Improving Quality of Care Based on CMS Guidelines

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Content KeyWe’ve coded the articles and information in this magazine to indicate which national quality initiatives they pertain to. Throughout the publication, when you see these icons you’ll know immediately that the subject matter on that page relates to one or more of the following national initiatives:•QIO–UtilizationandQualityControlPeerReviewOrganization•AdvancingExcellenceinAmerica’sNursingHomes

We’ve tried to include content that clarifies the initiatives or gives you ideas and tools for implementing their recommendations. For a summary of each of the above initiatives, see Pages 6 and 7.

Improving Quality of Care Based on CMS Guidelines 95

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Page 51

Page 42

Page 62

Page 36

Survey Readiness

24 Pressure Ulcer Rates: Prevalence and Incidence

36 Butterflies in the Nursing Home

42 Embracing Change: Promoting a Continence Management Program

in Your Facility

Prevention

48 Challenges of Preventing Moisture Associated Skin Damage in the

Intensive Care Units Using No Sting Spray Skin Protectant

62 Automated Hand Hygiene Compliance Monitoring Systems

Special Features

9 Maintaining Quality Care During Challenging Times

14 2012 Prevention Above All Discoveries Grant Program

15 2011 Prevention Above All Discoveries Grant Recipients

17 Identification of Staff RN’s Ability to Assess Community-Acquired

Pressure Ulcers Among Ethnically Diverse Patients

27 Pressure Ulcer Prevalence Day

32 Impact of Pressure Ulcers Across Care Settings

51 The Bathing of Older Adults with Dementia

72 New QA System Improves Resident Quality Care; Builds Staff Morale

83 Congratulations, Lexington Medical Center: First Place Winner Pink

Glove Dance Competition

Regular Features

6 Two Important Quality Initiatives for Improving Quality of Care

68 Hotline Hot Topic: Addressing Resistance to New Types of Wound

Dressings for Skin Tears

Caring for Yourself

76 Fear: How to Kill It Dead!

86 Healthy Eating: Roasted Winter Vegetables

Forms & Tools

89 Cover Your Cough

90 Supporting Your Employees’ Physical Activity Goals

91 Safe Disposal of Needles and Other Sharps

92 Device Decision Guide

HealtHy Skin

EditorSue MacInnes, RD

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

Senior WriterCarla Esser Lake

Creative DirectorMichael A. Gotti

Clinical Team

Dionie Bibat, BSN, RN, WOCN

Clay Collins, BSN, RN, CWOCN, CFCN, CWS, DAPWCA

Lorri Downs, BSN, RN, MS, CIC

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 Board

Christine 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, PhD, RN, APN-C, 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 76

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

Improving Quality of Care Based on CMS Guidelines 3

©2012 Medline Industries, Inc. Healthy Skin is published by Medline Industries, Inc. One Medline Place, Mundelein, IL 60060. 1-800-MEDLINE.

4 Healthy Skin

The “patient” has always been the focus. However, today, the patient is an even more integral part of the culture of health care than ever before. Why? Because our potential patients have higher expectations, their families have higher expectations and each of them wants to participate in both decision making and the care they will receive. The “patient experience” has taken on new meaning. It is no longer about “satisfaction.” A satisfied patient feels that his or her care is average. Average does not make patients raving fans of your in-stitutions. Today consumers want an “experience” that is memorable, an experience they would like to share with a friend. Good is no longer good enough. And it’s no wonder, because we, as consumers, are paying a lot for health care and expect to get what we are paying for. We do not expect to pay a lot to be the unfortunate recipient of medical errors, infections or complications.

So as we move closer to a healthcare model where we all must work together, it’s time we started learning about each other. This edition has a lot of information and insight on just one leg of the healthcare continuum: skilled nursing care. Skilled nursing care is an important part of the continuum of care. If you work in an acute care setting, you need to understand your partners out-side of the hospital. Skilled nursing care today includes patient-centered care, participation of families and resi-

dents and choices involving dignity and an environment you would want for your own mother or father.

Hopefully this edition of Healthy Skin will begin to bridge the gap between all of us as we focus on some of the key issues in long-term care, i.e. bathing with dignity, the long term care survey process, the changing culture and importance of establishing a robust continence care program. These are but a few of the topics discussed in this edition.

It is an exciting time, a time to learn and share with each other. If you work in the acute care setting, use this opportunity to see how you can reach out to your long-term care and home care affiliates. If you are a long-term care or home care professional, begin with creating rela-tionships in the hospital setting. You can only learn from each other. And, those educational experiences will begin to bridge the gap, ultimately building a transparent process regardless of who is providing the health care.

Thanks for listening, and I welcome your comments.

Sue MacInnes, RDEditor

Healthy Skin Letter from the Editor

It’s 2012 and things are changing rapidly in health care. No longer can different care set-tings maintain their own personal individuality. It’s time for all of us to push for collaboration,

teamwork and communication to include all providers of care…the hospital, the skilled nurs-ing facility, the homecare setting and the physician’s office. Basically anywhere the patient goes for health care needs to be a part of a cooperative system operating with one voice…guiding the patient between settings, communicating necessary data, following up amongst each other as professionals and sharing our successes so that everyone benefits.

Healthy Skin Letter from the Editor

• Averagereductioninfacility-acquired pressureulcers:67.8%

• Averageannualsavings:$153,000

How does it work?With a compelling combination of products and education:1. Medline’s strategic product bundle, including skin care and incontinence products2. Medline’s free educational program for nurses and nursing assistants, including 4 CE credits for nurses plus online, interactive competencies

©2012 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.

If you are interested in:

Implementing a program that allows you to achieve these results and sustain them over time

Reducing the incidence of pressure ulcers at your facility

Learning more about Medline’s Pressure Ulcer Prevention Program

Get results with Medline’s Pressure Ulcer Prevention Program

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

VIEWAPRESSUREULCERPREVENTIONPROGRAMSUCCESSSTORY

6 Healthy Skin

Two Important National Initiatives for Improving Quality of Care

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

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

Origin: The QIO Statement of Work is based upon Part B of the Title XI of the Social Security Act. The Medicare-funded “10th Scope of Work” plan became effective August 1, 2011 and will remain in effect through July 31, 2014.

Purpose: To carry out statutorily mandated review activities, such as: • Reviewingthequalityofcareprovidedtobeneficiaries; • Reviewingbeneficiaryappealsofcertainprovidernotices; • Reviewingpotentialanti-dumpingcases;and • Implementingqualityimprovementactivitiesasaresultofcasereviewactivities.

Of note: QIOs are required to help Medicare promote Four Aims: 1. Beneficiary and family-centered care 2. Improve individual patient care - Reduce healthcare-associated infections - Reduce healthcare-acquired conditions by 40% in nursing homes - Reduce adverse drug events and medication harm 3. Integrate care for populations and communities - Improve quality of care for Medicare patients through a comprehensive community effort designed to reduce readmissions following hospitalization by 20% over three years 4. Improve health for populations and communities - The QIO shall improve participation in the Physician Quality Reporting System (PQRS) and improve the use of EHR for care management

Under the direction of the Centers for Medicare and Medicaid Services (CMS), the QIO Program consists of a national network of 53 QIOs located in each of the 50 U.S. states, the District of Columbia, Puerto Rico and the Virgin Islands.

Origin: A coalition-based campaign initiated on September 26, 2006 to improve quality of life for nursing home residents and staff. Purpose: A coalition consisting of the Centers for Medicare & Medicaid Services (CMS), organizations representing providers, consumers and government that developed a grassroots campaign to build on and complement the work of existing quality initiatives including Nursing Home Quality Initiative (NHQI), Quality First and the culture change movement.Goal: To ensure that continuous quality improvement is comprehensive, sustainable and consumer-focused, the coalition has adopted goals that seek to improve clinical care, incorporate nursing home resident and family satisfaction surveys into continuing quality improvements and increase staff retention to allow for better, more consistent care for nursing home residents.

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

QIO Utilization and Quality Control Peer Review Organization 10th Round Statement of Work1

Advancing Excellence in America’s Nursing Homes2

Improving Quality of Care Based on CMS Guidelines 7

QIO Utilization and Quality Control Peer Review Organization 10th Round Statement of Work

Advancing Excellence in America’s Nursing Homes

Three Key HHS Activities Shape the 10th Statement of Work: • NationalQualityStrategy • PartnershipforPatients • HHSActionPlantoPrevent Healthcare-AssociatedInfections

National Quality StrategyThreeBroadAims: 1. Betterhealthcare 2. Betterhealthforpeopleandcommunities 3. Lowercoststhroughimprovement

SixPriorities: 1. Makingcaresafer 2. Promotingeffectivecoordinationofcare 3. Assuringcareisperson-andfamily-centered 4. Promotingthebestpossiblepreventionandtreatment oftheleadingcausesofmortality,startingwith cardiovasculardisease 5. Helpingcommunitiessupportbetterhealth 6. Makingcaremoreaffordableforindividuals,families, employersandgovernmentsbyreducingcostsofcare throughcontinualimprovement

Partnership for PatientsTwoGoals: 1. Keeppatientsfromgettinginjuredorsicker.Bytheend of2013,preventablehospital-acquiredconditionswould decreaseby40%comparedto2010. 2. Helppatientshealwithoutcomplication.Bytheendof 2013,preventablecomplicationsduringatransitionfrom onecaresettingtoanotherwouldbedecreasedsothat allhospitalreadmissionswouldbereducedby20% comparedto2010.

HHS Action Plan to Prevent Healthcare-Associated Infections TwoTiers: 1. Focusonsixhigh-priorityHAI-relatedareaswithinthe acutecarehospitalsetting: • Surgicalsiteinfections • Centralline-associatedbloodstreaminfections • Ventilator-associatedpneumonia • Catheter-associatedurinarytractinfections • Clostridiumdifficile • Methicillin-resistantStaphylococcusaureus(MRSA)

2.Expandeffortsoutsideoftheacutecaresettinginto outpatientfacilities,includingstrategiestoreduceHAIsin ambulatorysurgicalcentersandend-stagerenaldisease facilities,aswellasastrategytoincreaseinfluenza vaccinationcoverageamonghealthcarepersonnel

10th Statement of Work (SOW)

Goal 1 – Staff Turnover: Nursinghomeswilltakestepstominimizestaffturnoverinordertomaintainastableworkforcetocareforresidents.

Goal 2 – Consistent Assignment:Beingregularlycaredforbythesamecaregiverisessentialtoqualityofcareandqualityoflife.Tomaximizequality,aswellasresidentandstaffrelationships,themajor-ityofNursingHomeswillemploy“consistentassignment”ofCNAs.

Goal 3 – Restraints:Nursinghomeresidentsareindependenttothebestoftheirabilityandrarelyexperiencedailyphysicalrestraints.

Goal 4 – Pressure Ulcers:Nursinghomeresidentsreceiveappropriatecaretopreventandappropriatelytreatpressureulcerswhentheydevelop.

Goal 5 – Pain:Nursinghomeresidentswillreceiveappropriatecaretopreventandminimizeepisodesofmoderateorseverepain.Objectivesforlongstayandshortstayareslightlydifferent.

Goal 5A:LongStay(longerthan90days)nursinghomeresidentswillreceiveappropriatecaretopreventandminimizeepisodesofmoderateorseverepain.

Goal 5B:ShortStay(shorterthan90days)Peoplewhocomefromahospitaltoanursinghomeforashortstaywillreceiveappropriatecaretopreventandminimizeepisodesofmoderateorseverepain.

Goal 6 – Advance Care Planning:Followingadmissionandpriortocompletingorupdatingtheplanofcare,allNHresidentswillhavetheopportunitytodiscusstheirgoalsforcareincludingtheirpreferencesforadvancecareplanningwithanappropriatememberofthehealth-careteam.Thosepreferencesshouldberecordedintheirmedicalrecordandusedinthedevelopmentoftheirplanofcare.

Goal 7 – Resident/Family Satisfaction: AlmostallNursingHomeswillassessresidentandfamilyexperienceofcareandincorporatethisinformationintotheirqualityimprovementactivities.

Goal 8 – Staff Satisfaction:Almostallnursinghomeswillassessstaffsatisfactionwiththeirworkenvironmentatleastannuallyanduponseparationandincorporatethisinformationintotheirqualityimprovementactivities.

Advancing Excellence Phase 2 Goals

Participating nursing homes: 7,894Percentage of participating nursing homes:* 50.4% Participating consumers: 3,138

VisitthisWebsitetoviewprogressbystate!www.nhqualitycampaign.org/star_index.aspx?controls=states_map

*Based on the latest available count of Medicare/Medicaid nursing homes

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Improving Quality of Care Based on CMS Guidelines 9

Maintaining Quality Care During Challenging TimesReducing costs while simultaneously improving care delivery is perhaps the central challenge for healthcare leaders today. American Health Care Association (AHCA) ABM Committee President and AHCA board member Shawn Scott, who works with the long-term care sector in his position with Medline, recently had the opportunity to speak with AHCA President and CEO Mark Parkinson, and AHCA Quality Officer David Gifford. You will find they share the same desire for collaboration across the continuum of care as leaders in other healthcare fields, such as acute care and home care.

In a time when there are budget cuts and budgets are tight, it’s really tempting to pull back on quality initiatives and quality measures, but we really need to do just the opposite. We have to continue to put quality at the forefront of everything we do because if we don’t, we’re not going to do well. If we do, the profession will thrive for a long time.”

Mark Parkinson, AHCA president and CEO,

45th Governor of the State of Kansas

“Shawn Scott: We’ve all heard about the Super Committee

and how Congress couldn’t agree on a plan to reduce the

deficit. We know that sequestration triggered an automatic

2% cut to Medicare providers. What can you tell us about

how AHCA views these cuts and their impact on the long-

term and post-acute care sector?

Mark Parkinson: The LTC sector has taken a significant number of cuts. They started out with the automatic cuts we received with the passage of the Affordable Care Act. Every year we now take a productivity adjustment that lowers our rates a little over 1%. Those were followed by cutbacks in states to Medicaid programs. Over 30 states have either frozen or reduced Medicaid rates. Most recently, Congress has put another 2% cut on us with sequestration.

SS: How do you think facility members will be affected by

these cuts?

MP: Each of the cuts has hurt, and when you add them up, they are an enormous problem. Collectively, these cuts have put the sector on the brink. Facilities that take care of the poorest members of the greatest generation, and therefore rely on Medicaid, are at risk of losing money. The combination of the cuts that we have already taken is taking its toll, and we’re at a point where we just can’t take any more cuts. So that’s been our clear message here on Capitol Hill, and it will continue to be our message.

Special Feature

10 Healthy Skin

SS: Knowing that skilled nursing facilities will still be held to

high quality standards by CMS despite the reimbursement

cuts, what can AHCA’s membership do to continue to meet

these standards?

MP: First, I am very proud that our members have been committed to making sure not to cut frontline nursing staff. They have gone out of their way to do everything they can to reduce the impact of the cuts on our residents. Instead, they’ve had to get creative and reduce costs in other areas, but they’re at a point where there just aren’t any more areas to cut. Over 50% of costs are in labor. If there are additional cuts, the consequence will be layoffs.

Our members are implementing technologies into their operations. The overall economy has seen a tremendous increase in productivity as we’ve integrated more technological advances into everyday business operations. Healthcare has been slow to do that. But our members are realizing that they need to speed that process along. So, you see more of them implementing electronic medical records (EMRs) and other systems to reduce costs and improve efficiencies.

SS: What suggestions would you give to companies such

as Medline on how they might help skilled nursing facilities

with today’s challenges?

MP: Our vendors have been very supportive of our membership during this difficult time, and we greatly appreciate the support. I tell our vendors that our members need products that both reduce our costs and improve quality.

A good example is a product Medline’s very involved with – abaqis. A lot of nursing homes have had a really difficult time transitioning to the QIS survey. They’ve had to spend an inordinate amount of time adjusting to the survey, reacting to bad surveys, and in some cases, even having to pay civil monetary fines because of bad surveys. The abaqis product has come in and helped people understand how to get through the survey process in a more seamless way, reducing deficiencies and increasing their overall operational ability. I think that’s one reason why the abaqis product has done so well.

Additional helpful products are those that allow nurses to walk around the floors and instantly pull up records and record exactly what’s happening with the residents. This is another way efficiencies have increased.

SS: This is the time of year when people are making

New Year’s resolutions. What would you say are AHCA’s

resolutions for 2012?

MP: Our resolution must be to continue our quality efforts. It is essential that we continue our quality improvement because it’s the right thing to do. It’s the reason most of our members got into this profession in the first place. It’s also critical because as payment models change, if we don’t continue along this quality journey, the nursing home sector is going to get left out. In a time when there are budget cuts and budgets are tight, it’s really tempting to pull back on quality initiatives and quality measures, but we really need to do just the opposite. We have to continue to put quality at the forefront of everything we do because if we don’t, we’re not going to do well. If we do, the profession will thrive for a long time.

The combination of the cuts that we have already taken is taking its toll, and we’re at a point where we just can’t take any more cuts.”“

Continued on page 12

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12 Healthy Skin

The skilled nursing facility of the future will be much more integrated into the healthcare delivery system with better relationships with the hospitals, emergency departments, physicians and home health agencies”

David R. Gifford, AHCA Senior VP of Quality and Regulatory Affairs,

former Director, Rhode Island Department of Health

“

Shawn Scott: The Affordable Care Act requires all skilled

nursing facilities to develop Quality Assurance and

Performance Improvement (QAPI) programs. Can you

explain what skilled nursing facilities need to do to develop

these programs?

David Gifford: CMS is still working on the requirements for these programs, but basically the objective is to move toward a proactive improvement approach. Rather than waiting until something bad happens, facilities need to devise strategies in advance. The programs should focus on more proactive improvements that allow staff to be more engaged in the process.

SS: We understand that you are an expert in the field of

quality, and you have been tasked by AHCA to develop

new programs to help association members provide high-

quality, person-centered care. Can you tell us a little about

AHCA’s quality objectives for 2012?

DG: I am very excited to be a part of AHCA. In the past the industry has approached quality improvement using a “disease of the month approach.” But we have found that there’s no spillover effect to other areas with that approach. It’s also difficult to sustain gains.

Now, we are focusing on four broad areas of quality improvement for 2012: preventing re-hospitalization, increasing staff stability, improving customer satisfaction and better management and prevention of behavior problems among individuals with dementia.

We see these four strategies fitting together, and I think they all complement each other. We are very excited that we will see changes not only in these specific areas but positive changes across the board.

SS: How does rehospitalization affect skilled nursing

facilities and why should they be concerned about

this issue?

DG: A lot of individuals come back from the hospital in worse condition than when they left the skilled nursing facility. They often return with pressure ulcers, HAIs, or are generally more debilitated. Sending an individual to the hospital is not always in their best interest. Actually, some data suggest that pneumonia (a leading cause for hospitalization) can be managed with the same outcomes by keeping the individual in the nursing facility rather than sending them to the hospital. Also, rehospitalization is a marker that people are declining and nearing the end of life. We need to have a better dialogue about end-of-life decisions regarding these individuals. Lastly, it’s really costly to have someone go back to the hospital, and hospitalizations in general are the major driver of healthcare costs in this country. The high costs of hospital care are making all of healthcare unsustainable. When we know you can manage someone just as effectively and it saves money, it’s a win-win situation and so that’s one of the reasons we think it’s very important. And if hospitalizations are not lowered, Medicare and payers are starting to cut payments until we do a better job.

SS: What are your thoughts on staffing stability and why

is this issue so important in the skilled nursing and post-

acute care sector?

DG: In fact, data suggest that in skilled nursing facilities staff retention is more highly associated with better quality measures than nurse-patient ratios. Data is also pretty strong that stable, consistent staffing helps prevent a lot of different problems across a whole array of diseases and conditions. Low turnover makes it easier to sustain programs. And when staff

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get to know residents and families, they are much more likely to notice problems early and get them treated before they lead to hospitalization or behavior problems. Also, it’s very costly to hire new staff in recruiting time, training, and overtime or outsourcing to cover empty positions. SS: How is quality going to be measured through customer

satisfaction?

DG: The only way to measure customer satisfaction is to ask the customer how satisfied they are. The two most important questions are: 1. How satisfied are you with the care you are receiving overall? 2. Would you recommend this facility to someone else? Those are the two most critical questions in pretty much every satisfaction survey instrument I’ve seen.

SS: Why is it so important to manage behavior issues in

individuals with dementia?

DG: A big component is that behavior issues often lead to prescribing a lot of different medications, which have adverse effects on individuals. Maintaining consistent staffing and understanding individuals and their preferences for waking, sleeping, and dining all really help prevent individuals with dementia from developing chronic behavior problems that are harmful to staff and other residents. Managing the behaviors in this way also helps prevent over-prescribing of medications.

SS: Everyone is very excited to have you on board with AHCA leading the drive for quality. What do you envision a skilled nursing facility of the future will look like?

DG: I’m really excited to be a part of AHCA. They have a long history of being committed to quality. Joining their team and being able to deal with the issues facing our members and nursing facilities as a whole – it’s just an exciting time. The skilled nursing facility of the future will be much more integrated into the healthcare delivery system with better relationships with hospitals, emergency departments, physicians and home health agencies, and will be providing a much wider range of services. Right now, nursing facilities mainly provide either skilled care after being hospitalized or long-term care for individuals who can’t go home. In the future, I believe they will be utilizing adult day care activities and visiting therapy services. I see a redesign that is less institutional and much more homelike, where the staff and residents are working more closely together on making sure that each resident can access the activities they want in terms of dressing, bathing, dining, waking and sleeping. The general perception of years past of nursing home residents just playing bingo and doing arts and crafts has already changed, but I really expect them to change even more in the near future.

