plan has little relevance topersons without substantial chronic conditions, but it is totallyrelevant to a patient with one or more chronic conditions thathave required hospitalization. With such a plan, one can oftenavoid readmissions that really do not serve the patient’s needs orvalues. What is, after all, worse than a readmission? Readmissionof a patient who does not want to be readmitted,” Jencks says.

Reprinted with permission from HCPro, Inc. (February 2011) CopyrightHCPro, Marblehead, MA. For more information, call 800/639-7477 or visitwww.HealthLeadersMedia.com.



Introducing Medline’s NewCONTINENCE MANAGEMENT PROGRAM

A wide variety of tools to help you provideindividualized continence care

Incontinence is one of the most costly and labor intensiveissues in nursing homes and long-term care facilities.Despite years of research and clinical efforts to improveit, the prevalence of incontinence remains high.

Medline has created this Continence ManagementProgram to help long-term care facilities developindividualized continence programs for residents andcomply with Medicare regulations.

The program includes:• RN/LPN workbook with 4 CE credits

• CNA workbook

• Reproducible care plans, assessmentguidelines and other quality assurance tools

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Replaces CompassBox F315


By Joyce Norman, BSN, RN, CWOCN, DAPWCA

Question:How should I assess a lower extremity wound?Where do I start?

Answer:We suggest breaking your assessment down intothree simple steps.

STEP 1. Inspect the lower extremity,and note your findings. (See also chart.)Venous leg ulcers tend to be weepy, swollen (edema),exhibit “normal” hair growth, cause severe pain or heav-iness, appear in the gaiter area. They can be irregularlyshaped and have heavy drainage.

Arterial wounds have an absence of hair growth, occuralong with muscle wasting, change color with position

changes, show temperature changes, often appear onthe tips of toes or on the ankles, lateral aspect of footand the shin, they have a round wound bed appearanceand light to no drainage. They usually develop from aminor trauma, such as bumping the extremity ona device.

Pressure ulcers exhibit “normal” hair growth, appearusually over a bony prominence, have a round woundbed and can have light to no drainage or heavy drainage.

Diabetic foot ulcers go along with muscle wasting, canappear on the tips of the toes (usually because of ill-fit-ting shoes), cause severe pain or no pain, show temper-ature changes, occur on the ankles, have a round woundbed (especially if a callous is also present) and exhibitlight to no drainage.

Regular Feature

Hotline Hot Topic

Assessing Lower Extremity Wounds

Characteristic Your Wound Venous Leg Pressure Arterial Diabetic FootUlcer (VLU) Ulcer (PU) Ulcer (DFU)

Weepy lower extremity XEdema lower extremity XNormal hair growth X XLack of hair growth X XMuscle wasting X XWounds on tips of toes X X (ill-fitting

shoes)Severe pain X XLack of pain XColor changes with X X Xposition changesTemperature changes X XGaiter area XAnkle X X XRound wound bed X X X (typically

with callous)Irregularly shaped wound XHeavy drainage X XLight to no drainage X X XOver a bony prominence X

STEP 2. Touch the extremity, especiallybony prominences.This is something that can easily be done as care is pro-vided not just during bathing. Feel the heels when reposi-tioning or turning. Note the temperature of the extremityas compared to the other leg. Is the skin dry? Does it feeland look good? Or is the skin overly moist?

STEP 3. Use the information you have gatheredto help determine the type of wound.Wounds on the foot are frequently related to neuropathyand diabetes. Although neuropathy can develop fromother causes, many times it is related to diabetes. Thesefoot wounds are commonly called diabetic foot ulcers(DFU). “Diabetic” wounds can also appear on the ankle.For diabetics, it is just as bad to wear ill-fitting or worn outshoes as it is to wear no shoes at all. If your patient/resi-dent has decreased sensation in the feet, he or she maynot realize footwear that is rubbing on the skin and form-ing a blister or that a foreign object such as a tack or peb-ble could be causing a problem. These wounds aretypically small in nature and present with a callous ringaround them. They will not always have a reliable AnkleBrachial Index (ABI) study, as the small vessels could be

calcified, resulting in a non-reliable measurement. Also,due to the neuropathy, the pain will vary from absent tovery severe.

Circulation problemsWhen caring for patients with factors that can affect theircirculation, we want to understand that not only can thiscause problems like stroke (CVA), or heart issues, (MI,atrial fib, hypertension, hyperlipidemia), it can also havean impact on their lower extremities. Some signs andsymptoms to be aware of include:• Atrophy of the calf muscle, with a straight

or stove pipe appearance to leg• Lack of hair• Diminished or absence of pulses• Color changes with position• Temperature changes (feet cooler)

These can be indications that the patient has lost bloodflow to the lower extremity, and minor injuries, such assimply bumping their shin on a chair or bed, might resultin a wound that will not heal. This is where the diminishedblood flow has affected the lower leg, and the end resultis a wound.

