Professional Documents
Culture Documents
VOLUME 9, ISSUE 1
Improving Quality of Care Based on CMS Guidelines
Volume 9, Issue 1
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©2011 Medline Industries, Inc. Medline and
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from the QIS
MKT211020/LIT822/30M/JBK5
JBK_CVR1_Layout 1 2/14/11 9:11 AM Page 2
1. Lateral malleolus
2. Lateral aspect of foot
3. Lateral aspect of knee
4. Greater trochanter
5. Ribs
6. Shoulder
7. Ear
8. Occiput
PERIOPERATIVE PRESSURE
9. Ear
ULCER EDUCATION.
10. Elbow
11. Dorsal thoracic area
MORE IMPORTANT
THAN EVER BEFORE
12. Sacrum/Coccyx
13. Heel
Content Key
We’ve coded the articles and information in this magazine to indicate which national quality initiatives To learn more about Medline’s Pressure
they pertain to. Throughout the publication, when you see these icons you’ll know immediately that Ulcer Prevention Programs for long-term
the subject matter on that page relates to one or more of the following national initiatives: care, acute care and perioperative
• QIO – Utilization and Quality Control Peer Review Organization services, call your Medline representative
• Advancing Excellence in America’s Nursing Homes or visit www.medline.com/pupp-webinar.
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. ©2011 Medline Industries, Inc.
Medline is a registered trademark of Medline Industries, Inc.
HEALTHY SKIN
Improving Quality of Care Based on CMS Guidelines
Survey Readiness
Editor 44 What’s in Store for QIS and MDS 3.0
Sue MacInnes, RD, LD 45 Removing Stress from the QIS
Clinical Editor
Margaret Falconio-West, BSN, RN, Prevention
APN/CNS, CWOCN, DAPWCA 19 225-Bed Community Hospital Reduces Pressure Ulcers
from 9% to 0% in 90 Days
Managing Editor Page 12
Alecia Cooper, RN, BS, MBA, CNOR
30 Creative Techniques for Preventing Resident Falls in
Long-Term Care
Senior Writer 32 Improving Hand Hygiene Compliance: A Multi-disciplinary
Carla Esser Lake Team Approach
Creative Director
56 Protecting Vulnerable Heels: Tips for Nursing Assistants
Mike Gotti 69 Easy Does It: Safe and Effective Lifting Practices
74 5-Step Approach for Avoiding VAP
Clinical Team
Clay Collins, BSN, RN, CWOCN, CFCN, Treatment Page 26
CWS, DAPWCA
36 Osteoporosis in Men
Lorri Downs, BSN, RN, MS, CIC
66 The Use of Superabsorbent Containing Fluid Lock Dressing
Cynthia Fleck, BSN,MBA, RN, CWS, DNC,
CFCN, DAPWCA, FCCWS in Hospice Patients
Joyce Norman, BSN, RN, CWOCN,
DAPWCA Special Features
Kim Kehoe, BSN, RN, CWOCN, DAPWCA 11 NE1 Wound and Skin Assessment Tool Award
Elizabeth O’Connell-Gifford, BSN, MBA, RN, 12 Preparing for Reform in Your Post Acute Setting
CWOCN, DAPWCA 18 CE Article Special Insert! Positive or Negative? You Decide:
Jackie Todd, RN, CWCN, DAPWCA Healthcare Reform’s Impact on Nursing Homes and LTC Facilities Page 32
26 Wound Care and Rehab Training in Lesotho, Africa
Wound Care Advisory Board
49 Inspiring Change: The Cozy Project Makes Older Patients
Zemira M. Cerny, BS, RN, CWS
More Comfortable
Patricia Coutts, RN
58 Pediatric Pressure Ulcers in the “Darnedest” Places
Cindy Felty, MSN, RN, CNP, CWS
83 Pink Glove Dance: The Sequel
Evonne Fowler, MSN, RN, CNS, CWOCN
87 Pink Glove Survey Results
Lynne Grant, MS, RN, CWOCN
Diane Krasner, PhD, RN, CWCN, CWS,
BCLNC, FAAN
Caring for Yourself
64 Top Tips for Winter Skin Care Page 58
Dea J. Kent, MSN, RN, NP-C, CWOCN
Andrea McIntosh, BSN, RN, APN, CWOCN
78 8 Principles for Achieving Inner Peace
Linda Neiswender, BSN, RN, CPN, CWOCN
Laurie Sparks, BSN, RN,CWOCN
Forms & Tools
Lynne Whitney-Caglia, MSN, RN, CNS,
94 WHO Glove Pyramid
CWOCN 95 WHO Exam Glove Technique
Laurel Wiersema-Bryant, RN, ANP, BC 96 CDC Clean Hands Poster
Linda Woodward, BSN, RN, OCN, CWOCN 97 CDC Clean Hands Poster – Spanish
Deborah Zaricor, RN, CWOCN 99 Urinary Incontinence Assessment and Implementation
Page 83
101 How Well Do You Know Pressure Points?
About Medline Meeting the highest level of national and international quality standards, Medline
Medline, headquartered in Mundelein, IL, manufactures and distributes more is FDA QSR compliant and ISO 13485 certified. Medline serves on major
than 100,000 products to hospitals, extended care facilities, surgery centers, industry quality committees to develop guidelines and standards for medical
home care dealers and agencies and other markets. Medline has more than 800 product use including the FDA Midwest Steering Committee, AAMI Steriliza-
dedicated sales representatives nationwide to support its broad product line and tion and Packaging Committee and various ASTM committees. For more
cost management services. information on Medline, visit our Web site, www.medline.com.
©2011 Medline Industries, Inc. Healthy Skin is published by Medline Industries, Inc. One Medline Place, Mundelein, IL 60060. 1-800-MEDLINE.
Healthy Skin
Letter from the Editor
W e realize that the more opportunities you have to educate yourself about our industry, the
latest trends, the constantly changing regulations, the financial challenges, the clinical
and quality issues in health care, the more valuable you are to your organization and to your
patients. It doesn’t matter what your specialty is, it is part of your responsibility to stay up-to-date
on our business.
So, as tax-paying citizens and concerned healthcare our money. And who would have thought that in the
professionals, many of you are delving deep into the category of infant mortality, the United States would rank
particulars of healthcare reform and what it means to dead last in this group. But we did.
you and your organization. (Be sure to check out the two
articles on healthcare reform in this issue!) As you dig So, there you have it, we are a country in trouble. But
deeper into where the United States stands as a country, what makes it even worse are the statistics for our aging
you will discover some head-turning data. population and what we can expect in the future. If we
look ahead to the year 2050, women age 85 and over
In 2009, 17.3 percent of the GDP (gross domestic product) will be the largest segment of the population. How can
in the United States was dedicated to health care. we sustain adequate health care for this important part
According to the Office of the Actuary in the Centers for of our population, how can we eliminate waste, how can
Medicare & Medicaid Services (CMS) National Healthcare we adopt better prevention strategies, and how can we
Expenditure projections, the dollars represented grew improve outcomes? All of these are questions depending
from $2.34 trillion in 2008 to $2.47 trillion in 2009—the on you in part for the answers.
largest one-year jump since 1960. CMS predicts total
U.S. healthcare spending in 2019 will be $4.5 trillion. And You are our future. Read more, learn more—and don’t
yet, as healthcare spending skyrockets, U.S. rankings be afraid to adopt new ideas.
against other countries are not what you would expect.
Best Regards,
In one study of seven different countries, including
Australia, Canada, Germany, Netherlands, New Zealand
and the United Kingdom, the United States consistently
ranked poorly (in most cases in last place), and yet the Sue MacInnes, RD, LD
cost of healthcare per capita was double that of any of Editor
the other countries. So, we spend more and get less for
According to Chip and Dan Heath, authors of the #1 New York Times bestseller Made
to Switch: How to Change Things When Change Is Hard, when it comes to change, the
rational mind and the emotional mind compete for control. This tension can sabotage
efforts to change. In Switch, the Heaths show how real people have brought both parts
of the brain together to achieve great results and successful change.
To order, visit www.barnesandnoble.com.
4 Healthy Skin
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Key benefits
• Increase accuracy of wound assessment Interactive training and online competencies available
on-demand at www.medlineuniversity.com
by more than 100 percent1
• Standardize wound documentation
To request a sample or additional details, contact your Medline
• Drive appropriate reimbursement due to
representative or call 1-800-MEDLINE (1-800-633-5463).
more accurate wound assessments
Reference
1. 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.
Origin: The QIO Statement of Work is based upon Part B of the Title XI of the Social Security Act. The Medicare-funded
“Ninth Scope of Work” plan became effective August 1, 2008 and will remain in effect through July , 2011.
Purpose: To carry out statutorily mandated review activities, such as:
Stay tuned for
• Reviewing the quality of care provided to beneficiaries; details on 10th Round
• Reviewing beneficiary appeals of certain provider notices; Statement of Work
• Reviewing potential anti-dumping cases; and COMING SOON
• Implementing quality improvement activities as a result of case review activities.
Goal: In the 9th SOW, the QIO Program has been redesigned with a framework for accountability and also in content. The
content now consists of four themes with the goal to help providers, both in long-term care and acute-care facilities,
prevent illness, decrease harm to patients and reduce waste in health care.
Of note: QIOs will be required to help Medicare promote three overarching themes: adopt value-driven healthcare,
support the adoption and use of health information technology and reduce health disparities in their communities.
Under the direction of the Centers for Medicare & Medicaid Services (CMS), the QIO Program consists of a national
network of 53 QIOs located in each of the 50 U.S. states, the District of Columbia, Puerto Rico and the Virgin Islands.
Origin: A coalition-based, two-year campaign initiated on September 26, 2006 to improve quality of life for nursing home
residents and staff. The coalition has continued the campaign beyond its first-round end of August 25, 2008 for an
additional 2 years (until September 26, 2010).
Purpose: A coalition consisting of the Centers for Medicare & Medicaid Services (CMS), organizations representing providers,
consumers and government that developed a grassroots campaign to build on and complement the work of existing
quality initiatives including Nursing Home Quality Initiative (NHQI), Quality First and the culture change movement.
Goal: To ensure that continuous quality improvement is comprehensive, sustainable and consumer-focused, the coalition
has adopted goals that seek to improve clinical care, incorporate nursing home resident and family satisfaction
surveys into continuing quality improvements and increase staff retention to allow for better, more consistent
care for nursing home residents.
Participating providers will commit to focusing on at least three of the eight measurable goals, including at least one clinical goal and
one operational process goal. Current participants may choose to continue with the same goals, add additional goals or change goals
for the next two-year campaign.
