New Techniques for Pressure Ulcer Prevention, Hand Hygiene and CAUTI Prevention
VOLUME 8, ISSUE 1
Improving Quality of Care Based on CMS Guidelines
PRESSURE ULCER PREVENTION IN LONG-TERM CARE
Volume 8, Issue 1
Learn more about continuous quality improvement for the prevention of avoidable pressure ulcers and F-Tag 314 citations, factors leading to pressure ulcers in long-term care facilities and comprehensive pressure ulcer prevention strategies and solutions. MARCH
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No More Skin Tears
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Sign up at www.medline.com/PUPP-webinar
HAND HYGIENE COMPLIANCE IMPROVEMENT STRATEGIES
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As the number one defense against healthcare-acquired conditions, hand hygiene plays an important role in the prevention of infections. Learn how hospitals and healthcare facilities are combining best-in-class products and education to achieve hand hygiene compliance while dramatically improving the skin condition of healthcare workers.
Exclusive: Diane Krasner on Skin Care At Life’s End
Sign up at www.medline.com/handhygiene
INNOVATION IN THE PREVENTION OF CAUTI Join your colleagues from around the country to learn more about strategies to prevent catheter-acquired urinary tract infections as well as Medline’s ERASE CAUTI system. MARCH
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Sign up at www.medline.com/erase/webinar.asp Hosted by Connie Yuska, RN, MS, CORLN and Lorri Downs, RN, BSN, MS, CIC
Let Us Hear From You!
Free CE! Skin Assessment & OASIS-C
HEALTHY SKIN Join the team!
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When it comes to hot topics in long-term care, you’re the experts! You, our readers, are on the front lines of everything that happens in the healthcare industry – and we want to hear from you! Have you ever wished you could write an article that would be published in a large-circulation magazine? Nowʼs your chance. Healthy Skin is looking
for writers and contributors. Whether youʼd like to try your hand at writing or offer suggestions for future articles, we want to hear what you have to say! You never know – the next time you open an issue of Healthy Skin, it might be to read your own article!
Contact us at [email protected]
to learn more!
Content Key Weʼve coded the articles and information in this magazine to indicate which national quality initiatives they pertain to. Throughout the publication, when you see these icons youʼll know immediately that the subject matter on that page relates to one or more of the following national initiatives: • QIO – Utilization and Quality Control Peer Review Organization • Advancing Excellence in Americaʼs Nursing Homes
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Weʼve 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 10 and 11.
©2010 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 Sue MacInnes, RD, LD Clinical Editor Margaret Falconio-West, BSN, RN, APN/CNS, CWOCN, DAPWCA Managing Editor Alecia Cooper, RN, BS, MBA, CNOR Senior Writer Carla Esser Lake Creative Director Mike Gotti Clinical Team Clay Collins, BSN, RN, CWOCN, CFCN, CWS, DAPWCA Lorri Downs, BSN, RN, MS, CIC
38 Survey Smarts: An Interview with Dr. Andy Kramer 44 Lessons Learned: One Nursing Homeʼs Winning Quality Assurance Strategies 51 Focus on Infection Control: Understanding the New F-Tag 441 Requirements 54 Ten Tips for Cleaning and Disinfecting Shared Medical Equipment 55 Product Spotlight: Dispatch Cleaning Solution for Use on Glucose Meters Prevention
13 17 56 59 65
Cynthia Fleck, BSN,MBA, RN, CWS, DNC, CFCN, DAPWCA, FCCWS Joyce Norman, BSN, RN, CWOCN, DAPWCA
Do the Math: Nutrient-Based Skin Care = Fewer Skin Tears No More Skin Tears Put Bacteria in its Place Changing the Catheter Culture at Your Facility Performance Under Pressure: The Legal Side of Pressure Ulcer Prevention
23 Skin Changes At Lifeʼs End (SCALE)
Kim Kehoe, BSN, RN, CWOCN, DAPWCA Elizabeth OʼConnell-Gifford, BSN, MBA, RN, CWOCN, DAPWCA Jackie Todd, RN, CWCN, DAPWCA Connie Yuska, RN, MS, CORLN Wound Care Advisory Board Mary Brennan, MBA, RN, CWON Zemira M. Cerny, BS, RN, CWS
7 Medline Healthcare Survey: Letʼs Talk About You! 14 Medline Donates Critical Medical Supplies to Haiti 29 Unraveling the Pressure Ulcer and Wound Care Sections of OASIS-C 64 Safe Handling of Residents: Which Technique Would You Use? 76 Medlineʼs Pink Glove Dance: A YouTube Sensation
Patricia Coutts, RN
Cindy Felty, MSN, RN, CNP, CWS Evonne Fowler, MSN, RN, CNS, CWOCN
10 Two Important Initiatives for Improving Quality of Care
Lynne Grant, MS, RN, CWOCN Diane Krasner, PhD, RN, CWCN, CWS, BCLNC, FAAN Dea J. Kent, MSN, RN, NP-C, CWOCN
Caring for Yourself
70 Nine Habits of Very Happy People 83 Recipe: Cheesy Potatoes
Andrea McIntosh, BSN, RN, APN, CWOCN
Forms & Tools
Linda Neiswender, BSN, RN, CPN Laurie Sparks, BSN, RN,CWOCN Lynne Whitney-Caglia, MSN, RN, CNS, CWOCN Laurel Wiersema-Bryant, RN, ANP, BC Linda Woodward, BSN, RN, OCN, CWOCN Deborah Zaricor, RN, CWOCN
86 89 91 93 95 101
OASIS-C: Integumentary Status H1N1 (Swine Flu) - Patient Handout (English) H1N1 (Swine Flu) - Patient Handout (Spanish) Clinical Fact Sheet: Quick Assessment of Leg Ulcers Infection Prevention and Control: Long-Term Care Audit Bariatric Assessment: Home Care/Long-Term Care Facility
About Medline Medline, headquartered in Mundelein, IL, manufactures and distributes more than 100,000 products to hospitals, extended care facilities, surgery centers, home care dealers and agencies and other markets. Medline has more than 800 dedicated sales representatives nationwide to support its broad product line and cost management services.
Meeting the highest level of national and international quality standards, Medline is FDA QSR compliant and ISO 13485 certified. Medline serves on major industry quality committees to develop guidelines and standards for medical product use including the FDA Midwest Steering Committee, AAMI Sterilization and Packaging Committee and various ASTM committees. For more information on Medline, visit our Web site, www.medline.com.