88 Healthy Skin

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

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

Skin changesChanges in the skin and edema are additional problemsthat can be assessed easily. Skin changes might include:• Edema below the knee, which resolves

with elevation• Red or ruddy colored skin, especially around

the ankle area• Wounds or scars that start at the ankle

These are classic signs and symptoms of venous hyper-tension, and can be resolved with elevation, educationabout proper ambulation and compression.

There can be other problems with the lower extremities aswell, which may require a specialist, such as a surgeon,lymphedema therapist, dermatologist or others.

ConclusionAlways remember that wounds are abnormal. The patientmay have a wound that can be easily resolved with thecorrect treatment. In cases where a wound or skin prob-lem is not resolving despite comprehensive care, some-thing else may be wrong, and the patient will requirefurther assessment.

© 2011 Medline Industries, Inc. Medline and Marathon are registeredtrademarks of Medline Industries, Inc.

Problem: Peristomal Irritation

Solution: Marathon® Cyanoacrylate LiquidSkin Protectant

Peristomal irritation can lead to decreased wear time, painand embarrassment about leakage. So it only makessense to do everything you can to protect the peristomalarea. Marathon Liquid Skin Protectant helps protectagainst irritation and maceration by creating a barrieragainst moisture and chemical assault.

Marathon, a cyanoacrylate, bonds to the skin surface,integrating with the epidermis on a molecular level toseal in moisture. While other skin protectants may flakeoff, Marathon stays in place, offering robust protectionand increased wafer wear time.

Stoma site beforetreatment with Marathon.1

Same stoma site aftertreatment 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


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Ventilator-Associated Pneumoniacan be deadly.

VAPrevent can be easy.

VAPreventfollows IHIVentilator Bundleguidelines. Withthis checklist,you can too.

Convenient,space-savingpackaging

Sequential dispensingsystem and thumb grip foreasy, one-at-a-time access— in the right order

The three parts of the VAPrevent program you’ll want to know:

ProductOnly Medline gives you these three options for oral care: IHI-recommendedchlorhexidine gluconate (CHG), the alcohol-free moisturizing of Biotene®,or the proven antisepsis of hydrogen peroxide. Procedure kits featureinnovative components, like graduated suction catheters and toothbrusheswith integrated gum and tongue scrubbers. Breakthrough package designcommunicates and educates, all while leaving less waste behind. And theintuitive stack-pack design with its one-at-a-time dispenser makes it easyfor caregivers to stay on track with care protocols.

ProgramWhen your staff knows how to use a product appropriately, its effectivenessincreases greatly. That’s why Medline developed the Medline VAP program,which helps build knowledge and clinical skills with educational modulesfor both novice and experienced clinicians, as well as an online interactivecompetency for oral care. A program manager helps you implement yourprogram and stays active as you progress, providing 90-day reports tohelp you track your incidence of VAP.

PriceIf you expected a VAP program this innovative would come at a pricepremium, you’re in for a pleasant surprise. VAPrevent from Medlinecomes to you for five to ten percent lower than competitors. In a tough,pay-for-performance environment, VAPrevent represents a major value.

References1 Bingham M, Ashley J, De Jong M, Swift C. Implementing a unit-level intervention to reduce the probabilityof ventilator-associated pneumonia. Nursing Research. 2010; 59(1): S40-S47.

2 Trouillet J, Chastre J, Vuagnat A, Joly-Guillou M, Combaux D, Dombret M, et al. Ventilator-associatedpneumonia cased by potentially drug-resistant bacteria. Am J Respir Crit Care Med. 1998. 157(2):531-539.


Clear visuals letyou identify theright kit quicklyfor your patient’sneeds

VAPrevent is a comprehensive system to give your staff the tools to deliver excellent oralcare. And for ventilator patients, excellent oral care may be part of the difference betweenventilator-associated pneumonia and staying healthy.

Evidence-based innovation in oral care for ventilator patients


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LEARN MORE ABOUT THE VAPREVENT SYSTEM

92 Healthy Skin

Make Your Facility a Greener Place to Work

Did You Know?• The National Institute for Occupational Safety andHealth (NIOSH) estimates that eight to 12 percent ofall healthcare workers have become allergic to latex.The likelihood of nurses developing asthma duringtheir career is 2.17 times greater if they used powderedlatex gloves. Latex-free gloves offer a safe alternativeand, with new technology, many feel just like latex.1

• Disinfecting and sterilizing agents and housekeepingchemicals can build up on surfaces and in the air eachtime cleaning or disinfecting occurs, and may lead toasthma, allergies, and other, more serious healthproblems. Besides using alternative products, facilitiescan increase education and awareness for staff onproper use and handling of chemicals. When mercury-containing equipment breaks, mercury vapors arespread through the air of a room where nurses workand breathe. Eliminate mercury-containing equipmentwherever possible at your facility.1

• 90 percent of nurses report workplace exposure tothe most commonplace healthcare hazards, whichinclude hand and skin disinfection products. Productsnurses use to clean or moisturize a patient’s skin or haircan contain ingredients that may be hazardous. Severalsafe alternatives exist that are not only safer for patientsand staff, but have less impact on the environment.