14 Healthy Skin

2012 Prevention Above All Discoveries Grant ProgramSupporting the adoption of solutions and interventions into everyday practice

In today’s healthcare environment, healthcare-acquired conditions, once considered a “side effect,” are no longer accepted. The government does not accept them, patients are not accepting them and the facilities themselves continually look for ways to build better systems to improve the quality of care. Knowing that clinicians in the field have some of the best ideas for improving care, Medline launched the Prevention Above All Discoveries Grant Program in 2008 as a way to help stimulate the gathering of solid evidence that supports the adoption of solutions into clinical practice. Through this innovative program, Medline has awarded more than $1.1 million in funding to front-line healthcare workers researching evidence-based solutions and interventions for the very conditions that CMS has declared as preventable.

Medline is accepting letters of intent from May 1 through June 30, 2012 for the 2012 Prevention Above All Discoveries Grant program and intends to award up to $1 million in grants for research on innovative ideas and evidence-based practices that will improve patient safety and quality of care. Healthcare providers interested in submitting letters of intent can apply for one of two funding categories: Pilot Grants of up to $25,000 for projects that can be completed within six months; or Empirical Study Grants of up to $100,000 for projects completed within 12 months.

How to apply for a grant More information about the grant program, as well as a sample letter of intent, can be found at www.medline.com/prevention-above-all/grants.asp. To submit a grant letter of intent, contact Toni Marchinski, grant coordinator, at grantprogram@medline.com or call 866-941-1998.

“Historically, these research projects are great ideas that could significantly help in the fight against some of the toughest hospital-acquired conditions,” said Andrew

Kramer, MD, Head of the Department of Medicine’s Health Care Policy and Research Division at the University of Colorado and Grant Review Committee Chair.

“What’s unique about this funding is that it is all going to providers who are on the front lines of health care. The feedback this group gives us is critical to advancing healthcare technology.”

Improving Quality of Care Based on CMS Guidelines 15

2011 Prevention Above All Discoveries Grant Recipients

Title: CAUTI Prevention Program

Institution: Piedmont Healthcare Philanthropy, North Carolina

Principal Investigator: Monica Tennant & Dee Tucker

Title: Incidence of Falls Among Oncology Patients Who Are Cared for by Family Caregivers within Their Home.

Institution: Siteman Cancer Center at Barnes Jewish Hospital, Missouri

Principal Investigator: Patricia Potter, RN, PhD, FAAN; Marilee Kuhrik RN, PhD; Nancy Kuhrik RN, PhD, Sarah Olsen RN, BSN.

Title: Quick Room Turnaround Time (QRTAT) Ultraviolet Light Disinfection for Decreasing HAI

Institution: Ohio State University Hospital, Ohio

Principal Investigator: Christina Liscynesky, MD & Julie E. Mangino, MD

Title: Warfarin Safety Pilot Program

Institution: Foundation for Quality Care, New York

Principal Investigator: Nancy Merlino Leveille, RN, MS & Darren M. Triller, Pharm.D.

Title: Sensor Technology for Tracking and Displaying Bed Elevation Data for Mechanically Ventilated Patients

Institution: University of Iowa Hospital, Iowa

Principal Investigator: Alberto Maria Segre, Philip Polgreen, Geb Thomas, Ted Herman

Title: Testing Patient Education Handbooks

Institution: Good Samaritan Hospital, Pennsylvania

Principal Investigator: Patricia Donley, RN, MSN, Stephanie Andreozzi, Doctorate in Physical Therapy

Title: Using GRASP as Home Treatment for Upper Extremity (UE) Paresis Post-Stroke

Institution: Abbotsford Regional Hospital, Canada

Principal Investigator: May Chan, B.OT, Janice Eng, Ph.D. PT, OT, Shu-Hyun Jang, M.Sc.OT

Title:

A Standardized Process of Preoperative Body Cleansing with Comfort Bath® Cleansing Washcloths

Compared to Sage® 2% Chlorhexidine Gluconate (CHG) Cloths to Reduce Prosthetic Joint Infections at

Cambridge Hospital

Institution: Cambridge Health Alliance, Harvard Medical Center, Massachusetts

Principal Investigator: Lou Ann Bruno-Murtha, DO, Virginia Caples, RN, CIC and Diane Lancaster, RN, PhD

Title: Falls Risk Assessment Study

Institution: Provena St. Joseph Medical Center, Illinois

Principal Investigator: Jackie Medland RN, PhD

Title: The Effectiveness of Team Training on Fall Reduction

Institution: Wellstar Health System, Georgia

Principal Investigator: Bethany Robertson, LeeAnna Spiva & Marcia Delk, MD

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Improving Quality of Care Based on CMS Guidelines 17

Identification of Staff RN’s Ability to Assess Community-Acquired Pressure Ulcers Among Ethnically Diverse Patients: Hispanics and African Americans Utilizing Simulation

Katherine Ricossa, MS, RNPrincipal Investigator, Director of EducationKaiser Permanente - San Jose, CaliforniaEmail: Kathy.Ricossa@kp.org

CE ARTICLE

1. Purpose, aims, hypotheses or research questionsAre RNs able to identify community-acquired pressure ulcers among ethnically diverse patient populations: Hispanics and African-Americans utilizing simulation?

2. Background and significanceRegulatory agencies such as the Department of Health and Human Services are required to be notified when a patient exhibits a Stage III pressure ulcer. If a nurse does not identify a community-acquired pressure ulcer upon admission, then it will be considered a hospital-acquired pressure ulcer, and the hospital will have to manage and treat this pressure ulcer as if it occurred in the hospital. It is in the best interest of hospitals to train RN staff to completely assess skin integrity to prevent a community-acquired pressure ulcer from turning into a hospital-acquired pressure ulcer for the health of the patient and subsequently reduce financial cost burden to the hospital.

There are few research studies on ethnically diverse patients with pressure ulcers. Upon reviewing the few articles that focus on pressure ulcers and ethnically diverse patients, most of those articles focus on prevention by using the Braden Scale as a risk indicator. There are no articles that discuss actual identification or lack of pressure ulcer detection on ethnically diverse patient populations.

3. Methods (design, sample characteristics, measures or instruments, procedures for data collection and data analysis)Prior to implementing the study, a pilot group tested the methods which were used, and changes were made accordingly. A randomized, controlled, crossover trial was conducted with a convenience sample of 72 staff RNs from Patient Care Services (Maternal Child, Med /Surg, Telemetry, Stepdown, ICU and ED).

Admission assessments were performed on simulated patients with dark pigmented skin and bony prominences while examining under medical assistive devices. Study subjects were randomly assigned to either the control or

Abstract:

Special Feature

Research Study Funded by Medline Industries, Inc.

Prevention Above All Discoveries Grant

18 Healthy Skin

CE ARTICLE

intervention group. The morning group was given two scenarios in which the RN was to perform an initial admission assessment without prompts to focus on skin assessment utilizing Hispanic and African-American mannequins as a baseline. Each mannequin, Hispanic and African-American, demonstrated the same pressure ulcer location, number and level of breakdown. After the first scenario was completed, targeted skin integrity education was presented, including deconditioning and assessing two Caucasian simulated models: pelvis and foot with pressure ulcers. Group 2 Post Intervention Group identified the number of pressure ulcers on a Caucasian simulation buttock and foot prior to participating in the two scenarios described above.

4. Data findings, results and conclusionsThere were no differences between Hispanic and African-American assessments of pressure ulcers. A slight improvement was noted between the morning session and the afternoon session. The skin integrity education supported the RNs’ ability to conduct a more thorough assessment of pressure ulcers during the afternoon session.

5. Implications for practice and further studyThis small study demonstrated further research is needed into additional education in assessing ethnically diverse patients and in-hospital devices that can contribute to pressure ulcers. The post test should have been conducted within four to six weeks post intervention to determine a difference between the baseline and post test. Skin beneath devices must be assessed with education and training provided initially upon hire and annually there after. Homogenous populations may need additional training on ethnic skin.

6. AcknowledgementThank you to Medline Industries, Inc. for funding this research study.

Abstract (continued):

Identification of Staff RN’s Ability to Assess Community-Acquired Pressure Ulcers Among Ethnically Diverse Patients: Hispanics and African Americans Utilizing Simulation

Improving Quality of Care Based on CMS Guidelines 19

such as the Department of Health and Human Services are required to be notified when a patient exhibits a hospital-acquired Stage III pressure ulcer or greater. It is in the best interest of hospitals to train RN staff to completely assess skin integrity upon admission to identify a CAPU from turning into a HAPU for the health of the patient and subsequently reduce financial cost burden to the hospital (Lapsley, 1996).

It is critical to assess any patient carefully and examine skin for any breakdown and lesions at the front end. However, it is more important to critically assess ethnically diverse patients since the skin pigment is varied and may obscure the nurse’s initial assessment of skin breakdown. Additionally, pressure ulcers have been found beneath devices and nurses need to remove them and inspect those vulnerable areas.

In the literature there are numerous articles on skin and pressure ulcers. However, there are few research studies on ethnically diverse patients with pressure ulcers. One study focused on the occurrence of pressure ulcers among Hispanics (Gerardo, 2009), while another study examined risk factors of pressure ulcers among African-Americans (Fogerty, 2009). However, most articles focus on prevention by using the Braden Scale as a risk indicator. There are no articles that discuss the actual assessment or identification of pressure ulcers on ethnically diverse patient populations.

IntroductionThe aim of this study is to determine whether registered nurses (RNs) are able to identify community -acquired pressure ulcers (CAPUs) on patients with dark pigmented skin on admission to the hospital. The research question asked: Are RNs able to identify community -acquired pressure ulcers among ethnically diverse patient populations: Hispanics and African-Americans utilizing simulation?

Background and significanceIn the United States, regulatory agencies such as the Department of Health and Human Services are required to be notified when a patient exhibits a hospital-acquired pressure ulcer (HAPU) stage III or greater. If nurses do not identify a CAPU upon admission, then it will be considered a hospital-acquired pressure ulcer with the hospital being responsible to manage and treat this pressure ulcer without reimbursement. In addition, many health insurers and Medicare are no longer paying for hospital-acquired pressure ulcers. “The new rule will result in hospitals seeing substantial reductions in payment for the care of individual patients with preventable complications” (Rosenthal, 2007, 1573). It is estimated that 2.5 million patients are treated for pressure ulcers in an acute facility with an estimated cost of $11 billion per year (O’Neil, 2004). Regulatory agencies

Kaiser Permanente Educational Services Left to right: Farouze Fahieh, Karla Manfut, Rosa Moreno, Kathy Ricossa, Linda Clar, Jean Hively, Bic Diep, Carol Bautista (Not pictured: Elizabeth Scruth, Gail DePinna)

20 Healthy Skin

diverse patients to determine whether or not there is a difference in nursing assessment of various skin tones. Utilizing simulation methodology, nurses will be facilitated and debriefed by nurse educators who have been trained as simulation experts. The training venue was the Center for Innovative Medical Simulation (CIMS), which is located on the campus of San Jose City College and operates as a high-fidelity community-based simulation center where ethnically diverse simulators are available to the community as a resource for training.

During this study, we examined the nurses’ ability to assess two patients head to toe focusing on actual pressure ulcers by using Kaiser Permanente’s downtime initial paper assessment documentation form to determine if there was a difference between the number of pressure ulcers identified by nurses between a Hispanic and an African-American patient. Nurses were not to stage the pressure ulcers, rather identify the number and location. Both simulated patients had the exact same number, location, and type of pressure ulcer for each session of training. After each scenario was completed, the team of participants reviewed their video for debriefing.

Prior to conducting this study, approval from the Institutional Review Board was obtained. For recruitment, a flyer was

This study will focus on targeted education by using medical simulation training. Medical simulation training is a leading-edge teaching methodology for adult learners to acquire and refresh their knowledge and skills through hands-on application in a “no harm” environment. This teaching methodology has been introduced to Kaiser Permanente San Jose staff nurses over the last two years to improve: (a) cognitive, (b) technical, and (c) behavioral skills at the bedside. High-fidelity human simulators are capable of mimicking real life patients.

Scenarios will capture “real world” medical situations, thus creating “reality without risk” to actual patients. The human simulators serve as “patients” coming in from a skilled nursing facility with pneumonia or another complex condition with equipment, such as: (a) oxygen, (b) tracheostomies, (c) splints, (d) anti-embolic hose, and (e) eye glasses as distractors for skin assessment. Many bony prominences featured pressure ulcers, as well as under devices.

MethodThe targeted education component addresses assessments of two human simulators (one Hispanic, one African-American) for an initial hospital assessment from a skilled nursing facility. Staff nurses will undergo two customized simulated scenarios to assess skin integrity of ethnically

Simulated wound on a mannequin with Hispanic skin tone.

Simulated pressure ulcer on a mannequin with African-American skin tone.

CE ARTICLE

Improving Quality of Care Based on CMS Guidelines 21

turning reminds the nurse to turn the patient at least every two hours. Incontinence is a prompt to toilet the patient. Nutrition is an alert for a dietary consult when appropriate.

Immediately following the education, the post test was given wherein both mannequins had new pressure ulcers. Each subject assessed the opposite mannequin. For data collection purposes, the frequency of the pressure ulcers was identified from the admission assessment document and placed on a spreadsheet identifying the pre and post test scores on each mannequin. This quantitative data was maintained in a locked file cabinet in an aggregate form to protect the privacy of each participant.

ResultsFor this study, a total of 72 RNs participated. On the first day of the study, a pilot was done to determine the effectiveness of the education. Two hospital nurses participated: one from labor and delivery and the other from the intensive care unit. The pre test (baseline assessment) was done followed by the treatment, and then the post test. For this pilot, there was no improvement from the pre and post test. The education was retooled to include a head-to-toe assessment with devices which have been known to contribute in the development of pressure ulcers. After this education was conducted, an improvement in scores was noted.

distributed to invite subjects to participate and offered eight hours of continuing education. The method was a randomized, cross over trial. A convenience sample of 72 registered nurses participated in this study, each for eight hours, totaling 576 hours. Informed consent was obtained; the documents were coded to protect the identity of the participants.

Before the study occurred, the nurses conducted a thorough inspection of the mannequins (pre-scenario, pre-application of pressure ulcers) to become familiarized. For the pretest, each nurse performed an admission assessment on one simulated patient with dark pigmented skin with pressure ulcers on bony prominences and devices. Following the first scenario, education consisted of: (a) identification of pressure ulcers through staging; (b) deconditioning; (c) examining of devices from head to toe; (d) inspection of pressure ulcer models (buttock and foot) and (e) a review of the SKIN bundle.

The SKIN bundle is a special intervention based on focused assessment which is performed by all nurses at Kaiser Permanente Northern California. SKIN is an acronym meaning the following: S - surface; K - keep turning; I - incontinence; and N - nutrition. The surface is observed and changes may be made based on patient needs. Keep

Comparison of Morning (AM) and Afternoon (PM) Sessions Using Frequency in Percentile and Numbers

22 Healthy Skin

Paired T-TestsComparison between Groups 1 and 2

AM and PM Assessments 0.6793

AM African American and PM Hispanic 0.7118

AM Hispanic and PM African American 0.8403

P < or = to 0.05 indicates statistical significance.

specialty focusing on the specific pressure ulcers that are unique to that area: (a) abdominal apron for laboring patients; (b) blanching in the coccyx area from immobility due to surgical procedures; and (c) nasal cannula use with neonates. Additional studies on the assessment of ethnic skin may need to be conducted in geographic areas with homogeneous patient populations focusing in on assessment of ethnic skin tones.

AcknowledgementsIn appreciation to our funders, I would like to thank Medline Industries, Inc. for the opportunity to study community- acquired pressure ulcers at our local facility and their generous financial support. Also, in gratitude for Kaiser Permanente Nursing Research for financial support for participation at the University of California, San Francisco Research Days and purchase of the poster. Finally, thank you to the clinical education staff at Kaiser Permanente San Jose. Without their participation, this project would not have been realized.

References

Fogerty, M., Guy, J., Barbul, A., Nanney, L., & Abumrad, N.M. (2009). African

Americana show increased risk for pressure ulcers: A retrospective analysis of acute

care hospital in America. Wound Repair and Regeneration, 17, 678-684.

Gerardo, M.P., Teno, J.M,. & More V. (2009). Not so black and white: Nursing

home concentration of Hispanics associated with prevalence of pressure ulcers.

Journal of American Medical Directors Association, 10:2, 127-32.

Lapsley, H.M. & Vogels, R. (1996). Cost and prevention of pressure ulcers in an

acute teaching hospital. International Journal of Quality Health Care, 8:1, 61-6.

O’Neil, C.K. (2004). Prevention and treatment of pressure ulcers. Journal of

Pharmacy Practice, 1.

Rosenthal, M.B. (2007). Nonpayment for performance? Medicare’s new

reimbursement rule. The New England Journal of Medicine, 16:357, 1573-1575.

After the pilot, 70 hospital RNs participated in eight hours of simulation training in specialty areas from: (a) maternal child, (b) medical surgical, (c) telemetry, and (d) critical care units. The statistical method was paired t-tests. The paired t-test compared results from morning to afternoon and a comparison between Hispanic and African American mannequins. (See bar graph.) The number of pressure ulcers identified between the morning and afternoon sessions improved slightly, however, there were no differences between the Hispanic and African-American mannequins. (See table above.) A reason for not having any differences between the Hispanic and African-American mannequin is that Kaiser Permanente San Jose, California is rich in cultural diversity, and our nurse population mirrors our patient population. Additionally, the paired t-test indicated that these results were not statistically significant between comparisons.

ImplicationsThere were several significant implications based on this study. It is important to provide education to all healthcare workers who provide patient care for examining diverse patient populations with medical devices. This education should be done initially as well as ongoing for all healthcare providers, such as: (a) respiratory therapists, (b) physical therapists, and (c) nursing assistants. Instead of conducting both the pre and post test together on the same day, a follow up study should be conducted between four and six weeks after the initial study. Results may show a difference by allowing the nurse time to assimilate the education with the post test. Within each specialty area, the sample size was small. Further research should be conducted in each

CE ARTICLE

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Improving Quality of Care Based on CMS Guidelines 23

8. What is medical simulation training? a. A leading-edge teaching methodology for adult

learners to acquire and refresh their knowledge and skills through hands-on application in a “no-harm” environment.

b. A traditional training method from the 1970s that utilizes the simulation of medical practice at an actual healthcare facility.

c. Training that simulates emergency medical techniques used during military combat.

d. None of the above.

9. How many opportunities did the nurses have to assess the skin integrity of the simulated ethnically diverse patients? a. 1 b. 5 c. 3 d. 2

10. In the SKIN bundle acronym, what does the letter N stand for ? a. Nursing care b. Nutrition c. Necrosis d. New

True/False

1. There are hundreds of research studies available on ethnically diverse patients with pressure ulcers. T F

2. The subjects of this study were actual hospital patients. T F

3. The research question asked if registered nurses (RNs) are able to identify community-acquired pressure ulcers among Hispanic and African-American patients. T F

4. The skin integrity education supported the RNs’ ability to conduct a more thorough assessment of pressure ulcers during the afternoon session. T F

5. Each RN received eight continuing education credit hours for completing this study. T F

Multiple Choice

6. Regulatory agencies must be notified when a patient exhibits a hospital-acquired pressure ulcer that is a. Stage I or greater b. Stage II or greater c. Stage III or greater d. None of the above

7. Which of the following specialty units were represented by nurses who participated in this study? a. Telemetry b. Surgery c. Maternal/Child d. Both a and c

Identification of Staff RN’s Ability to Assess Community-Acquired Pressure Ulcers Among Ethnically Diverse Patients

CE TEST

24 Healthy Skin

Two types of measures can be monitored: prevalence and incidence rates.

• Prevalence describes the number or percentage of people who have a pressure ulcer while at your facility, whether it was acquired before or after admission. Prevalence reflects the number of individuals with pressure ulcers at a certain point or period of time.

• Incidence describes the number or percentage of people who developed a new pressure ulcer while in your facility. In other words, incidence only counts pressure ulcers that develop after admission.

PressureUlcerRates:Prevalence and IncidenceA basic principle of quality measurement is: If you can’t measure it, you can’t improve it.

Therefore, pressure ulcer performance must be counted and tracked as one component of a quality

improvement program. By tracking performance, you will know whether care is improving, staying the

same, or getting worse in response to efforts to change practice.

Prevalence rates include all pressure ulcers

present in a group of individuals: those that developed during their stay at your facility as well as those that developed before admission.

Incidence rates capture only new pressure

ulcers that develop during a patient’s stay at your facility.

Prevalence =

# or % people with a pressure ulcer at your facility

Incidence =

# or % people who developed a new pressure ucler at your facility

Advancing

Improving Quality of Care Based on CMS Guidelines 25

Rates are calculated as follows:

Prevalence measures the number of individuals with pressure ulcers at a certain point or period in time:

• Thenumeratorwillbethenumberofindividualswithanypressureulcer.

• Justcountindividuals;NOTthenumberofulcers.Evenifsomeonehasfour Stage II ulcers, he or she is only counted once.

• Thedenominatoristhenumberofpatientsduringthatmonth.

• Dividethenumeratorbythedenominatorandmultiplyby100togetthepercentage.

Example: 17 individuals with any pressure ulcer ÷ 183 individuals = 0.93 x 100 = 9.3%

Incidence measures the number of individuals who developed new pressure ulcers during a specific period in time.