©2010 Medline Industries, Inc. Healthy Skin is published by Medline Industries, Inc. One Medline Place, Mundelein, IL 60060. 1-800-MEDLINE.
Improving Quality of Care Based on CMS Guidelines 3
Letter from the Editor
Dear Reader, Last week was one to remember! There were several peer-reviewed articles recently published, showing compelling evidence on the clinical efficacy of Medline’s Remedy® skin care line. I get so excited because there is nothing that makes a company like ours prouder than to see our products perform with excellence. Anyway, we thought it would be really neat to have the industry experts speak about these studies, film them doing so, and make the information available to all of you. As I was working out the logistics, it occurred to me that if we were going to film these presentations, why not do it in front of a live audience! So, instead of simple individual filming, we ended up orchestrating three conferences. I called it the “Trifecta.” Three meetings, over 200 attendees in a 48-hour period – now that’s a challenge. But it worked, and I got to hear firsthand from our customers some excellent information on improving outcomes as they relate to skin tears, and improving the skin condition of your hands to promote better hand hygiene. Our cover shot for this issue shows Diane Krasner sharing secrets on reducing and treating skin tears with a group of long-term care professionals. I had NO idea the number of skin tears industry wide each year is over 1.5 million. The next meeting was with Dr. Marty Visscher from Cincinnati Children’s Hospital. Her study was published in the January 2010 issue of AJIC. She presented to a group of infection preventionists about improving hand hygiene. The next day we had a half-day meeting with nursing leaders of hospitals and WOCNs. What a great combination. There were even four area CNOs who spoke on a panel discussion on barriers they encounter in
On the cover Wound care expert Diane Krasner presented on skin tears to an audience of long-term care professionals during Medline’s Trifecta of meetings. See also page 23 for an interview with Dr. Krasner about her experiences as co-chair of the SCALE Panel.
preventing pressure ulcers in their facilities. All of these presentations are now available for everyone to watch on Medline University at www.medlineuniversity.com. Now, that brings me to another fun activity that we do at many of our meetings, and that is a pre-survey. For each conference, we put together a series of questions and then report the group response at the meeting. I am always fascinated with the results. So, what do you say we try a national survey from you, our Healthy Skin readers? On page 7, we’ve included a list of questions about your workplace. You can take the survey online or you can mail or fax it in. For each survey we receive, we will send you a FREE Medline doll. In addition, we’ve posed a question to find out more about the exceptional work you are doing. Submit your answer to the question and receive the entire Medline doll series. The first place answer will also receive a plaque acknowledging their efforts. I can’t wait to see your responses and report back to you in the next edition of Healthy Skin. Based upon your responses, we are going to focus that edition on addressing some of your issues and finding practical solutions we all can share. Thank you in advance for your participation!
Sue MacInnes, RD, LD Editor
I had no idea the number of skin tears industry wide each year is over 1.5 million
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We’re confident you’ll find TenderWet Active more effective than wet gauze therapy because TenderWet Active can be left in place for up to 24 hours without drying out while simultaneously removing harmful microorganisms and stubborn necrotic tissue.
©2010 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.
Let’s Talk About
All winne and submis rs will be featu sions upcoming is red in sues of
Healthy Skin !
Step 1: Complete the Survey! The first 1000 survey submissions will receive the latest and greatest addition to our Medline Doll collection. The doll is Top Secret and will debut in April. Results of the survey will be published in the next issue of Healthy Skin!
Step 2: Answer the Bonus Question! In 50 words or less, describe an innovative program, initiative and/or solution implemented at your facility or your organization that made a significant impact on quality and patient/resident care.
First Prize The entire Medline Doll collection A plaque awarding the 2010 Contribution to Healthy Skin!
Second Prize There will be several second place award winners, who will all receive the entire Medline Doll collection.
Everyone can be a winner! You can submit the survey three ways: 1. Complete the survey online at www.medline.com/healthyskinsurvey 2. Manually complete the survey, tear it out and fax it to 847-949-3073. 3. Mail it back to us at Medline Industries, Inc., One Medline Place, Mundelein, IL 60060 Attn: Marketing Department – Healthy Skin
MEDLINE HEALTHCARE SURVEY Let’s talk about you! Special Feature
1. Tell us about yourself
5. What are your top three priorities?
Credentials (i.e., RN, LPN, etc.)______________
❏ < 5%
❏ More than 25%
❏ 6% - 10%
❏ Does not apply
Facility ______________________________ Street Address ________________________ City/Town ____________________________ State/Providence ______________________ Zip/Postal Code ________________________ Phone (
❏ 11% - 25% 6. Which of the following is most helpful in improving patient care?
11. Do you see skin tears as a problem in
❏ Continuing Education ❏ Competency
your facility? ❏ Yes
7. How often do you believe education
12. Do you have a facility protocol for
is transferred by the clinician to
bedside practice? 2. Where do you work?
10. What is the CNA turnover rate at
❏ 0% – 20%
❏ 61% – 80%
❏ Nursing Home
❏ 21% – 40%
❏ 81% – 100%
❏ 41% – 60%
❏ Long-Term Care
13. What percentage of the time do you feel the facility protocol is followed?
❏ Long-Term Acute Care
8. Which staff member are you most
❏ Home Health Care
concerned about when it comes to
implementing the necessary changes
❏ Other (please specify)
at your facility to be successful?
3. Number of beds at your facility? ❏ < 100
❏ 101-199 ❏ 500+
14. Average number of skin tears at
❏ Managers ❏ Physicians ❏ Other (please specify)
❏ 200-349 4. What is your job title? ❏ Director of Nursing (DON) ❏ Staff Nurse ❏ Staff LPN ❏ Nurse Manager ❏ Aide/Technician ❏ Treatment Nurse ❏ Wound Care Nurse ❏ Clinical Educator ❏ Risk/Quality Manager ❏ Restorative Nurse
15. How much time do you spend on skin tears during new employee orientation?
9. What medium would you like to see education materials offered in? (Choose all that apply)
16. Do you currently use treatment
❏ Online (e-Learning)
protocols or algorithms to treat wounds
after they have been diagnosed?