Environmental health is a concern for every nurse. Latex, chemical cleaners and disinfectants,

deodorizers, and skincare products all have been linked with allergies, skin or eye irritation and/or

asthma. Talk to your materials manager about implementing policies that support a healthier

work environment.

For more information on Medline’s Sustainability Program, contactFrancesca Olivier at 847-643-3821 or [email protected].

Reference

1 Environmental Working Group website. Nurses’ workplace exposures. Available at

http://www.ewg.org/node/28128. Accessed April 26, 2011.

Learn More and Take ActionJoin the EnviRN Knowledge Network, the online learningresource for nurses concerned about environmental health.It is made possible by the Alliance of Nurses for Environ-mental Health (ANHE), a national organization of nurses andnursing organizations working to promote healthy peopleand healthy environments by educating and leading thenursing profession, advancing research, incorporatingevidence-based research and influencing policy. Here arejust a few things you can do at EnviRN.org:

• Take the Nurses Pledge: By making simple changesin your everyday life, you can live and work in healthierenvironments. EnviRN is asking nurses to make threepersonal changes and three changes where you work.

• Click on “Essentials” for an introduction to the intersectionof environmental health nursing practice.

• At “Hazards A – Z” you will find a library onenvironmental hazards and the health concerns theytrigger, along with news articles and educationalresources.

Special Feature

94 Healthy Skin

3,100 Miles. 57 days. $208,613The Wound, Ostomy and Continence Nurses Society(WOCN), partnering with one of its founding members Dr.Katherine Jeter, age 72, embarked on one of its mostcomprehensive fundraising initiatives to date: Raising$208,613 in scholarship funds to support the continuededucation of WOC nurses.

Katherine began her journey with intensive training begin-ning in 2010, and then she traveled 3,100 miles by bicyclefrom San Diego, CA to St. Augustine, FL from March 4,through April 29, 2011.

CongratulationsDr. Jeter and WOCN!

San Diego, CA

Experience Katherine’s journey day by dayhttp://cyclingforscholarships.blogspot.com

Special Feature


With Age Comes Satisfaction“Although I’ve given up a lot of things this past year, I’mcompletely satisfied with what I’ve gained. Many ask me,“Has it been worth it?” In other words, have I sacrificedthings that I wish I had not? I won’t lie, I have missed somethings this past year, including entertaining friends at ourmountain home and some of the ski season, but it was allworth it.

“I’ve grown as a person. I’m working on maintaining ahealthy physique to prevent the recurrence of breast cancer.I have met a whole group of new friends. And I hope I'mencouraging young and old alike to be active.

I may be retired, but that doesn’t mean I should sit aroundand do nothing. It feels good to work toward growing asan individual, while giving back.”

Opposite page: Evonne Fowler, MSN, RN, CNS, CWOCN, sendsKatherine off with a smile at the start of the trip in California.

Above: Medline Clinical Education Specialist Kim Kehoe, BSN,RN, CWOCN, DAPWCA congratulates Katherine at the finish linein Florida.

St. Augustine, FL

How toENERGIZE

96 Healthy Skin


by Wolf J. Rinke, PhD, RD, CSP

YOUR TEAM

98 Healthy Skin

Let’s face it—health care is a team “sport.” No matter what yourcurrent role, sooner or later you’ll end up being a team leader.And when that happens, your success depends on your teammembers’ willingness to go the extra mile. (Hint: if you are notyet a team leader, read this anyway because the time topractice is now.) Here are six strategies to keep your teammembers “juiced.”

1. Treat all team members as if they are volunteers.I refer to this as the most important leadership principle of alltime. I discovered it while I was a Board member of one of myprofessional associations and the Chair for the Council onEducation. In that role the Board looked to me to implementnew Standards of Education, which had been in limbo forcountless years. A team of 12 professionals was on my com-mittee. All highly educated, all volunteers, all having their ownagenda. I quickly became aware that all the “crutches” that Irelied on during my “day job” did not work. For example, one ofmy committee members, let’s call her Julie, was really gung-ho.Any time there was a project to be done she was the first oneto volunteer. There was only one problem—Julie seldom deliv-ered. Forget delivering on time, she just did not deliver. At work,when any of my team members did that, I could counsel themand if that did not work I could use the ultimate “crutch”—I could fire them. Trying that with Julie, however, produced justthe opposite results. Her response: “Hey I don’t need this; I’moutta here—more time with the family.”

After banging my head against the proverbial brick wall severaltimes I finally figured out that my autocratic strategies simplydid not work with volunteers. I had to develop an entirely differentskill set to motivate these people. And after I had masteredthem, I transferred these new strategies to my “day job.” Forme this was a defining moment that enabled me to transformmyself from an autocratic manager to a highly effective leader.What was that concept? Are you ready for it? This is BIG! Drumroll please! Treat all employees as if they are volunteers.