• Thenumeratorwillbethenumberofpatientwhodevelopanewpressureulcerafteradmission.

• Justcountindividuals;NOTthenumberofulcers.EvenifsomeonehasfourStageIIulcers,heor she is only counted once.

• Thedenominatoristhenumberofallpatientsadmittedduringthattimeperiod.

• Dividethenumeratorbythedenominatorandmultiplyby100togetthepercentage.

Example: 31 individuals with a new pressure ulcer ÷ 227 individuals = 0.14 x 100 = 13.7%

Source: Agency for Healthcare Research and Quality (AHRQ), www.ahrq.gov/research/ltc/pressureulcertoolkit

How to calculate pressure ulcer prevalence and incidenceTo calculate pressure ulcer prevalence and incidence rates, you need to know who has a pressure ulcer and when it developed:

1 Perform a comprehensive skin inspection on every individual. Look carefully for any lesions or discolored areas on the skin and determine whether they are pressure ulcers.

2 Document the results of the comprehensive skin inspection for all individuals.

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Improving Quality of Care Based on CMS Guidelines 27

The nursing profession is responsible for keeping patients safe, providing quality care, reducing errors, and upholding high standards. Healthcare organizations are challenged every day to prevent adverse patient outcomes along with identifying the appropriate staff and practices that will have the biggest impact. At the same time the goal of all nursing educational programs is to prepare students with the skills necessary to provide safe, quality care to their patients. Unfortunately, a gap exists between academia and service in that students are not involved in meeting these challenges until they are well on their way in their profession. Nursing students need to learn the importance of these issues as part of their clinical training. One such issue specific to nursing care is the prevention of pressure ulcers. Gaps between education and clinical practice have been identified relative to pressure ulcers.1 Ayello, Zullowski, and Capenzuti (2010) state that discrepancy between best practice guidelines and the undergraduate education on pressure ulcers still continues today.2

The Essentials of Baccalaureate Education for Professional

Nursing Practice provides the educational framework for the preparation of professional nurses. This framework allows for opportunities to build upon baccalaureate education in order

By Elizabeth Cotter, PhD, RN-BC and Chenel Trevellini RN, MSN, CWOCN

Students Are Part of the SKIN TEAM:

Pressure Ulcer Prevalence Day

28 Healthy Skin

to meet the challenges of today’s healthcare industry.3 Nurse educators need to continue to identify and provide opportunities for educational growth for their students. Sherwood and Drenkard (2007) suggest that educators match practice realities with opportunities for student involvement in patient safety initiatives and process improvement activities to ensure quality and safety in nursing education.4 Faculty need to provide opportunities for students to be actively involved in transitioning the theory into practice connection. The opportunity to facilitate evidence-based practice can enhance the students’ ability to draw conclusions and make connections between quality care and the outcomes.

St. Francis Hospital, The Heart Center® in Roslyn, NY and Molloy College in Rockville Centre, NY, have a long history of collaboration. The foundation of this partnership is based on respect, trust and a shared commitment to quality patient care and student education. St. Francis Hospital and Molloy College are continuously working together to close the gap between education and clinical practice. The introduction of Nursing Quality Indicators within the clinical setting will serve a dual purpose of improving clinical knowledge and strengthening collaboration between academia and service. Elizabeth Cotter, Assistant Professor of Nursing at Molloy College, identified a need to include additional clinical experiences involving pressure ulcer prevention for her students. She partnered with Chenel Trevellini, Wound Specialist at St. Francis Hospital, inviting Molloy students to participate in Pressure Ulcer Prevalence Day.

St. Francis Hospital’s Professional Nursing Practice Model (PNPM) serves as the framework for the educational initiative known as SKIN Champion Program. The characteristics of the St. Francis Hospital PNPM include authority, autonomy, and accountability. The characteristic of authority provides recognition and use of the nurse’s rights, power, and responsibility to use nursing knowledge, skills, and judgments. Autonomy influences independent nursing decisions regarding

best practices. Accountability focuses on acceptance of responsibility related to nursing assessment, plan, interventions, and judgments. The combination of authority, autonomy, and accountability assists in promoting safety, which positively impacts patient outcomes.

Participating in the didactics and hands-on components of the SKIN Champion Program empowers the clinical RN to incorporate critical thinking in the individualization of the interdisciplinary plan of care in preventing and treating pressure ulcers. The SKIN Champion program provides the process and structure required to deliver evidence-based education and policy on pressure ulcer prevention. The program provides an environment that promotes continuous quality improvement, where practitioners are empowered to utilize the nursing process to deliver optimal skin care. During this process, the SKIN champions measure, analyze, track and trend the relationship between nursing care at St. Francis Hospital and Nursing Quality Indicators. This initiative has led to the empowerment of clinical registered nurses and ancillary staff with the knowledge, skills, and tools to provide extraordinary skin care.

Monthly Pressure Ulcer Prevalence StudiesSKIN Prevalence Teams are established specifically to conduct monthly pressure ulcer prevalence studies for an entire quarterly data collection period. Each team consists of a clinical nurse specialist, clinical nurses, and ancillary staff. The team begins each prevalence study day with two-hour didactics,

By participating in SKIN Champion Prevalence Day the students increased their knowledge on the identification of pressure ulcers, staging, risk factors, product use and preventive measures.

Left to right: Kevin Guevara (Molloy nursing student); Mike Eckstein, RN; Joanne Cefalu, RN; Maureen Troise, PCA and Erin Markey, CNS.

Improving Quality of Care Based on CMS Guidelines 29

which include skin assessment, staging, and data collection requirements. The teams then proceed to their assigned units and conduct a pressure prevalence study. The day ends with a one-hour post conference. Involving the students to be part of this team gives them the opportunity to experience the practical realities of a nursing career. The students can be a witness to implementation of evidence-based practice and the different research projects that have been conducted to bring us to the point of giving the best care to our patients. Participating in this program also develops the students’ awareness of the responsibilities and professional duty required to participate in creating a safer patient environment. Students see firsthand how the skin tells a story about what is happening to the patient.

Pressure Ulcer Training ProgramThe students were also instructed by their professor to navigate through The National Database of Nursing Quality Indicators (NNDQI) website and complete the Pressure Ulcer Training Program and post test to reinforce what they learned during Prevalence Day. The training program included four modules. Module I focused on definition of pressure ulcers, pressure ulcer location, and pressure ulcer staging. Module II described other wound types and skin injuries. Information included a review on arterial, venous, diabetic ulcers, skin tears, and perineal dermatitis. Module III included content related to conducting an NDNQI pressure ulcer survey; suggested training, staging for survey team, and risk assessment and prevention. Module IV focused on differences among community, hospital, and unit-acquired pressure ulcers.5 Each student scored 100% on the test.

The goal for this collaborative effort was to improve the accuracy of the students’ data collection ability on hospital-acquired pressure ulcers and allow meaningful comparison of nursing care performance. By participating in SKIN Champion

Chart Review Questions

• Most recent Braden Score

• Most recent skin assessment

• Is the patient at risk for pressure

ulcer development?

• If yes, is the Pressure Ulcer

Prevention Protocol in place?

Prevalence Day the students increased their knowledge on the identification of pressure ulcers, staging, risk factors, product use, and preventive measures. Being active learners in this process allowed the students to learn firsthand what needs to be done to prevent, identify, and care for pressure ulcers. Having the students assist the SKIN team collect and analyze data related to this critical nurse sensitive indicator provides the students with a real –life learning situation.

Clinical days that followed included a change in the students’ practice. The students knew to check the patients bathing products to ensure that they were appropriate and located in the basin. The students checked that specialty beds were functioning correctly. The students looked at lab work such as albumin levels and also reviewed the required nursing paperwork relating to skin, including the Braden score, in their documentation. The students have new insight on the importance of pressure ulcer prevention and the role they play. The students also have an increased awareness of “Nurse Sensitive Indicators” and the impact nurses have on patient outcomes and healthcare costs.

Student Comments from the Fall 2011 Group Ana Hernandez: I think every hospital should have Prevalence Day. It was a wake-up call for the nursing students on the importance of skin care. Prevalence Day made me feel more confident in my assessment.

Kesha Manragh: Being part of Prevalence Day will impact my practice because I feel more comfortable when it comes to preventive measures and pressure ulcer interventions. I also know how important and critical the first nursing assessment (especially skin assessment) is when there is a new admission. I will also make sure that everything is documented upon each assessment in my nursing notes.

Left to right: Kiera O’Leary (Molloy nursing student) and Nicole Mikicic, RN.

30 Healthy Skin

Kevin Guevara: Working with the team helped me see the importance of collaboration. Everyone in the group gave input and opinions as to whether the ulcer was stageable or non-stageable. Was it an injury from pressure or moisture? The group then worked together to obtain the accurate information. Prevalence Day helped me grasp a better understanding of the word teamwork.

Judith Lopez: Prevalence Day at St. Francis Hospital was a thorough representation of the importance of skin assessment and treatment of skin conditions. We learned that pressure ulcers are a significant healthcare problem because they increase the amount of nursing care required, the patient’s length of stay, and the healthcare costs, as well as compromise patient health and cause pain. Prevention is the key. Aneta Gorazda: Being part of Prevalence Day increased my knowledge about skin care, which included risks of hospital-acquired breakdowns, use of appropriate devices, and skin care products to prevent the skin from breaking down. I have also gained knowledge to assess and distinguish between different stages of pressure ulcers and suspected deep tissue injury and moisture-related dermatitis.

Chelsea Ryan: Being an active part of Prevalence Day showed me how important it is to advocate for patients, provide them with the equipment/products to assist in improving their stay in the hospital, and quality of life. As a student, I think that Prevalence Day has shown me the importance of many aspects of patient care including keeping skin intact, accuracy of the nurse’s assessment, performing a Braden score assessment, and accurate documentation.

Kiera O’Leary: This was a great learning experience working as part of the team to prevent and treat pressure ulcers.

Natasha Kernahan: This experience confirmed what I learned in my nursing lecture. It gave me the opportunity to witness the preventive methods used to assist in avoiding pressure ulcers. Students’ involvement in Prevalence Day is very important because we are the future.

References1. Gould, D (1992). Teaching students about pressure ulcers. Nursing Standard; 18, 28-31.2. Ayello, EA, Zullowski, KM,& Capenzuti, E.(2010). Pressure ulcer content in undergraduate programs. Nursing Outlook. 58, 43. American Association of Colleges of Nursing (2008). The essentials of baccalaureate education for professional nursing practice. Retrieved from http://www. aacn.nche. edu/Education/pdf/BaccEssentials08.pdf4. Sherwood, F & Drenkard, K.(2007). Quality and safety curricula in nursing education: matching practice realities. Nursing Outlook. 55, 151-155. 5. American Nurses Association (2011).The National Database of Nursing Quality Indicators (NNDQI) Pressure Ulcer Training retrieved from www.nursing quality .org

Left to right: Chelsea Ryan (Molloy nursing student) and Laura Gregorovic, CNS.

Prevalence Day at St. Francis Hospital was a thorough representation of the importance of skin assessment and treatment of skin conditions. - Judith Lopez

Admit it. Readmissions are a problem.Readmissions to acute care hospitals are a problem for them, and that

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abaqis is the answer.

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©2012 Medline Industries, Inc. abaqis is a registered trademark of Providigm, LLC. Medline and Medline University are registered trademarks of Medline Industries, Inc.

Use abaqis to showcase your quality care. Call your Medline rep at 1-8000-MEDLINE, scan the QR code, or visit medline.com/programs/abaqis

Quality Assurance System

32 Healthy Skin

Impact of Pressure Ulcers

AcrossCare Settings

of nurses in the ED report a knowledge

deficit regarding wound care1

76%

number of pressure ulcer hospitalizations that end in death3

number of nursing home residents with

a pressure ulcer5

of pressure ulcers occur in persons older than 654

68% of pressure ulcer patients report pain 2% of those patients receive analgesia8

1 in 25:

1 in 101 Niehuser M. Routine Skin and Wound Care in the Emergency Department of Kennestone Hospital. Poster presented at: Southeast Region Wound, Ostomy & Continence Nurses Society 2011 Conference; September 2011; Chattanooga, Tenn. Available at: http://serwocn.org/2011Conf/Images/Poster1.pdf. Accessed January 10, 2012.2 Center for Medicare & Medicaid Services. Proposed Changes to the Hospital IPPS and Fiscal Year 2009 Rates. Federal Register. 2008;73(84):23550. Available at: http://edocket.access.gpo. gov/2008/pdf/08-1135.pdf. Accessed January 10, 2012. 3 Agency for Healthcare Research and Quality. Pressure Ulcers are Increasing Among Hospital Patients. Available at: http://www.ahrq.gov/research/jan09/0109RA22.htm. Accessed January 10, 2012.4 Whittington K, Patrick M, Roberts JL. A national study of pressure ulcer prevalence and incidence in acute care hospitals. Journal of Wound Ostomy Continence Nursing. 2000;27(4):209–215. Available at: http://www.ncbi.nlm.nih.gov/pubmed/10896746. Accessed January 10, 2012.

5 Park-Lee E & Caffrey C. Centers for Disease Control and Prevention. Pressure Ulcers Among Nursing Home Residents: United States, 2004. Available at: http://www.cdc.gov/nchs/data/ databriefs/db14.htm. Accessed January 10, 2012.6 Aronovitch S. Intraoperatively acquired pressure ulcers: are there common risk factors? Ostomy Wound Management. 2007;53(2):57-69. Available at: http://www.o-wm.com/content/intraoper- atively-acquired-pressure-ulcers-are-there-common-risk-factors. Accessed January 10, 2012.7 Cox J. Predictors of pressure ulcers in adult critical care patients. American Journal of Critical Care. 2011;20(5):364-374. Available at: http://ajcc.aacnjournals.org/content/20/5/364. full.pdf+html. Accessed January 10, 2012.8 Gunes UY. A descriptive study of pressure ulcer pain. Ostomy Wound Management. 2008;54(2):56-61.

References

Average cost of hospital stay to treat a pressure ulcer2

66% incidence of intraoperatively acquired

pressure ulcers6

73%

2%

In the ICU, 34% of pressure ulcers take more than 6 days to detect7

68%

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

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

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

Relieve Pressure on Vulnerable Heels

©2012 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.

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

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

Straight-back strapping provides extra room, ventilation and protection against foot drop

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MENTIONTHISADTORECEIVEA10%DISCOUNTONYOURFIRSTHEELMEDIXHEELPROTECTORORDER

Introducing Ultrasorbs AP Dry Sheet technology in a larger size (40 x 90) suitable for the OR table.

CHALLENGE:• Perioperative-relatedpressureulcersare affectedbyimmobility,pressureandmoisture.• Incidenceofpressureulcersoccuringasa resultofsurgeryhasbeenashighas66%.1

MEDLINE’S SOLUTION:• UltrasorbsAPhasbeenclinicallyshownto helpmaintainskinintegrityaspartofanoverall pressureulcerpreventionprogram.2

• UltrasorbsAPisnowavailableasaDrySheet fortheOR.

New! ULTRASORBS® AP DrySheetfortheORAdvancedtechnologyforongoingmoisturemanagement.

Patented SuperCore® absorbent sheet is thermo-bonded to provide better pad integrity, excellent skin dryness andexceptional absorbency.

Air-permeable backsheet for betterskin comfort and compatibility withunder-patient warming

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For a free sample, contact your Medline sales representative

36 Healthy Skin

Treatment

Butterflies in the

Nursing Home

Incontinence: Change Your Culture – Change Your Brief

Butterflies go through a process of change or transformation

known as metamorphosis. It is through this process that this

insect is able to change its appearance becoming the beautiful

butterfly we ultimately see and enjoy.

Since the federal Nursing Home Reform Law’s enactment in 1987 emphasizing dignity, choice, and self-determination in the care for its residents, we are seeing the culture changing within our nursing homes today. This culture change, like the metamorphosis of the butterfly, is bringing about beautiful new changes or transformations in our nursing homes.

Survey Readiness

Improving Quality of Care Based on CMS Guidelines 37

Much like the butterfly going through its changes, we are seeing a change from the old institutional nursing home setting to ones with a more home-like, resident-centered living module. The change is about respecting residents, promoting dignity and individualized care. This new philosophy is shown to help residents function at their highest practicable physical, mental, and psychosocial well-being. Step-by-step, in little ways and big, we’re delivering better care, and granting more autonomy and confidence to our residents.

I am seeing beautiful dining rooms with tables set with china and elegant flatware. Residents come to dinner as if they were going out to a fancy restaurant. Residents today have a choice to eat in the facility’s dining area or if they prefer have “room service” deliver their food to their own private rooms. Today’s culture is about making choices based on personal preferences, tastes, likes and dislikes – not a “one-size-fits-all” approach so commonly used in our industry.

Despite these positive changes, one key area that has not caught up to this cultural revolution is in the area of incontinence care. Attitudes still pervade the industry that reflect, “This is the way we’ve always done it” with regard to product choices, application of those products, staff and resident education and empathy to those residents afflicted with incontinence. Unfortunately, the “one size fits all” mentality still exists in many

nursing homes when it comes to this important health and quality of life issue.

That is not to say nursing home staffs are not well intentioned. They want to do the right thing. They have compassion and pride in doing a great job for our loved ones whom they care for day and night. What is lacking is keeping up with new education and products with regard to “culture change” in incontinence care. Continence management is a vital area that is deficient in practice and should be incorporated into the wave of culture change today.

All too often we see residents dress for an elegant dinner, but worry how they will maintain their dignity if they happen to suffer the effects of incontinence. How will they be kept dry while they dine? How will they maintain their comfort while having to wear an incontinence product without it showing or being detected by their friends? Unfortunately these are the questions that keep residents from leaving their rooms in fear of the indignity of incontinence.

When it comes to changing an adult brief on a resident while in the bed, most nursing homes still employ an old time bed-making technique that is out-dated and impractical. But there are newer application techniques available that nursing leadership can find by talking with their incontinence supply vendor.

We are seeing a change from

the old institutional nursing

home setting to ones with

a more home-like, resident-

centered living module…

Despite these positive

changes, one key area that

has not caught up to this

cultural revolution is the area

of incontinence care.

38 Healthy Skin

Similarly, many adult brief products are still made with a “one size fits all” strategy, which makes it very difficult to maintain a high level of dignity for the resident. Poor fitting products do not promote a high degree of confidence, comfort, and continence management. Ill-fitting products are also uncomfortable and do not keep the resident’s skin dry, which can lead to skin breakdown, wet beds, and increased risk for pressure ulcers. Clearly, “one size does not fit all” when it comes to adult incontinent products.

But incontinent products, like resident care techniques and education, are improving. Innovative brief manufacturers are utilizing enhanced technology along with a sharper focus on proper fit and comfort, to design products that work and feel better for the resident. When a resident is properly fitted with an incontinent brief, they will naturally feel a sense of well-being, dignity, and confidence.

By combining better products with educational tools and resources, you will foster a culture of change that is designed with each individual’s needs in mind. Moreover, these programs and products will inspire your staff to embrace individualized continence management care, which will lead to enhanced levels of satisfaction for both staff and residents.

When administrators and directors of nursing are asked what types of continence management programs or systems are in place, I am usually told, “We don’t really have a system,” or

“We want to implement a system, but I’m too busy right now.” Continence management is far too important of an area to be ignored anymore.

In addition, with the recent change to MDS 3.0, facilities are missing the connection that bridges the MDS 3.0 / Section H in implementing an effective individualized continence care program. Often times the facility MDS coordinator is not in coordination with a continence management team in the facility. Not only is this a missed opportunity for improved reimbursement for the facility, but it is also a missed opportunity to bring culture change in this area as well.

Culture change with regard to continence management in the nursing home environment is evolving slowly but its time has come. While many facilities are concentrating on physical changes to their building, they must now consider what types of changes will impact something so intimately related to individual residents themselves as continence management.

A culture change in continence management in your nursing home will allow your resident to truly participate in life to the fullest inwardly while experiencing your beautifully changing nursing homes outwardly.

Debra J Birchman, RN.BS.WCC, is a Clinical Services Manager

for the Personal Care Division at Medline Industries, Inc.

Printed with permission from Advance for Long-Term Care Management.

By combining better products with

educational tools and resources, you

will foster a culture of change that is designed with each individual’s

needs in mind.

100% medical grade honey helps promote debridement, moist healing environment, reduced wound odor

The high sugar levels (87%) in TheraHoney result in osmotic pressure that helps promote autolytic debridement of necrotic tissue, provides a moist wound healing environment and helps rapidly reduce wound odor.

TheraHoney products contain 100% medical-grade Manuka honey, which is derived from the pollen and nectar of the Leptospermum soparium plant in New Zealand. The honey comb is used only one time, and once harvested, the honey is carefully filtered, irradiated and tested in a laboratory.

Use TheraHoney Gel on difficult to dress wounds to promote autolytic debridement and a moist healing environment. Use TheraHoney Gauze to maintain a moist healing environment while permitting the passage of exudate into a secondary dressing.

The sweet solution for wound care

TheraHoney™ Sterile Wound Dressings

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TheraHoney™ Gel

TheraHoney™ Gauze

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©2012 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.

Change your CULTURE.Change your BRIEF.

A culture change is sweeping through long term care. It honors

individuals. It’s where “the way we’ve always done it” is replaced

by “How would you like us to do it?”

The importance of personal choices and care is a central

theme of the culture change movement. Asking a resident to fit

into your routines is the old way; adapting to fit individual needs

is the new way.

Medline is proud to provide you videos, tools and educational

resources to help you identify and nurture changes that keep

your facility moving forward.