❏ Audio ❏ Video/CD/DVD
❏ Live Presentation ❏ Webinar ❏ Other (please specify)
Continued on page 8
❏ Other (please specify)
Improving Quality of Care Based on CMS Guidelines 7
MEDLINE HEALTHCARE SURVEY Let’s talk about you! 17. What is your pressure ulcer incidence?
Bonus Question: (For a chance to win the entire Medline Doll Collection) Everyone whose answer is chosen for publication in Healthy Skin will receive the collection.
18. What are your biggest barriers to pressure ulcer prevention?
In 50 words or less, describe an innovative program, initiative and/or solution implemented at your facility or your organization that made a significant impact on quality and patient/resident care.
19. Has your organization ever been involved in a legal suit involving pressure ulcers? ❏ Yes
20. Have you personally ever been involved in a legal suit involving pressure ulcers? ❏ Yes
21. Which of the following technologies do you have? (Check all that apply) ❏ PDA (Blackberry®, Palm®, iPhone®) ❏ Cell phone ❏ iPod®/mp3 ❏ DVD player ❏ CD player ❏ Electronic reading device (Kindle®, Sony®, iPad®) ❏ Computer 22. If you checked PDA, what type do you have? ❏ iPhone®
Fax or mail completed survey to:
❏ Blackberry® ❏ Palm® ❏ Droid™ ❏ Other
Blackberry is a registered trademark of Research In Motion Limited Palm is a registered trademark of Research In Motion Limited iPhone is a registered trademark of Apple Inc. iPod is a registered trademark of Apple Inc. Kindle is a registered trademark of Amazon Technologies, Inc. Sony is a registered trademark of Sony Corporation Droid is a trademark of Lucasfilm Ltd.
Marketing Department – Healthy Skin magazine Medline Industries, Inc.
One Medline Place Mundelein, IL 60060 Fax (847) 949-3073
ALL NEW AND UPGRADED CONTENT. WWW. MEDLINEUNIVERSITY.COM Easier navigation to find what you need – faster. Interactive courses and competencies Continuing education courses are still available, and now you can earn all credits for FREE! In addition, we are adding online competencies. Courses and competencies are more interactive with more graphics, sound and animation to make learning more fun.
And for facilities participating in the Pressure Ulcer Prevention and Hand Hygiene programs, all materials, pre- and post-tests are now conveniently located online at www.medlineuniversity.com. Log on to www.medlineuniversity.com today and start earning CE credits —FREE.
Facility-specific features Now each facility has the option of creating a group account on Medline University. This will help you and your facility view and keep track of all completed courses.
©2010 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.
Two Important National Initiatives for Improving Quality of Care Achieving better outcomes starts with an understanding of current quality of care initiatives. Hereʼs what you need to know about national projects and policies that are driving changes in nursing home and home health care.
QIO Utilization and Quality Control Peer Review Organization 9th Round Statement of Work
The QIO Statement of Work is based upon Part B of the Title XI of the Social Security Act. The Medicare-funded “Ninth Scope of Work” plan became effective August 1, 2008 and is a three-year work plan. Purpose: To carry out statutorily mandated review activities, such as: • Reviewing the quality of care provided to beneficiaries; • Reviewing beneficiary appeals of certain provider notices; • Reviewing potential anti-dumping cases; and • Implementing quality improvement activities as a result of case review activities. Goal: In the 9th SOW, the QIO Program has been redesigned with a framework for accountability and also in content. The content now consists of four themes with the goal to help providers, both in long-term care and acute-care facilities, prevent illness, decrease harm to patients and reduce waste in health care. Of note: QIOs will be required to help Medicare promote three overarching themes: adopt value-driven healthcare, support the adoption and use of health information technology and reduce health disparities in their communities. Under the direction of the Centers for Medicare & Medicaid Services (CMS), the QIO Program consists of a national network of 53 QIOs located in each of the 50 U.S. states, the District of Columbia, Puerto Rico and the Virgin Islands. Quality Improvement Organization Program’s 9th Scope of Work Theme The official Executive Summaries for the 9th SOW Theme are available at: http://providers.ipro.org/index/9SOW_summaries
Advancing Excellence in America’s Nursing Homes
A coalition-based, two-year campaign initiated on September 26, 2006 to improve quality of life for nursing home residents and staff. The coalition has continued the campaign beyond its first-round end of August 25, 2008 for an additional 2 years (until September 26, 2010). Purpose: A coalition consisting of the Centers for Medicare & Medicaid Services (CMS), organizations representing providers, consumers and government that developed a grassroots campaign to build on and complement the work of existing quality initiatives including Nursing Home Quality Initiative (NHQI), Quality First and the culture change movement. Goal: To ensure that continuous quality improvement is comprehensive, sustainable and consumer-focused, the coalition has adopted goals that seek to improve clinical care, incorporate nursing home resident and family satisfaction surveys into continuing quality improvements and increase staff retention to allow for better, more consistent care for nursing home residents. Participating providers will commit to focusing on at least three of the eight measurable goals, including at least one clinical goal and one operational process goal. Current participants may choose to continue with the same goals, add additional goals or change goals for the next two-year campaign. Advancing Excellence The coalition is meeting to consider the following additions for the next two-year campaign: 1. Improving immunizations as a clinical goal 2. Including target setting in all goals 3. Changes to the order in which the goals are presented
10 Healthy Skin
The 9th Scope of Work Content Themes Theme #1: Beneficiary Protection Activities will focus on nine Tasks: 1. Case reviews 2. Quality improvement activities (QIAs) 3. Alternative dispute resolution (ADR) 4. Sanction activities 5. Physician acknowledgement monitoring 6. Collaboration with other CMS contractors 7. Promoting transparency through reporting 8. Quality data reporting 9. Communication (education and information) Theme #2: Patient Pathways/Care Transitions Activities will focus on three Tasks: 1. Community and provider selection and recruitment 2. Interventions 3. Monitoring Theme #3: Patient Safety Activities will focus on six primary Topics: 1. Reducing rates of health care-associated methicillin-resistant Staphylococcus aureus (MRSA) infections 2. Reducing rates of pressure ulcers in nursing homes and hospitals 3. Reducing rates of physical restraints in nursing homes 4. Improving inpatient surgical safety and heart failure treatment in hospitals 5. Improving drug safety 6. Providing quality improvement technical assistance to nursing homes in need
Theme #4: Prevention Activities will focus on nine Tasks: 1. Recruiting participating practices 2. Identifying the pool of non-participating practices 3. Promoting care management processes for preventive services using EHRs 4. Completing assessments of care processes 5. Assisting with data submissions 6. Monitoring statewide rates (mammograms, CRC screens, influenza and pneumococcal immunizations) 7. Administering an assessment of care practices 8. Producing an Annual Report of statewide trends, showing baseline and rates 9. Submitting plans to optimize performance at 18 months There will be two periods of evaluation under the 9th SOW. The first evaluation will focus on the QIO's work in three Theme areas (Care Transitions, Patient Safety and Prevention) and will occur at the end of 18 months. The second evaluation will examine the QIO's performance on Tasks within all Theme areas (Beneficiary Protection, Care Transitions, Patient Safety and Prevention). The second evaluation will take place at the end of the 28th month of the contract term and will be based on the most recent data available to CMS. The performance results of the evaluation at both time periods will be used to determine the performance on the overall contract. Focus for the 9th Scope of Work – Move away from projects that are “siloed” in specific care settings – Focused activities for providers most in need – New emphasis on senior leadership (CEOs, BODs) involvement in facility quality improvement programs
Clinical and Operational/Process Goals Clinical Goals: Goal 1: Reducing high-risk pressure ulcers Goal 2: Reducing the use of daily physical restraints Goal 3: Improving pain management for longer-term nursing home residents Goal 4: Improving pain management for short-stay, post-acute nursing home residents
Goal < 10% < 5%
Actual 11% 3%
Operational/Process Goals: Goal 5: Establishing individual targets for improving quality Goal 6: Assessing resident and family satisfaction with quality of care Goal 7: Increasing staff retention Goal 8: Improving consistent assignment of nursing home staff so that residents receive care from the same caregivers
Goal > 90%
Actual 36.5% 22.5% 13.9% 26.6%
Trends in Goal Selection Each nursing home participating in Advancing Excellence selects a minimum of three goals (outlined above). The goals – and the percentage of participating nursing homes that have selected them – are listed below.