Now, stop and think, what would you say to your team mem-bers if indeed they were volunteers? How about: "Please.""Thank you!" "Can I count on you?" "I need your help." "I reallyappreciate what you’ve done." "Thanks for being on my team!""Thanks for showing up." And now the one that blows theautocratic managers away: "Could you do me a favor?" Thatone just doesn’t sit well with lots of managers. Here are someof the things they’ve said to me: "What are you talking about?You’re paying them; they owe you a good job." Or "You’ve gotto be nuts. They are not doing you any favor, it’s their job," andso on. All really good arguments, and all really, really incorrect.(If you agree with any of these, it’s time to wake up and smell thecoffee. Because the only thing pay will do is get team membersto show up, and stay with you. (Not bad, but certainly not peakperformance.) And the fastest way to achieve peak perform-ance is to treat all employees as if they are volunteers.

2. Catch team members doing things almost right!Most of us were taught to supervise team members by catch-ing them making mistakes. Someone even gave it a name:management by exception. Unfortunately most team memberswill live up or in this case down, to your expectation. To reversethis, you will need to learn to catch team members doing thingsright. No wait, let me modify that, catch team members doingthings almost right! The problem is that if you are a perfection-ist some of your team members just have a tough time gettingit right, especially if right is defined as the way you would havedone it. Then you must compliment or recognize that positiveperformance in some way. In other words, you must learn to

...the fastest way to achieve peakperformance is to treat all employeesas if they were volunteers


©2011 Medline Industries, Inc. Medline is a registered trademarkof Medline Industries, Inc

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practice management by appreciation (MBA). Although difficultto master, this is a more powerful strategy than you will everlearn in any university MBA program. Catching team membersdoing things almost right means you use your abundant men-tal energy to look for your team members moving in the right di-rection, instead of using the same amount of energy to catchthem messing up. If you look hard enough, you will find thatmost team members do several things each day that they feelreally great about. Find it, and then be sure to make a big dealabout it, ideally in public. If you still find yourself slipping backinto old habits use the 10 penny system. Put 10 pennies in yourleft pocket or in case you don’t have pockets, the left side ofyour desk. Every time you catch one of your team membersdoing something almost right and let them know about it, trans-fer one penny from your left pocket to your right pocket. On theother hand if you provide negative reinforcement to one of yourteam members, reverse the process; but this time move threepennies back to the left pocket. Your goal is to have all penniesin your right pocket at the end of each day.

3. Make work fun.I learned a long time ago that if it’s fun, it gets done. So askyourself, are your team members having fun? Better yet askthem. It’s very hard to be motivated and energized if work is abig pain. In fact Sigmund Freud got this right when he identifiedthe Pleasure Principle, which basically says that all humanbeings move themselves in the direction of pleasure and movethemselves away from pain. So if you have a high turnover rate,have team members who abuse sick leave or have trouble get-ting team members to show up for work on time, you can besure that working for you is painful. What to do? Ask five of yourteam members to serve on a “Celebration or Fun Team.” Givethem a budget. If you don’t have one, suggest that they con-tact local merchants who’d love to achieve greater visibility inyour organization. Suggest that they ask those merchants tomake donations to your Celebration Team. Example: movie tick-ets, a weekend for two at a local resort, etc., etc. Just be sureto give those who donate lots of visibility. Now ask the Cele-bration Team to get together to identify specific things they areplanning to do each month that make work fun. Tell them any-thing goes, provided that they stay within their allocated budgetand it does not violate any laws, rules or regulations.

4. Be positive and energeticAttitudes, just like colds arecatching. Positive attitudes arecaught just as easily as negativeattitudes. The only problem isthat negative attitudes suck theenergy out of your team mem-bers like a giant sponge—some-thing your peak performers arejust not going to put up with. Onthe other hand, positive attitudesare like the little Energizer bunny.They will keep your team mem-

I learned a longtime ago that if it’sfun, it gets done.


HEELMEDIX™ Heel ProtectorPressure relief and skin protection all in one

The heels are the most common site for facility-acquired pressureulcers in long-term care, and the second most common site over-all.1 According to clinical experts, the most effective aspect ofpressure ulcer prevention for heels is pressure relief, also knownas offloading.1,2 Offloading is achieved with the use of pillows orheel protection devices that relieve pressure by elevating the heel.

The HEELMEDIX Heel Protector is designed to help eliminatepressure, friction and shear on the skin by elevating the heel.Made of soft, suede-like material on the inside and easy-to-cleannylon on the outside. Adjustable straps are soft against vulnerableskin. Includes a mesh laundry bag with patient ID label to simplifywashing and sorting.

Relieve Pressure on Vulnerable Heels


1Fowler E, Scott-Williams S, McGuire JB. Practice recommendations for preventing heel pressureulcers. 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.