In continence care, fostering a culture of change means using

a brief that is designed with each individual’s needs in mind. It

must deliver dignity and comfort. And the idea of “one size fits

all” is replaced by choosing one that will FitRight.

http://www.medline.com/fitright

Make the change to FitRight.

The all-new FitRight brief helps accelerate your culture of patient-centered care.

• Designedwithindividualinmind

• Morehigh-techfeaturesforhighperformance

• Discreet,comfortable,garment-likefitandfeel

• 4Dcorewithodorprotectionfordrynessanddignity

Ask your Medline rep for a free sample and more about the FitRight story.

1-800-MEDLINE I www.medline.com

Skin-Safe Closures Provide secure, safe, and repeated refastenability.

Ultra-Soft Cloth-Like Backsheet Provides a discreet, garment-like, natural feel.

Soft Anti-Leak Guards Reduce leakage and improve containment. Restore patient confidence, impact facility utilization.

4D Core with Odor Protection Wicks fluid away quickly to promote dryness and help maintain skin integrity.

TM

42 Healthy Skin

Embracing Change:Promoting a Continence Management Program

in Your Facility

Improving Quality of Care Based on CMS Guidelines 43

The healthcare industry continues to face new challenges with constant pressure to promote individualized care while managing operation costs. With the feeling of near-constant change related to updates in government reimbursements and mandates, it may feel nearly impossible to try to effect change when maintaining status quo is challenge enough. Many nursing homes are concerned about how to maintain quality service while improving clinical outcomes, especially with the recent 11.1% cut in Medicare payments.

In the midst of all of this we cannot overlook the importance of assessing our core business values and the required commitment to provide resident-centered care. The transition to the MDS 3.0 platform is an opportunity to ensure we are embracing the goal of changing facilities’ focus from simply managing incontinence to promoting continence. This is an industry change, shifting attention from reacting to the symptom to actually addressing the root of the problem.

Although most public initiatives are focused on pressure ulcers, falls, or healthcare-acquired conditions or infections (HAC’s or HAI’s). incontinence is addressed as more of a sidenote to pressure ulcers and falls, for example. Because of this lack of singular focus, many myths about incontinence have been perpetuated, including the concept that incontinence is an inevitable part of aging.

This is the time to debunk the myths and embrace culture change. But how does a facility embrace that change, and what might that look like?

The overarching goal should be to promote as much continence as possible. For some individuals, this may mean a complete return to continence. For others, even one small improvement can have a large impact on the resident’s quality of life and satisfaction with their care.

Survey Readiness

44 Healthy Skin

11Geteveryoneonboard.Once you decide to implement a continence program, everyone’s commitment is crucial to its success. All tiers of the organization, from executives and administrators through all levels of management and staff, must be on board.

Assembleacontinencemanagementteamwithproactivenursingleadership. Recommended team members might include:• Facilityadministrator• Directorofnursing• Restorativenurse• Treatmentorwoundcarenurse• SeveralLeadCNAs

Weekly meetings are suggested. To start, you will set up expectations and the philosophy of your continence management program. Once the program has been implemented, you will discuss concerns and make revisions to the program as necessary.

Educatethenursingstaffatalllevelsregarding:• Typesofincontinence• Behavioralprograms• Varietyofabsorbentproductsavailable• Properskincare• Protocolsandproceduresforincontinence and where they are located

Important: Be sure to put a system in place to educate new employees as well.

Selectateamleaderforeachunitwho will be responsible for continence care questions, troubleshooting, training and skin care. This person should receive additional education regarding incontinence and absorbent product selection.

Each unit should conduct daily meetings during shift changes, which devote about five minutes to incontinence.

1

2

3

Start by empowering your staff. Provide them with training to identify factors such as the type of incontinence, proper product usage, and proper sizing techniques. Individualized care plans for each resident will go a long way toward improving outcomes. Standard protocols that recommend simply using one of two different brief sizes paired with checking and changing every two hours will not go far toward promoting your residents’ dignity, nor will they comply with MDS 3.0, Section H.

As you create your continence management plan, keep in mind the twin goals of staff convenience and residents’

improved quality of life. A plan that your staff finds impossible to adhere to will fail, and all the best plans profit nothing if in the end they do not benefit your residents. Meet the need to promote as much continence as possible.

Remember, one small change can result in better quality of life for your residents. Decide to make those changes, one clinician at a time, one facility at a time. All it takes is one step forward to make a change.

What will your first step be?

11STEPS for implementing a successful continence management program

4

Improving Quality of Care Based on CMS Guidelines 45

Create an incontinence product identification system toidentifytheproducteachresidentuses. This information should include the correct size. Consider a discreet sticker system to discreetly identify the size and type of product each individual requires.

Determine an incontinence product delivery system.Decide how and when absorbent products will be delivered to each resident’s room. Many facilities designate a location in the resident’s closet for his or her own absorbent products. Discourage sharing of product. Locking up the incontinence products encourages the team leader (who has the key) to evaluate why a resident may be going through too much product.

Arrange a family night meeting to educate residents’ family members and caregivers about incontinence treatments and absorbent product options.

Assess new residents and reevaluate current residentsfor level of incontinence, sizing, skin condition, and product selection. If a voiding diary has not been completed previously, schedule a 72-hour time frame

to complete one. Then decide whether the resident is a candidate for a toileting program. Also, select appropriate absorbent products, determining the correct size.

Implement the treatment program and educate the resident regarding the types of products available and whether they will be participating in a toileting program. Team leaders can be an asset in monitoring and revising continence treatment plans.

Maintain a good incontinence program by schedulingregular meetings with team members to discuss problems and address concerns. Determine whether the correct product and size are still being used by selecting a few residents at random to audit. Provide ongoing education regarding product usage and program implementation for all staff.

Reviewandrevisethecontinencemanagementprogramasnecessary to accommodate new staff, new products, new technology and new regulations.

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©2012 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.

Introducing Medline’s NewCONTINENCE MANAGEMENT PROGRAM

A wide variety of tools to help you provide individualized continence care

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

Medline has created this Continence Management Program to help long-term care facilities develop individualized continence programs for residents and comply with Medicare regulations.

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

• CNA workbook

• Reproducible care plans, assessment guidelines and other quality assurance tools

Replaces Compass Box F315

www.medline.com/programs/continence-management-program

Replaces Compass Box F315

©2012 Medline Industries, Inc. Medline is a registered trademark and OctylSeal is a trademark of Medline Industries, Inc.

Introducing Medline’s OctylSeal high viscosity tissue adhesive for closure of simple wounds

• Flexiblestructuremoveswiththeskin,minimizingthe chanceofcracking• Actsasabarriertomicrobialpenetrationaslongasthe adhesivefilmremainsintact• 40percentmoregluepercontainerthanmostother tissueadhesives(0.7gramsversus0.5grams)• Easy,versatileapplication–interchangeabletips(swab andnozzle)includedineverypackage;violetcolorfor easieridentificationonskin• Metaltubeinsteadofglassampulemeansnoriskof brokenglassenteringthewound

Indications for useTopicalapplicationonlytoholdclosedeasilyapproximatededgesofwoundsfromsurgicalincisions,includingpunc-turesfromminimallyinvasivesurgeryandsimple,thoroughlycleansedtrauma-inducedlacerations.OctylSealmaybeusedinconjunctionwith,butnotinplaceofdeepdermalsutures.Availablebyprescriptiononly.

StickwithOctylSeal™ Flexiblewoundclosurethat’seasyonyourbudget

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48 Healthy Skin

Challenges of Preventing Moisture Associated Skin Damage in the Intensive Care Units Using No Sting Spray Skin Protectant*

BackgroundThepreventionofmoistureassociatedskindamage(MASD)hasbecomeachallengeinmanyintensivecareunits.WhenlifethreateninginjuriesandconditionsariseinICUs,especiallyinpatientswithmultipleco-morbidities,moisture/bodyfluidrelatedskinmanagementissuestendtoassumesecondpri-ority.Thisoccurssometimessimplybecauselargeareasoftheskinmaynotbepracticallyanddirectlyaccessibletothenurseinimmobilepatientswhoareconnectedtoseverallifesupportingdevicesatatime.Turningthepatientstoexaminetheirskinisnotaneasyoption.Undertheselessthanoptimalconditionsfromtheperspectiveofmanagingskinissuesandpreventionofskinassociatedinjuries,askinprotectivebarriermaybedeemedtobeaneffective,practicalsolution. Theproperuseofsuchbarriersmayprotectnegativealterationtoskinintegrity,reducepainassociatedwithcontinuedmoisture/bodyfluiddamagetodenudedskin,andmaypreservethehealthysurrounding tissue incaseofskindamage/woundsthatarealreadypresentorcannotbeprevented.

Skin Management ModalityRecentlywehavebeeninterestedintestinganonstingspraybarrier that utilizes a unique “polymer” formulation. Suchpolymersformaprotectivefilmontheskinuponapplication.Suchaskinbarrierisappropriateinouropinion,forgeneralskinprotectionfrommoisture/bodyfluidsandirritatedincontinencedamaged skin, or uncontained body fluids around tubes,fistulas,andalsoforprotectingperiwoundmaceration.Inourintensivecareunitthepopulationiselderly,immunosuppressed,transplant,cardiac,andDICpatients,whoall tend tohavevery fragile, thin, andoften compromised skin. A no sting,affordable,easilyappliedbarrierishighlyappropriate.

ResultsandDiscussionIneachof thepatients, resolutionof theskinhealthwithinreasonabletimewasobservedfollowingtheuseofthetrialedskinsprayprotectantbarrier. Barriersassistwiththepreventionofstrippingoffragileskinbytendingtodecreasetheseparationforcedirectlyontheskinofadhesivedressingsoradhesivetrauma.Thetrialednonsting

CASE STUDY

Patient #1–3/10/2009 60y/omalewithahistoryofhepatitisC,cirrhosisandhepaticcarcinoma.Livertransplantwithrecurrentrejection,worseninghepatitis,pancytopenia,CAD,TIA.PresentswithmelenaandBRBPR,aswellaslightheadedness.EGDrevealedesophagealandgastricvarices.

Patient #2 –11/9/2009 89y/ofemalewithahistoryofmorbidobesitywithrestrictivedisease,asthma,pulmonaryembolisms/pIVCfilter,RLEDVT(2010),afib,severechronicLEedema,andpostherpeticneuralgiaadmittedwithatypicalchestpain.

Improving Quality of Care Based on CMS Guidelines 49

Challenges of Preventing Moisture Associated Skin Damage in the Intensive Care Units Using No Sting Spray Skin Protectant*

Patient #3–2/15/2009 41y/ofemalewithapastmedicalhistoryofdepressionandanxiety.Shepresentswithrefractorypneumonia.ShedevelopedhypoxemicrespiratoryfailurerequiringintubationandARDSrequiringtransferforECMO.

Patient #4–2/22/2008 91y/omalewithapastmedicalhistoryofchronickidneydisease,coronaryarterydisease,s/pMI,ischemicCMP,CHFandDM.AftercomplicatedCABGcourse,developedrenalfailure,vasodilatoryshock,enterobactersepsis,andcardiogenicshock.

Patient #5–3/20/2009 62y/omalepresentedwithahistoryofdiverticulitis,laryngealCA,melanomaandskinSCC,admittedwithchronicdiarrheaandfailuretothrive.Surgicalcoursecolonresectionwithendcolostomy.

Denise Robinson, MPH, RN, CHWOCN Juliet Smith, MSN, RN, CWOCN Bernadette Melido, BSN, RN, CWOCNNew York Presbyterian Hospital, Columbia UniversityNew York, New York

skinprotectantwasclinicallyeffectiveasaprimaryskinmanagementtooltotheareasinneedofprotection.Thisproductprovidedanalternativetoprotectivecreamssuchaszincoxideandpetrolatumbasedproductsonewouldtypicallyuseifsuchsprayablebarrierswerenotavailable.Onemust remember thatcreambarriers tend tocauseoverlying adhesive dressing detachment, because theingredientpresentinthesebarriersdonotallowefficientattachment of dressing adhesive to skin. In contrast,thesprayfilmprotectantsof thetypetestedofferadry,adherent(toadhesivedressings),androbustplatform.

Ourpatients reported comfort in the areasof affectedskin,andnopainorstingingwasnotedduringapplicationon the damaged skin areas being subject to the trialspray.Thisisnotsurprisinggiventhatthereisnoalcoholin thisspray formulation (alcohol isacommonstingingingredient). Healthy at-risk skin was protected in ourpatients, and no mechanically induced skin strippingwasreportedonthesepatientsduringoverlyingadhesivedressingremoval.InourlimitedtrialonICUpatients,weconcludethattheskinprotectanttrialed,whichisbasedonauniquepolymerfilmformingtechnology,demonstratedclinically effective results in the management, andprotectionofskindamagefrommoisture/bodyfluids.Wethinkthatlargerstudiesonacontrolledpatientpopulationarewarrantedforthisuniquetechnology.

*Sureprep No Sting®, Medline Industries Inc., Mundelein, IL

References 1. GrayM.Incontinence-RelatedSkinDamage:EssentialKnowledge. http://www.o-wm.com/article/8161.Accessed4-5-11. 2. CouttsP,SibbaldRG,QueenD.Peri-WoundSkinProtection: AComparisonofaNewSkinBarriervs.TraditionalTherapies inWoundManagement.PosteratCAWCMeeting,London, Ontario.November2001. 3. SibbaldRG,MD,CampbellK,CouttsP,andQueenD.Intact Skin–AnIntegrityNottoBeLost.http://www.o-wm.com/ content/intact-skin-an-integrity-not-be-lost?page=0,6. Accessed4-5-11.

Prevention

ReadyBath Total Body Cleansing System includes pre-moistened disposable washcloths that require no rinsing or drying and offers excellent patient care on a variety of levels.

Relieves fear and anxiety.Confinedspacessuchasshowerstallscanbeuncomfortableandfrighteningforelderlypatients,especiallythosewithdementia.ReadyBathallowsforacalmbathingexperienceat thebedside.

Reduces cross-contamination.ReadyBathimprovespatientcarebyeliminatingtheneedforreusableplasticbasinsthathavebeenshowntoincreaseexposuretoharmfulbacteria.

Improves skin care.ReadyBathcontainsspecialcleansersandmoisturizersthatcanhelpsootheandsoftenskin.AllReadyBathformulasarepHbalancedandhavebeenhypoallergenicallytested.

©2012 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.

Excellentpatientcare,soothingcomfort

Total Body Cleansing System

To learn more about ReadyBath Bathing products, contact your Medline representative or call 1-800-MEDLINE (1-800-633-5463). To request a sample, email mmalczyk@medline.com.

Improving Quality of Care Based on CMS Guidelines 51

Bathingindependently,oneofthemostpersonalandcomplexoftheactivitiesofdailyliving,requiressignificantcognitiveandphysicalabilities,includingdexterity,flexibility,balance,strength,and coordination.1 To the person who requires assistance inbathing,thechangecanrepresentadecline inwell-beingandcause emotional and physical discomfort.2 Indeed, caregiversand recipientsalike, inbothhomesand institutions,oftensayassistedbathingisdifficultanddistressing.

A significant number of older adults have difficulty or needassistance with bathing. In one study of 626 community-dwellingolderadultsages73yearsandover,195 (31%)metthe criteria for “bathing disability” (those “requiring assistanceor having difficulty washing or drying the whole body”).1 Andaccordingtoareport issuedbytheNationalCenterforHealthStatistics, Nursing Homes, 1977-1999: What Has Changed,WhatHasNot?at least90%ofnursinghome residentsneedsomeassistancewithbathing.3

Abstract OVERVIEW:Olderadultswhoneedassistancewithbathingoftenfindtheactivitytobeboth

physicallyandemotionallydemanding,asdotheircaregivers.Researchhasidentifiedseveralcontributingfactors,includingpain;fatigueandweakness;confusion;anxietyresultingfrombeingnakedinfrontofstrangers,beingafraidoffalling,andbeinginanoisyorunfamiliarplace;anddiscomfortfromcoldordraftybathingareasorharshwatersprays.Theauthorsofthisarticlemakethecasefortheeliminationofforcedbathing.Researchsupportsthischangeinphilosophyandpractice,wherebybathingisnotatasktobeperformedbutratherahumaninteraction.Inexpensive,practical,andevidence-basedalternativesarediscussed.

Ourexperience,supportedbyotherresearch,hasshownseveralfactorscontributingtobathingdifficulties,including1,4

• painfrommusculoskeletalconditions,suchasarthritisinthetoes,knees,andneck.

• fatigue and weaknesscausedbyfrailtyandother medical conditions.

• fear and misunderstandingbecauseofmemoryloss,cognitivedecline,previousnegativeexperience,oracombinationofthese.

• anxiety and apprehensionbecauseofsuchfactors asfearoffalling,beingtransportedtoanoisyarea, beingnakedinfrontofstrangers,andbeinghoisted highintheair(asonaHoyerlift).

• discomfortfromcold,draftyairorharsh showersprays.

By Joanne Rader,MN,RN,Ann Louise Barrick, PhD,Beverly Hoeffer DNSc,RN,FAAN,

Philip D. Sloane MD,MPH,Darlene McKenzie PhD,RN,Karen Amann Talerico PhD,RN,

Johanna Uriri Glover PhD,RN

The of Older Adults

Dementia with

Bathing

SpecialFeature

52 Healthy Skin

In our series of studies we’ve found nurses to be critical inimproving thebathingexperience forolderadults. In fact,ourrecentclinicaltrialtestedtwoperson-centeredbathingmethods(methodstailoredtotheneedsandcomfortlevelofthepersonbeing bathed) aimed at reducing discomfort, agitation, andaggression in nursing home residentswith dementia, andwefoundnursestoplayacentralrole.5Andwiththegrowthofthegeriatric population, particularly those85 years old andolder,nurseswillincreasinglyneedtoassistwithbathing.

Drawing on more than a dozen years of clinical work andresearch,wesuggesttheeliminationofforcedbathinginhomesandinstitutions,apracticeweconsideronaparwithrestraintuse.Bothpracticesgenerallywentunchallengedandwereoncethought tobe adequate standardsof care-somepractitionersmay still think so-despite the frequent protests and physicalresistanceofthosebeingrestrainedorforcedtobathe.Butsolidevidencenowdisputesthesafetyandnecessityofbothofthesepractices.Bathingpeopleroutinelyagainsttheirwishes-“fortheirowngood”-shouldbecomepartofnursinghistory,asperson-centeredcarebecomesthenorm.

We believe that to bathe people against their wishes, unlessthereisanacute,compellinghealthreasontodoso,constitutesabuse.Wehopetoencouragenursestothinkcreativelyabouthow to individualize care and inform and support those whoprovidedirectcare.

CurrentBathingPracticesIn the home. Many community-dwelling older adults adapt their bathingmethodsastheyageorbecomeill,butthosewhohavedementiaandthoseneartheendoflifeusuallyrequireassistanceandcanbeparticularlychallenging.Andtryingtobatheapersonwhoisvery frail,aspeopleoftenareat theendof life, inatraditionalshowerortubcanbephysicallyexhaustingorimpossible.

In the hospital. Sincehospitalstayshavedecreasedinlengthandpatientacuityhas increased, bathing has been less of a focus in facilities.Someacutecare facilitiesareusingpremoistened, individuallywrapped, no-rinse, disposable cloths that can be heated ina microwave oven. Bathing is often delegated to bedsidecaregivers,with very little professional oversight.Nurses,withtheirmanycompetingpriorities,maynotbeawareofproblemswhentheyariseorarepoorlypreparedtodealwiththem.

In the long-term care facility. Most nursing homes in the United States schedule routineshowersortubbathsforresidentsatleasttwiceperweek.Thebathingmethodandscheduleareusuallybasedonthefacility’sroutineandnotontheresidents’preferences.Thevastmajorityareshowered.6Inourexperience,we’vefoundthattheshoweror tub roomsareoftencoldandnoisy,with tubsandshowerequipment that may be unfamiliar or look intimidating. Staff

Pain

anxiety

FATIG

UE

fear

WEAKNESS

discomfort

misunderstandingapprehension

Improving Quality of Care Based on CMS Guidelines 53

We hope to encourage nurses to think creatively about how to individualize care and inform and support those who provide direct care.

have reported tous that they feel rushed toget residents upandshoweredbeforebreakfast.Ahighproportionofresidentshavecognitiveimpairmentandmaybeeasilyconfusedormadeanxiousbybeingbathed.

Painduringbathingisalsocommoninpeoplewithdementia.Onestudy found that 88%of 17 subjects hada history of arthritis,osteoporosis, or joint pain.7 The movements required duringbathing (such as transferring out of bed into a shower chairand raising and lowering the arms and legs) can cause pain,fear, and discomfort. In our experience it’s not uncommon tohearresidents’screamsandprofanitiesfromtheshowerortubroom, andmany staff and residents’ families have told us thattheybelievesuchbehaviorsandothersignsofdiscomfortduringbathing are inevitable. Caregivers tell us that theyworry aboutensuringhygieneinasafeandcomfortableway.It’sstressfultoresidentsandprofessionalandfamilycaregiverstogivecarethatresultsinpain,exhaustion,andagitatedreactionssuchashitting,biting,crying,andscreaming.

ClinicalTrial:BathingPeopleWithDementiaThegoodnews is that thestressorsassociatedwithassistedbathingcanbemodified.Bathingcanbepleasantandwithoutharmtoolderadults in thehome, thehospital,and long-termcare facility.