Goal 1: 70.9%
Goal 5: 32.1%
Goal 2: 45.3%
Goal 6: 62.8%
Goal 3: 54.2%
Goal 7: 41.2%
Goal 4: 39.6%
Goal 8: 31.3%
Participating nursing homes: 7,481 Percentage of participating nursing homes:* 47.6% Participating consumers: 2,233 Average number of goals per nursing home: 3.8
Visit this Web site to view progress by state! www.nhqualitycampaign.org/star_index.aspx?controls=states_map *Based on the latest available count of Medicare/Medicaid nursing homes
Improving Quality of Care Based on CMS Guidelines 11
Happenings on the Hill
Labor HHS-Education Appropriations Bill Allocates Funds for Health Care
Nursing home and medical facilities inspections $347 million ($54 million above 2009) This funding has been allocated within the Centers for Medicare and Medicaid Services (CMS) for enhanced state inspections in nursing homes and other medical facilities where healthcare-associated infections are rising. The funds will give inspectors greater opportunities to identify infection control problems. CMS is also urged to include additional infection control measures in its hospital performance reporting system, Hospital Compare, and its “pay for performance” and “pay for reporting” systems. Healthcare-associated infections (HAIs) $190 million ($28 million above 2009) This funding will help continue an aggressive campaign to dramatically reduce life-threatening infections patients acquire while receiving treatment for medical or surgical conditions. HAIs are among the top 10 leading causes of death in the United States, accounting for nearly 100,000 deaths, 1.7 million infections and $30 billion in excess healthcare costs every year. Nurse training $244 million ($73 million above 2009) The substantial increase in funding for nurse training is essential because the United Sates is in the midst of a nursing shortage that is expected to intensify as baby boomers age and the need for health care grows. The Health Resources and Services Administration (HRSA) estimates that the nation’s nursing shortage will grow to more than one million nurses by the year 2020. Source: Memo – United States Congress Committees on Appropriations, December 8, 2009. Available at: http://appropriations.house.gov/pdf/FY10_LHHS_Conference_Summary.pdf. Accessed January 25, 2010.
12 Healthy Skin
Do the Math Nutrient-Based Skin Care = Fewer Skin Tears A skin care regimen using a phospholipid-based cleanser and a dimethicone/nutrient-based moisturizing cream resulted in skin tear likelihood that was 30 times less than in a similar group using a surfactant-based cleanser and dimethicone/aloe moisturizing cream. Just released in the January/February 2010 issue of the Journal of Wound Ostomy and Continence Nursing, researchers recommend nutrient-based skin care (NBSC) as one part of a comprehensive skin tear prevention program, along with other preventive interventions such as staff education, proper positioning, protective clothing, turning, lifting and transferring techniques. The six-month study at a 108-bed convalescent center in southern Illinois compared outcomes after randomly assigning one half of a resident population (n = 100) to a group using Remedy® cleanser, moisturizer and skin protectant products (all NBSC products). The second group (n = 100) was cared for with a surfactant-based cleanser and dimethicone/aloe moisturizer and a zinc oxide barrier product when indicated.
Incidence of Skin Tears A group of 100 residents experienced a total of 180 skin tears during the initial six-month period when non-NBSC products were used compared to 1.6 skin tears per resident over six months when a NBSC was used. The number of expected skintear-free days when skin care was completed using NBSC was 179.7 days as compared to 154.8 days when non-NBSC products were used, yielding an incremental effect of 24.9 days.
Cost Implications In addition to a 250 percent greater likelihood of maintaining intact skin when the NBSC products were used, the researchers considered cost of treatment.
The expected cost to treat a skin tear in the NBSC group was $287.70 per resident versus $331.80 per resident in the non-NBSC group. The cost per skin-tear-free day was $1.60 per resident for treatment with NBSC and $2.14 per resident for treatment with non-NBSC products. NBSC was found to be significantly less costly and more effective than a reginmen using non-NBSC products. A limited number of reprints of the full study are available from your Medline representative or by calling 1-800-Medline. The Remedy® Advanced Skin Care Line is available through Medline Industries, Inc. For additional information, visit www.medline.com/skincare.
Remedy is a registered trademark of Medline Industries, Inc. Source: Groom M, Shannon RJ, Chakravarthy D, Fleck CA. An evaluation of costs and effects of a nutrient-based skin care program as a component of prevention of skin tears in an extended convalescent center. Journal of Wound, Ostomy and Continence Nursing. 2010; 37(1):46–51.