Straight-back strappingprovides extra room,ventilation and protectionagainst foot drop

50%LESSFRICTIONthan the leadingcompetitor3

Criss-cross strappingisolates the foot andfloats the hell


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102 Healthy Skin

bers going, and going, and going (well, you get it.) To build apositive attitude, become aware of your conversations includingthe ones that you have inside of your head. Recognize that pos-itive language energizes you, and negative, cynical, “stinkingthinking” conversations de-energize you and your team mem-bers. Make it a practice to say positive things, especially aboutother people, or say nothing at all. Also recognize that yourmind can hold only one thought at a time. It can either be pos-itive or negative, it is your choice! So when you catch yourselfthinking positive thoughts, congratulate yourself. On the otherhand when you are thinking negative thoughts, catch yourself,change those thoughts, then give yourself credit. Rememberbecause of “mirror neurons” your team members take their cuefrom you! You must be the role model for the kind of behaviorsyou want them to exhibit. (For in-depth strategies of how tomake this happen read Make It a Winning Life--SuccessStrategies for Life, Love and Business available at http://wol-frinke.com/miwlbook.html.)

5. Build on team members' strengths.Statistics tell us that 25% of the US population hates what theydo, another 56% could take it or leave it, and only 19% lovewhat they do. Typically team members who love what they doare in jobs that let them build on their strengths. So find outwhat your team members love to do and do everything in yourpower to assign them to those projects or place them in thosepositions. What if you end up losing them? Think about it: wouldyou rather have team members who love what they do andhence are peak performers, or those who stick with youbecause they can’t get a job anywhere? Even your most dedi-cated team members are going to get burnt out really fast ifthey are not building on their strengths. So you would be muchbetter served to get team members in positions or projects thatenable them to build on their strengths even if you lose them.Just remember that whoever inherits one of your team mem-bers will be much more likely to reciprocate in the future. Plusthe team member who has left you will become an "ambas-sador of goodwill" for you. And in today's competitive healthcare industry, good will is a very valuable commodity when youneed to fill your next vacancy.

6. Get team members to listen to motivationalaudio programs.

Mary Kay sales associates, or for that matter all highly suc-cessful sales professionals, have this figured out. You must pro-vide team members with external motivation if you want themto consistently perform at peak performance. So start buildingan audio-program library. Suggest to your team members thatthey listen to a program every day on their way to work. Meetin brief weekly meetings and have team members share onepowerful principle they learned from each program. That wayeveryone can learn from everyone else, and energize each otherat the same time. Supplement these activities by showing a mo-tivational program during your next in-service. (Aren’t your teammembers getting tired of the same mandatory training?) Or bet-ter yet hire a motivational speaker to energize your next "allhands" team meeting. Your team members will be positivelysurprised, feel honored and energized. And when they areenergized everyone’s job will be much more enjoyable, and totop it all off, your patients will be less grumpy and may even getbetter faster.

© 2011 Wolf J. Rinke

Dr. Wolf J. Rinke, RD, CSP is a keynotespeaker, seminar leader, management con-sultant, executive coach and editor of the freeelectronic newsletter Read and Grow Rich,available at www.easyCPEcredits.com. In ad-dition he has authored numerous CDs, DVDsand books including Make It a Winning Life:Success Strategies for Life, Love and Busi-

ness, Winning Management: 6 Fail-Safe Strategies for BuildingHigh-Performance Organizations and Don’t Oil the Squeaky Wheeland 19 Other Contrarian Ways to Improve Your Leadership Effec-tiveness; available at www.WolfRinke.com. His company also pro-duces a wide variety of quality pre-approved continuingprofessional education (CPE) self-study courses, available atwww.easyCPEcredits.com. Reach him at [email protected].

Recognize that positivelanguage energizes you.

Yes, They’re Genuine.

Only Medline’s Pink Pearl™ gloves combinealoe, nitrile and breast cancer awareness.

©2011 Medline Industries, Inc.Medline is a registered trademarkand Pink Pearl is a trademark ofMedline Industries, Inc.

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Order pink gloves for BreastCancer Awareness Month

- Participate in breast cancer walk- Visit the National Breast Cancer

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- Remember to do monthly selfbreast exams.

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Oct

104 Healthy Skin

2011 Things to do

Countdown to Breast CancerAwareness Month!

Celebrate!

Special Feature


Medline celebratessix years of breastcancer awareness

Since 2006, Medline has been hosting “Together We Can SaveLives Through Early Detection” breast cancer awareness break-fast forums at the Association of periOperative RegisteredNurses (AORN) Annual Congress to raise breast cancer aware-ness and share the importance of early detection.

Every year, Medline invites a celebrity breast cancer survivor toshare her survival story and her own inspirational message ofhope. At the 2011 breakfast forum, held March 21 in Philadel-phia, Pa., more than 1,100 operating room nurses gathered tohear actors Jill Eikenberry and Michael Tucker, stars of the T.V.hit L.A. Law, talk about Eikenberry’s battle with breast cancer.

A big surprise occurred at the end of their talk when Eikenberrywas greeted by the nurse that cared for her during her initial boutwith breast cancer almost 25 years ago and again during herrecurrence two years ago.

"I took care of her both times and gave her extra care," saidRubita Conception, a perioperative registered nurse at TheMount Sinai Medical Center in New York City. "I am a regular atMedline's annual breast cancer awareness breakfast, but whenI saw that Jill and Michael were speaking, I had to make sure Icame today."