We recently workedwith othermembers of a research teamtostudy twobathingmethods innursinghomeresidentswithdementia.5Wediscoveredseveralsolutionsthatbenefitedbothcaregivers and residents. (Although we studied people withdementia,most of our ideas andprinciples are relevant to allolderadultswhorequirebathingassistance.)Thestudywasarandomized,controlled trialwith twoexperimentalgroupsandausual-carecontrol group, conducted in ninenursinghomesin Oregon and six in North Carolina. Two interventions wereevaluated: person-centered showering and towel bathing inbed.Weworkedwith 73 residents (69 completed the study)and37certifiednursingassistants(CNAs).Tobeincludedinthestudy,residentshadtobeage55orolder,haveadiagnosisofAlzheimerdiseaseorotherdementia,havemoderateorseverecognitiveimpairment,beabletobeshowered,anddemonstrateagitationoraggressionduringbathing.

The focus of both bathing methods was the resident’scomfortandpreferences.ParticipatingCNAsandnurseswereencouragedtoviewresistanceandotherbehavioralsymptoms

misunderstanding

54 Healthy Skin

as expressions of unmet needs. Theywere taught to employappropriatecommunication techniques,applyproblem-solvingapproaches to identify causes of and potential solutions forbehavioral symptoms, and adapt the environment to theresidents’comfortandsecurity.

Showeringusesawidevarietyofperson-centeredtechniques,suchascoveringtheresidentwithtowelsasmuchaspossibleduring the shower, distracting the resident with food andinterestingobjects,usingfavoritesoapsandno-rinseproducts,modifying the shower spray, and providing choices (such aswhetherhairiswashedfirst,last,ornotatall).

Thetowelbath,aperson-centered,in-bedmethodadaptedfromtheTotmantechniqueinwhichthecaregiverusesalargetowel,oneortworegular-sizetowels,washcloths,abathblanket,no-rinsesoap,andwater.8Manynursesrememberthisprocedurefromobstetricsandhospitalpractice30yearsago.9

Of the15nursinghomesparticipating inourstudy, fiveservedas control and 10 as experimental homes. Recruited facilitieswere randomly assigned to three groups of five facilities each.One treatment group received the towel bath during the firstinterventionperiodandshoweringduringthesecondperiod.Theothertreatmentgroupreceivedthesameinterventionsinreverseorder.Inthecontrolgroup,consentanddatacollectionoccurredas in the treatment groups, but no intervention took place. Inthe10treatmentfacilities,clinicians(aclinicalnursespecialistinOregon and a licensed psychologist inNorthCarolina)workedwithparticipatingCNAstounderstandthecausesofagitationand

aggressionandtodevelopanindividualizedbathingplandesignedtoaddressthosecauses.TheclinicianandCNAsworkedtogetheroneortwodaysperweekforfourweekswitheachresidentinthestudyduringeachofthetwointerventionperiods.

In conducting the interventions, the team learned the following:Focusing on the person and the relationship rather than thetaskgreatly reducesdiscomfort andbehavioral symptoms.Wefound that caregivers assisting with bathing often felt rushedand frustrated, while residents felt a loss of control and evenattacked.Oneof us (Rader)was showered in a nursing homeduring a preliminary study and found the acceptedpractice tobecoldanddistressing.Taking the resident’spointofview,werealizedthatthebehaviorswehadpreviouslylabeled“aggressive”or “resistive”wereoftendefensiveactions residents tookwhenfeeling threatened and anxious. (For more information, see“Making Sense of Aggressive/Protective Behaviors in PersonswithDementia”byTalericoandEvansintheOctober-December2000issueofAlzheimer’sCareQuarterly.)

We found that by shifting the focus to getting to know theresident, communicating clearly (by reassuring or apologizingforanydiscomfortcaused,forexample),andthinkingcreatively,behavioralsymptomslessened.Therewasamarkedreductionin all behavioral symptoms (by32% in the showergroupand38%inthetowel-bathgroup).Aggressiondeclinedby53%intheshowergroup,60%inthetowel-bathgroup,andonly7%inthecontrolgroup.

vs.

Use no-rinse products to shorten and simplify bathing

Improving Quality of Care Based on CMS Guidelines 55

Itdoesn’ttakealotofwatertogetclean.Dryskinisaproblemforaboutthree-quartersofpeopleage65orolder.10Inplanningour study,we knew several of the bathing strategies had theadvantage of managing dry skin (for example, reducing thefrequency of bathing can prevent scaling or cracking of theskin).First,wereducedthefrequencyoftotal-bodybathingfromtwiceperweektoonceperweekformostsubjects.Second,weswitchedfromstandardsoapstoano-rinsecleanser,Septi-Soft,withasoybean-oilbase.Third,norinsingwasperformedduringthetowelbath,whichfurtherreducedexposuretowater.

Wewereconcernedthatlessfrequentbathingandusinglesswaterinbathingmightcompromisehygiene.Thestudydemonstratedthatthetowelbathdoesn’tadverselyaffectskinconditionorleadtotheaccumulationofpathogenic,odor-causingbacteria.Skinconditionwassignificantlyimproved,infact,andlessdebrisanddirtwereleftontheskin.Apersondoesn’thavetobedousedordunkedtobereallyclean.Abedbathcansafelysubstituteforashower.

There are many ways to meet hygiene needs. MostnursesandCNAsaretaughttostartabathattheheadandworkdownbecause it’sassumedthat theheadandfaceare cleaner than other areas. But for people with dementia,waterdrippinginthefaceandhavingtheheadwetaregenerallythemost upsetting parts of the bath; this causes distress at

thebeginningof thebath.Onealternative is towashthe faceandhairat theendof thebathoratanother time.Another istouseno-rinseproductsthatcanshortenandsimplifybathing.Infection-controlconcernscanbeaddressedby thecaregiverwashingherhandsandusingafresh,cleanclothaftercleansinga part of the body thatmight cause contamination. Althoughmanyhavebeen taught tocover thepersonduringashoweror tub bath, few actually do this, possibly leaving the personcold and feeling exposed, embarrassed, and without dignity.Covering the person with a towel and washing beneath italleviatesthisdistress.Thesechangesaresimple,practical,anddonotincreasethelengthofbathingtime.

Pain is often the cause of behaviors. The prevalence of pain or potentially painful conditionsamong institutionalizedolderadultshasbeenestimated tobebetween 43% and 71%,11-13 with musculoskeletal conditionsthemostcommonsource.Manynursinghomeresidentswithdementiacan’tdescribetheirpainverbally,leadingtobehavioralsymptomssuchasaggression,resistingcare,andvocalizations.Themovementsnecessaryinroutinebathing,suchaswalking,standing,transferringfrombedorwheelchairtotuborshowerchair, and moving joints and limbs, can often exacerbatechronicpainorprecipitateacutepain.Wealsofoundthatpainisparticularlycommonwhenwashingbetweenthetoes,under

Alternative techniques:

Bathingpeoplewithdementia

MostnursesandCNAsaretaughttostartabathattheheadandworkdown.

Waterdrippinginthefaceandhavingtheheadwetaregenerallythemostupsettingpartsofa bath.Thefollowingalternativebathingmethodsmayhelptomakebathingmorecomfortablefor thepersonbeingbathed:

Alternative 1: Washthefaceandhairattheendofthebathoratanothertime.

Alternative 2: Useno-rinseproductsthatcanshortenandsimplifybathing.

Alternative 3: Washthefaceandhairattheendofthebathoratanothertime.

Alternative 4: Coveringthepersonwithatowelandwashingbeneathittokeepsthe personwarm,unexposed,andlessexposed.

56 Healthy Skin

Towel-bath interventions resulted in the greatest decline (26%) in discomfort in residents with musculoskeletal conditions 11-13

thearms,andonsensitiveareassuchasthegenitalsandface.Inourstudy,residents’discomfortdeclinedsignificantlyinbothintervention groups, but not in the control group; the largestdeclinewaswiththetowel-bathintervention(26%).

PracticalApproachesToreducepainassociatedwithbathing,nursinghomestaffandothercaregiversshouldexploretheneedforroutineanalgesiaornonpharmacologicapproachessuchasapplyinghotpackstosorejointsbeforeabath.Duringthebathorshower,caregiversshouldmovethelimbscarefully,warnthepersonbeforemovingorwashingapotentiallypainfulbodypart,andbeawareofsignsof discomfort. Letting the person assist in cleansing a painfulareacandiminishaggravation,aswellasinstillasenseofcontrolthatcandiminishdistress.Andwhileit’snotalwayspracticalinallsettings,givingapersontimetosoakinatubwithoutbeingrushed can help reduce chronic pain frommuscular tension.Also,caregivers inallsettingsshouldbe familiarwithanduseuniversalprecautionswithanybathingmethod,wearinggloveswhenappropriateforprotectionandinfectioncontrol.

Nursesshould thinkaboutbathingothersas theywould thinkaboutbathingthemselves.Whenyouhadaparticularlypleasantbathorshower,whatmadeitenjoyable?

Conceptualize bathing as a pleasant experience. Nursesshould thinkaboutbathingothersas theywould thinkabout bathing themselves. When you last had a particularlypleasantbathor shower,what sensationsmade it enjoyable?Whenaskedthisquestion inaworkshopsetting,nurseshavementioned specific preferences: time of day, shower or tub,watertemperature,lengthofshowerorbath,musicplaying(ornot),andscent. It’s rare thatanyonementions theprocessofwashingorthegoalofgettingclean.

This is in stark contrast to the experience ofmany frail olderadults,whodependonothersforbathingandwhosedistressanddiscomfortcanbring them to thepointof resistanceandaggression. Nurses and other caregivers have traditionallyidentified these behaviors as the problem and reducing oreliminating them as the goal. But such behaviors should bethoughtofassymptomsoftherealproblem:unpleasantbathing.

Suggestions for the shower or tub. Inthehome,ifthepersonishavingdifficultygettingintoandoutoftheshowerortub,haveaphysicaloroccupationaltherapistperform an assessment. A hand-held showerhead, a bathbench,andproperlyplacedgrabbarscanbeofgreathelpandalsofosterindependence.4Somespousesreportbetterresultswhentheyshoweralongwiththeperson,ifspacepermitsanddoing so is customary.When older adults find getting in andout of bathtubs and showers difficult or frightening, despiteenvironmentaladaptations,thenextstepisoftentodospongebathsatthesink.Familiesandotherdirectcaregiversshouldbemadeawareofthewidevarietyofno-rinseproductsavailable,sincetheyoftenmaketheprocessquicker, lesscomplex,andlesslikelytocauseagitation.InourstudywefoundthatSepti-Soft,whendiluted,wasusefulinshowerortub.

The typicalplastic-pipeshowerchairused in institutionsoftenaddstopainanddiscomfortintheshower.Suchchairsusuallyhaveanunpaddedseat,aratherlargeopening,andnosupportforthefeet.Oneofus(Rader)foundthatwhenshewasshoweredinthistypeofchair,shesankintheopeningandherfeetdangledunsupportedandturnedblue-purplefromimpairedcirculation.Beforethispersonalexperience,shehadassumedthatthefootdiscolorationshe’doftenobservedinfrailolderadultswastheresultofirreversiblephysiologicchanges.

Improving Quality of Care Based on CMS Guidelines 57Improving Quality of Care Based on CMS Guidelines 57

In a preliminary study we purchased a shower chair with a padded seat and foot support.14 Staff members reported that residents who weren’t cognitively impaired requested this chair specifically once they’d felt how comfortable it was. Since purchasing new shower chairs isn’t always an option, try these adaptations:

• Use a small plastic stool (6-in. to 9-in. tall) or an overturned plastic washbasin to support the feet.

• Cover the cold, often wet, nylon-mesh chair back with a dry towel.

• Cover the arms with closed-cell foam pipe insulation.

• Pad the seat using small towels or washcloths, or purchase an inexpensive potty-seat insert and place it in the hole in the shower chair to pad the seat and make the hole smaller.

• Disinfect shower chair additions along with the shower chair.

• Check for small tears or cuts in the surface of the foam or seat insert and replace for infection control.

In assisted living facilities and nursing homes, a trusted staff member (and the same staff member) assisting with bathing is very important. Think about how difficult bathing would be if someone different were to bathe you each time. If the facility has consistent assignments, and the same person cares for the same resident over time, the caregiver and resident can develop a relationship and tailor the method, time, and frequency of bathing according to the resident’s needs.

Hospitalized patients, unlike nursing home residents, may wish for more frequent bathing or a soothing bath or shower as a way to feel better. Family members can help with this, which can minimize fear and misunderstandings and also allow the patient to schedule bathing according to his energy level and other preferences.

Suggestions for in-room bathing. Professional and family caregivers should consider routine bathing options outside the bath or shower. Here again, the use of no-rinse products can make bathing more pleasant and easier. Prepackaged “bath-in-a-bag” products, consisting of up to eight premoistened, presoaped, no-rinse, disposable cloths, can be used in all settings. The following is a checklist for using them:

• Heat the package according to instructions.

• Checktoensure that the cloths are not too warm.

• Remove a cloth and wash the person, using a new cloth for each part of the body.

• Wash under the covers if the person is very sensitive to cold.

Drying isn’t usually required because there’s minimal moisture. A “bath in a bag” does not require water, so a person can be washed in a variety of places. People living at home at the end of life can be adequately bathed while resting comfortably in a recliner. Even the toilet can be an appropriate place for this type of cleansing; for example, if the person has limited energy, requires an extended period on the commode, or feels pain when transferred, this method might be useful.

The typical plastic-pipe shower chair often adds pain and discomfort in the shower.

Padded shower chairs make the bathing experience more comfortable.

vs.

58 Healthy Skin

Ifdisposableproductsaretooexpensive,createtheequivalentusingadilutedno-rinseproduct,anumberofcleanwashcloths,andasmallplasticbag.Besurethepersoniswarmandcoveredbeforeyouprepareyourequipment:

• Placethewashclothsintheplasticbag.

• Fillagraduateorpitcherwithwarmwater (nohotterthan105ºF).

• Addaquartertohalfounceofno-rinseproduct (suchasSepti-Soft)tothewaterandpourjustenoughsolutionintothebagtomoistenthewashcloths.

• Takethebagtothebedsideorwhereverthewashing willtakeplace.

• Washeachsectionofthebody,keepingtherest coveredandwarm.

• Placetheusedwashclothsinasecondplasticbag.

If a more relaxed way of bathing is desired, the towel-bathmethodcanbeverycomfortingandenjoyable (seeTheTowelBath,nextpage).Thismethodcanbepresentedtothepersonasa“nice,warmmassage”inbedratherthana“bath.”Avoidingthewords “wash” and “bathe” can be helpful to peoplewithdementia,whooftenassociatethewordswithacold,frightening,and uncomfortable experience. Once the caregiver is familiarwiththeprocedures,thetowel-bathtechniqueissimple,quick,andeasytoperform.Infacilitiesthatroutinelyusethistechnique,it’susefultohavethebagsandtowelsprepackagedbylaundryorcentralsupplyandplacetheminthelinenclosetforstaffuse.

Suggestions for hair washing.Goingtothebeautyparlororbarber is a pleasant experience formany people. Continuingthis activity in people with dementia is desirable because it’sfamiliar, it enhances the person’s physical appearance, and itgivesanopportunitytosocialize.Butatraditionalbeautysalonmayoverwhelmapersonwhohasdementia.Whenabeauticianis no longer appropriate or available, separating hairwashingfromtheshowerorbathisoftenusefulinpreventingagitation.

When hair washing is the most dreaded part of bathing, it’shelpful to wash the hair only when it’s absolutely necessary,usingamethodthathasbeen foundtobe themostpleasantandtolerable.Forexample, ifyouchoosetowashthehairaspartofashowerortubbath,waituntiltheend,coverthepersonwithdrytowels,andthenwashthehair,asfollows:

• Use very little water,pouringfromapitcherandcarefullydeflectingthewaterawayfromtheeyeswitheitherthehandorawashcloth;ordampenthehairwithwetwashcloths.

• Useas little shampoo as possibletoreducetheneed for rinsing.

Whenwashing the hair outside of the shower room,abasin-and-washclothmethodallowsthepersontoremainfullyclothed.Hereisone:

• Firstplaceaplasticbagandthenatowel aroundtheperson’sneckandshoulders.

• Dampenthehairwithawetwashcloth.

• Addasmallamountofshampoo.

• Massagethehead.

• Usethewetwashclothtoremovetheshampoofromthehaironesectionatatime,rinsingtheclothinthebasinofwaterfrequently.

• Gentlydrywithatowel.

An in-bed inflatable basin is useful when hair-washing isperformed separately from thebath or shower.Other optionsincludeadryorno-rinseshampooorano-rinseshampoocap.

Continuing hair washing in people with dementia is desirable because it’s familiar, enhances the person’s physical appearance, and it gives an opportunity to socialize.

Improving Quality of Care Based on CMS Guidelines 59

Working with, Rather Than Against, ResistanceNurses in all settings should work with families so that theycan better understand the many ways that hygiene can bemaintained. Family members may think the person shouldbe showered or bathedmore often than is actually needed,desirable, or is actually tolerable. Without information, familymembersmayseeless-frequentshoweringasawayfornursinghomestafftogetoutofdoingthework,forexample,ratherthanasamethodofindividualizingcare.

ResourcesAn interactive CD-ROM and videopackage, Bathing Without a Battle, producedbythreeofus(Barrick,Rader,and Sloane), was sent to all federallyfundednursinghomes inJanuary2004.It is available for purchase online at www.bathingwithoutabattle.unc.edu.4

Abookbythesamename(andauthors)isalsoavailableinstoresandonline.

Acaregiverispreparinganursinghomeresidentforbathingandtheresident,anolderwomanwithdementia,isresisting.“Youthinkyouknowmoreaboutmyownbody,”shesays,grabbingat the caregiver’s arms and twisting the collar of her blouse.“Youdon’twantmetoliveinmyownbody.”Thecaregiversaysitisn’tso,andtheresidentcounterswith,“Well,whydon’tyoukeepyourhandsoffofme?”

This is a scene fromaCD-ROMand videopackage,Bathing

Without a Battle: Creating a Better Bathing Experience for Persons

with Alzheimer’s Disease and Related Disorders,createdbythreeofus(Rader,Barrick,andSloane),whichdepictsactualscenesofassistedbathingthatunfoldwithvaryingdegreesofsuccess.Thefamiliarformsofresistance,suchashitting,biting,andshouting,areshown,asarestrategiesthatcaregiversmightuse.

Inanothersequence,acaregiveroffersawashclothtoanolderwoman. The woman takes the washcloth and washes herown face. The caregiver then asks the woman’s permissionbeforeremovingherhospitalgownandletsthewomantestthetemperatureofthewaterbeforewettingherskin.Theseactionshelp theperson feel that she has somecontrol,which helpsmakeforasmootherprocess.

Improvingthe ShowerorTubExperience

•Switchbathingtoadifferentorfamiliar time of the day.

•Separate hair washingfrombodywashingifeitherisdistressingoroverwhelmingtothepersonbeingbathed.

• Cover the personbeingbathedwithadrytowelwhenusingahand-heldshowertopreventthepersonfrombeingwet,naked,andcold;simplyliftupthetoweltowash.

References

1. NaikAD,etal.Bathingdisabilityincommunity-livingolderpersons:common,consequential,andcomplex.JAmGeriatrSoc2004;52(11):1805-10.

2. EvansLK.Thebath!!Reassessingafamiliarelixirinoldage.JAmGeriatrSoc2004;52(11):1957-8.

3. DeckerFH.Nursinghomes1977-1999:whathaschangedandwhathasnot?Hyattsville,MD:NationalCenterforHealthStatistics;2005.http://www.cdc.gov/nchs/data/nnhsd/NursingHomes1977_99.pdf.

4. BarrickAL,etal.Bathingwithoutabattle:creatingabetterbathingexperienceforpersonswithAlzheimer’sdiseaseandrelateddisorders[CD-ROM].ChapelHill,NC:UniversityofNorthCarolina;2003.

5. SloanePD,etal.Effectofperson-centeredshoweringandthetowelbathonbathing-associatedaggression,agitation,anddiscomfortinnursinghomeresidentswithdementia:arandomized,controlledtrial.JAmGeriatrSoc2004;52(11):1795-804.

6. SloanePD,etal.BathingtheAlzheimer’spatientinlongtermcare:resultsandrecommendationsfromthreestudies.AmJAlzheimersDisOtherDemen1995;10(4):3-11.

7. MillerL,etal.Developmentofaninterventiontoreducepaininolderadultswithdementia:challengesandlessonslearned.Alzheimer’sCareQuarterly2005;6(2):154-67.

8. SloanePD,etal.Bathingpersonswithdementia.Gerontologist1995;35(5):672-8.

9. Towel-bath-Totmantechnique[protocol].St.Louis:Calgon-VestalLaboratories;1975.

10.DavisG,LuggenA.Geriatricnursepractitionercareguidelines:pruritusandxerosisintheelderlyperson.GeriatrNurs2003;24(4):247-8.

11.FerrellBA,etal.Painincognitivelyimpairednursinghomepatients.JPainSymptomManage1995;10(8):591-8.

12.MarzinskiLR.Thetragedyofdementia:clinicallyassessingpainintheconfusednonverbalelderly.JGerontolNurs1991;17(6):25-8.

13.ParmeleePA.Painincognitivelyimpairedolderpersons.ClinGeriatrMed1996;12(3):473-87.

14.HoefferB,etal.Reducingaggressivebehaviorduringbathingcognitivelyimpairednursinghomeresidents.JGerontolNurs1997;23(5):16-23.

Reprintedwithpermission.AmericanJournalofNursing.2006;106(4):40–48.