6 Healthy Skin
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Theme #1: Beneficiary Protection Activities will focus on Theme #4: Prevention Activities will focus on nine Tasks:
nine Tasks: 1. Recruiting participating practices
1. Case reviews 2. Identifying the pool of non-participating practices
2. Quality improvement activities (QIAs) 3. Promoting care management processes for preventive services
3. Alternative dispute resolution (ADR) using EHRs
4. Sanction activities 4. Completing assessments of care processes
5. Physician acknowledgement monitoring 5. Assisting with data submissions
6. Collaboration with other CMS contractors 6. Monitoring statewide rates (mammograms, CRC screens, influenza
7. Promoting transparency through reporting and pneumococcal immunizations)
8. Quality data reporting 7. Administering an assessment of care practices
9. Communication (education and information) 8. Producing an annual report of statewide trends, showing baseline
and rates
Theme #2: Patient Pathways/Care Transitions Activities 9. Submitting plans to optimize performance at 18 months
will focus on three Tasks:
1. Community and provider selection and recruitment There will be two periods of evaluation under the 9th SOW. The first
2. Interventions evaluation will focus on the QIO's work in three Theme areas (Care
3. Monitoring Transitions, Patient Safety and Prevention) and will occur at the end
of 18 months. The second evaluation will examine the QIO's perform-
Theme #3: Patient Safety Activities will focus on six ance on Tasks within all Theme areas (Beneficiary Protection, Care
primary Topics: Transitions, Patient Safety and Prevention). The second evaluation will
1. Reducing rates of health care-associated methicillin-resistant take place at the end of the 28th month of the contract term and will be
Staphylococcus aureus (MRSA) infections based on the most recent data available to CMS. The performance
2. Reducing rates of pressure ulcers in nursing homes and hospitals results of the evaluation at both time periods will be used to determine
3. Reducing rates of physical restraints in nursing homes the performance on the overall contract.
4. Improving inpatient surgical safety and heart failure treatment
in hospitals Focus for the 9th Scope of Work
5. Improving drug safety – Move away from projects that are “siloed” in specific care settings
6. Providing quality improvement technical assistance to nursing – Focused activities for providers most in need
homes in need – New emphasis on senior leadership (CEOs, BODs) involvement
in facility quality improvement programs
©2011 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.
jbk_HealthySkin17.3-mag_Layout 1 2/14/11 9:48 AM Page 9
BREAKING NEWS
New data released
Pennsylvania Pressure
Ulcer Partnership Reduces
Pressure Ulcers
In early January 2011, the Pennsylvania Pressure Ulcer Part- The rate of pressure
nership released the results of its pressure ulcer reduction ulcers decreased 23%
project showing collaborative efforts to reduce the rate
of pressure ulcers and prevent pressure ulcers from
getting worse.
The partnership also conducted a baseline and follow-up
Three of the state’s leading healthcare organizations—The
survey to assess the extent to which participating hospitals
Hospital & Healthsystem Association of Pennsylvania (HAP),
had adopted certain practices and strategies. The survey
The Healthcare Improvement Foundation (HCIF), and Hospital
collected information about specific processes identified
Council of Western Pennsylvania (HCWP)—collaborated in
as important to improvement, including leadership support
2008 to create the Pennsylvania Pressure Ulcer Partnership
for pressure ulcer prevention and treatment; organizational
for hospitals. The project involved 58 hospitals from across
policies; monitoring the accuracy of pressure ulcer risk
the state. They focused on risk assessments, turning and
assessments and skin inspections; use of triggers for risk
repositioning, pressure reduction devices and techniques,
reassessment; documentation; and education and training.
nutrition, skin cleansing and moisturizing, and diligent
wound care.
Of the 36 hospitals that completed both the baseline and
follow-up survey, improvements were achieved in 88% of the
The project was formed because Pennsylvania hospitals
41 questions asked.
recognized that pressure ulcers, are one of the five most com-
mon types of harm experienced by patients in healthcare
“As health reform rolls out, Medicare and Medicaid payments
facilities. The nationwide costs associated with pressure
to hospitals will be increasingly tied to quality and patient
ulcers and their complications are approximately $13 billion a
safety outcomes,” said Jane Montgomery, RN, vice president
year—under Medicare alone.
of clinical services and quality for HCWP. “It is critical that
hospitals across the state build on their patient care
Findings from the project: successes in the coming years.”
• the rate of pressure ulcers that developed decreased
by 23% (5.3% to 4.1%) The Pennsylvania Pressure Ulcer Partnership was made
• pressure ulcer risk assessments upon admission possible through funding from Medline Industries, Inc., Capital
improved from 93% to 97% Blue Cross, Highmark Blue Shield, and the Partnership for
• the rate of pressure ulcers that progressed (worsened) Patient Care, an initiative funded jointly by Independence Blue
decreased by 81% (2.1% to 0.4%) Cross and health systems in southeastern Pennsylvania.
• ongoing risk assessments improved from 87% to 97%
—both statistically significant Source: The Hospital & HealthSystem Association of Pennsylvania.
www.haponline.org
\ Cy∙an∙o∙a∙cry∙late \
A fast-acting adhesive that bonds with the skin
to create a barrier against moisture and friction.
1. Data on file
Treatment
Nancy Estocado, a physical therapist and certified used after five min-
wound specialist, won the National Hospital Corpora- utes of training, she
tion of America (HCA) Innovators Award for her idea said the results
“NE 1 Can Stage”— Skin and Wound Assessment Tool. showed nurses and
clinicians were 69
“I could fall out of my chair with how excited I am,” percent correct in
said Estocado. “Because of how many hospitals are wound assessments.
in the corporation and how many people entered the She said the nurses
contest, to think that mine made it to the top is mind- continue to improve
boggling,” she said. Sunrise President and CEO Sylvia their accuracy the
Young said employees are celebrating the recognition more they use the
alongside Estocado. tool.
“People are so thrilled that our hospital was selected Estocado’s findings
for this national award and they have such high regard have been approved
for Nancy,” said Young. “She’s a great caregiver, she’s for publication in
a real role model, and I think people are just proud Advances in Skin
to be associated with her and that it started here and Wound Care. Nancy Estocado won an HCA Innovators
at Sunrise.” She would like to Award for her NE 1 Can Stage — Skin
see the tool pilot- and Wound Assessment Tool.
Estocado’s innovative tool provides a simple, easy-to- tested at Sunrise
use, economical method for skin and wound assess- and expanded throughout HCA. Medline Industries,
ment and documentation by any care provider at the Inc. has also picked up the tool to make it avail-
bedside. The paper, single-use, L-shaped measuring able to the public.
device allows providers to frame the wound, take a
photograph and match the picture to the guide’s “I really hope it goes huge,” said Estocado. “I’ve been
nationally recognized wound conditions and meas- working on it for almost three years. I didn’t know
urements. This process allows the wound to be prop- where it was going to go, but I knew I could help
erly assessed and provides a standard in care for people. I knew I had something.”
wounds.
Estocado said she spent a lot of her own money to
“My goal is that this would become the standard of create the tool and apply for a patent, so she hopes
practice for everyone,” said Estocado. “Home health, to use the prize money to pay off some of her debt.
nursing homes, in the hospital — everyone can be on She said the entire HCA Innovators Award process
the same page, measuring and monitoring wounds in has inspired others around her to get creative.
the same way.”
“I can’t tell you how many other people have come up
In previous studies, the average clinician or nurse was to me with ideas. Through this contest and award, it’s
only about 30 percent correct when assessing motivating people to be innovative. They think, ‘Hey,
wounds, according to Estocado. When her tool was if she can do it, I can do it.’”
Used by permission from HCA and not intended as an endorsement for Medline Industries, Inc. or any other entity.
Special Feature
R
Preparing for EFORM
in your post acute setting
by Glen Roebuck
12 Healthy Skin
jbk_HealthySkin17.3-mag_Layout 1 2/14/11 9:50 AM Page 13
Currently reimbursement is on a fee-for-service basis, with no Becoming a Successful Partner in Healthcare Reform
connectivity or accountability between providers based upon a Below are specific steps that must occur for a post acute
patient’s care delivery through the system. In the paradigm of center to be successful in the reform-driven, ACO world:
bundled services, Medicare pays one entity: the ACO. It will then
fall to the ACO to effectively and efficiently manage the patient’s 1. Post acute centers must become masters of the
care and direct the patient to the most appropriate level of Medicare system. Becoming a master of the Medicare
services to impact effective and efficient care. The ACO then system will require that providers move from only providing
pays the PAC providers. Medicare services for residents who return to their facilities
14 Healthy Skin
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Performance data
will become your
best friend or
your downfall.
6. Your “competitors” are now your “partners.” If you have experience to include the monitoring and analysis of
not developed close relationships with other post acute complex and integrated data. Performance data will
setting leaders, the time is now. As ACO networks mature, become your best friend or your downfall. Begin now to
you will likely receive admissions from sources other than develop ways to monitor and track performance data for
hospitals, including home health, skilled nursing, assisted your post acute center including things such as falls,
living, medical homes and hospice. Non-medical support wounds and re-hospitalizations. Having the tools and
services may report findings to physicians or ACO knowledge to track and improve these metrics will
admissions coordinators who may direct admissions position you as a valuable partner in health care reform.
to your setting.
10. Educate your direct customers. When these initiatives
7. Take care of sick people. You may think this sounds silly. begin to play out and directly impact the lives of your
But with up to two thirds of re-hospitalizations viewed as customers, it will be a time of confusion and angst for
preventable, it is not. Patients who are admitted to a post many. This presents a tremendous leadership opportunity
acute setting on Thursday with a diagnosis of pneumonia for you to become a public voice and positive influence.
simply cannot be readmitted to an acute setting on
Much will continue to evolve in the months and years to come
Saturday with… pneumonia. Post acute settings must
related to the passage of PPACA. The accompanying
be prepared to initiate more advanced care such as IV
regulations are yet to be released as of this writing. Will the
fluids and medications, closely monitoring vitals and
three-day required hospital stay be upheld with reform? Where
changes in condition, and assess potential declines to
will the rights of patients fall in choosing their post acute serv-
initiate interventions with the physician early in the process.
ice provider? How will your specific healthcare community
These measures help avoid unnecessary re-hospitalizations.
respond to reform? These issues, and others, will continue to be
8. Assess your clinical prowess and make changes now. a part of the changing reform landscape. Your active partnership
To achieve the cultural evolution noted above, the clinical in leading your post acute setting and your community is
talent and skills of your staff must be assessed and critical to your success.
necessary skills must be acquired quickly. This may
require additional certification and education, along
Glen Roebuck is senior vice president of operations for
with re-examination of the distribution of licensed staff,
Health Dimensions Group in Minneapolis. He can be reached
particularly LPNs/LVNs and RNs. These staff members at 612-770-6163, or via email at glenr@hdgi1.com. Health
must clearly understand that an unplanned re-hospitaliza- Dimensions Group is a leading provider of short term
tion will be reviewed as a measure of their performance. consultation and long term management solutions for health
care providers. For more information, please contact Glen and
9. Monitor your performance and share your results.
visit www.healthdimensionsgroup.com.
In the new world of healthcare reform, performance and
success will be expanded beyond a successful survey
©2010 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.
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©2010 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.
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18 Healthy Skin
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TRUE STORIES
“
pharmaceuticals and supplies (based
on a projected incidence rate of 6 We believe that skin integrity and the prevention of pressure ulcers is one area
“
pressure ulcer cases avoided through of hospital health care where our nurses can really make a difference. We are
this program and using calculations
continually trying to improve that care.
provided by the Centers for Medicare
and Medicaid Services).