At the event, Medline Chief Marketing Officer Sue MacInnes pre-sented National Breast Cancer Foundation (NBCF) PresidentJanelle Hail with a check for $242,606 to help fund mammo-grams for underserved women. Over the past five years, Medlinehas donated more than three quarters of a million dollars to theNBCF as part of its campaign to promote early detection andawareness of breast cancer. Mammography is among the bestforms of screening for breast cancer. Early detection canincrease the five-year survival rate by 93 percent.1

Reference1. Survival rates for breast cancer. American Cancer Society website. Available at:

http://www.cancer.org/cancer/breastcancer/overviewguide/breast-cancer-overview-survival-rates <http://www.cancer.org/cancer/breastcancer/overviewguide/breast-cancer-overview-survival-rates>. Accessed April 28, 2011.

Special Feature

106 Healthy Skin

Healthy Eating

1 cup finely shredded cheddar cheese½ cup sour cream8 oz. cream cheese, softened1 pkg. taco seasoning12 green olives or green chiles/pimentos3 large tortillas

Directions:Mix ingredients together, and spread onto the tortillas. Roll uptortillas. Place into a zip lock bag and chill. When ready to serve,slice and serve with salsa.

Hint: Healthier alternative ~ low fat cheese and low fat sourcream and whole wheat tortillas may be used.

Judy DeSalvo, Marketing Business Manager – MundeleinJudy DeSalvo has been working at Medline for nine years. Shebasically “does it all” to keep the Marketing Department runningefficiently. Judy sees print projects through to completion, mak-

ing sure vendor estimates are correct oninvoices, all the way down to ensuringmarketing materials arrive on time and inthe right location at trade shows andmeetings. She’s often been sighted mov-ing boxes of brochures and Medline dolls,and she’s even been known to wield ascrewdriver to repair a piece of officeequipment in a pinch so coworkers canget their jobs done.

This recipe is Judy’s favorite appetizer, which she inherited fromher Aunt Judy a year ago. It’s a highly requested dish at themany events Judy attends.

Judy was also involved in creating Medline’s first and secondedition cookbooks, which feature recipes fromMedline employ-ees. The latest edition is available for purchase, and the pro-ceeds go to Medline’s Spirit of Giving fund, which helps supportMedline employees in times of need.

Aunt Judy’sTortilla Roll-Ups

NutritionInformation

Servings: 9Calories: 166Fat: 15.6 gSodium: 159 mgFiber: 0.1 g

�

The Medline employee cookbookis $10. To purchase your owncopy, please e-mail Judy [email protected].


The following pages containpractical tools for implementingpatient-focused care practices

at your facility.

FORMS & TOOLS

Wound CareWhat Type of Wound Is It?……………………………….108

Patient SafetyOne Needle, One Syringe, Only One Time………..…. .110Spinal Injection Procedures Performed withouta Facemask Pose Risk for Bacterial Meningitis……….117

DiabetesNational Diabetes Fact Sheet, 2011................................ 111


The following pages containpractical tools for implementingpatient-focused care practices

at your facility.

FORMS & TOOLS

Wound CareWhat Type of Wound Is It?……………………………….108

Patient SafetyOne Needle, One Syringe, Only One Time………..…. .110Spinal Injection Procedures Performed withouta Facemask Pose Risk for Bacterial Meningitis………..99

DiabetesNational Diabetes Fact Sheet, 2011................................ 111

108 Healthy Skin

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

Usually over a bony prominence

Usually circular

Can have viable or necrotic tissue

Can be very large or very small

Can vary from none to heavy

Can be localized, usually not seen

Usually not present

N/A

N/A

Usually, but often undertreated

• Remove necrotic tissue

• Maintain optimal moisture

• Protect periwound skin

• Control bioburden

• Remove pressure

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

Gaiter area (ankle to mid calf), oftenmeedial malleolus, may be circumferential

Irregular shaped

Usually shallow, can have viable ornecrotic tissue

Usually large

Can vary from none to heavy to general-ized weeping

Generalized edema to lower extremity

Usually seen

> 0.8

Usually normal, or undetectable dueto edema

Often in dependent position, with edema

• Compression

• Remove necrotic tissue


• Protect periwound skin

• Control bioburden

• Ensure lower extremity moisturization

Definition

Location

Wound Margin

Wound Bed

Wound Size

Exudate

Edema

Limb Staining

Ankle Brachial Index(ABI)

Pedal Pulses

Pain

Best Practice

WOUNDAPPEARANCE

PRESSURE VENOUS

What type of wound is it?