60 Healthy Skin

Bathing with Dignity for Caregivers

Make bathing a more pleasant experience for residents and caregivers through a more adaptable, personalized approach

Understand how to turn small changes into a culture shift

Participate in an interactive virtual competency that allows you the chance to practice what you learn

Bathing with Dignity for Administrators

Learn simple, practical ways to improve the bathing experience and reduce resident distress

Learn to shift the focus from viewing bathing as a task to a more pleasant activity

Participate in an interactive virtual competency that allows you the chance to practice what you learn

More Bathing Guidance from Joanne RaderEarn CE credit with these free courses at MedlineUniversity.com

Joanne Rader, RN, MN, PMHNP is an award-winning author and founding member of the Pioneer Network. She is renowned for her work involving culture change in the long-term care setting, and she developed the above continuing education courses especially for Medline University.

Practice what you learn with interactive competencies

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1 Go to www.medlineuniversity.com

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Improving Quality of Care Based on CMS Guidelines 61

PolicyAmoisttowelettebathwillbeusedonindividualsrequiringabedbath,unlesscontraindicated,andwillbeavailabletoanyotherindividual.

GoalToprovidetheindividualswithabaththatwillleaveacleanandrefreshedfeelingwhilemaintainingcomfort and dignity.

SuppliesBath-in-a-BagMoistToweletteBathingSystemShowerlessShampooCap(optional)Warmingunit(centralsupplylocation)GlovesBathblanketCleangownorclothingTowel(optional)

Procedure1. Knockonthedoorandidentifytheindividual.

2. Introduceyourselfandexplaintheprocedure. •Therewillbeseveraltowelettesfordifferent

partsofthebody.Showthediagramonthepackagetotheresident,ifappropriate.

•Thetowelettesaresaturatedwithahydratingno-rinseformula.

•Thereisnoneedforadditionalbasins,washcloths,ortowels.

•Ifyouareusingawarmingmethod(microwaveorwarmer),followinstructionsforthatparticularmethodtowarmproduct.

3. Removetheindividual’sgownorclothingandanyremovableelasticbandages,stockings,orrestraints.Provideabathblanketforprivacyandwarmth.Usethebathblankettocoveranyexposedareas.

Bath-in-a-BagMoistToweletteBathingSystemElizabeth O Connell-Gifford, RN,BSN,CWOCN,DAPWCA,MBA

4. Donglovesifnecessary.

5.Encouragetheindividualtoparticipatetotheextentthathe/sheiscapable.

6.Ifgivingashampoo,placethewarmcaponthehead.

7.Removethebathingclothfromthepackage,thenresealpackagetoretainheat.

8.Atowelmaybeusedtogentlydryareas,especiallybetweenskinfolds.

9.Discardtheusedtoweletteinatrashreceptacle.DO NOT FLUSH!

10.Startwiththeface,neckandchest

11.Rightarmandaxilla

12.Leftarmandaxilla

13.Perinealregion

14.Rightleg

15.Leftleg

16. Back

17. Buttocks

18.Whileeitherbathingorassistingwiththebath,assesstheindividual’sskinforanysignsofbreakdownoranychanges.

19.Finishtheshampoobymassagingthehead,removethecap,andthencomboutthehair.

20.Dress,orhelptheindividualgetdressed,withacleangownorotherappropriateclothing.Reapplyanyelasticbandages,stockings,orrestraintsthatwereremovedpriortobathing.

21.Document.Recordthedateandtimeofthebath.Notetheindividual’stolerancetothebath,anyself-careability,andanyunusual

62 Healthy Skin

Improving Quality of Care Based on CMS Guidelines 63

Perhaps you remember your grade school hall monitor. For me, it was Mrs. Angeloni. Amongst us kids, she was anything but an “angel.” She was a tough woman who took her job seriously—maybe too seriously. I don’t think she ever cracked a smile! Years later, I realized it was her obligation to watch over us. She made sure we complied with the class schedule. In hindsight, we should have embraced her resolve, we should have thanked her for enabling us to learn more as a result of her dedication and we should have befriended her instead of fearing and being intimidated by her. It turns out that Mrs. Angeloni, my grade school hall monitor, was an angel of sorts.

Though the stakes are much higher, the role of monitor plays a huge part in the daily routine of healthcare professionals. Today, patients’ lives are in the balance, and caregivers rely on monitors to provide useful information such as vital signs and blood glucose levels. And because hand hygiene is one of the most important ways to prevent the spread of infections,1 the most important patient safety monitor might be the hand hygiene compliance monitor.

Going all the way back to 1847 when Dr. Ignaz Semmelweis first identified the cause and effect relationship between disease and unclean hands, the goal of 100 percent hand hygiene compliance has been difficult to reach. It is widely recognized that Dr. Semmelweis used his strong personality, and sometimes not so subtle words, to change the behavior of his colleagues. He was the first documented “hand hygiene compliance monitor.” Perhaps he felt he had to be shocking and demonstrative because the science of hand hygiene was unknown. Thankfully, he persevered and the science has evolved. Today, hand hygiene is regarded as the most effective single measure to prevent health care-associated infections.2 And yet, 100 percent hand hygiene compliance remains an elusive goal, and measuring compliance remains a challenge. Many would argue it is time for the science of compliance measurement to evolve as well.

Partner or Big Brother?

Automated Hand Hygiene Compliance Monitoring Systems

Prevention

By Marc Lessem

64 Healthy Skin

Measurement Methodology Description Merits Drawbacks

Observation

Anonymous(secret shopper)

observationandrecording

ofhandhygieneeventsby

individualcaregiver

•Individualaccountability

•Complianceandtechnique

canbemeasured

•AbilitytomonitorperWHO

“MyFiveMoments”model

•Requiresdedicatedandcostly

laborresources

•“Hawthorn”effectmayresultin

overstatedcompliancerates

Consumption

Soapand/orsanitizerusage

isrecordedandcompared

withcensusdays

•Relativelysimple

•Costeffectivetoimplement

•Cannotmeasureindividualcare-

givercomplianceortechnique

Self-ReportingHealthcareworkerssubmit

self-evaluations.

•Lowcosttoimplement

•Staffcommitment

•Overstatedcompliancerates

unsubstantiatedbyunbiased

observers

Traditional methods for measuring compliance

Traditionally, hand hygiene compliance has been measuredthrough self-reporting, consumption and/or observation. Whileeachmethod can provide a quantitative compliance rate for adefinedtimeperiod, it is therelativechangeoverthosedefinedtimeperiodsthatistracked.Interventionsaredeemedsuccessfulif thetrendmoves intherightdirection.Eachmethodologyhasbothmeritsanddrawbacks,someofwhicharedetailedinTable1.Isthereabetterwaytomeasurehandhygienecompliancethanwiththesetraditionaloptions?Theanswermaybeyes!

New technologies for measuring compliance

Electronic hand hygiene compliance measurement systems,such as RFID (radio frequency identification) and RTLS (real-time location system) are now being promoted to infectionpreventionistsandC-suitepersonnel.Insomecases,thesystemsare part of the nurse call or asset tracking systems already inplace. These systems deploy dispensers or alcohol-sensing

Table 1. Traditional Methods for Measuring Hand Hygiene Compliance

devicesthatinterfacewithhealthcareworkers’namebadgesandremindhealthcareworkerstocleansetheirhandsthroughtheuseofaudible,visualorvibratingcues.

Thebadgeorbadgeholdercommunicateswithadevicetypicallymounted near the doorway or bed of each patient room. Forexample,abadgemayflash “red” if ahandhygieneeventhasnotoccurredprior topatientcontactand “green” if it has.The“smart”badgealsocommunicateswithadatacollectionserver.Through the use of proprietary software, the data is collectedand management reports designed to monitor hand hygienecompliancearegenerated.Dependingon thedesired reportingand the system capabilities, these reports can be sorted byhealthcareworkertitle(e.g.,RNson2-West)orbyindividual(e.g.,SallyJohnson).Thereportscanbeusedtotrackcompliancetoallowfortrainingandeducationinterventionswhencomplianceislackingandrewardandrecognitionwhencomplianceimproves.

Improving Quality of Care Based on CMS Guidelines 65

Points to consider before implementing

an automated compliance system

Implementing an automated hand hygiene compliancemonitoring system is a complex interdisciplinary decision.Priortoimplementation,considerengaginginthoughtfuldiscussionofthefollowing:

Expense. Purchased outright, these systems can be costly.By acquiring the system via a monthly service fee, capitalexpenditurescanbeavoided.Netcost,however,isdependentonhowtheimpactofhealthcare-acquiredinfectionsisfactoredintotheequation.AcasecanbemadethatwithanominalreductioninHAIs,thesesystemsareawise investmentwithanattractivereturnoninvestmentversusexpense.Anothercasecanbemadethatthemoneyisbetterspentelsewhere.

Individual accountability. Management reports generatedfromthesesystemswillbeusedtofavorablyimpactcompliance.Somewillchoosetousethedatatorewardcompliantpersonnel.Othersmayusethedataforpunitivepurposesfornon-compliantoffenders. The impact of labor unions must be considered aswell. Unionsmay desire that themonitoring systembe flexibleenoughtocollectdatawithsomedegreeofanonymityaswellasbyindividualname.

Workflow interruption.Twoofthemostcommonobstaclestocompliancearelackoftimeandbehaviormodification.Sometimesjustgettingthehealthcareworkertothedispenserisdeemedavictory.After recognizing thedispenseruservia “smart”badge,someautomatedcompliancesystemsrequireasecondsteptoverifyapplicationofthehandhygieneagenttothehands.Suchsystemsrequiremoderateretraining.

Desire to monitor hand washing. Whilemonitoring for theuse of alcohol-based hand sanitizer appears achievable for allsystems, some automated monitoring systems are limited in theirabilitytomonitorhandwashingwithsoapandwater.Somesystemsareunabletomonitorsoapandwaterevents,whereas

othersystemsrequirefacilitiestousespecificsoapswithcertainlevelsofalcoholsotheycanbedetectedelectronically.

RFID vs RTLS.Thesearethetwomostprevalenttechnologies.RTLSsystemsarecommonplaceforassettracking,andalthoughitmightbetemptingtoexpandonaRTLSplatformtoleveragethatinvestment,RTLSdiffersfromRFIDandatechnicalcapabilityreview is required foraccuratehandhygienemonitoring.Moststand alone systems that are designed for the purpose ofmonitoringhandhygienecomplianceutilizeRFID.

Installation/Maintenance.Somesystemsarebattery-operatedand can be installed with double-sided tape, whereas othersrequireapowersource,suchasACpower,tooperatesomeoftherelateddevices. Installation issuesrelatedtofacilitymodificationand patient inconvenience must be considered. Furthermore,batterylifeand/orrechargingcapabilitiesmustbeaccountedforaswell.

IT involvement. Communications technology and devicecapabilitiesarecritical. Informationtechnologyexpertswillwantto reviewthehardwarerequired. Fromasoftwareperspective,mostsystemdesignsattempttocommunicateoutsidethefacilitynetwork.Thisisdesirablebecauseithastensimplementationandeliminates security concerns.

Measuring to the WHO “5 Moments” Model. Doyouwishtomonitorhealthcareworkersas theyenterand leave thepatientroomordoyouprefer tomonitorwithinanarrowpatient zonearoundthepatient’sbedtomorecloselyapproximatetheWorldHealthOrganization’s“My5MomentsforHandHygiene”3model?

66 Healthy Skin

Partner or big brother? You decide.

After all considerations are evaluated and a decision ismade,thereremainsasingleverychallengingquestiontobeanswered.Arestaffandadministrationreadyfortherealizationthatpreviouslyreportedcomplianceratesmaybegrosslyoverstated?Forsomefacilities that report compliance rates in the 80 to 90 percentrange, as calculated by one of the more traditional methodsdescribed earlier, it can be a rude wake up call to see howobjective reporting fromthousandsofdatapointsmay result infarlowerreportedcompliancerates.Howtodealwiththisfromamotivationandcompensationperspectiverequiresprospectivethoughtandbenevolentseniorleadership.

Thedecisiontodeployanautomatedcompliancesystemishighlydependentonthehealthcareteam’sresourcesandcommitmenttohandhygiene.Ifembraced,theseemergingtechnologiescanbea true infectionpreventionpartner in the fightagainstHAIs.Yet, some healthcare workers might consider themmore “BigBrother” and feel threatened. As with any innovative action,implementinganautomatedhandhygienecompliancemonitoringsystemrequiresthesupportofboldleaderswhocaneffectivelycommunicateandmotivate.Iftheendresultisimprovedpatientoutcomes,couldanyonearguethatthesemonitorsareasangelicasMrs.Angeloni?

Reference

1.CentersforDiseaseControlandPrevention.HandHygieneBasics.Availableat:http://www.

cdc.gov/handhygiene/Basics.html.AccessedDecember9,2011.

2.ScheithauerS,Oude-AostJ,HeimannK,HaefnerH,WaitschiesB,KampfG,etal.Hand

hygieneinpediatricandneonatalintensivecarepatients:dailyopportunitiesandindication-

andprofession-specificanalysesofcompliance.AmericanJournalofInfectionControl.2011;

39(9):732-737.

3.WorldHealthOrganization.AboutSAVELIVES:CleanYourHands.MyMomentsforHand

Hygiene. Available at: http://www.who.int/gpsc/5may/background/5moments/en/index.

html.AccessedDecember9,2011.

As with any innovative action, implementing an automated hand hygiene compliance monitoring system requires the support of bold leaders who can effectively communicate and motivate.

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68 Healthy Skin

ADDRESSING

RESISTANCE TO

NEW TYPES OF

WOUND DRESSINGS

FOR SKIN TEARS

H O T L I N E

T O P I C

Question:I am a director of nursing (DON) in a long-term care facility. After forming a wound team, and developing and implementing protocols, I am frustrated that the staff follows the protocols except when it comes to skin tears. Our nurse aides received many hours of education about moisturizing the skin to prevent skin tears, but we still have a fair number of skin tears.

The protocol is to apply a gel dressing every three days. If the wound bed is dry it is covered with a gauze dressing, and if the wound has moderate drainage, it is covered with a foam dressing and changed every five to seven days. Rather then seeing this protocol followed, instead, I consistently find Xeroform or Adaptic with an antibiotic ointment covered with a telfa to be changed daily.

This type of dressing puts the facility at risk with the department of health survey team. How can I get my staff to follow the policy?

Answer:We receive many calls like this on the hotline from frustrated supervisors, case managers and DONs in long-term care, home care and hospice. Some even relate that the day shift may apply the correct dressing, and then an off-shift nurse may change the dressing to an old style wet to dry “because they don’t believe in all these new fangled dressings.” The staff may also be under fire from relatives or the patients themselves about leaving the wound open to air.

Staff not following policies or protocols puts facilities at risk for a deficiency in a department of health survey, and sets the stage for negligence from not following a physician’s orders. When you say you developed and implemented protocols, I am assuming that you had input and final approval from the physician team for the skin and wound care approach you want your team to follow.

I recently attended a seminar that discussed the legal implications of wound care. The author discussed several points that seem to apply here.

Regular Feature

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

Improving Quality of Care Based on CMS Guidelines 69

ADDRESSING

RESISTANCE TO

NEW TYPES OF

WOUND DRESSINGS

FOR SKIN TEARS

Protocols versus guidelinesA recommendation was made to change the words “policy, procedure or protocol” to “guidelines,” so that if the staff does not follow the wording of the document exactly they are not setting themselves up for “conduct that falls below the standards of care.”

If the protocol indicates the nurse should be applying a gel dressing every three days, and he or she chooses to apply antibiotic ointment and xeroform/adaptic (or use the generic petroleum gauze) without a physician’s order, then that nurse is essentially practicing medicine without a license since antibiotic ointment is an over-the-counter topical drug.

You mentioned the extensive education provided. What did it involve specifically? Were the protocols just verbally reviewed during an in-service or was a return demo or competency required to validate the nurses’ knowledge?

What about the “new fangled” products? How was the information delivered? Did the staff have a chance to touch and feel the products and ask questions about the mechanisms of wound healing? Did you show your staff photos of a wound after three to five days with the dressing and point out the drainage prior to the wound being cleansed? Does your staff understand the concepts of moist wound healing?

Having spent several years as a staff development instructor and infection control nurse, I am very aware that what I said is not always what the staff heard. There are several concepts that staff need to understand for them to accept new ideas and new products.

Moist wound healingEarly in the 19th century it was common practice to leave smaller lesions, surgical incisions or wounds such as skin tears open to air or to shine a lamp on a wound such as a bedsore using “dry healing” to close an open area. The scab that was formed was thought to be a quality indicator of healing. It wasn’t until the 1960s that scientists discovered that covering a wound up with a moisture retentive dressing such as a film, hydrocolloid and some foams to retain the moisture actually increases the speed of healing. The collection of fluids, or “wound soup,” contains platelets, growth factors, white blood cells, macrophages and components that perform moist healing. Your staff needs to understand and embrace this moist wound healing concept, which has become a standard of care.

In addition, the action of daily dressing changes may cause the patient pain, may expose the wound bed to additional microbes and most likely will decrease the wound bed temperature. Healing will not begin again until the wound bed temperature rises to the patient’s normal temperature.

Infection misconceptionThe words we learn in nursing and medical school to identify and explain infection: “red,” “warm,” “local edema” and “pain” are the same clinical markers that describe the inflammatory phase of wound healing. The subtleties are in how pronounced the signs and symptoms present themselves.

Often the ingredients in new thin dressings, such as starch molecules in a hydrogel or the carboxymethylcellulose (CMC) of a hydrocolloid, absorb exudate from the wound, and the resultant liquid drainage may appear green or tan in color with a chunky texture and an odor. An inexperienced staff nurse may believe the wound is infected, and he or she may even call the physician to report these findings and suggest that the dressing is changed to an antibacterial, antimicrobial or silver-containing product. These dressings must be re-applied daily because the medication is released in 24 hours, and after that they become ineffective. The nurse may even suggest the patient requires an antibiotic for “cellulitis.”

Call

Medline’s

Educare Hotline at

888-701-SKIN (7546) to

discuss a wound care issue with

one of our experienced wound care

nurses. The hotline is available

Monday through Friday,

8 am to 5 pm, Central Time.

888-701-SKIN (7546)

Are you facing a skin or wound care

dilemma with a patient or resident?

Regular Feature

888-701-SKIN (7546)

70 Healthy Skin

Nurses are often not educated that a true assessment of the wound bed cannot begin until the wound is cleaned. Then the drainage from the wound and the odor of the wound bed should be noted. So what is all that awful-looking drainage? The odor may be a result of the components of wound fluid-cellular waste products, dead cells (cadaverine) and dead fat (putrisene) and components of the product. This is one of the reasons why certain nurses and physicians do not trust new dressings. Education on new types of wound dressings should include the science of what is taking place and how the dressing category works with that physiology.

What to do with the “peekers”Medical professionals who continue to subscribe to daily treatments may do so because they do not trust that a dressing can be left in place with nothing bad happening to the wound. They belong to a class of nurses I call “peekers.” Changing skin tear dressings daily may add to increased overall costs when you calculate supplies, increased time to closure and additional pain medication for the patient.

An alternative to daily dressings are dressings with silicone borders that allow the staff to peek and re-seal the edges without disturbing the wound bed or dropping the wound temperature. Most wounds initially do not require treatment with a product to protect the wound from bacteria and fungus. The decision to initiate such products should occur when there are signs and symptoms that indicate microbes are impeding healing. In that case, a silver antimicrobial gel or silver foam could be initiated.

Changing skin tear dressings daily may add to increased overall costs when you calculate supplies, increased time to closure and additional pain medication for the patient.

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Marathon, a cyanoacrylate, bonds to the skin surface, integrating with the epidermis on a molecular level to seal in moisture. While other skin protectants may flake off, Marathon stays in place, offering robust protection and increased wafer wear time.

Stoma site before treatment with Marathon.1

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

Reference

1.KentDJ.Effectsofajust-in-timeeducationinterventionplacedonwounddressingpackages.JournalofWound,OstomyandContinenceNursing.

2010;37(6):609-614.©2012MedlineIndustries,Inc.MedlineisaregisteredtrademarkofMedlineIndustries,Inc.

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

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72 Healthy Skin

OurNursingFacilityMorseGeriatricCenterisanot-for-profit,mission-driven,280-bedlong-termcarefacilitydesignedanddedicatedtoservingtheelderlyinFlorida’sPalmBeachCounty.MorseGeriatricCenterisalsoadesignatedteachingnursinghomebytheFloridalegislature.

MorseGeriatricCenterhasreceivedtheGoldSealAwardfromtheStateofFlorida,Governor’sPanelonExcellenceinLong-TermCare.TheGoldSealAwardwasestablishedin2002torecognizeFloridanursinghomesthatconsistentlydemonstrateexceptionallyhighstandardsandqualityofcare.

OurChallengeIguessyoucouldsaywe’reearlyadaptersatMorseGeriatricCenter.InOctober2006,FloridawasaddedtotheQualityIndicatorSurvey(QIS)demonstrationprojecttotestastatewideimplementationapproachtoprepareforanationalQISrollout.IwasselectedastheQIStrainerforourfacilityandsubsequentlytrainedallofourcorporatestaffandkeypersonnel,includingadministrativestaff,nurses,dietitians,housekeepers,certifiednursingassistantsandsocialworkers.

ThetrainingopenedoureyestothenewQIS,whichisradicallydifferentthanthetraditionalsurvey.Weimmediatelyrealizedweneedededucationandnewinternalprocessestobeproactivetothesurvey

InnovativequalityassurancetoolreplicatesQISprocess andempowersstafftoimproveresidents’qualityoflife.