TRUE STORIES
“ “
Medline introduced us to their Pressure Ulcer Prevention Program (PUPP) which included
intensive staff education and a specifically designed line of pressure ulcer prevention skincare
products aimed at reducing our incidence levels to 0%.
20 Healthy Skin
jbk_HealthySkin17.3-mag_Layout 1 2/14/11 9:52 AM Page 21
TRUE STORIES
“ The end goal of this training was to help modify behavior and motivate
our nurses and nurse assistants toward improved patient care.
“
But before any of that training could happen, we had to first establish
exactly where we were starting from.
Implementation According to a recent CMS roundtable, and tools and, of course, pre and post
We introduced these products into the sys- among the main roadblocks to creating an tests. The workbook Medline created for
tem and started using them in our targeted effective pressure ulcer prevention program the CNAs included basic information cov-
test area. Almost immediately we had a are: lack of resources, inconsistent staff ering skin care, patient turning, inconti-
number of patients say “I really like this education and nonexistent patient and fam- nence care and basic nutrition. The
product!” Even our staff commented on ily education. We were determined to start workbook created for the RNs and LPNs
how much they liked the smell and the feel with consistent staff education. covered pressure ulcer assessment, skin
of the Medline products. care, nutrition and documentation. The
Medline’s program addressed these issues overall acceptance of the training and of the
At the same time we were introducing by providing clinical and educational program was better than we anticipated.
these new products into the system, we resources and assessment tools to our One of our LPNs summed it up when she
kicked off the educational components of nurses from the beginning. The educational said “The workbooks make it very easy for
the Medline program. We started by ad- tools they provided were targeted to two us to do the right thing!” Everyone who par-
ministering a “pretest,” provided by Med- primary groups: first, our nursing assistants ticipated in the training received a certificate
line, to all of the nursing staff. This pretest (CNAs), because they are critical to early of completion and a lapel pin signifying they
was designed to give us an indication of detection and prevention of pressure ulcers. had gone through the training. Our staff’s
where our staff was starting from in terms of They turn the patients, deal with inconti- post test scores (taken after training) were:
pressure ulcer prevention knowledge. The nence when it occurs, and otherwise RNs and LPNs averaged 97% (up 18%
average scores for this pretest, by nursing administer creams and lotions for skincare. over the pretest) and CNAs averaged 93%
group were: RNs and LPNs 79%, and The second critical element was our RNs (up 29% over the pretest). These numbers
CNAs 64%. Upon completion of the and LPNs. The educational component for are significant because they indicate the
pretest, the nursing staff was provided with this group was designed to ensure that level of acquired knowledge and hands-on
either a nursing workbook or a nursing these nurses understood their role in experience our staff had achieved and they
assessing and documenting skin condition, give us confidence that going forward the
assistance workbook. We would administer nutrition, and overall health improvement of program will experience sustainability for
a “post test” at the conclusion of the 90- the patient. long-term success in our fight to eliminate
day trial period. We would be able to com- pressure ulcers in our hospital.
pare the pre and post test results as well as All nursing personnel included in the 90-day
the results from the 90-day trial on one unit trial satisfactorily completed all phases of Medline supplied the training materials and
utilizing the Medline skin care products, the pressure ulcer prevention training. The the management team at Jennie Edmund-
compared to the other units in the hospital. training materials provided included: a CMS son provided the encouragement to com-
We saw a dramatic improvement in nursing presentation, pressure ulcer prevention plete the training, but to a very large extent,
staff scores after the educational training. workbooks, an instructor’s guide, forms the staff took it upon themselves to learn
TRUE STORIES
“
the material through reading, memorizing
Our results were so good we’ve now gone hospital wide with the “
and small study groups.
Medline PUPP program. We have adopted the Remedy products
The Results and UltraSorb underpads throughout the whole facility.
At the conclusion of the 90-day trial period,
in April of 2009, the PUPP program had
lived up to all our expectations. As of May
15, 2009 we had assessed 57 patients and Future Initiatives
had zero new pressure ulcers. Six months The success Jennie Edmundson has
later, on November 6, 2009 we assessed enjoyed as a result of engaging in a sys-
63 patients hospital wide and again we had tematic approach to the prevention and
no new pressure ulcers. As of the writing of treatment of pressure ulcers has encour-
this case study we are still experiencing a aged us to look at other programs that can
0% incidence rate of new hospital-acquired improve our patient outcomes through staff
pressure ulcers. However the real plus is and resident education as well as product
that even the skeptics among our nursing improvements. One area we are especially
staff have become converts. No change is interested in is the reduction of catheter-
easy when it comes to nursing care, and associated urinary tract infections (CAUTIs).
our new Pressure Ulcer Prevention Program Some of these catheter-associated infec-
was not only about change, but also about tions may be the result of catheters being
documenting the results of those changes. placed unnecessarily. Other potential
And that required some discipline. But as a causes for these infections include leaving
result of the positive direction this program the urinary catheters in place too long and
has taken, I am pleased to say everyone contamination that can occur during inser-
has gotten on board. tion. We are looking at another Medline
program, ERASE CAUTI, that we believe
At this point, our Administrator and our may offer the potential to help us reduce the
financial management people are in com- risk of CAUTI in our hospital. The Medline
plete support of the program. This, as a program includes three distinct parts:
result of showing them how by reducing the 1) a new innovative catheter tray design
number of potential pressure ulcers from six that promotes better processes 2) an edu-
(6) to (0) zero over a one year time span we cational component that provides strategies
had in fact saved the hospital $247,800 (the to prevent CAUTI in the first place and 3) an
number of pressure ulcers reduced multi- awareness campaign, “The Race to ERASE
plied by the average cost to treat one, CAUTI,” that we believe would get our
$41,300, as calculated by CMS). nurses on board.
About the Author – Beth L. Edwards, RN BS is the Clinical Quality Specialist at the Jennie Edmundson Hospital in
Council Bluffs, Iowa. In this position Beth has responsibility for performance improvement, Joint Commission readiness,
and variance event report monitoring. She brings over 25 years of nursing experience to the job, including 5 years in
Patient Safety & Quality Improvement and 10 years in clinical research. In addition to nursing, Beth enjoys spending
time with her daughter and family, and doing knitting and stitchery.
22 Healthy Skin
jbk_HealthySkin17.3-mag_Layout 1 2/14/11 9:52 AM Page 23
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.
©2011 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.
jbk_HealthySkin17.3-mag_Layout 1 2/14/11 9:52 AM Page 24
©2011 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.
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26 Healthy Skin
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Special Feature
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Teresa Conne
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rvice.
28 Healthy Skin
jbk_HealthySkin17.3-mag_Layout 1 2/14/11 9:54 AM Page 29
St. Joseph’s
Nursing Co
one of the o llege in Rom
ldest and la a, Lesotho
rgest trainin is
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30 Healthy Skin
jbk_HealthySkin17.3-mag_Layout 1 2/14/11 9:55 AM Page 31
“
“ One quite obvious technique that just
may help: Get EVERYONE involved.
Falls Prevention Strategies
Keeping the general rule of increased communication in mind,
some of the following strategies may be employed in your long-
term care facility:
References
1. Wagner LM, Damianakis T, Mafrici N, Robinson-Holt K. Falls communication
patterns among nursing staff working in long-term care settings. Clin Nurs Res.
2010;19(3):311-326. Available at: http:/cnr.sagepub.com/content/19/3/311.
Accessed December 21, 2010.
2. Falls in Nursing Homes. Centers for Disease Control and Prevention website.
Available at: http://www.cdc.gov/ncipc/factsheets/nursing.htm. Accessed
December 21, 2010.
Prevention
Improving
Hand Hygiene
Compliance
A Multi-disciplinary Team Approach
By Lorri A. Downs RN, BSN, MS, CIC
Although it’s been more than ten years since the Institute of hygiene, however, appears to encompass the ultimate know-
Medicine’s eye-opening report To Err Is Human issued its call ing/doing gap among healthcare professionals. That is to say,
to action to reduce healthcare errors, improving quality and they know when they are supposed to wash their hands, yet
reducing healthcare-acquired infections continue to be two of observed hand-hygiene compliance has been poor; with
the greatest challenges in health care today. We must get average baseline rates around 40 percent.2
healthcare professionals to understand that hands are com-
mon vessels for passing pathogens from patient to patient.1 Known barriers to proper hand hygiene are a lack of knowl-
edge and lack of accessibility to sinks and alcohol-based
Appropriate hand hygiene is one practice with the potential to foam and gels.1
prevent a great deal of healthcare-acquired infections. Hand
32 Healthy Skin
jbk_HealthySkin17.3-mag_Layout 1 2/14/11 9:55 AM Page 33
Survey Readiness
RSV
Staphylococcus
Influenza
Candida
Klebsiella
Enterococcus
Pseudomonas
Steps to improved hand hygiene compliance1 violet light to see how well they cleaned their hands. Many
Improving hand hygiene is a daunting task, and using a employees had to repeat this activity two or three times
multidisciplinary approach can address numerous barriers. If before their hands were adequately washed.
your facility is having difficulty focusing on hand hygiene
compliance, try implementing the following steps to get Intervention # 3: Proper supplies.
your team motivated. All employees and physicians received pocket-sized bottles
of hand sanitizing gel to use throughout the day. Alcohol foam
1. Form a multidisciplinary team; include a wide range of staff dispensers were also placed both inside and outside patient
such as staff nursing, physicians, infection control and rooms, which addressed a barrier identified in the brain-
quality, and administration. Physician champions can help storming session that the dispensers inside the room were
reach every area quicker. not easily accessible. Signs were placed in patient rooms
2. Roll out an aggressive education program with clear reminding the staff to wash their hands, and patients were
expectations for compliance for employees. educated to remind the staff to sanitize their hands after they
3. Partner this campaign with education about hand hygiene entered the room.
Meet regularly to discuss the campaign progress and
make improvements. Intervention # 4: Hand sanitizing stations.
5. Remove unexpected barriers. The final part of the intervention was putting hand sanitizing
stations in the lobby and waiting rooms on the patient care
What does a successful multidisciplinary hand hygiene floors. The nursing staff educated visitors on the importance
campaign look like? of hand hygiene and educational handouts were also placed
The following is an example of one organization’s hand by the hand sanitizing stations.
hygiene campaign, as outlined in the American Journal of
Infection Control. The interventions were implemented as a way Using these interventions, the hand hygiene compliance rate
to break down the barriers to hand hygiene compliance.1 increased from 66 percent to 90 percent. As hand
hygiene compliance improved, it was noted that, during
Intervention # 1: “You Bugged Me” program. the same time, infection rates decreased.