Improving Quality of Care Based on CMS Guidelines 13
Medline Donates Critical Medical Supplies to
Medline Industries, Inc. has donated more than $250,000 in initial humanitarian aid to the people of Haiti in response to the devastating earthquake that struck the country recently. The aid includes medical and surgical supplies, as well as logistics resources and support to both U.S.-based hospital systems and international aid organizations that are providing medical supplies, doctors and other resources to the people in Haiti.
We are deeply saddened by the devastation from the earthquake and the millions of victims left in its wake,” said Bill Abington, President of Operations for Medline. “As we have done in past disasters when people are in need, we immediately initiated our Disaster Response Plan that mobilized our distribution and logistics network around the country to prepare and stage medical and surgical supplies that are needed in this type of disaster to assist with the heroic efforts taking place in Haiti.
Abington said the supplies were immediately delivered to aircraft and ships being utilized by Medline’s key healthcare partners and global relief organizations. Throughout the coming months Medline will continue providing support to organizations aiding Haiti.
Major Infectious Complications of Haitian Earthquake
Wound infections Diarrheal illness - Cholera, shigella, Salmonella Mosquito borne infections - Malaria, dengue fever Preventable illness eradication disruption - Lymphatic filariasis, parasites, tuberculosis Interruption in chronic medication treatments - HIV/AIDS
14 Healthy Skin
How you can help In order to ensure that relief efforts are conducted in the most effective and efficient manner, individuals interested in volunteering or donating to help the people of Haiti are advised to get in touch with a relief organization. The following is a list of resources. American Medical Association http://www.ama-assn.org/ama/pub/news/news/haitiearthquake-response/help.shtml American Red Cross www.redcross.org Center for International Disaster Information (CIDI) www.cidi.org/incident/haiti-10a/ Department of Health and Human Services http://www.hhs.gov/haiti/ Medscape Nurses http://www.medscape.com/viewarticle/579888 Source: Medscape. Earthquake in Haiti and the Medical Aftermath of Natural Disasters. Available at: www.medscape.com/features/slideshow/haiti-earthquake. Accessed February 4, 2010.
Prevention Above All Discoveries Grants: Supporting the adoption of solutions into everyday clinical practice Knowing that clinicians in the field have some of the best ideas for improving health care, Medline is now accepting applications for research funding through their Prevention Above All Discoveries Grant program. Through the grant program, Medline intends to award up to $1 million in grants for research on innovative ideas and evidence-based practices that will improve patient safety and quality of care. Healthcare providers interested in submitting letters of intent can apply for one of two funding categories: pilot grants of up to $25,000 for projects that can be completed within six months or empirical study grants of up to $100,000 for projects completed within 12 months. Pilot study grantees, if successful, may qualify for future funding through an empirical study grant.
Expert Review Board Recognizing that the grant target groups haven't had much experience in developing research studies, the review board has come up with a creative way to ensure that a rigorous research process is followed. An Expert Review Board (ERB) composed of members who represent a breadth of research and practice knowledge will independently review each request. Applicants whose proposals are selected for funding will then be assigned an ERB member as a mentor to help develop a final proposal that will then receive funding.
Deadline for grant applications is March 31, 2010. For more information on the grant program visit www.medline.com/prevention-above-all/grants.asp and for a sample letter of intent visit www.medline.com/prevention-aboveall/pdf/LofI_Example.pdf. To submit a grant contact Toni Marchinski, grant coordinator, at [email protected]
or call 866-941-1998.
PERIOPERATIVE PRESSURE ULCER EDUCATION. MORE IMPORTANT THAN EVER BEFORE
I have seen an increase in the number of legal issues linking facility-acquired pressure ulcers to post-surgical patients. A pressure ulcer program for the OR is more critical than ever.” Diane Krasner, PhD, RN, CWCN, CWS, BCLNC, FAAN
Medline’s Pressure Ulcer Prevention Program now has a component designed specifically for the perioperative services. The easy-to-use interactive CD addresses the following: • Hospital-acquired conditions • CMS reimbursement changes • Best practices for pressure ulcer prevention • Perioperative assessment tools • Critical patient and equipment risk factors
To learn more about Medline’s Pressure Ulcer Prevention Programs for long-term care, acute care and perioperative services, call your Medline representative or visit www.medline.com/pupp-webinar.
©2010 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.
MEDLINE’S REVOLUTIONARY SHOW-AND-TELL PACKAGING
Each package is a 2-Minute Course in Advanced Wound Care ™
Medline’s Educational Packaging offers all the information you need, step by step, short and sweet, to help the Medline dressing do its job of healing. For more information visit www.medline.com/ep.
©2010 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.
Techniques for Prevention and Treatment
Aging skin, coupled with reliance on others for assistance with activities of daily living, puts the elderly at high risk for skin tears. Firmly gripping delicate elderly skin while offering assistance can lead to tissue trauma and tearing. In fact, an estimated 1.5 million skin tears occur in institutionalized adults each year,1 with nearly 80 percent appearing on the arms and hands.2 Minimizing the occurrence of skin tears begins with an understanding of the skin’s structure and common risk factors, followed by developing a plan of care using the most effective products for prevention and treatment.