New QA System Improves Resident Quality Care; Builds Staff Morale

Morse Geriatric Center was an early adapter of the Quality Indicator Survey (QIS), having participated in a demonstration project in 2006 to test a statewide implementation approach for Florida.

By Carmen Shell

Improving Quality of Care Based on CMS Guidelines 73

With abaqis, both staff and residents immediately felt the lines of communication open up.

process.Moreover,ourpastperformanceonthetraditionalsurveywassatisfactory,butwewantedzerodeficienciesandourgoalistohaveourfacilityoperateatthehighestlevelcontinuously,notjustinoursurveywindow.

TheQISprocessisresident-centered,customerservice-orientedanddesignedtomoreaccuratelyandobjectivelyevaluatefacilitycompliancewithfederalregulations.Thesurveysampleisrandomlyselectedandusesestablishedthresholdmarkerstoconsistentlyidentify,andthereforeconfirmareasofnon-compliance.

OneofthebiggestchangeswiththenewQISprocessisthatitisdesignedtobemoreconsistentandlesssubjectivewitharesident-centered/customerservicefocus.Asaresultofthesechanges,weneedednotonlynewprocessestohelpusprepareforthesurvey,butanewqualityassurancetooltoguideusinreflectingthattheresidentisthefocalpointofourbusiness.

TheSolutionTheintroductionofthenewQIScoincidedwithourmissiontoimprovecustomerservice.Ourprioritywastofirstfindacontinuousqualityassurancetooltohelpusachievethesegoals.Weknewifwecouldbetteridentifyqualityandcustomerserviceissues,wecoulddirectlyaffectourday-to-dayoutcomesandsurveyresults.

Inthewinterof2007,wewereexposedtoanewqualityassurancetoolfornursinghomesthatwastieddirectlytotheQIScalledabaqis.MarketedanddistributedexclusivelybyMedlineIndustries,Inc.,abaqisisaweb-basedtoolthatusesthesamecalculations,

thresholdsandanalysesastheQIStoquicklyhighlightresidentsatrisk.abaqisalsowouldprovetobeatoolthatcouldeasilybetaughttoourstaffandthatallowedmetoaccessreportsquicklyand easily.

Replicates QIS Survey

TheabaqisStageISuiteexamines125resident-centeredindicatorsofqualityoflife(QCLIs)thatareusedtoidentifycareareasforaStageIIin-depthinvestigationandpossiblecitationsduringaQIS.

TheseindicatorsarecontainedinsixmodulesthatreplicateexactlytheQISassessmentsconductedonsiteduringthesurvey,plusonemodulethatuploadsandreviewsMDSdata.Themodulesare: • ResidentInterview • FamilyInterview • StaffInterview • ResidentObservation • CensusSampleRecordReview • AdmissionSampleRecordReview • MDSData

Just one month to implement abaqis system wide

Oncewelearnedabouttheabaqissystem,wetrainedthekeypeopleatourfacilitywhowouldbeimplementingthenewtool,includingadministrativeassistants,clinicians,dietitians,housekeepersandsocialworkers.Thetrainingwasnotdifficultandtookaboutonemonthintotaltogetourfacilitytrainedandreadytoimplementabaqis.

SpecialFeature

74 Healthy Skin

Thegoalistohavetheresident,familyandstaffinterviewscompletedquarterlybyanadministrativeassistant,dietitian,unitmanagerorasocialworker.Chartreviewsareonthesametimeline,butareusuallyconductedbytheclinicians.WethenhaveQAmeetingsonamonthlybasistoreviewperformancemeasuresandareasforimprovement.

LiketheQISsurvey,abaqisalsouseslaptopcomputersortabletPCstocapturedata.Earlyonweusedtraditionalpenandpaper,andthenenteredthedataintoacentralcomputer.ButnowwearemakingthetransitiontocomputersorWOWs(workstationsonwheels),whichreducesadministrativetimesubstantiallyandallowsustoutilizeabaqisandourstaffmoreefficiently.

‘Real-time’ summary reports reveal deficiencies

Thedatafromourfacilityisaggregatedonacentralfilesowecanreviewsummaryreportsontheentirefacility.Thisenablesustodetermineourprogressandwhatactionstepsneedtobetaken.Forinstance,wecanviewreportsthatshowhowmanyresidentsstillneedtobeinterviewed,whatareascouldbeflaggedfordeficiencyorwhattrendsaredevelopinginspecificareasorfacilitywide.

Anotherkeybenefitofabaqisisthatitletsusseeresultsinrealtime.Assoonasthedataisenteredintothecomputer,weareabletoaccessitonourcomputers,analyzeitandidentifyareasofconcern.

Results Staff attitude shifts to resident-centered care Atfirst,manyofourstaffdidnotfeeltheyhadtimetoimplementanewongoingQAprocess.Theywerehesitantandreluctanttochange.Fortunately,soonafterthestaffstartedusingabaqis,sawtheresults,andrealizedthebenefits,theybecamebelieversinournewcontinuousqualityimprovementtool.

Becauseabaqisasksresidentsquestionsabouthowtheyfeeltheyarebeingtreatedinspecificareasoftheircaresuchasfoodpreparation,dailyactivitiesorevenwhattimetheygotobed,bothstaffandresidentsimmediatelyfeltthelinesofcommunicationopenup.Residentssensedagreatervoiceandstaffhadanevidence-basedplatformtodirectcareandservices.

Real change to improve care

OurpreviousQAsystemoftendidnotenableustoeasilydrilldowntofindtheheartofaproblem.Itseemedourauditswereallretrospective.abaqisisreal-time,anduponcompletionofallStageIandStageIImodules,wewereabletodetermineiftheproblemwasastructure,processoroutcomeissue.

Similarly,withQISandabaqisredefiningwhatqualityassurancemeanstoourfacility,ourstaffnowhasarenewedsenseofempowermentandteambuilding.Theyaskourresidentswhattheywantandhowtheyfeel,andifaresidentwantssomethingchanged,ourstaffhastherealsensethattheycanimproveourresidents’lives.

Askingtheresidentandfamilyinterviewquestionshasforcedustotakeahardlookatourselvesandaskthehardquestion,“Arewetrulymeetingtheneedsandchoicesofourresidentsandfamilies?”Theinterviews,aswellasresidentobservations,canreallyrevealafacility’sweakspots.

Afterseveralmonthsusingabaqisandemployingongoingqualityassurance,ourlinestafffeltpreparedfortheQISsurveyandconfidenttheyknewwhattoexpect.

About the AuthorCarmen Shell, RN, CDONAhasserved,since2000,astheVicePresidentofClinicalServicesatMorseLife,acomprehensiveseniorcarecommunitylocatedinPalmBeachCounty.Ms.ShellhasclinicalandoperationalresponsibilityforNursing,Social

Services,Admissions,RehabilitationandTherapeuticRecreationforthecampuswhichincludesmorethan400SNF/IL/ALbedsandastaffof800+employees.

NO CATHETERIS THE BEST CATHETER

ERASE CAUTI®

NO CATHETERIS THE BEST CATHETER

ERASE CAUTI

www.erasecauti.com

76 Healthy Skin

Caring for Yourself

FEAR:

HOW TO KILL IT

DEAD!

Improving Quality of Care Based on CMS Guidelines 77

By Wolf J. Rinke, PhD, RD, CSP

ErikWeihenmeyersuccessfullyclimbedMt.Everestandfouroftheworlds’tallestpeaks.Nobig

deal,right?Wrong!It’saverybigdealbecauseErikisBLIND!Contrastthattothefactthatmany

ofushavedifficultytacklingeventhemostmundanechallenges.Forexampleyoumaybeafraid

ofaskingforthatraiseyouknowyouhaveearned.Ifyou’vehadadisagreementwithyourboss

youmaybeafraidtotalktoheraboutit.Oryoumaybeavoidingtogetintouchwiththatwonder-

fulyoungmanyoumetatthepartylastweekend.Whatpreventsmostofusfrombeingmorelike

Erik?It’sthatdirtyfourletterword:FEAR!Herearesixspecificstrategiesyoucanusetohelpyou

get rid of fear.

HOW TO KILL IT

78 Healthy Skin

Acknowledging that fear of failure is normal allows us to seeourselvesastypicalhumanbeingsinsteadof“chickens.”Itpro-videsuswiththemechanismforgettingoffourcase.Formostofus,wearetheoneswhoholdusbackmorethananythingor anyone else.Some time ago I shared a taxiwith a youngmanonmyway fromChicago’sO’Hare airport todowntownChicago.HetoldmethatheworkedforCBSandwasonhiswaytomakeabigpresentationtotheCBSboardofdirectors.WhenItoldhimthatIwasaprofessionalspeaker,managementconsultant,andauthorhegotexcited.Heimmediatelybegantoquizmeonhowhecouldbeamoreeffectivepresenterforthisbigmeetinghehadcomingup.Iaskedhimwhathewantedtoimprove.Aftersomeprying,he toldmehewantedtobe lessnervous.Iaskedhimwhyhewantedtodothat.Whenhegavemea funny look that said:Wonderwhat kindof professionalspeakerthisguyis?Iexplainedthatspeakerswhoarenotner-vousareterriblespeakersbecausetheyaredeadly.(Rememberthatprofessorthatputyoutosleepduringeverylecture?)Iassuredhimthatbeingnervousisabenefit,providedthener-vousenergyischanneledintherightdirection.Aftercoachinghim,Ilefthimwithathoughtthatheeagerlywrotedown:“Everyspeakerhasbutterflies.Excellentspeakersmakethebutterfliesfly in formation.”Oneweek later he sentmea note togetherwithanorder formybookandaudioprogram. Inhisnotehetoldmethathehadmadehisbutterfliesflyinformationandthathehadmadethebestpresentationofhislife.(Ifyou’dlikehelpwiththisreadKnock’emAlivePresentationSkills:HowtoMakeanEffectivePresentationfor1or1,000,2ndEdition,(C208),20CPEUs, available atwolfrinke.com/CEFILES/cepd.html#C208,or inane-course formatatwolfrinke.com/CEFILES/ecourses.htm#C208.)

1. Acknowledge It

Improving Quality of Care Based on CMS Guidelines 79

Thinkaboutwhatyou fear themost, and do it. Probably thebiggest confidence builder inyour life is todothethingyoufear. It may be quitting yourcurrent job, jumpingoutof anairplane(doputonaparachutefirst, and, while you are at it,get some decent instructions too),livinginthewilderness,scubadiving,orgivingaspeech.Doyourhomework,getyourselfmentallyandphysicallycondi-tioned,andbreakthetaskintosmall,doablestepssothatyoucanbenefit fromtheprincipleof incrementalsuccess.Forex-ample,tightropewalkersstartlowtotheground.Aftertheyhaveitmasteredatthatheight,theygoupalittlebitatatime.Whentheygetdangerouslyhigh,theyaddasafetynet.Onlyaftertheyhavemasteredthetasktothepointthattheycoulddoitintheirsleepdotheyremovethesafetynet.Afterexperiencing incre-mentalsuccessesatwhateveryouareafraidof,youwillbeabletodoit,andwillnolongerbeafraidofit.Mostimportantly,itwillempoweryouandputyouinchargeofyourlife,providingyouwiththeconfidenceofasupremelysuccessfulhumanbeing.

WheneverIampresentedwithachallengethatscaresme, Iaskmyself,“Whatistheworstthingthatcanpossiblyhappen?”AfterI identifythat,Iaskmyself,Canyoulivewiththat?Iftheanswerisyes,Iforgettheworstcase,vi-sualizemyself succeeding, andgo for it. If that does notworkforyou,doabasicBenFranklindecisionmakinganalysis.(Actu-allyPlatocameupwithitfirst.)Foreachoption,listthe“Pros”and“Cons.”NowpicktheoptionthathasthegreatestnumberofProsandthefewestCons,andgoforitwithgusto.(Forotherusefuldecisionmakingstrategiesgotohttp://en.wikipedia.org/wiki/Decision_making.)

IhavefoundovertheyearsthattheminuteIannounceanin-novativeidea,anewbusinessventure,agreatsuggestionforanouting,oranythingelsethatisdifferent,thereareinnumerablepeoplewhotellmethatitwon’twork,isnotfeasible,oristoorisky.Thenaysayersonggoesonandon.Ifyouhaveworkedinatraditionalhealthcareorganization, Iknowthatyoutoohaveheardthatsongmanytimes.Thattypeofadviceusedtoslowmedown. Itmademecautious,mademerethinkmyoriginalthoughts,causedmetoworry,andledmetofocusonallthereasonswhysomethingcouldnotwork,dissipatingmyenergyto thepoint that I couldno longer seeall the reasonswhy itcouldwork.

BeforeIknewit,Igaveuponwhatmighthavebeenamillion-dollaridea.Notanymore.Ihavedevelopedasimplebutpow-erfulstrategytosilencethenaysayersbysaying:“Iappreciateyourconcern.Haveyouyourselfdonethisbefore?” If thean-swerisno,Ithankthemfortheirinterestandignoretheiradvice.Ontheotherhand,iftheansweris“yes”I listenattentivelysothatIcanlearnfromtheirmistakes.Ifirmlybelievethatonlythepeoplewhohavetakenthejourneyandwhohaveexperiencedtherisksareabletoprovideyouwithmeaningfuladvice.MostoftheotherswanttobesurethatyouremainonelevelbelowthemsothattheycanfeelOKaboutthemselves.Afterall,ifyousucceedtoomuch,itmightlowertheirself-esteem.

2. Ignore others

3. Do the Thing You Fear

4. Conduct a Worst-Case Analysis

80 Healthy Skin

Allofusaremotivatedbytwoverypowerfulhumanemotions:fear and desire. Both are extremely powerful and both workequallywell,althoughinoppositedirections.Toovercomefear,wemust recognize that the humanmind can only hold onemajorthoughtatatime.Totakeadvantageofthisphenomenon,wemustgetinthehabitofsubstitutingdesireforfearwhenwecommunicatewithourselves andwithothers. Insteadofpro-gramming ourmindwith the thingswe do notwant to havehappenwemustusethesamecreativeenergytotellourselveswhatitisthatwewanttohavehappen.Tellingourselveswhatwewant shouldbe supplementedwith visualizingwhatwedesireinclear,vivid,dramaticpictures.Onceyouhaveformu-lated that picture in yourmind, think of all the positive con-sequencesassociatedwithsucceeding.Thatwayyouwillbefocusingon the rewardsof success insteadof thepenaltiesof failure.

ThePINtechniquewillhelpyoufocusonthepositiveinsteadofthenegative,seetheopportunityinsteadoftherisks,andgen-erallyminimize“stinkingthinking.”Internalizingandconsistentlyapplying the PIN technique has enabled me to transformmyselffromaperpetualpessimistintoaneternaloptimist.ThePINtechniqueconsistsofathree-stepmentalprocessthatyou

5. Replace Fear with Desire canuse tofirst focusonwhat ispositive (P), thenonwhat isinterestingorinnovative(I),andlastonwhatisnegative(N).ByPINingit,insteadofNIPingit,youwillprovideyourselfwiththeabilitytofocusyourvastmentalenergiesonpositivethoughtsinstead of squandering them on negative and nonproductiveideas.NIPing it closes the proverbialmental shadewhereasPINing it allows you to go beyond your customary responsepatternandprovidesyouwithatechniquethatwillletyouseethehiddenopportunitiesandfocusondesireinsteadoffear.

ForotherempoweringstrategiesreadorlistentoMakeItaWin-ningLife:SuccessStrategiesforLife,LoveorBusinessavailableat http://wolfrinke.com/MIWL.htmlor if youneedCPEcreditsdevour How toMaximize Professional Potential and IncreaseYourEarningPower(C187)approvedfor30CPEUs,availableathttp://www.wolfrinke.com/CEFILES/cepd.html#C187.)

©2011WolfJ.Rinke

Dr. Wolf J. Rinke, RD, CSP is a keynote speaker, seminar leader, management con-sultant, executive coach and editor of thefree electronic newsletter Read and GrowRich,availableatwww.easyCPEcredits.com.InadditionhehasauthorednumerousCDs,DVDsandbooksincludingMakeItaWinningLife: Success Strategies for Life, Love and

Business,WinningManagement:6Fail-SafeStrategies forBuild-ing High-Performance Organizations and Don’t Oil the SqueakyWheeland19OtherContrarianWaystoImproveYourLeadershipEffectiveness;availableatwww.WolfRinke.com.Hiscompanyalsoproducesawidevarietyofqualitypre-approvedcontinuingprofes-sional education (CPE) self-study courses, available both in printandelectronicformatsatwww.easyCPEcredits.com.ReachhimatWolfRinke@aol.com.

6. PIN it

©2012 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 to accurately measure and record wound characteristics, featuring a unique right angle design to see length and width measurements at the same time. It also contains areas to record the type of wound, plus the date, time and clinician’s name.

Key benefits• Increase accuracy of wound assessment

by more than 100 percent1

• Standardize wound documentation• Drive appropriate reimbursement due

to more accurate wound assessment

NE1™ Wound Assessment Tool Accurate identification, consistent documentation

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

Winner ofNational HCA Innovators

Award

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 NPUAP stage to pressure ulcers. Advances in Skin & Wound Care. In press.

Camera not included.

www.medlinene1.com

NEW 10 pack available!

Yes, They’re Genuine.

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

©2012 Medline Industries, Inc. Medline is a registered trademark and Pink Pearl is a trademark of Medline Industries, Inc.

pinkglovedance.com

Improving Quality of Care Based on CMS Guidelines 83

Congratulations Lexington Medical Center

for taking first place in Medline’s first Pink Glove Dance Competition

Medline Chief Marketing Officer Sue MacInnes presents a check for $10,000 to Lexington Medical Center

President and CEO Michael J. Biediger. The money was donated to the Vera Bradley Foundation for Breast

Cancer, Lexington’s chosen charity.

Special Feature

84 Healthy Skin

FeaturinghospitalCEOswith“moveslikeJagger,”adancingjanitor,andoctogenarianspoppingwheeliesintheirwheelchairs,Medline’sfirstnationalPinkGloveDancevideocompetitionwasahitbyanymeasure.

Withmorethanhalfamillionvotesinandcounted,LexingtonMedicalCenterinWestColumbia,S.C.,wonfirstplacewith61,054votes—morethanfourtimesthepopulationoftheirentirecity(14,061).Theircreativevideofeaturesadancingenvironmentalservicesassistant,aswellashundredsofhospitalstaff,includinganumberofbreastcancersurvivors,alldancinginpinkglovestoKatyPerry’shitsong“Firework”—allinthenameofbreastcancerawareness.

AveryclosesecondplacewascapturedbyHighlandHospitalinRochester,N.Y.,withalmost58,000votes,followedbyVictoriaHospital,PrinceAlbertParklandHealthRegioninPrinceAlbert,Saskatchewan,Canada,whotookhomethirdplacehonorswithmorethan38,000votes.

Lexington Medical Center

61,054 Votes

What did you like best about participating in the

Pink Glove Dance Competition?

I loved the camaraderie this event promoted

among everyone in our hospital from EVS

right up to the CEO.

Creating the video was so much fun and supporting breast cancer

awareness was truly special.

““

”” Teams Competed

to Raise Breast Cancer

Awareness

139

FirstPlaceWinner

Improving Quality of Care Based on CMS Guidelines 85

Inall,139teamsfromhospitals,nursinghomes,schoolsandotherorganizationsfrom40U.S.statesandCanadaparticipatedinthethree-weekcompetitionduringBreastCancerAwarenessMonthinOctober.Morethan17,000peoplewerefeaturedinthevideos,whichareallavailable forviewingatpinkglovedance.com.

SponsoredbyMedline,themanufacturerofthepinkgloves,theinauguralcompetitionquicklybecameasocialmediaphenomenonwithmorethan1.2millionviews,halfamillionvotesandthousandsoftweets,blogsandtexts.

Forwinningfirstplace,Medlinedonated$10,000toLexingtonMedicalCenter’sbreastcancercharityofchoice,theVeraBradleyFoundationforBreastCancer.Medlinedonated$5,000onbehalfofHighlandHospitaltotheBreastCancerCoalitionofRochester;andVictoriaHospitalearneda$2,000donationfromMedlinetotheSaskatoonCancerAgency.

Medline’soriginalPinkGloveDancevideopremieredinNovember2009andfeaturedmorethan200workersfromProvidenceSt.VincentinPortland,Ore.wearingpinkglovesanddancinginsupportofbreastcancerawarenessandprevention.Todaythevideohasmorethan13millionviewsonYouTube®andhasspawnedhundredsofpinkglovedancevideosandbreastcancerawarenesseventsacrossthecountryandaroundtheworld.

Throughouttheyear,foreverycaseofMedline’sGenerationPink®glovespurchased,Medlinewilldonate$1.00totheNationalBreastCancerFoundation(NBCF)tofundfreemammogramsforunderservedwomen.Todate,Medline hasdonatedmorethan$800,000totheNBCF.

Highland Hospital

58,000 Votes

Victoria Hospital, Prince Albert Parkland

Health Region

38,000 Votes

Second PlaceWinner

Third PlaceWinner

We asked the 139 contestants: What impact did the Pink Glove Dance have on your facility?

More than 80 percent of participants

said that staff morale and

satisfaction increased at their facility.