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

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

“Punched out,” well defined borders

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

Can be small, often increases due to lackof arterial perfusion

Minimal to no exudate

If present, localized

Usually not present

< 0.8< 0.5 - indicates inability to heal

Usually reduced or absent

Occurs at rest, nocturnal, or whenextremity is elevated

• If perfusion not adequate, considervascular consult

• If perfusion is adequate, follow protocolbased on wound assessment andcharacteristics

• If dry, stable eschar leave intact

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

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

Similar to arterial, usually with acallous edge

Similar to arterial

Often small

Similar to arterial

Similar to arterial

Similar to arterial

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

Not reliable

Due to neuropathy, pain may be absentor severe


• Control diabetes, if appropriate

• Repetitive removal of callous

• Bioburden control and preventionof systemic infection

• Remove pressure with appropriateoffloading shoe or other appliance

NEUROPATHIC/DIABETICARTERIAL

For more information, please visit:

www.ONEandONLYcampaign.org

The One & Only Campaign is a public healthcampaign aimed at raising awareness amongthe general public and healthcare providersabout safe injection practices.

1 needle1 syringe1 time+infections0

It’s elementary!

Patients and healthcare providers mustboth insist on nothing less than One Needle,One Syringe, Only One Time for each andevery injection.

Forms & Tools One & Only Campaign

National Center for Chronic Disease Prevention and Health PromotionDivision of Diabetes Translation

FAST FACTS ONDIABETES

CS217080A

National Diabetes Fact Sheet, 2011

Among U.S. residents aged 65 years and older, 10.9 million, or 26.9%,�

had diabetes in 2010.

About 215,000 people younger than 20 years had diabetes (type 1 or�

type 2) in the United States in 2010.

About 1.9 million people aged 20 years or older were newly�

diagnosed with diabetes in 2010 in the United States.

In 2005–2008, based on fasting glucose or hemoglobin A1c levels,�

35% of U.S. adults aged 20 years or older had prediabetes (50% of

adults aged 65 years or older). Applying this percentage to the entire

U.S. population in 2010 yields an estimated 79 million American

adults aged 20 years or older with prediabetes.

Diabetes is the leading cause of kidney failure, nontraumatic lower-�

limb amputations, and new cases of blindness among adults in the

United States.

Diabetes is a major cause of heart disease and stroke.�

Diabetes is the seventh leading cause of death in the United States.�

Diabetes affects 25.8million people8.3% of the U.S. population

DIAGNOSED18.8million people

UNDIAGNOSED7.0million people

All ages, 2010

Citation

Centers for Disease Control andPrevention. National diabetes factsheet: national estimates and generalinformation on diabetes and prediabetesin the United States, 2011. Atlanta, GA:U.S. Department of Health and HumanServices, Centers for Disease Control andPrevention, 2011.


CDC Diabetes Facts Forms & Tools

112 Healthy Skin

Heart disease and stroke

In 2004, heart disease was noted on 68% of diabetes-related death certificates among people aged 65 years or older.�

In 2004, stroke was noted on 16% of diabetes-related death certificates among people aged 65 years or older.�

Adults with diabetes have heart disease death rates about 2 to 4 times higher than adults without diabetes.�

The risk for stroke is 2 to 4 times higher among people with diabetes.�

Hypertension

In 2005–2008, of adults aged 20 years or older with self-reported diabetes, 67% had blood pressure greater than or equal to�140/90 millimeters of mercury (mmHg) or used prescription medications for hypertension.

Blindness and eye problems

Diabetes is the leading cause of new cases of blindness among adults aged 20–74 years.�

In 2005–2008, 4.2 million (28.5%) people with diabetes aged 40 years or older had diabetic retinopathy, and of these, 655,000�(4.4% of those with diabetes) had advanced diabetic retinopathy that could lead to severe vision loss.

Kidney disease

Diabetes is the leading cause of kidney failure, accounting for 44% of all new cases of kidney failure in 2008.�

In 2008, 48,374 people with diabetes began treatment for end-stage kidney disease.�

In 2008, a total of 202,290 people with end-stage kidney disease due to diabetes were living on chronic dialysis or with a kidney�transplant.

Nervous system disease

About 60% to 70% of people with diabetes have mild to severe forms of nervous system damage. The results of such damage�include impaired sensation or pain in the feet or hands, slowed digestion of food in the stomach, carpal tunnel syndrome,erectile dysfunction, or other nerve problems.

Almost 30% of people with diabetes aged 40 years or older have impaired sensation in the feet (i.e., at least one area that lacks�feeling).

Severe forms of diabetic nerve disease are a major contributing cause of lower-extremity amputations.�

Amputations

More than 60% of nontraumatic lower-limb amputations occur in people with diabetes.�

In 2006, about 65,700 nontraumatic lower-limb amputations were performed in people with diabetes.�

Complications of diabetes in the United States

Forms & Tools CDC Diabetes Facts


9

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9


BioCon™- 500Bladder ScannerSafely MeasuresBladder VolumeMinimize unnecessary catheterizationResearch has shown that 80 percent of urinary tract

infections acquired at healthcare facilities are associated

with an indwelling urethral catheter.1 This type of infection

is known as CAUTI, or catheter-associated urinary

tract infection.

Avoiding unnecessary catheter use

is a primary strategy for preventing

CAUTI, and clinical guidelines

recommend the consideration of

alternatives to catheterization.2

Bladder scanners 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-associatedurinary tract infections in acute care hospitals. Infect Control Hosp Epidemiol.2008;29:S41-S50.