Improving Quality of Care Based on CMS Guidelines 17
Structure of the skin Epi der
The basic structure of the skin has a great deal to do with how and why skin tears occur. First, it’s important to know that the skin consists of three layers:
1. The epidermis — outermost layer 2. The dermis — the thicker second layer that contains hair follicles, sweat glands and nerves
ut an eo
us ti s su
3. The subcutaneous tissue — the fatty layer that provides cushioning and protection Between the epidermis and dermis is the basement membrane, a moving junction that both separates and attaches the epidermis and the dermis (also known as the dermalepidermal junction). This junction provides structural support and allows for the exchange of fluid and cells between the skin layers. The epidermis has an irregular shape resembling downward, finger-like projections called rete ridges or pegs, and the dermis has upward projections. These upward and downward projections fit together like puzzle pieces anchoring the epidermis to the dermis. This connection helps to prevent the epidermis from sliding back and forth across the dermis with normal movement and skin manipulation. The two move together as one unit in people with healthy, young skin. As the skin ages – typically by the sixth decade of one’s life – these rete ridges or pegs begin to flatten between that dermal-epidermal junction.3 This diminished anchoring between the two layers increases the potential for the epidermis to detach from the dermis, leading to tearing of the skin, especially in older adults.4
Assessment In the late 1980s Payne and Martin developed the PayneMartin Classification System for Skin Tears, which addresses assessment, prevention and treatment of skin tears. The system, which was revised in 1993, defines a skin tear as “a traumatic wound occurring principally on the extremities of older adults as a result of friction alone or shearing and friction forces that separate the epidermis from the dermis or separate both the epidermis and the dermis from underlying structures.” The Payne-Martin Classification System places skin tears into three categories:5
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Category I: Skin tears without tissue loss Category II: Skin tears with partial tissue loss Category III: Skin tears with complete tissue loss
Risk factors Patients and residents who are completely dependent on others for activities of daily living, such as dressing, bathing and positioning, are at the highest risk for sustaining skin tears.2 Often, these individuals are elderly and may have a history of previous skin tears, compromised nutrition, fluid volume deficit, confusion, limitations in mobility, lack of independence and bruised skin. Certain medications, including steroids, also make skin more prone to injury by causing further thinning as well as suppression of the immune system. In addition, wound healing progresses more slowly in the elderly due to several factors, including decreased inflammatory response, delayed angiogenesis (i.e., formation of new blood vessels), slower epithelialization, decreased function of sebaceous glands, decreased collagen synthesis, alternation in melanocytes (resulting in skin discoloration) and thinning of all the skin layers. Less adipose tissue means decreased insulation and protection. The subcutaneous tissue also atrophies in very specific areas: the face, hands and feet.6 Research has shown that 25 percent of skin tears are caused by wheelchair/geri-chair injuries. Another 25 percent occur from accidents involving bumping into objects, 18 percent involve patient or resident transfers and 12.4 percent are the result of falls.1 These situations increase contact with the skin, thus increasing the potential for the skin to tear.
Residents of a 173-bed, long-term care facility developed fewer skin tears when an emollient soap was used during bathing.
Prevention of skin tears The basics. Common sense strategies, such as clothing residents in long sleeves and long pants, the use of gentle adhesives and staff education on gentle handling of the skin, are all good first steps toward preventing skin tears.7 Use great care while providing full or partial assistance with activities of daily living. These tasks increase contact with the skin, thus increasing the potential for the skin to tear.8 Use of appropriate equipment (i.e., lifts, walkers, transfer and turn aids, etc.) to assist with toileting and transferring also can be helpful in decreasing the chance of developing skin tears. Skin care. Advanced skin care products that deliver endermic nutrition as well as antioxidants can provide for nourished skin topically – even if the patient or resident is not receiving adequate nutrition from oral, enteral or parenteral nutrition.9 One study looked at skin tear incidence in a 100-bed longterm care facility and showed a reduction from 180 skin tears in a six-month period to two skin tears in a six-month time period.10 This particular facility used a gentle, advanced skin care line with pH-balanced soap and surfactant-free cleansers; moisturizers containing amino acids and free radical scavengers like grape seed extract, vitamin C (ascorbic acid), and hydroxytyrosol (from olives); essential fatty acids like omega-3, -6 and -9; and tenacious skin protectants containing sophisticated combinations of silicones. Similarly, in a four-month prospective crossover study comparing the use of emollient soap (containing moisturizers) with non-emollient soap, Mason found that residents of a 173-bed,
long-term care facility developed fewer skin tears when an emollient soap was used during bathing. When comparing the total rate of skin tears per resident, the rate of skin tears when emollient soap was used was 34.8 percent lower than when non-emollient soap was used.8 Plante and Regan conducted a controlled study among 64 residents of a long-term care facility to compare the effects of using a non-detergent, no-rinse cleanser to bathing with soap and water. After 12 weeks, the total number of skin tears decreased by 90 percent, with an 82 percent reduction in skin tears in the treatment group. Annual cost savings for patients in the treatment group was $2,446.11 Skin Tear Prevention Strategies12 • Perform risk assessments to identify at-risk individuals • Use moisturizers/emollients daily • Make sure vulnerable individuals wear long-sleeved shirts, pants and stockings • Use skin sleeves and leg protectors • Maintain individuals’ hydration and nutrition
Treatment of skin tears Despite your best efforts to prevent skin tears, they can still happen. The primary goals for treating skin tears are to stop bleeding, recover skin integrity, prevent infection of the wound, minimize pain and promote comfort.12 There are several good topical products that can help alleviate the discomfort of skin tears while protecting the area to allow healing. It is also important to look at your dressing choices and choose products that allow you to avoid adhesives, decrease dressing changes and maintain an optimally moist wound healing environment.