This activity consisted of staff members presenting a “You
Bugged Me” card if they witnessed other employees not A prospective controlled trial conducted in a hospital
washing their hands or not following proper infection control nursery, and many other investigations conducted over the
practices. The card, which listed the misdoing, was turned past 40 years, have confirmed the important role
in to the employee’s supervisor by the end of the shift. The contaminated healthcare workers’ hands play in the
infection control coordinator was also notified by the individ- transmission of health care-associated pathogens.3
ual completing the card. Employees who received three cards
were required to present an educational in-service at a staff The time to act is now! We must partner and create multidis-
meeting. Those who received five cards were required to ciplinary clinical teams to get the message out that this rela-
write a research paper. Receiving seven cards meant the tively simple process of hand hygiene must be implemented
employees had to present their research paper to the facility’s in every healthcare setting and sustained at a compliance
policy and quality committee. Finally, employees who level of zero tolerance for poor practices. Our challenge in
received 10 cards were scheduled to meet with the CEO and leadership is to remove barriers, role model best practices
chief nursing officer (CNO) regarding their noncompliance. and hold our staff accountable.
References
Intervention # 2: Hand hygiene education. 1 Helms B, Dorval S, St. Laurent P, Winter M. Improving hand hygiene compliance:
The hospital’s infection control coordinator attended all the A multidisciplinary approach. The American Journal of Infection Control.
2010,38(7):572-574
staff meetings in all departments, providing education on 2 Boyce JM & Pittet D. Guideline for hand hygiene in health-care settings:
proper hand hygiene techniques. One of the tools involved recommendations of the Healthcare Infection Control Practices Advisory
Committee and the HICPAC/SHEA/APIC/IDSA/ Hand Hygiene Task Force.
was called Glitter Bug Potion, a fluorescent lotion that is used
MMWR. 2002;51(RR16):1-44.
with an ultraviolet lamp, making it possible to see how well 3 Historical perspective on hand hygiene in health care. In: WHO Guidelines on
hands are cleaned. After applying Glitter Bug, the employees Hand Hygiene in Health Care. 2009:9.
34 Healthy Skin
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©2011 Medline Industries, Inc. Medline and Epi-clenz are registered trademarks of Medline Industries, Inc.
jbk_HealthySkin17.3-mag_Layout 1 2/14/11 9:56 AM Page 36
36 Healthy Skin
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Treatment
steoporosis
in men
Osteoporosis is a disease that causes the skeleton However, in the past few years the problem of osteoporosis in
to weaken and the bones to break. It poses men has been recognized as an important public health issue,
particularly in light of estimates that the number of men above
a significant threat to more than two million men
the age of 70 will continue to increase as life expectancy
in the United States. One in four men over age 50 continues to rise.
will have an osteoporosis-related fracture in their
remaining lifetime. Clearly, more information is needed about the causes and
treatment of osteoporosis in men, and researchers are turning
Despite these compelling figures, surveys suggest that a their attention to this long-neglected group.
]majority of American men view osteoporosis solely as a
“woman’s disease.” Moreover, among men whose lifestyle For example, researchers supported by the National Institutes
habits put them at increased risk, few recognize the disease as of Health are studying how much the risk of fracture in men
a significant threat to their mobility and independence. is related to bone mass and structure, biochemistry, lifestyle,
tendency to fall, and other factors.
Osteoporosis is called a “silent disease” because it progresses
without symptoms until a fracture occurs. It develops less often The results of such studies will help doctors to better understand
in men than in women because men have larger skeletons, their how to prevent, manage, and treat osteoporosis in men. This
bone loss starts later and progresses more slowly, and they fact sheet describes the highlights of what is already known.
have no period of rapid hormonal change and bone loss.
35
Key
30
2002 2010 2020
Number of people
25
20
15
10
Source: America’s Bone Health: The State of Osteoporosis and Low Bone Mass in Our Nation.
Washington, DC: National Osteoporosis Foundation, 2002.
By age 65 or 70 men and women are losing bone mass at the same rate.
What Causes Osteoporosis? men younger than 70 years old; in older men, age-related
Bone is constantly changing—that is, old bone is removed and bone loss is assumed to be the cause.
replaced by new bone. During childhood, more bone is
produced than removed, so the skeleton grows in both size and The majority of men with osteoporosis have at least one
strength. For most people, bone mass peaks during the third (sometimes more than one) secondary cause. In cases of
decade of life. By this age, men typically have accumulated secondary osteoporosis, the loss of bone mass is caused by
more bone mass than women. After this point, the amount certain lifestyle behaviors, diseases, or medications. The most
of bone in the skeleton typically begins to decline slowly as common causes of secondary osteoporosis in men include
removal of old bone exceeds formation of new bone. exposure to glucocorticoid medications, hypogonadism
(low levels of testosterone), alcohol abuse, smoking, gastroin-
Men in their fifties do not experience the rapid loss of bone mass testinal disease, hypercalciuria, and immobilization.
that women do in the years following menopause. By age 65 or
70, however, men and women are losing bone mass at the Causes of Secondary Osteoporosis in Men
same rate, and the absorption of calcium, an essential nutrient
• glucocorticoid medications
for bone health throughout life, decreases in both sexes.
• other immunosuppressive drugs
Excessive bone loss causes bone to become fragile and more
• hypogonadism (low testosterone levels)
likely to fracture.
• excessive alcohol consumption
• smoking
Fractures resulting from osteoporosis most commonly occur in
• chronic obstructive pulmonary disease and asthma
the hip, spine, and wrist, and can be permanently disabling.
• cystic fibrosis
Hip fractures are especially dangerous. Perhaps because such
• gastrointestinal disease
fractures tend to occur at older ages in men than in women,
• hypercalciuria
men who sustain hip fractures are more likely than women to die
• anticonvulsant medications
from complications.
• thyrotoxicosis
• hyperparathyroidism
Primary and Secondary Osteoporosis
• immobilization
There are two main types of osteoporosis: primary and
• osteogenesis imperfecta
secondary. In cases of primary osteoporosis, either the
• homocystinuria
condition is caused by age-related bone loss (sometimes called
• neoplastic disease
senile osteoporosis) or the cause is unknown (idiopathic
• ankylosing spondylitis and rheumatoid arthritis
osteoporosis). The term idiopathic osteoporosis is used only for
• systemic mastocytosis
Continued on page 40
38 Healthy Skin
jbk_HealthySkin17.3-mag_Layout 1 2/14/11 9:56 AM Page 39
w 200 courses
w 20 curriculum tracts
w Interactive competencies
w Flexible access: PC, iPhone, iPad
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40 Healthy Skin
jbk_HealthySkin17.3-mag_Layout 1 2/14/11 12:04 PM Page 41
What Are the Risk Factors for Men? inadequate, dietary vitamin D intake should be between
Several risk factors have been linked to osteoporosis in men: 600 and 800 IU (International Units) per day. (See Table
• Chronic diseases that affect the kidneys, lungs, 1.) The amount of vitamin D found in 1 quart of fortified
stomach, and intestines or alter hormone levels milk and most multivitamins is 400 IU.
• Regular use of certain medications, such as • Engage in a regular regimen of weight-bearing
glucocorticoids exercises in which bones and muscles work against
• Undiagnosed low levels of the sex hormone testosterone gravity. This might include walking, jogging, racquet
sports, climbing stairs, team sports, weight training,
• Unhealthy lifestyle habits: smoking, excessive
and using resistance machines. A doctor should
alcohol use, low calcium intake, and inadequate
evaluate the exercise program of anyone already
physical exercise
diagnosed with osteoporosis to determine if twisting
• Age. The older you are, the greater your risk.
motions and impact activities, such as those used in
• Race. Caucasian men appear to be at particularly golf, tennis, or basketball, need to be curtailed.
high risk, but all men can develop this disease.
• Discuss with your doctor the use of medications that
are known to cause bone loss, such as glucocorticoids.
What Treatments Are Available?
• Recognize and seek treatment for any underlying
Once a man has been diagnosed with osteoporosis, his doctor
medical conditions that affect bone health.
may prescribe one of the medications approved by the FDA for
this disease. The treatment plan will also likely include the
nutrition, exercise, and lifestyle guidelines for preventing bone Table 1. Recommendations for Calcium
loss listed at the end of this fact sheet. and Vitamin D Intake
Age Calcium (mg) Vitamin D (IU)
If bone loss is due to glucocorticoid use, the doctor
19 to 30 1,000 600
may prescribe a medication approved to prevent or treat
glucocorticoid-induced osteoporosis, monitor bone density and 31 to 50 1,000 600
testosterone levels, and suggest using the minimum 51 to 70 1,200 600
effective dose of glucocorticoid. 70+ 1,200 800
Source: Institute of Medicine, 2010.
Other possible prevention or treatment approaches include cal-
cium and/or vitamin D supplements and regular physical activity.
42 Healthy Skin
jbk_HealthySkin17.3-mag_Layout 1 2/14/11 9:58 AM Page 43
• Locks odor-causing moisture away in the absorbent core Our latest Ultrasorbs innovation.
The advanced features of Ultrasorbs AP
• Makes for a fresher room
plus antimicrobial Ultra-Fresh to inhibit
• Clinically shown to help maintain skin integrity as part bacteria and yeast that cause odor**
of an overall pressure ulcer prevention program.1
n case you were wondering, the new minimum data set Care Area has QCLIs mapped to it that originate from one or
same going forward and some that will change temporarily. For example, the Pressure Ulcer Care Area currently has
seven QCLIs that are calculated from Staff Interviews, Census
New QIS software, implemented in November [2010], will still Sample Record Reviews, Admission Sample Record
generate random resident census samples and admission Reviews, and MDS. Only two of these are calculated from the
samples for the QIS process based on MDS data. Surveyors MDS items, so the remaining five pressure ulcer QCLIs will be
will continue to require from the nursing facility an alphabetical utilized during QIS surveys.
resident census list of all residents who are in the facility,
including those who may be in the hospital or out on a home The calculation and use of QCLIs based solely on MDS will
visit. They will also require the list of recent admissions. be on hold until sufficient numbers of MDS 3.0 assessments
have been submitted by nursing facilities. Thus, although MDS
Surveyors will also continue to reconcile the software-gener- QCLIs will temporarily not be used to determine triggered
ated random sample of residents with the alphabetical resi- Care Areas for a Stage 2 in-depth investigation, these care
dent census and new admission list to finalize their samples areas will be included in QIS because of the QCLIs from other
for survey. sources. Some of the MDS QCLIs that can be calculated from
MDS 3.0 data are expected to be used in QIS beginning in
What will change, temporarily, is that the QIS software will not early 2011.
calculate or utilize the 44 Quality of Care and Life Indicators
(QCLI) that are derived from MDS data. However, almost every Printed with permission from Provider magazine.
44 Healthy Skin
jbk_HealthySkin17.3-mag_Layout 1 2/15/11 2:09 PM Page 45
SUCCESS STORIES
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46 Healthy Skin
jbk_HealthySkin17.3-mag_Layout 1 2/14/11 9:58 AM Page 47
Quality Assurance
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This webinar gives a QIS overview and demonstration on how the abaqis® system can
help prepare for both the traditional and QIS survey processes. This demonstration also
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the needs of residents, aiding your efforts to improve consumer satisfaction
Now with the new Stage 2 module featuring:
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• Investigative tools to determine deficiencies in triggered care areas
jbk_HealthySkin17.3-mag_Layout 1 2/14/11 9:58 AM Page 48
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©2011 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.
jbk_HealthySkin17.3-mag_Layout 1 2/14/11 9:59 AM Page 49
Special Feature
Inspiring change:
The Cozy Project makes older
patients more comfortable
By Tina Weitzel MA, RN-BC
While Rosemary Muller, 82, was hospitalized with pneumonia, she often
complained about feeling cold. One evening she told her nurse that she
couldn’t go to sleep because she was too cold. The temperature of her
room was 23[degrees] C (74[degrees] F), but Mrs. Muller was still uncom-
fortable, despite being covered with three blankets.