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

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

©2011 Medline Industries, Inc.Medline is a registered trademark of Medline Industries, Inc.


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LEARN MORE ABOUT BIOCON-500

Preventing diabetes complicationsGlucose control

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CDC CLINICAL REMINDER

Spinal Injection Procedures Performedwithout a Facemask Pose Risk forBacterial Meningitis

Summary:

The Centers for Disease Control and Prevention (CDC) is concernedabout the occurrence of bacterial meningitis among patientsundergoing spinal injection procedures that require injection ofmaterial or insertion of a catheter into epidural or subdural spaces(e.g., myelogram, administration of spinal or epidural anesthesia, orintrathecal chemotherapy). Outbreaks of bacterial meningitisfollowing these spinal injection procedures continue to beidentified among patients whose procedures were performed by ahealthcare provider who did not wear a facemask (e.g., may belabeled as surgical, medical procedure, or isolation mask),1 with themost recent occurrence in October 2010 (CDC unpublished data).This notice serves as a reminder that facemasks should always beworn by healthcare providers when performing these spinalinjection procedures.2

Background:CDC has investigated multiple outbreaks of bacterial meningitisamong patients undergoing spinal injection procedures. Recentoutbreaks have occurred among patients in acute care hospitalswho received spinal anesthesia or epidural anesthesia, and alsoamong patients at an outpatient imaging facility who underwentmyelography.

In each of these outbreak investigations, nearly all spinal injectionprocedures that resulted in infection were performed by a commonhealthcare provider who did not wear a facemask. The strain ofbacteria isolated from the cerebrospinal fluid of these patients wasidentical to the strain recovered from the oral flora of the healthcareprovider who performed the spinal injection procedure. Thesefindings illustrate the risk of bacterial meningitis associated withdroplet transmission of the oral flora from healthcare providers topatients during spinal injection procedures.

National Center for Emerging and Zoonotic Infectious DiseasesDivision of Healthcare Quality Promotion

LICDCC MIEAL RCINLI RDENMI


CDC Clinical Reminder Forms & Tools

118 Healthy Skin

Since facemasks have been shown to limit spread of droplets arising from the oral flora,3 the CDC hasrecommended their use by healthcare providers when performing spinal injection procedures.2

In addition to wearing a facemask, healthcare providers should ensure adherence to all CDCrecommended safe injection practices including using a single-dose vial of medication for only onepatient.2

Recommendations:Anyone performing a spinal injection procedure should review the following CDC recommendations toensure that they are not placing their patients at risk for infections such as bacterial meningitis.

� Facemasks should always be used when injecting material or inserting a catheter into the epiduralor subdural space.2

� Aseptic technique and other safe injection practices (e.g., using a single-dose vial of medication orcontrast solution for only one patient) should always be followed for all spinal injectionprocedures.2

These recommendations apply not only in acute care settings such as hospitals, but in any setting wherespinal injection procedures are performed, such as outpatient imaging facilities, ambulatory surgerycenters, and pain management clinics.

Additional information is available at:http://www.cdc.gov/hicpac/2007IP/2007ip_part3.html

References:1. Centers for Disease Control and Prevention. Bacterial meningitis after intrapartum spinal

anesthesia - New York and Ohio, 2008-2009. MMWRMorbMortal Wkly Rep. 2010;59(3):65-9.

2. Centers for Disease Control and Prevention. 2007 Guideline for isolation precautions: preventingtransmission of infectious agents in healthcare settings. Available at:http://www.cdc.gov/hicpac/pdf/isolation/Isolation2007.pdf. Accessed January 25, 2011.

3. Philips BJ, Fergusson S, Armstrong P, Anderson FM, Wildsmith JA. Surgical face masks are effectivein reducing bacterial contamination caused by dispersal from the upper airway. Br J Anaesth.1992;69(4):407-8.

NCEZID Atlanta:For more information please contact Centers for Disease Control and Prevention1600 Clifton Road NE, Atlanta, GA 30333Telephone: 1-800-CDC-INFO (232-4636)/TTY: 1-888-232-63548Email: [email protected] Web: www.cdc.gov

Forms & Tools CDC Clinical Reminder

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

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fibroblast migration.2 The high

strength of the MicroScaffold2

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

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

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

In vitro studies show that Puracol Plus has the abilityto reduce the levels of elastase and MMPs fromsurrounding fluid.2

1. Schultz GS, Mast BA. Molecular analysisof the environment of healing and chronicwounds: Cytokines, proteases, and growthfactors.Wounds. 1998;10 (6 Suppl): 1F-9F.2. Data on file.

©2011 Medline Industries, Inc.Puracol is a registered trademark of Medline Industries, Inc.Medline is a registered trademark of Medline Industries, Inc.


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©2011 Medline Industries, Inc. Medline and Remedyare registered trademark of Medline Industries, Inc.

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healthy skin magazine - volume 9; issue 2

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