Improving Quality of Care Based on CMS Guidelines 19
Three Steps for Treating Skin Tears12
1 2 3
Cleanse using normal saline, tap water or wound cleanser
Assess according to the Payne-Martin scale or by classifying wounds as partial thickness or full thickness
Dress the wound using recommended products
Hydrogel sheets. Hydrogel sheets are clear or translucent water- or glycerin-based products that can be used to maintain a moist wound environment.13 They look like a thin slice of sticky gelatin and can handle the initial fluid from a wound for the first 24-48 hours. They vary in thickness and are nonadherent to the wound base. The hydrogel sheet may be held in place with elastic net dressing or a tubular-type dressing. Protective sleeves. The use of protective sleeves or elastic tubular support bandages that come on a roll is a good way to hold dressings in place without irritating sensitive skin with adhesive tape. They also protect the patient or resident who is prone to picking at the dressing. Use caution with adhesive closure strips. Adhesive closure strips are common for keeping skin tears closed while they heal, however, caution is advised. Traction on the fragile epidermis combined with inflammatory action can cause skin damage. When it’s time to remove the closure strips, use extra care, as blood crusts can tear off the epidermis. 14
Outdated Treatments for Skin Tears12 • Transparent films (as primary dressing) • Telfa-type non-adherent dressings • Sutures • Removal of a viable skin flap immediately post-injury
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Conclusion Overall, when it comes to skin tears, keep it simple. Basic strategies, such as a comprehensive skincare program that avoids soap and includes nutrient-based moisturizers, consuming plenty of fluids and a nutritious diet, combined with using extra care to protect patients’ or residents’ skin from injury, will go a long way toward preventing skin tears. When a skin tear does occur, be sure to keep it protected from infection and further injury. Avoid outdated treatments, such as telfa-type non-adherent dressings or removal of a viable skin flap. One very effective treatment is use of a hydrogel sheet kept in place with an elastic net dressing. With these tips and techniques, your facility will be well on its way toward eliminating skin tears all together. References 1. Brillhart B. Preventive skin care for older adults. Geriatrics & Aging. 2006;9(5):334339. 2. Baranoski S. How to prevent and manage skin tears. Advances in Skin & Wound Care. 2003;16(5):268-70. 3. Humbert P, Sainthillier JM, Mac-Mary S. Capillaroscopy and videocapillarsocopy and assessment of skin microcirculation: dermatologic and cosmetic approaches. J Cosmet Dermatol. 2005;4(3):153-162. 4. Baranoski S, Ayello E. Skin: an essential organ. In: Baraoski S, Ayello E, eds. Wound Care Essentials: Practice Principles. Springhouse, Penn.:Lippincott Williams & Wilkins; 2004. 5. Baronoski S. Skin tears: the enemy of frail skin. Advances in Skin & Wound Care. 2000; 13(3 Pt 1):123-126. 6. Thomas-Hess C. Fundamental strategies for skin care. In: Krasner D, Rodheaver G, Sibbald G., eds. Chronic Wound Care: A Clinical Source Book for Healthcare Professionals. 2nd ed. Wayne, Pa: HMP Communications; 1997. 7. Fleck CA. Ethical wound management for the palliative patient. ECPN. 2005;100:3846. 8. Mason SR. Type of soap and the incidence of skin tears among residents of a longterm care facility. Ostomy Wound Management. 1997;43(8):26-30. 9. Groom M. Decreasing the incidence of skin tears in the extended care setting with the use of a new line of advanced skin care products containing Olivamine. Presented at the 18th Annual Symposium on Advanced Wound Care and the 15th Annual Medical Research Forum on Wound Repair in San Diego, Calif. April 21-24, 2005. 10. Frantz RA, Gardner S. Clinical concerns: management of dry skin. J Gerontol Nurs. 1994;20(9):15-18, 45. 11. Birch S & Coggins C. No-rinse, one-step bed bath: the effects on the occurrence of skin tears in a long-term care setting. Ostomy Wound Management. 2003;49(1):64-67. 12. Krasner D. Prevention and Treatment of Skin Tears in Older Adults. Presented at Medline’s Prevention Above All Symposium in Oakbrook, Ill. January 26, 2010. 13. Hess CT. When to use hydrogel dressings. Advances in Skin & Wound Care. 2000;13(1):42. 14. Meuleneire F. Using a soft silicone-coated net dressing to manage skin tears. J Wound Care. 2002;11(10):365-369.
Are Your Physicians Making the Grade? A recent survey graded physicians’ abilities to recognize, assess and document Stage III and IV pressure ulcers at a “D” level. Medline’s new Pressure Ulcer Prevention Program MD Education CD contains everything physicians need to brush up on their skills and comply with the new CMS Inpatient Prospective Payment System (IPPS).
The new MD Education component of Medline’s Pressure Ulcer Prevention Program is critical for acute-care facilities to ensure that physicians understand their role in recognizing and accurately documenting POA pressure ulcers.” Michael Raymond, MD, Associate Chief Medical Quality Officer, NorthShore University HealthSystem, Skokie Hospital, Skokie, IL
To learn more about Medline’s Pressure Ulcer Prevention Programs and FREE webinars for acute care and perioperative services, call your Medline representative, or visit www.medline.com/pupp-webinar.
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1-800-MEDLINE | www.medline.com © 2010 Medline Industries, Inc. Medline® and Marathon are registered trademarks of Medline Industries, Inc.
It’s another level of
Restore®/Remedy® briefs provide maximum dryness with skin nourishment built right in. Restore®/Remedy® briefs not only keep wetness away from your residents’ skin, they also help provide protection from skin irritation with a coating of Medline’s Remedy® Skin Repair Cream on the inner liner. Using a combination of the Remedy skincare line and the Restore/Remedy brief was shown to keep the pressure ulcer incidence rate and incontinence-associated dermatitis prevalence rate down according to a retrospective, cohort study conducted at Meridian Nursing and Rehabilitation in Brick, NJ.1 The brief’s absorbent UltraCare core helps provide maximum dryness for improved comfort and protection. And the cloth-like outer cover is comfortable against the skin, helping to minimize rash or irritation.
Purchase a 12 month supply of Restore/Remedy briefs and receive one month free. For details contact your Medline representative or call 1-800-MEDLINE. 1 Shannon R., Fisher K. A Nursing and Rehabilitation Center Project in New Jersey: Expected Value of Remedy Skin Care and Restore Briefs in an At-Risk Resident Population for Pressure Ulcer and Incontinence-Associated Dermatitis Prevention. ©2010 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.
Wound care expert Dr. Diane Krasner shares her experiences as co-chair of the SCALE Panel and corresponding author of the SCALE Final Consensus Statement.
Skin Changes At Life’s End Healthy Skin Editor Sue MacInnes interviews SCALE Panel Co-Chair Diane Krasner Diane Krasner, PhD, RN, CWCN, CWS, BCLNC, FAAN
Sue MacInnes: What is the SCALE Panel and why was it formed? Diane Krasner: The SCALE Panel was convened to explore the issues surrounding skin conditions associated with dying patients. The panel reviewed existing literature, best practices and research on the issue. Eighteen participants met for the first panel meeting April 4-6, 2008 in Chicago, which was funded by an unrestricted educational grant from Gaymar Industries, Inc. Participants included nurses, physicians, legal experts and a medical writer. All had an interest in or clinical experience with skin conditions in dying patients. Included in the panel were Karen Lou Kennedy, a nurse practitioner who has published on the Kennedy Terminal Ulcer (www.kennedyterminalulcer.com) and Dr. Diane Langemo, who proposed the concept of skin failure. SCALE Panel members represented the continuum of care from acute care to hospice. Dr. Gary Sibbald and I served as panel co-chairs. Cindy Sylvia was the panel facilitator. Jim Lutz served as the medical writer. Dr. Thomas Stewart conceived the acronym SCALE: Skin Changes At Life’s End.