In an effort to help her relax and sleep, her nurse gave her a p.r.n. sedative.
During the night, Mrs. Muller woke up because she needed to urinate.
Feeling light-headed and confused, she fell when she got out of bed to go
to the bathroom.
The Professionals Improving Care for Health System Elders (PICHE) group
at our hospital recognized that being cold was a risk factor for older adults
such as Mrs. Muller. We questioned why hospitalized older adults are
dressed in short-sleeved, open-backed gowns that cover far less of the
body than clothing worn at home.
The amount and type of clothing selected by older adults may be related to
changes in thermoregulation, which cause them to feel cold in an environ-
ment that’s comfortable for younger people. The PICHE nurses decided to
investigate.
Reading up
The first step was to review the literature to better understand physiologic
changes that contribute to older adults feeling cold. We discovered that their
response to cold is affected by a decrease in their abilities to produce and
conserve heat.
Although core body temperature remained stable for the younger subjects,
older subjects experienced progressively lower core temperatures.2 Other
researchers found that increasing skin temperature as little as 0.4[degrees]
C led to decreased nocturnal wakefulness.3
Hospitalized older adults are likely to have chronic illnesses that may con-
tribute to thermoregulatory problems. Those who are malnourished will have
even less subcutaneous fat, which may contribute to less ability to maintain
warmth. Disorders such as hypothyroidism and hypoglycemia may affect
the shivering response, and immobility associated with conditions such as
stroke, arthritis, and parkinsonism may lead to decreased heat production.
Continued on page 52
50 Healthy Skin
jbk_HealthySkin17.3-mag_Layout 1 2/14/11 9:59 AM Page 51
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Medications for pain, depression, or anxiety can diminish the nurse and said they were much more comfortable. One of the
shivering response or act as vasodilators, further increasing patients with dementia seemed very pleased and said, “I have
discomfort in a cool environment.4 When the thermostat can’t one just like this at home.” Patient ages ranged from 75 to 89,
be adjusted, older adults need extra clothing and bedcovers beds had 2 to 4 blankets, and room temperature ranged from
to trap warm air next to their body. 74[degrees] F to 77[degrees] F.
Introducing the Cozy Project After the intervention, the nurses documented nonverbal
The PICHE group decided to investigate whether warmer behavior. Notes included the words smiling, quiet, and sleeping.
clothes could make a difference in the comfort of our older We discovered that when the older women were offered a
patients, starting with donated “gently worn” long-sleeved long-sleeved shirt, they often refused, but when we called it
turtleneck shirts. We decided to evaluate the effectiveness of a long-sleeved blouse, they usually accepted the garment.
the Cozy Project in a trial of patients with these characteristics:
women age 75 and older in a medical unit who said they’re The story of one patient demonstrates the effectiveness of our
cold and uncomfortable and were observed to be restless project. This patient, 88, said she was cold and tired but couldn’t
or fidgeting. go to sleep. She was covered with two blankets, and her room
temperature was 77[degrees] F. During the first observation
The women who met these criteria were offered a warm period, the nurse noted that the patient constantly fidgeted.
garment. For patients with I.V. devices, the garment was cut Ten minutes after the nurse helped her put on a long-sleeved
up the back to make it easier to get on and off and to facilitate turtleneck, the patient was sleeping.
changing the devices and dressings.
Continued on page 54
We decided to systematically collect data for the PICHE group
to analyze. The RNs who participated and documented their
observations attended a 2-hour educational session that
included the opportunity to practice taking notes while watch-
ing a videotaped patient-interaction scenario. Before and after
the intervention, the nurses were asked to:
Comforting results
We evaluated the results based on notes about the first five
women who were identified as patients who might be more
comfortable wearing a long-sleeved turtleneck. Immediately
after their shirts were put on, three of the patients thanked their
52 Healthy Skin
jbk_HealthySkin17.3-mag_Layout 1 2/14/11 10:00 AM Page 53
Changing
your look
just got
more
affordable
New lower prices on all
your favorite brands!
This project indicates that this simple intervention can improve In a previous study in our hospital, blankets from a blanket
comfort in older adults. The PICHE group decided to solicit warmer were also found to improve the comfort level of older
additional donations of gently worn long-sleeved turtlenecks adults.5 The long-sleeved garments may be an additional sim-
and expanded our project to additional units. These donated ple intervention to enhance warmth.
turtlenecks were laundered and then stored in a designated bin
on the nursing units. Nurses could take a turtleneck and cut it Florence Nightingale wrote that nurses should provide comfort
as needed; for example, to accommodate any venous access through proper use of “fresh air, light, warmth, cleanliness,
devices. The garment would then be discarded when it was quiet, and the proper selection and administration of diet.”6
soiled or when the patient was discharged. Making a patient comfortable has always been an integral com-
ponent of nursing.
We placed a collection box near the cafeteria and requested
donations in the hospital newsletter. Very quickly, the collection
box was filled. When supplies get low, we place another References
1. Talley HC, Talley CH. AANA Journal course. Update for nurse anesthetists.
request in the hospital newsletter. We’ve had no difficulty
Evaluation of older adults. AANA J. 2009;77(6):451-460.
obtaining long-sleeved turtlenecks. 2. Degroot DW, Kenney WL. Impaired defense of core temperature in aged humans
during mild cold stress. Am J Physiol Regul Integr Comp Physiol.
2007;292(1):R103-R108.
Understanding the implications
3. Raymann RJ, Swaab DF, Van Someren EJ. Skin deep: enhanced sleep depth by
Feeling cold may aggravate pain for those who suffer from cutaneous temperature manipulation. Brain. 2008;131(Pt 2):500-513.
arthritis or any other musculoskeletal illness. Patients who are 4. Halter J, Ouslander J, Tinetti M, et al., eds. Hazzard'sGeriatric Medicine and
recovering from surgery and report acute pain may also bene- Gerontology. 6th ed. Chicago, IL: McGraw-Hill; 2009.
5. Robinson S, Benton G. Warmed blankets: an intervention to promote comfort for
fit from wearing long-sleeved garments because the warmth elderly hospitalized patients. Geriatr Nurs. 2002;23(6):320-323.
may decrease muscle tension. 6. Nightingale F. Notes on Nursing: What It Is and What It Is Not. London, England:
Harrison and Sons; 1860.
54 Healthy Skin
jbk_HealthySkin17.3-mag_Layout 1 2/14/11 10:00 AM Page 55
50%
less
friction
than the leading
competitor3
The heels are the most common site for facility-acquired pressure
ulcers in long-term care, and the second most common site over-
all.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
2 Strapping Methods
heel protection devices that relieve pressure by elevating the heel.
1
Fowler E, Scott-Williams S, McGuire JB. Practice recommendations for preventing heel pressure
ulcers. Ostomy Wound Management. 2008;54(10):42:48.
2
Langemo D, Thompson P, Hunter S, Hanson D, Anderson J. Heel pressure ulcers: stand guard.
Advances in Skin & Wound Care. 2008;21(6):282-292.
©2011 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.
jbk_HealthySkin17.3-mag_Layout 1 2/14/11 10:00 AM Page 56
Prevention
Protecting
Vulnerable
Heels
Tips for Nursing
Assistants
56 Healthy Skin
jbk_HealthySkin17.3-mag_Layout 1 2/14/11 10:01 AM Page 57
You can help prevent heel pressure ulcers by turning Moisturizers and padding devices
patients regularly and by making sure they’re well- Padding devices (sheep skin or bunny boots) and mois-
nourished and well-hydrated. There are also many helpful turizers help minimize friction and shear, but they don’t
products available for heels. provide protection from excessive pressure.5
Special Feature
t r i c P r e s s u r e
Pedia
U l c e r s i n t h e
s t” P l a c e s
“Dar nede
by Margie Rodriguez, RN, MSN, WCC
58 Healthy Skin
jbk_HealthySkin17.3-mag_Layout 1 2/14/11 10:02 AM Page 59
SAFER CATHETERIZATION
FOR KIDS
Pediatric
Catheter
Tray
Children’s
Introducing Medline’s new Activities
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You trust Medline for clinical innovations, such as our To learn more about Medline’s ERASE CAUTI
industry-leading catheter tray design. Now, we can be program and alternatives to catheterization,
your patient’s buddy, too. visit http://erasecauti.com.
©2011 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.
jbk_HealthySkin17.3-mag_Layout 1 2/15/11 2:31 PM Page 60
Confounding factors
A majority of the special needs population are subject to skin
issues related to the use of medical devices, alternate feed-
ing modalities, cognitive impairment (congenital or patholog-
ical), metabolic compromise, neurological deficits and chronic Stage III just below the occipitus/present upon admission
illness, making this population vulnerable to pressure ulcers
during their childhood years and into adulthood—basically for
their entire lifetime. Technological advancements in the care of
critically ill infants and children has undoubtedly saved lives
and greatly extended the life span among many children.
However, these successes have posed unforeseen chal-
lenges as these individuals enter adulthood.3
Unstageable
60 Healthy Skin
jbk_HealthySkin17.3-mag_Layout 1 2/14/11 10:05 AM Page 61
Even though children can suffer from pressure ulcers, very About the author
little research is available regarding the prevalence, incidence Margie Rodriguez, RN, MSN, WCC, is a
and risk factors associated with pressure ulcers among the wound care nurse at the Elizabeth Seton
Pediatric Center, a pediatric long-term care
pediatric population.1 Despite the lack of available research,
facility for palliative, rehabilitation and long-
suffice it to say there is a possibility we are not reaching far term care services in New York City. Her
enough in pursuit of this data, which encompasses not just accomplishments include creating a skin
the acute care setting but all spectrums of care. Evidence- care program, publishing articles, and in
based clinical practice guidelines for prevention and treatment 2010, working with NPUAP to help revise
of pressure ulcers specifically addressing the unique needs definitions for pressure ulcer staging. She is also on faculty for
the Beth Israel School of Nursing. You can reach her at
of the neonatal and pediatric population are needed.
margie.rodriguez@setonpediatric.org.
References
1 Suddaby EC, Barnett S, Facteau L. Skin breakdowns in acute
care pediatrics. Pediatric Nursing. 2005; 31(2):132-138.
2 National Pressure Ulcer Advisory Panel (2009). Prevention
of Pressure Ulcers: Quick Reference Guide.
3 Gray M. Context for WOC practice – urban myths and the
randomized control trial. 2010. JWOCN; 37(6):583–585.
4 National Pressure Advisory Panel. (Dec. 2010). Mucosal
Pressure Ulcers: A NPUAP Position Statement.