86 Healthy Skin

Healthy Eating

Ingredients2 tablespoonsoliveoil1 cupbabycarrots1 largeonion,coarselychopped1 mediumsweetpotato,peeledandcut into1-inchcubes2 largebeet,peeledandcutinto1-inchcubes2 parsnips,peeledandcutinto1-inchcubes¼cupmincedparsleySaltandpepper

Directions:Preheatovento500degrees.Pouroilintolargeroastpanorjellyrollpan.Placepanintoovenuntiloilishot,about1minute.Addvegetablestohotpanandroastfor20-30minutes,stirringevery10minutesuntilvegetablesaregoldenbrownandsweetpotatomasheseasilywhenpressed.Seasonwithsaltandpepperandgarnishwithparsley.

Diane Christensen, RN,isaclinicalcoordinatorintheQual-itydivisionatMedline’scorporateheadquartersinMundelein,IL.Shebeganlearninghowtocookatage8,afterherfather

Roasted Winter Vegetables

Nutrition Information

Servings:4Calories:197Fat:7.2gSodium:80mgFiber:7.1g

The Medline employee cookbookis $10. To purchase your own copy, please e-mail Judy at jdesalvo@medline.com.

2

passedawayandhermotherwaswork-inglonghours.Dianestartedouthelpingpreparemeals,andbeforelongshewasafull-fledgedcook.

“Istilllikecooking,andIamalwayslook-ingfornewthingstotry.AnytimeIcomeacrossanewrecipe,Iadjustittomakeitmyown,”Dianesaid.

Improving Quality of Care Based on CMS Guidelines 87

The following pages contain practical tools for implementing patient-focused care practices

at your facility.

Forms & Tools

Infection Control CoverYourCough..............................................................89

Physical Fitness

SupportingYourEmployees’PhysicalActivityGoals.........90 Sharps Safety SafeDisposalofNeedlesandOtherSharps........................91 Device Safety DeviceDecisionGuide....................................................92-95

Introducingthe newBioCon™- 700Thefutureofbladderultrasoundtechnology

Minimize unnecessary catheterizationResearchhasshownthat80percentofurinarytract

infectionsacquiredathealthcarefacilitiesareassociated

withanindwellingurethralcatheter.1Thistypeofinfection

isknownasCAUTI,orcatheter-associatedurinary

tract infection.

Avoidingunnecessarycatheteruse

isaprimarystrategyforpreventing

CAUTI,andclinicalguidelines

recommendtheconsiderationof

alternativestocatheterization.2

Bladder scanners accurately

assessbladdervolumes,

and many urinary

catheterizations

canbeavoided.3

1.LoE,NicolleL,ClassenD,AriasA,PodgornyK,AndersonDJ,etal. SHEA/IDSApracticerecommendation:strategiestopreventcatheter-associated urinarytractinfectionsinacutecarehospitals.InfectControlHospEpidemiol.2008;29:S41-S50.

2.Stokowski,LA.Preventingcatheter-associatedurinarytractinfections.MedscapeNursingPerspectives.February3,2009.

3.StevensE.Bladderultrasound:avoidingunnecessarycatheterizations.Med/SurgNursing.2005;14(4):249-253.

©2012 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.www.erasecauti.com/bladder-scanner

Improving Quality of Care Based on CMS Guidelines 89

CoverYourCough Forms & Tools

Stop the spread of germs that can make you and others sick!

You may be asked to put on a facemask to protect others.

If you don’t have a tissue, cough or sneeze into your upper sleeve or elbow, not your hands.

Wash hands often with soap and warm water for 20 seconds. If soap and water are not available, use an alcohol-based hand rub.

Cover your mouth and nose with a tissue when you cough or sneeze.Put your used tissue in the waste basket.

CS208322

90 Healthy Skin

Forms & Tools PhysicalActivityGoals

Everyday Fitness Ideas from the National Institute on Aging at NIH

www.nia.nih.gov/Go4Life

Supporting Your Employees’ Physical Activity Goals

Physical activity is one of the most effective ways of staying healthy.

It can improve strength and endurance, reduce the risk of heart disease, and improve overall well-being. Here are a few tips to help employees be more physically active.

Create a supportive atmosphere. l Make sure management (including the top boss) supports

efforts to promote physical activity. Management can do this by: – Coming to employee sporting or physical activity events. – Being physically active themselves. – Encouraging and congratulating employees in internal

publications or meetings. l Join forces with community programs that promote

physical activity. l Invite a local health and fitness expert to make a

presentation or give a demonstration. l Invite families to worksite physical activity events like

softball games. l Use the free materials on the Go4Life website, such as

tip sheets, posters, and newsletter articles.

Make physical activity happen. l Organize a group walk during the lunch hour or form

after-work sports leagues. l Provide information about nearby fitness centers, walking

trails, and sports fields. l Make it easy for people to be physically active at your

worksite: – Provide secure bike racks in convenient locations. – Make sure the stairs are safe and inviting to use. – Consider flexible scheduling so that employees can be

active during the day. – Host active meetings. Encourage people to stand when

they speak or provide mini-exercise breaks during meetings.

Quick Tip

Lead by example. Be a “physically active” role model for your co workers.

VIsIt www.nia.nih.gov/Go4Life

l Print useful tools.

l Order free exercise guides, DVDs, posters, and bookmarks.

“Playing softball with my

coworkers keeps me active

and builds teamwork. Plus,

we have a ball!”

— Patty, age 66

National Institute on Aging National Institutes of Health

U.S. Department of Health & Human Services

Improving Quality of Care Based on CMS Guidelines 91

SharpsSafety Forms & Tools

DO’s and DON’Ts Safe Disposal of Needles and Other Sharps Used At Home, At Work, or While Traveling

Do • Immediatelyplaceusedneedlesandothersharpsinasharpsdisposalcontainertoreducetheriskofneedle-sticks,cuts,orpuncturesfromloosesharps.

• UseanFDA-clearedsharpsdisposalcontainer,ifpossible.IfanFDA-clearedcontainerisn’tavailable,someorganizationsandcommunityguidelinesrecommendusingaheavy-dutyplastichouseholdcontainer(i.e.laundrydetergentcontainer)asanalternative.

• Makesurethatifahouseholddisposalcontainerisused,ithasthebasicfeaturesofagooddisposalcontainer.(Seeboxatrightformoreinfo.)

• Beprepared—carryaportablesharpsdisposalcontainerfortravel.

• Followyourcommunityguidelinesforgettingridofyoursharpsdisposalcontainer.

• Callyourlocaltrashorpublichealthdepartment(listedinthecountyandcitygovernmentsectionofyourphonebook)tofindoutaboutsharpsdisposalprogramsinyourarea.

• Askyourhealthcareprovider,veterinarian,localhospitalorpharmacisto whereandhowyoucanobtainanFDA-clearedsharpsdisposalcontainer,

o iftheycandisposeofyourusedneedlesandothersharps,oro iftheyknowofsafedisposalprogramsnearyou.

• Keepallneedlesandothersharpsandsharpsdisposalcontainersoutofreachofchildrenandpets.

All sharps disposal containers should be:

•madeofaheavy-dutyplastic;

•abletoclosewithatight-fitting,puncture-prooflid,withoutsharpsbeingabletocomeout;

•uprightandstableduringuse;

•leak-resistant;and

•properlylabeled.

Don’t • Throwneedlesandothersharpsintothetrash.

• Flushneedlesandothersharpsdownthetoilet.

• Putneedlesandothersharpsinyourrecyclingbin— theyarenotrecyclable.

• Trytoremove,bend,break,orrecapneedlesusedbyanotherperson.Thiscanleadtoaccidentalneedlesticks,whichmaycauseseriousinfections.

• Attempttoremovetheneedlewithoutaneedleclipperdevicebecausetheneedlescouldfall,flyoff,orgetlostandinjuresomeone.

Best Way to Get Rid of Used Needles and Other Sharps:

Step 1: Placeallneedlesandothersharpsinasharps disposalcontainerimmediatelyaftertheyhave beenused.

Step 2: Disposeofusedsharpsdisposalcontainers accordingtoyourcommunityguidelines.

Formoreinformationvisit,www.fda.gov/safesharpsdisposal.

Safe Disposal of Needles and Other Sharps www.fda.gov/safesharpsdisposal

92 Healthy Skin

Forms & Tools DeviceDecisionGuide

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ach

thei

r leg

s or

toes

(if

capa

ble)

?

Dev

ice

is a

rest

rain

t.If

devi

ce is

use

d:

- C

ode

MD

S P4

Proc

eed

to S

tep

2

- Car

e pl

an fo

r use

/

impa

ct.

NO

YES

Dev

ice

is n

ot a

rest

rain

t.If

devi

ce is

use

d:

- D

o no

t cod

e M

DS

P4Pr

ocee

d to

Ste

p 2

- C

are

plan

for u

se/

im

pact

, eve

n if

not a

r

estr

aint

.

NO

Com

plet

e al

l 3 S

TEPS

in o

rder

giv

en to

det

erm

ine

if de

vice

is a

rest

rain

t and

/or e

nabl

er a

s wel

l as p

oten

tial h

azar

ds. A

fter

com

plet

ing

thes

e in

itial

3 st

eps a

ny

devi

ce m

ust b

e ca

re p

lann

ed in

STE

PS 4

-8. I

f dev

ice

is n

ot u

sed,

doc

umen

t rat

iona

le a

nd c

are

plan

for a

ltern

ativ

es.

Resi

dent

Nam

e/Ro

om N

umbe

r:

D

ate:

Com

plet

ed B

y:

Page

1 o

f 4

Improving Quality of Care Based on CMS Guidelines 93

DeviceDecisionGuide Forms & Tools

YES

NO

STEP

2: D

eter

min

e En

ablin

g Q

ualit

ies

Enab

ling

Qua

litie

s1.

Doe

s th

e de

vice

allo

w th

e re

side

nt to

do

som

ethi

ng th

at w

ould

im

prov

e qu

ality

of l

ife?

2. D

oes

it al

low

the

resi

dent

to p

artic

ipat

e in

an

activ

ity o

ther

wis

e in

capa

ble

of?

3. D

oes

it im

prov

e ph

ysic

al o

r em

otio

nal s

tatu

s?

If an

y en

ablin

g qu

aliti

es,

devi

ce is

an

enab

ler.

- I

f dev

ice

is o

nly

an e

nabl

er,

s

tate

men

t of m

edic

al

nec

essi

ty n

ot re

quire

d.

Proc

eed

to S

tep

3

- Ca

re p

lan

for u

se/im

pact

Cons

ider

the

follo

win

g qu

estio

ns a

nd in

clud

e in

car

e pl

an:

If no

ena

blin

g qu

aliti

es,

devi

ce is

not

an

enab

ler.

If de

vice

is u

sed:

Pr

ocee

d to

Ste

p 3

- C

are

plan

for u

se/im

pact

DEv

icE

DEc

iSiO

N G

uiD

E: R

estr

aint

, Ena

bler

, and

Saf

ety

Haz

ard

Com

plet

e on

ly a

fter

STE

P 1.

A d

evic

e m

ay h

ave

both

rest

rain

ing

and

enab

ling

qual

ities

or i

t may

hav

e qu

aliti

es o

f one

, but

not

the

othe

r. Co

nsid

er a

ll po

ssib

le e

ffect

s.

Resi

dent

Nam

e/Ro

om N

umbe

r:

D

ate:

Page

2 o

f 4

94 Healthy Skin

Forms & Tools DeviceDecisionGuide

STEP

3: D

eter

min

e Sa

fety

Haz

ards

Eval

uate

eac

h ha

zard

. Wei

gh

agai

nst b

enefi

t.If

devi

ce is

use

d: P

roce

ed to

Ste

p 4

-

Care

pla

n fo

r use

/impa

ct,

ha

zard

avo

idan

ce

Ther

e ar

e no

saf

ety

risks

. If

devi

ce is

use

d:

Pro

ceed

to S

tep

4 -

Care

pla

n fo

r use

/impa

ct

NO

1. Is

resi

dent

vul

nera

ble

to h

azar

d?

Vuln

erab

ility

cha

nges

. Ris

k fa

ctor

s: re

side

nt’s

func

tion,

med

ical

con

ditio

n, c

ogni

tion,

moo

d, a

nd tr

eatm

ents

(e.g

., m

edic

atio

ns),

etc.

YES

2. D

oes t

he d

evic

e pl

ace

the

resi

dent

at r

isk

for:

- Dep

ress

ion

- Los

s of

mus

cle

tone

- L

oss

of D

igni

ty

- Str

angu

latio

n - A

gita

tion

- Inc

ontin

ence

- UTI

s

- Con

stip

atio

n- D

ecre

ased

mob

ility

- Pre

ssur

e U

lcer

s- I

njur

y fr

om d

evic

es n

ot a

dapt

ed o

r fitt

ed to

resi

dent

- Inj

ury

from

def

ectiv

e or

impr

oper

ly u

sed

devi

ces

DEv

icE

DEc

iSiO

N G

uiD

E: R

estr

aint

, Ena

bler

, and

Saf

ety

Haz

ard

Cons

ider

all

poss

ible

neg

ativ

e eff

ects

and

saf

ety

haza

rds

of th

e de

vice

. Dev

ices

can

be

ther

apeu

tic a

nd b

enefi

cial

; but

may

not

be

risk

free

. If r

esid

ent f

ound

in a

n at

risk

po

sitio

n w

ith d

evic

e, d

isco

ntin

ue u

se a

nd re

eval

uate

with

team

.

- Asp

hyxi

atio

n - E

ntan

glem

ent

- P

ain

from

lack

of m

ovem

ent

- Ski

n te

ars/

scra

pes/

brui

ses

- Dec

reas

ed b

one

dens

ity/

incr

ease

d fr

actu

res

3. Is

resi

dent

at r

isk

for e

ntra

pmen

t?

- Res

iden

ts m

ost a

t ris

k:

- Res

iden

ts u

sing

Spe

cial

ity M

attr

ess:

Com

pres

sion

of m

attr

ess

wid

ens

gap

betw

een

mat

tres

s an

d ra

il. A

s re

side

nt c

hang

es p

ositi

on, m

attr

ess

may

infla

te a

nd tr

ap h

ead,

che

st,

neck

, or l

imbs

bet

wee

n m

attr

ess

and

side

rail

resu

lting

in fr

actu

res,

asph

yxia

tion

and

deat

h.

- Fol

low

man

ufac

ture

r rec

omm

enda

tion

for i

nflat

ion

base

d on

resi

dent

’s w

eigh

t.

NO

NO

YES

YES

Resi

dent

Nam

e/Ro

om N

umbe

r:

D

ate:

Page

3 o

f 4

• Eld

erly

or f

rail

resi

dent

s w

ith:

- A

gita

tion

- C

onfu

sion

- Del

irium

- P

ain

- Fec

al Im

pact

ion

- U

ncon

trol

led

body

m

ovem

ents

*The

se c

ondi

tions

may

cau

se re

side

nt to

mov

e ab

out a

nd e

xit f

rom

a d

evic

e or

bed

.

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Content KeyWe’ve coded the articles and information in this magazine to indicate which national quality initiatives they pertain to. Throughout the publication, when you see these icons you’ll know immediately that the subject matter on that page relates to one or more of the following national initiatives:•QIO–UtilizationandQualityControlPeerReviewOrganization•AdvancingExcellenceinAmerica’sNursingHomes

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Improving Quality of Care Based on CMS Guidelines 95

Device Decision Guide Forms & Tools

MO

-09-

02-R

EST

Mar

ch 2

009

This

mat

eria

l was

pre

pare

d by

Prim

aris

, the

Med

icar

e Q

ualit

y Im

prov

emen

t Org

aniz

atio

n fo

r Mis

sour

i, un

der c

ontr

act w

ith th

e Ce

nter

s fo

r Med

icar

e &

Med

icai

d Se

rvic

es (C

MS)

, an

agen

cy o

f the

U.S

. Dep

artm

ent o

f Hea

lth a

nd H

uman

Ser

vice

s, an

d ad

apte

d fr

om L

HCR

. The

con

tent

s pr

esen

ted

do n

ot n

eces

saril

y re

flect

CM

S po

licy.

Dev

ice

care

Pla

nnin

g Pr

oces

sN

ow th

at y

ou’v

e de

term

ined

whe

ther

the

devi

ce is

a re

stra

int,

enab

ler a

nd/o

r saf

ety

haza

rd, p

roce

ed to

STE

P 4

of th

e pl

anni

ng p

roce

ss. T

he u

se o

f any

dev

ice

requ

ires a

car

e pl

an. T

he fo

llow

ing

info

rmat

ion

shou

ld b

e in

clud

ed in

the

resi

dent

’s in

divi

dual

car

e pl

an.

Resi

dent

Nam

e/Ro

om N

umbe

r:

D

ate:

Page

4 o

f 4

a.

Doc

umen

t a d

etai

led

hist

ory

of th

e sy

mpt

om fo

r usi

ng a

dev

ice.

CM

S

sta

tes t

hat “

falls

do

NO

T co

nstit

ute

self-

inju

rious

beh

avio

r or a

med

ical

s

ympt

om th

at w

arra

nts t

he u

se o

f a re

stra

int.”

(S&

CLet

ter-0

7-22

: Res

trai

nt

Cla

rifica

tion,

June

200

7)b.

I.D

trig

gers

for r

estr

aint

use

from

MD

S.

c.

Not

ify p

ract

ition

er a

bout

sym

ptom

s req

uirin

g de

vice

. d.

I.D

if p

robl

em is

chr

onic

/irre

vers

ible

or a

cute

/rev

ersi

ble.

e.

Atte

mpt

alte

rnat

ives

to m

anag

e th

e pr

oble

m. C

omm

unic

ate

risk/

bene

fits

to

resi

dent

and

fam

ily.

f.

Doc

umen

t abi

lity

to p

urpo

sefu

lly re

mov

e de

vice

and

per

form

act

ivity

of

ch

oosi

ng.

STEP

4: A

sses

smen

t and

Pro

blem

Rec

ogni

tion

a.

Mon

itor i

mpa

ct o

f dev

ice

on re

siden

t and

pro

blem

s or r

isks f

or w

hich

it w

as

use

d.b.

Mon

itor f

or c

ompl

icat

ions

rela

ted

to d

evic

e an

d st

op o

r adj

ust u

se.

c.

Expl

ain

why

con

tinue

d us

e w

as n

eede

d de

spite

com

plic

atio

ns.

d. M

aint

ain

ongo

ing

mon

itorin

g fo

r saf

ety

haza

rd, s

top

use

imm

edia

tely

and

r

eass

ess i

f haz

ard

dete

cted

. e.

Per

iodi

cally

(at l

east

qua

rter

ly) r

eass

ess t

he re

siden

t for

con

tinue

d ne

ed fo

r

d

evic

e an

d do

cum

ent i

n ca

re p

lan.

STEP

7: M

onit

orin

ga.

D

ocum

ent a

ttem

pted

alte

rnat

ives

and

out

com

es.

b. D

ocum

ent r

atio

nale

for u

se. *

Iden

tify

reas

ons f

or se

lect

ing

devi

ce. B

ase

use

o

n ris

ks/b

enefi

ts fo

r res

iden

t.c.

D

ocum

ent h

ow y

ou m

anag

e ca

uses

of f

allin

g, p

robl

emat

ic b

ehav

ior,

or

ano

ther

con

ditio

n fo

r whi

ch a

dev

ice

is us

ed O

R ex

plai

n w

hy c

ause

s cou

ld n

ot

o

r sho

uld

not b

e m

anag

ed.

d.

Use

dev

ice

corr

ectly

: App

ly it

cor

rect

ly, r

elea

se it

at r

ight

tim

e, p

rovi

de fo

r

exer

cise

. Con

sider

risk

fact

ors a

nd h

ow to

min

imiz

e.e.

Id

entif

y go

al fo

r dev

ice

use,

incl

udin

g le

ast r

estr

ictiv

e an

d re

duct

ion

(i.e.

,

corr

ectio

n of

und

erly

ing

caus

es).

STEP

6: c

are

Plan

- Tr

eatm

ent a

nd M

anag

emen

t

*Be

spec

ific!

e.g

. “Se

at b

elt f

or p

ositi

onin

g” is

inad

equa

te. I

nclu

de ca

use

of

posi

tioni

ng p

robl

em.

a.

Iden

tify

likel

y ca

uses

(med

icat

ion

side

effec

ts o

r env

ironm

enta

l fac

tors

) of

fal

ling,

pro

blem

atic

beh

avio

r, or

oth

er p

robl

em fo

r usin

g a

devi

ce.

b.

Did

pra

ctiti

oner

hel

p id

entif

y sp

ecifi

c m

edic

al s

ympt

oms

to u

se re

stra

int?

c.

If th

e re

side

nt w

as n

ot e

valu

ated

for t

he m

edic

al s

ympt

om(s

) prio

r to

usi

ng re

stra

int,

docu

men

t why

.d.

F

or a

ny d

evic

e th

at is

a re

stra

int,

obta

in p

ract

ition

er’s

orde

r. O

rder

s

m

ust r

eflec

t pre

senc

e of

med

ical

sym

ptom

; how

ever

, the

ord

er a

lone

is

not

suffi

cien

t to

war

rant

use

.

STEP

5: D

iagn

osis

and

iden

tify

cau

se

*If R

esid

ent/

Fam

ily/R

espo

nsib

le p

arty

requ

ests

dev

ice

and

if no

t req

uire

d to

trea

t a

med

ical

sym

ptom

, the

faci

lity

mus

t eva

luat

e re

ason

for r

eque

st a

nd im

pact

on

resi

dent

. Fac

ility

may

not

use

if v

iola

tes t

he re

gula

tion

base

d on

lega

l sur

roga

te /

repr

esen

tativ

e’s re

ques

t /ap

prov

al.

Improving Quality of Care Based on CMS Guidelines

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