62 Healthy Skin
jbk_HealthySkin17.3-mag_Layout 1 2/14/11 10:05 AM Page 63
Medline University
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Top Tips
for Winter Skin Care
You may not realize the health threats associated with the
glaring sun and bitter cold air of the winter season. By itself,
dry skin isn’t a medical worry, but serious cases can result
8 more ways to keep your skin healthy:
64 Healthy Skin
jbk_HealthySkin17.3-mag_Layout 1 2/14/11 10:05 AM Page 65
®
Medline Remedy
Serious care.
Serious results.
1. Shannon RJ, Coombs M, et al. Reducing hospital-acquired pressure ulcers with a silicone-based dermal nourishing emollient-associated
skincare regimen. Adv Skin Wound Care, 2009;22:461-7.
©2011 Medline Industries, Inc. Medline and Medline Remedy are registered trademarks of Medline Industries, Inc.
jbk_HealthySkin17.3-mag_Layout 1 2/14/11 10:06 AM Page 66
CASE STUDY
INTRODUCTION METHODOLOGY
The management of exudating wounds presents chal- In this safety and effectiveness study, a convenience
lenges in the hospice environment, where the focus is on sample of three patients with multiple wounds were cho-
the comfort of the resident and the elevation of quality of sen. In all cases, the dressings were changed as needed
life factors. In our practice, we have sought the use of based on visual observation of the dressing saturation
absorbent dressings that are versatile on wound exudate, and potential exudate overloads. More frequent change
emerge at variable rates depending on the type of wound, was not needed during use.
and act as a single product across the spectrum of exu-
dation levels. Such optimization is desirable because it CASE DETAILS AND OBSERVATIONS
allows us to focus more energy on the patient rather Case 1: DG is a 74-year-old female, admitted to our
than on managing the choice and inventory of many program with multiple Stage lll and lV pressure ulcers.
different dressings for various types of wounds. Her terminal diagnosis is AFTT. Her albumin level was
2.4. During her hospital stay just prior to her hospice
We chose patients who suffered from exudating wounds, admission, lab cultures revealed MRSA in her ulcers and
with some wounds being more exudative than others, at one point she was treated for septicemia. Initially,
even within the same patient. The purpose of this limited while in hospice care she required dressing changes
trial was to check if a new variety of superabsorbent par- as frequently as 2 times a day for several of the pres-
ticle containing dressings were versatile enough on this sure ulcers with foam dressings. When the new super-
vulnerable population, and whether the dressings had any absorbent dressing was introduced, dressing change
undesirable properties such as tendency to leak, or to frequently decreased considerably. The trial with the new
cause discomfort during removal. This new superab- product was started with two of her pressure ulcers. The
sorbent dressing consists of a contact layer that has spe- high capacity of the dressing contributed to our patient’s
cial microchannels that allow directional fluid flow, from comfort by reducing occasions of dressing change, and
the wound into superabsorbent particles dispersed inside proportionally reduced the caregiver’s time which then
an internal core layer. Laboratory data shows that these impacted the cost of care.
dressings, when subjected to pressure, still allow fluid
absorption. Compression on the dressings leads to min- Case 2: JH is a 68-year-old female who was admitted
imum fluid loss. These properties are thought to be sig- to our program with a terminal diagnosis of pancreatic
nificant in managing periwound maceration. Because cancer. She presented on admission with four ulcers,
maceration of periwound skin is a major problem in hos- which were identified as being Pyoderma Gangrenosum
pice patients with exudating wounds, and all too frequent in etiology. We used the superabsorbent dressing on a
dressing changes impact cost and quality of care. This highly exudating wound on her right hip. The new dress-
trial also examined whether the new superabsorbent ing managed exudate without any maceration to peri-
dressing can alleviate care and cost concerns in a hos- wound skin.
pice environment.
Case 3: MKL, an 84-year-old female, was admitted to
our program with a terminal diagnosis of vascular
dementia. She presented with two venous leg ulcers.
The foam dressings in use initially were replaced with the
new superabsorbent dressing. Compared to the
frequency of the foam dressing change, the number of
dressing changes was greatly reduced, increasing our
patient’s comfort and freeing up the caregiver to focus
on patient comfort.
66 Healthy Skin
jbk_HealthySkin17.3-mag_Layout 1 2/15/11 2:27 PM Page 67
References
1. Sibbald Gary et al. The role of moisture balance in wound healing.
Advances in Skin and Wound Care: 2007: 20:39-53.
2. Steinlecher E, Rohrer C, Abel M. Absorbent dressings with superabsorbent
polymers – a new generation of wound dressings. Poster 374.
18th Conference of the European Wound Management Association.
OPTILOCK™
Super Absorbent Wound Dressing
Gentle on wounds,
tough on exudate
OPTILOCK’s superabsorbent polymer
core absorbs moderate to heavy exudate,
locks in fluid—even under compression—
and protects periwound skin from maceration.
Non-adherent contact layer prevents the dressing
from sticking to the wound. Gentle removal and fewer
dressing changes mean greater patient comfort.
©2011 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.
jbk_HealthySkin17.3-mag_Layout 1 2/14/11 10:06 AM Page 69
Prevention
EASY DOES IT
Safe and Effective Lifting Practices
How effective is mechanical lifting equipment indicated that residents’ acceptance of a safe lifting program
in preventing injuries to caregivers? was moderate when the program was first implemented but
Safe resident lifting programs can be highly effective in high at the end of the research study. 5,6
reducing a healthcare worker’s exposure to heavy loads and
awkward working postures that contribute to back and other Injuries to residents are also reduced because the mechanical
musculoskeletal injuries. Research has shown that safe res- lifts protect residents from being dropped. Anecdotal infor-
ident lifting programs reduce resident-handling workers’ mation indicates that a reduction in skin tears and bruises
compensation injury rates by 61 percent, lost work day injury may result when residents are handled mechanically rather
rates by 66 percent, restricted work days by 38 percent, and than manually.8
the number of workers suffering from repeat injuries.3 Similar
findings have been reported by other investigators.4,5,6 Fur- Does it take more time to use a mechanical lift to move
thermore, this research has shown an increase in caregiver a resident than to manually transfer the resident?
job satisfaction and a decrease in “unsafe” patient handling It is quicker to manually transfer a resident. However, using a
practices performed. Nurses ranked lifting equipment as the mechanical lift is much safer for the caregiver and provides a
most important element in a safe lifting program.5,6 The more comfortable and secure transfer for the resident. The
increase in bariatric residents has also led lifting equipment long-term health and wellness of the caregiver will be much
manufacturers to develop equipment with higher lifting greater over the long term by taking a few extra minutes to
capacities to accommodate the special needs of some lighten the daily burden of work. Much of the extra time to
bariatric residents. use a mechanical lift is spent in locating and bringing the lift
to the bedside. Convenient storage and adequate numbers
How does lifting equipment benefit nursing home residents? of mechanical lifts greatly reduce the time required to move
Although some residents may be reluctant to try new lifting a resident and increase staff adherence to the program.
devices, the use of mechanical lifting equipment increases Ceiling-mounted lifts address the concern of bringing the lift
a resident’s comfort and feelings of security when to the bedside because they are conveniently stored in the
compared to manual methods.7 The findings from one study resident’s room.
What kind of training is necessary to ensure all caregivers What approaches promote the effective implementation of a
are prepared to use lifting equipment? safe resident lifting program?
Training should focus on how to use the lifting equipment for It is important to include caregivers and staff from all depart-
residents with a range of physical limitations and should ments in the program development. Keeping the staff trained
include hands-on practice. Caregivers should be required to and competent in the use of the mechanical lifting equipment
demonstrate that they are proficient in the use of the lifting is a key component of a successful program. Lack of com-
equipment for residents with a range of disabilities. Training is pliance may result if newly hired employees do not know how
generally provided by the lifting equipment manufacturer to use the equipment.
when equipment is purchased; however, a member of the
care giving staff and/or peer safety leaders should be trained Adapted from “Safe Lifting and Movement of Nursing Home
in all aspects of lifting equipment usage and should be pre- Residents,” Department of Health and Human Services.
pared to provide periodic refresher training to newly hired and
existing staff.
72 Healthy Skin
jbk_HealthySkin17.3-mag_Layout 1 2/14/11 10:07 AM Page 73
“ Oh
Yeah!
Learning opportunities for
“
CNAs at Medline University
Access courses
on your computer,
iPhone or iPad.
Follow us
Be the first to know when we
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VAP
3. Peptic ulcer disease prophylaxis
4. Deep vein thrombosis prophylaxis
5. Daily oral care with chlorhexidine
References
1. Kollef MH. What is ventilator-associated pneumonia and why is it
important? Respiratory Care. 2005;50(6):714-724. Available at:
www.rcjournal.com/contents/06.05/06.05.0714.pdf. Accessed
November 4, 2010.
2. Implement the Ventilator Bundle. Institute for Healthcare
Improvement (IHI) website. Available at: www.ihi.org/IHI/Topics/Criti-
calCare/IntensiveCare/Changes/ImplementtheVentilatorBundle.htm.
Accessed November 4, 2010.
74 Healthy Skin
jbk_HealthySkin17.3-mag_Layout 1 2/14/11 10:07 AM Page 75
Prevention
1. Elevating the Head of the Bed 30 Degrees 3. Peptic Ulcer Disease Prophylaxis
• Implement a mechanism to ensure head-of-the-bed • Include peptic ulcer disease prophylaxis as part of
elevation, such as including this intervention on your ICU order admission set and ventilator order
nursing flow sheets and as a topic at set. Make application of prophylaxis the default
multidisciplinary rounds. value on the form.
• Create an environment where respiratory therapists • Include peptic ulcer disease prophylaxis as an item
work collaboratively with nursing to maintain for discussion on daily multidisciplinary rounds.
head-of-the-bed elevation. • Empower pharmacy to review orders for ICU
• Involve families in the process by educating them patients to ensure that some form of peptic ulcer
about the importance of head-of-the-bed elevation disease prophylaxis is in place at all times.
and encourage them to notify clinical personnel
when the bed does not appear to be in the 4. Deep Venous Thrombosis Prophylaxis
proper position. • Include deep venous prophylaxis as part of your
• Use visual cues to easily identify when the bed is ICU order admission set and ventilator order set.
in the proper position. Make application of prophylaxis the default value
• Include this intervention on order sets for initiation on the form.
and weaning of mechanical ventilation, delivery of • Include deep venous prophylaxis as an item for
tube feedings, and provision of oral care. discussion on daily multidisciplinary rounds.
• Empower pharmacy to review orders for ICU
2. Daily “Sedation Vacations” and Assessment patients to ensure that some form of deep venous
of Readiness to Extubate prophylaxis is in place at all times.
• Implement a protocol to lighten sedation daily at
an appropriate time to assess for neurological 5. Daily Oral Care with Chlorhexidine
readiness to extubate. Include precautions to • Educate registered nurses (RNs) about the rationale
prevent self-extubation such as increased supporting good oral hygiene and its potential
monitoring and vigilance during the trial. benefit in reducing ventilator-associated pneumonia.
• Include a “sedation vacation” strategy in your overall • Develop a comprehensive oral care process that
plan to wean the patient from the ventilator; if you includes the use of 0.12% chlorhexidine oral rinse.
have a weaning protocol, add “sedation vacation” • Schedule chlorhexidine as a medication, which then
to that strategy. provides a reminder for the RN and triggers oral
• Assess that compliance daily during care process delivery.
multidisciplinary rounds.
Source: www.ihi.org/IHI/Topics/CriticalCare/IntensiveCare/Changes/Implement-
• Consider implementation of a sedation scale
theVentilatorBundle.htm
(e.g., the Riker Scale) to avoid oversedation.
Ventilator-Associated Pneumonia
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jbk_HealthySkin17.3-mag_Layout 1 2/14/11 10:07 AM Page 77
VAPrevent is a comprehensive system to give your staff the tools to deliver excellent oral
care. And for ventilator patients, excellent oral care may be part of the difference between
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communicates and educates, all while leaving less waste behind. And the
intuitive stack-pack design with its one-at-a-time dispenser makes it easy
for caregivers to stay on track with care protocols.
Program
When your staff knows how to use a product appropriately, its effectiveness
increases greatly. That’s why Medline developed the Medline VAP program,
which helps build knowledge and clinical skills with educational modules
for both novice and experienced clinicians, as well as an online interactive
competency for oral care. A program manager helps you implement your
program and stays active as you progress, providing 90-day reports to
help you track your incidence of VAP.
Price
If you expected a VAP program this innovative would come at a price
premium, you’re in for a pleasant surprise. VAPrevent from Medline
comes to you for five to ten percent lower than competitors. In a tough,
pay-for-performance environment, VAPrevent represents a major value.
References
1 Bingham M, Ashley J, De Jong M, Swift C. Implementing a unit-level intervention to reduce the probability
of ventilator-associated pneumonia. Nursing Research. 2010; 59(1): S40-S47.
2 Trouillet J, Chastre J, Vuagnat A, Joly-Guillou M, Combaux D, Dombret M, et al. Ventilator-associated
pneumonia cased by potentially drug-resistant bacteria. Am J Respir Crit Care Med. 1998. 157(2):531-539.
©2011 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.
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8 Principles
For Achieving Inner Peace
by Wolf J. Rinke, PhD, RD, CSP
Travel alerts, seemingly never ending natural and manmade 2. Think empowering thoughts
disasters, cranky patients bugging you…stress accelerat- As a man thinkest, so he becomes, says
ing at logarithmic speed! We certainly live in a very unsettling the Bible. And yet most of the time we
and stressful time. A time where achieving inner piece are totally inattentive to our thoughts.
seems totally out of reach. And yet I have found that you It’s almost like they run amok—totally
can attain it by relentlessly practicing the eight principles out of control—doing their own thing. To
that follow. achieve inner peace requires us to first
become aware of our thoughts—instead
1. Be honest of just letting them ruminate at the sub-
BP, politicians, clergy … do I need to conscious level. Second we must ask ourselves: is this a
say more? But before you get too smug, thought that empowers me and makes me stronger, or does
better look at the face in the mirror. it make me feel mad, bad or sad? And third we must be-
Study after study has shown that most come aware that at any one nanosecond our minds can
people lie. We inflate our resumes, hold only one thought. It can be a positive thought that gives
fudge our accomplishments and exag- us inner peace and improves our quality of life, or it can be
gerate even inconsequential events. a negative thought that does just the opposite. It’s so sim-
And when we lie there is no trust, and ple, yet difficult, to develop this powerful new awareness
without trust you can’t have solid relationships, without and transform it into a habit.
relationships there is no love, and without love you won’t
have inner peace. Call me old-fashioned; I believe there is 3. Take advantage of the
no excuse for lying … none. There is not even a good rea- abundance all around you
son for exaggerating. Because if you do, you will have to When we are struggling and having trou-
talk from the head, always checking your memory to make ble making ends meet, it is really difficult
sure you are consistent. And who can keep track of that, to see the abundance. What we see
when most of us have trouble remembering where we put instead—almost oppressively—is scarcity.
our car keys. Only by getting in the habit of always telling I know firsthand. Having been born right
the truth—especially if it is at your own expense—will you be after World War II in Germany, with my
able to talk form the heart and that will set you free. This in parents losing all their earthly posses-
turn will enhance your leadership skills because people sions—yes, everything—we had less than scarcity, we had
follow people they can trust. And it will put you on the fast desperation. Finding enough food and shelter to keep us
track in any endeavor. It will also enrich your personal rela- alive is what consumed my parents. Then some 17 years
tionships and, most importantly, will get you to like and later—when I immigrated to the United States—scarcity,
respect yourself—the foundation for achieving inner peace. although not as extreme, reared its ugly head again. Basi-
cally I only spoke a few words of English, had $20 in my pocket So begin right now to become your own best friend, because if
and the proverbial shirt on my back. And I certainly had trouble it is not you, who is it going to be? In addition to taking really
finding all “the milk and honey” that supposedly was just wait- great care of your thoughts, also take extraordinary care of your
ing for me. However, it was all around me, and over time body. And if you want to avoid psychosomatic illnesses—which,
I learned to find it by internalizing a powerful concept that I as you probably know, account for the majority of illnesses in
learned from several different mentors: If you want more of this country—then you must eat right—which means you learn
something, you have to give it first. I know it sounds counterin- to stop when it tastes the best. Get adequate rest—seven to
tuitive. (By the way, lots of things are…otherwise men would eight hours of sleep is a great start—and do 25-30 minutes of
ride sidesaddle. If that didn’t at least make you smile, you’re aerobic exercise three times per week, alternating with strength
taking this much too seriously.) Here is how it works: If you want training for the other three days. (Go ahead and take Sunday
more love in your life, give more love. If you want to be happier, off.) It also means that you don’t put stuff into your body that
make others happy. If you want people to trust you, give does not belong there—read drugs and nicotine. (Please don’t
unconditional trust. Of course the only way you can take yawn. This is important. You only will be given one body—a the
advantage of this principle is to internalize the next one. one you’ve got is it. So treat it accordingly.)
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Just about an hour later the scene repeated itself all over again. us. And then, we wonder why our life stinks. Part of what we
Except this time it was a young lady who was also interviewing carry around in our bag is resentment, hate and blame. All of
for the same job. She, too, had done her homework and these emotions will attack our souls and diminish the quality of
wanted to make a great impression. She also asked the secu- our spirit and our physiology.
rity guard, “What are the people like around here?”
In turn, he asked, “What were they like where you came from?” Instead, go ahead pay tribute to your past. Visit it. And then
The vivacious young lady answered, “Oh, I just loved the people toss it in the trash. You can make that happen by taking own-
at my former hospital. They were kind, supportive and hard- ership of all that is going on in your life. Your life is not a func-
working. Everyone worked together as a team. We cared so tion of what other people have done to you; it is today what it
much for each other that I developed some of the best friend- is because of the choices you have made in the past. And if
ships. It’s really a shame that my husband is relocating to this your feelings of resentment, hate and blame are attributed to
area. I just hate to leave all those wonderful people behind.” the actions of others, then you have to wait for those people to
“Well,” the wise elderly man answered, “I believe you will find change—which may never happen. And don’t even try to
the same kind of people here.” change them! Think about how many of us have difficulty
changing ourselves, let alone others. Instead live by the axiom:
6. Let go of the past If it is to be it is up to me. Once you’ve done that, you are ready
It’s amazing how much we mental energy to take it to the next level by substituting the emotions of love,
we spend in a place over which we have empathy and kindness for resentment, hate and blame, which
absolutely no control—the past. It was Dr. will put you on the fast track to inner peace.
Wayne Dyer who likened our past to a bag
of manure that we carry around with us. We And while you are at it, force yourself to get off your case, quit
keep putting more and more manure into living in the past, and become future-oriented by learning from
the bag. Once in a while we put the bag every action. If an action gives you the results you desired, keep
down, reach in and smear manure all over doing it. If the action did not accomplish the intended result,
review what happened; make a commitment to do it differently 8. Never give up on your dreams
in the future, then quit doing it and let it go. No wait, I mean The purpose of life is not to make it safely to
really let it go. Get on with your life by refocusing your thoughts the grave. Pursue your dreams no matter
on the only moment you and I have any control over, the now. how late or how “weird.” Let me share an
example. Doris Haddock had a passion. She
7. Kill your ego felt that Congress needed to get off their
Ego, right along with greed and envy, is one duff and change the campaign finance
of the most powerful destroyers of inner laws! Unlike most of us; however, Doris did
peace. A look at history confirms that these not sit around and complain and whine.
emotions are responsible for more evil. Instead, Doris started to walk from
Think Napoleon, Stalin and Hitler—and more Pasadena, Calif.; walking 10 miles a day, every day. Fourteen
corporate catastrophes. Think Toyota’s and months and 3,200 miles later she arrived in Washington, DC.
even venerable Johnson & Johnson’s recent Now, here comes the startling part of the story. Doris, better
recalls—as well as relationship killers. And known as Granny D, had a severe case of arthritis, wore a brace
yet we can get rid of our ego with just five and turned 90 years “young” while on the trail. And for an added
powerful phrases expressed liberally and from the heart: measure, she was arrested twice demonstrating for her beliefs.
• You are right about that. Any time you get into a conflict, Why? Because she had a dream and a passion. So whatever
use this phrase and you will have no more conflict— you do, don’t ever give up on your dreams, it’ll make you
guaranteed! cranky. Instead, get off your butt and act on your dreams today,
• I’ve made a mistake. This phrase helps you get off your and you, too, will be on the road to achieving the most coveted
high horse gracefully. All human beings make mistakes— of all possessions—inner peace.
and since you are a…I think you get it. There is only one
omnipotent force in the universe—and it is not you. So © 2011 Wolf J. Rinke
quit defining unrealistic expectations for yourself.
• I changed my mind. You are an evolving human being,
one who is like red wine and gets better all the time. That Dr. Wolf J. Rinke, RD, CSP is a keynote
means you have to let go of your past beliefs. (Remember speaker, seminar leader, management con-
that the only person who can change his/her mind is the sultant, executive coach and editor of the free
electronic newsletter Read and Grow Rich,
one who has one.)
available at www.easyCPEcredits.com. In
• I don’t know. Admit it. You don’t know everything. It lets
addition he has authored numerous CDs,
other people know that you have high levels of self-esteem.
DVDs and books including Make It a Winning
(Only people who are OK inside of their own skin can admit Life: Success Strategies for Life, Love and
they don’t know everything.) Business, Winning Management: 6 Fail-Safe
• Let’s agree to disagree. The phrase to use if all else fails. Strategies for Building High-Performance Organizations and Don’t
By the way, do try all five of these at home; the positive Oil the Squeaky Wheel and 19 Other Contrarian Ways to Improve
results will astound you. Your Leadership Effectiveness; available at www.WolfRinke.com.
His company also produces a wide variety of quality pre-approved
continuing professional education (CPE) self-study courses, avail-
able at www.easyCPEcredits.com, including his Beat the Blues:
How to Manage Stress and Balance Your Life, approved for 28
CPEUs, from which this article was extracted. Reach him at
WolfRinke@aol.com.
82 Healthy Skin
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Special Feature
PGD2
Pink Glove Dance: The Sequel
From Halifax, Novia Scotia to San Francisco, Califor- Pink Gloves for a Cause
nia, Medline traveled across North America in 2010 Our goal is to create a Pink Glove Nation – that is, get
showcasing the spirit of breast cancer survivors and as many people as possible talking about breast can-
caregivers who performed in the Pink Glove Dance: cer and to raise awareness for early detection. To that
The Sequel. To see videos of Pink Glove Dancers in end, medline donates partial proceeds from our pink
action visit www.pinkglovedance.com. gloves and other pink ribbon products to the National
Breast Cancer Foundation (NBCF) to help fund mam-
Thank you, Pink Glove Dancers, for welcoming us to mograms for women who cannot afford them.
your city!
• New York, NY • La Jolla, CA
• Chicago, IL • Portland, OR
• San Francisco, CA • New Orleans, LA
• Indianapolis, IN • Denver, CO
• Minneapolis, MN • Halifax, Novia Scotia
• Richmond, VA • Plano, TX
• Tallahassee, FL • Baltimore, MD
• Newark, NJ
84 Healthy Skin
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DID YOU
KNOW?
Medline has donated over half
a million dollars to the National
Breast Cancer Foundation (NCBF)
since 2005.
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A
What our readers said:
It means unity, joy, excitement, a cause
“on the go” for all involved.
Shannon Sessoms, RN, BSN, CNOR
Southeast Missouri Hospital
Cape Girardeau, MO
Q
Christina Zoltowski, RN
Greenville Memorial Hospital
Greenville, NC
90 Healthy Skin
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It makes me smile.
Debra Ann Caise, RN, BSN
Provena St. Mary’s Hospital
St. Anne, IL
Healthy Eating
Nutrition
Information
Servings: 6
Calories: 749
Fat: 19.5 g
Sodium: 1427 mg
1 lb. lean ground beef 1 green pepper, chopped 1 15-ounce can kidney beans
1 lb. lean ground turkey 4 teaspoons minced garlic 1 15-ounce can spicy chili beans
4 teaspoons chili powder 1 16-ounce can tomato sauce 1 bottle beer
1 teaspoon ground cumin 1 16-ounce can diced tomatoes 1 teaspoon black pepper (or to taste)
1 large onion, chopped 1 15-ounce can chili with beans Hot sauce to taste
2 jalapeno peppers, chopped 1 6-ounce can tomato paste
Add kidney beans, chili beans, 3 teaspoons chili powder, pepper “It’s a healthier chili recipe, made with lean meat,” she said. You’ll
and hot sauce and simmer at least 30 minutes. also notice that the onions and peppers are sautéed with cooking
spray rather than oil.
“I find the longer it simmers, the better the
taste, so after the last round of ingredients Jennifer has always enjoyed cooking, having learned by watching
are added, I let it simmer on low for 6 to 8 her mother from the age of six. Her favorite meals include
hours,” Jennifer said. seafood with lots of butter and garlic.
Senior Product Specialist Jennifer In addition to cooking, Jennifer, who lives on Illinois’ Chain
Sutschek, who has worked Medline’s O’Lakes with her husband and two children, enjoys water
corporate headquarters in Mundelein, Ill. sports, such as boating, and in the winter months, she
since 1998, won second place for this enjoys snowmobiling and skiing.
92 Healthy Skin
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Hand Hygiene
WHO Glove Pyramid……………………………………….94
WHO Exam Glove Technique……………………………..95
CDC Clean Hands Poster………………………………… 96
CDC Clean Hands Poster – Spanish……………………. 97
Incontinence
Urinary Incontinence Assessment
and Implementation………………………………………. .99
Pressure Ulcers
How Well Do You Know Pressure Points?..................... 101
STERILE
GLOVES
INDICATED
Any surgical procedure;
vaginal delivery; invasive
radiological procedures;
performing vascular access
and procedures (central lines);
preparing total parental nutrition
and chemotherapeutic agents.
EXAMINATION GLOVES
INDICATED IN CLINICAL SITUATIONS
Potential for touching blood, body fluids, secretions,
excretions and items visibly soiled by body fluids.
DIRECT PATIENT EXPOSURE: Contact with blood; contact with
mucous membrane and with non-intact skin; potential presence of
highly infectious and dangerous organism; epidemic or emergency
situations; IV insertion and removal; drawing blood; discontinuation
of venous line; pelvic and vaginal examination; suctioning non-closed
systems of endotrcheal tubes.
INDIRECT PATIENT EXPOSURE: Emptying emesis basins; handling/cleaning
instruments; handling waste; cleaning up spills of body fluids.
All reasonable precautions have been taken by the World Health Organization to verify the information contained in this document. However, the published
material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with
the reader. In no event shall the World Health Organization be liable for damages arising from its use.
94 Healthy Skin
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Influenza
jbk_HealthySkin17.3-mag_Layout 1 2/14/11 10:36 AM Page 96
RSV
Hand Hygiene Poster
Klebsiella Pseudomonas
Enterococcus
Alcohol-rub or wash
before and after EVERY contact.
www.cdc.gov/handhygiene
LAS MANOS LIMPIAS SALVAN VIDAS
Departamento de Salud y Servicios Humanos
CENTERS FOR DISEASE CONTROL AND PREVENTION
Proteja a los pacientes, protéjase usted
Gripe
Estafilococo
jbk_HealthySkin17.3-mag_Layout 1 2/14/11 10:37 AM Page 97
Candida
VSR
Klebsiella Pseudomonas
Hand Hygiene Poster - Spanish
Enterococo
Lávese o frótese con alcohol
antes y después de CADA contacto.
www.cdc.gov/handhygiene
www.cdc.gov/handhygiene
Forms & Tools
BioCon™- 500
Bladder Scanner
Safely Measures
Bladder Volume
Minimize unnecessary catheterization
Research has shown that 80 percent of urinary tract
infections acquired at healthcare facilities are associated
with an indwelling urethral catheter.1 This type of infection
is known as CAUTI, or catheter-associated urinary
tract infection.
2. Determine Resident’s Voiding Pattern See Tab 3 (Survey Readiness Resource Book)
Every resident should have a completed voiding diary upon admission and with significant changes in condition.
Voiding diary scheduled (date) ________________________ Date completed _______________________ Initials__________
Did the resident have a pattern? _______ For pattern, see voiding diary.
3. Evaluate for Behavioral Program See Tab 4 (Survey Readiness Resource Book)
What is the MDS coding for item B0800 (Ability to understand others)?
If 0, 1 If 2, 3
Consider MDS coding on G0110, 1-I Scheduled Voiding
(self performance/toileting)
Residents with the following conditions could still benefit from
participating in a prompted or scheduled voiding program:
If 0, 1, 2 If 3, 4 • Those who cannot feel “urge” to urinate
• Agitated or disoriented residents
Bladder Rehabilitation or Prompted Voiding
• Bedridden residents or those with mobility limitations
Pelvic Floor Rehab
4. Determine Appropriate Absorbent Product See Tab 5 (Survey Readiness Resource Book)
Minimum Data Set (MDS) Version 3.0 — Section H 0300 & 0400, Bladder and Bowel
0 1 2 3
Always Continent Occasionally Incontinent Frequently Incontinent Always Incontinent
H0300 & H0400 Bladder—less than 7 episodes Bladder—7+ episodes, at least Bladder—No episodes of
of incontinence 1 episode of continence continent voiding
Bowel—1 episode of Bowel—2+ episodes, at least Bowel—No episodes of
incontinence 1 continent bowel movement continent voiding
Ambulatory
Liner Heavy Liner
Weight-bearing Bladder Control Pad:
(females without bowel
incontinence episodes)
Liner
Nonambulatory Adult Brief
Protective Underwear
Contracted Heavy/Overnight Brief
Chronic diarrhea Adult Brief Ultrasorbs Dry Pad
Combative Ultrasorbs Dry Pad (on a low air loss mattress) (on a low air loss mattress)
5. Determine Sizing of Absorbent Product See Tab 6 (Survey Readiness Resource Book)
Determine and document the size by selecting the larger of the hip or waist measurement,
or use sizing matrix reference based on gender/weight.
Gender: M F Weight ___________________
MOLICARE BRIEF WITH STRETCH BACKING
Hip measurement ________ Waist measurement ________
Small: Blue backing 20" – 34"
ADULT BRIEF Medium/Large: White backing 27" – 47"
Small: Green backing 20" – 31" Large/X-Large: Blue backing 39" – 59"
Regular: Purple backing 40" – 50" KNIT PANTS FOR TWO-PIECE SYSTEMS
Large: Blue backing 48" – 58" Med/Large: Blue/Brown thread at waist 20" – 60"
X-Large: Beige backing 59" – 66" X-Large: Green thread at waist 45" – 70"
XX-Large: Green backing 60" – 69" XX-Large: Purple thread at waist 50" – 75"
Bariatric: Beige or Green backing 65" – 94" XXX-Large: Red thread at waist 65" – 85"
1. _____________________ 19
2. _____________________
3. _____________________
14 20
4. _____________________
5. _____________________
6. _____________________
7. _____________________
8. _____________________
9. _____________________
10. _____________________ 15
11. _____________________
12. _____________________
13. _____________________
14. _____________________
15. _____________________ Answer key to
16 quiz on page 103
16. _____________________
17. _____________________
18. _____________________
19. _____________________
20. _____________________
17 18
1. Schultz GS, Mast BA. Molecular analysis of the environ- ©2011 Medline Industries, Inc.
ment of healing and chronic wounds: Cytokines, proteases, Puracol is a registered trademark of Medline Industries, Inc.
and growth factors. Wounds. 1998;10 (6 Suppl): 1F-9F. Medline is a registered trademark of Medline Industries, Inc.
2. Data on file.
JBK_CVR1_Layout 1 2/14/11 9:11 AM Page 2
1. Lateral malleolus
2. Lateral aspect of foot
3. Lateral aspect of knee
4. Greater trochanter
5. Ribs
6. Shoulder
7. Ear
8. Occiput
PERIOPERATIVE PRESSURE
9. Ear
ULCER EDUCATION.
10. Elbow
11. Dorsal thoracic area
MORE IMPORTANT
THAN EVER BEFORE
12. Sacrum/Coccyx
13. Heel
Content Key
We’ve coded the articles and information in this magazine to indicate which national quality initiatives To learn more about Medline’s Pressure
they pertain to. Throughout the publication, when you see these icons you’ll know immediately that Ulcer Prevention Programs for long-term
the subject matter on that page relates to one or more of the following national initiatives: care, acute care and perioperative
• QIO – Utilization and Quality Control Peer Review Organization services, call your Medline representative
• Advancing Excellence in America’s Nursing Homes or visit www.medline.com/pupp-webinar.
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. ©2011 Medline Industries, Inc.
Medline is a registered trademark of Medline Industries, Inc.
VOLUME 9, ISSUE 1
Improving Quality of Care Based on CMS Guidelines
Volume 9, Issue 1
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Principles
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