Sue MacInnes, RD, LD
Sue MacInnes: What process did the SCALE Panel use to reach consensus? Diane Krasner: After reviewing the existing literature on the topic and hearing presentations by selected panel members, the SCALE panel worked in three teams, drafting preliminary consensus statements. Jim Lutz used audiotapes and notes from the April 2008 meeting to craft a Preliminary Consensus Statement. This document was reviewed and edited by the entire panel. From September 2008 to June 2009 the Preliminary Consensus Statement was presented internationally at wound conferences, published and posted on the SCALE website. Stakeholders were encouraged to circulate the document for comments. All the comments were used to generate a Final Consensus Statement, which was then returned to the original 18-member expert panel and a 52-member reviewer panel. The two groups of panel members then voted on each of the 10 statements for consensus using a modified Delphi Method approach. A quorum of 80 percent that strongly agreed or
Improving Quality of Care Based on CMS Guidelines 23
10 statements proposed by the SCALE Expert Panel: somewhat agreed with each statement was used as a pre-determined threshold for having achieved consensus on each of the statements. A consensus based on 52 votes was reached after the first round of the Delphi. Numerous comments were made, and a final draft was written to incorporate the comments. The SCALE Final Consensus Statement was released on October 1, 2009. Sue MacInnes: How would you describe the SCALE Final Consensus Statement? Diane Krasner: The SCALE Final Consensus Statement reflects the current evidence and best practices surrounding Skin Changes At Life’s End. The ten statements represent the expert opinions of thought leaders from around the world. There is clear agreement that more research needs to be undertaken to enhance our understanding of the multiple and complex skin change phenomena that occur during the dying process. In the meantime, the 10 consensus statements give practical and focused suggestions for clinical management. In addition to the 10 consensus statements, which are reprinted in this issue of Healthy Skin, the SCALE Final Consensus Statement includes a glossary, a reference list and several charts/enablers for clinical practice. Sue MacInnes: How can the SCALE documents be accessed and utilized? Diane Krasner: Free downloads of the SCALE documents are available at the website of the panel sponsor, Gaymar Industries: www.gaymar.com. Look under “Clinical Support and Education” and “SCALE Consensus Documents.” In addition to the 19-page final consensus statement, there is a three-page guide and the SCALE annotated bibliography. All of these documents can be utilized for education and training. The SCALE documents have relevance across the continuum of care for all members of the interprofessional wound care team. For further information, contact corresponding author Dr. Diane Krasner at [email protected]
Statement 1 ........................................................................ Physiologic changes that occur as a result of the dying process may affect the skin and soft tissues and may manifest as observable (objective) changes in skin color, turgor, or integrity, or as subjective symptoms such as localized pain. These changes can be unavoidable and may occur with the application of appropriate interventions that meet or exceed the standard of care.
Statement 2 ........................................................................ The plan of care and patient response should be clearly documented and reflected in the entire medical record. Charting by exception is an appropriate method of documentation.
Statement 3 ........................................................................ Patient centered concerns should be addressed including pain and activities of daily living.
Statement 4 ........................................................................ Skin changes at life’s end are a reflection of compromised skin (reduced soft tissue perfusion, decreased tolerance to external insults, and impaired removal of metabolic wastes).
Statement 5 ........................................................................ Expectations around the patient’s end of life goals and concerns should be communicated among the members of the interprofessional team and the patient’s circle of care. The discussion should include the potential for SCALE including other skin changes, skin breakdown and pressure ulcers.
Statement 6 ........................................................................ Risk factors, symptoms and signs associated with SCALE have not been fully elucidated, but may include:
■ Weakness and progressive limitation of mobility. ■ Suboptimal nutrition including loss of appetite, weight loss, cachexia and wasting, low serum albumin/pre-albumin, and low hemoglobin as well as dehydration.
■ Diminished tissue perfusion, impaired skin oxygenation, decreased local skin temperature, mottled discoloration, and skin necrosis.
■ Loss of skin integrity from any of a number of factors including equipment or devices, incontinence, chemical irritants, chronic exposure to body fluids, skin tears, pressure, shear, friction, and infections.
■ Impaired immune function. Statement 7 ........................................................................
Dr. Krasner is a Wound & Skin Care Consultant in York, PA. She works part-time at Rest-Haven York, is the lead co-editor of Chronic Wound Care (www.chronicwoundcarebook.com) and clinical editor of Wound Source (www.woundsource.com).
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A total skin assessment should be performed regularly and document all areas of concern consistent with the wishes and condition of the patient. Pay special attention to bony prominences and skin areas with underlying cartilage. Areas of special concern include the sacrum, coccyx, ischial tuberosities, trochanters, scapulae, occiput, heels, digits, nose and ears. Describe the skin or wound abnormality exactly as assessed.
SCALE Final Consensus Statement Determined as a result of a two-day panel discussion and subsequent panel revisions with input from noted wound care experts using a modified Delphi Method approach. Figure 1: The SOAPIE mnemonic with the 5P enabler.
Evaluate & revise care plan as needed
Evaluate & revise care plan as needed
Statement 8........................................................................ Consultation with a qualified health care professional is recommended for any skin changes associated with increased pain, signs of infection, skin breakdown (when the goal may be healing), and whenever the patient’s circle of care expresses a significant concern.
Statement 9........................................................................ The probable skin change etiology and goals of care should be determined. Consider the 5 Ps for determining appropriate intervention strategies:
A = Assess and document etiology: An assessment should then be made of the general condition of the patient and a care plan.
P = Plan of care: A care plan should be developed that includes a decision on skin care considering the 5P’s as outlined in Figure 1. This plan of care should also consider input and wishes from the patient and the patient’s circle of care. I = Implement appropriate plan of care: For successful implementation, the plan of care must be matched with the healthcare system resources (availability of equipment and personnel) along with appropriate education and feedback from the patient’s circle of care and as consistent with the patient’s goals and wishes.
■ Prevention ■ Prescription (may heal with appropriate treatment) ■ Preservation (maintenance without deterioration) ■ Palliation (provide comfort and care) ■ Preference (patient desires)
E = Evaluate and educate all stakeholders: The interprofessional team also
S = Subjective skin & wound assessment: The person at the end of life needs to be assessed by history, including an assessment of the risk for developing a skin change or pressure ulcer (Braden Scale or other valid and reliable risk assessment scale).
O = Objective observation of skin & wound: A physical exam should iden-
needs to facilitate appropriate education, management, and periodic reevaluation of the care plan as the patient’s health status changes.
Statement 10...................................................................... Patients and concerned individuals should be educated regarding SCALE and the plan of care.
tify and document skin changes that may be associated with the end of life or other etiologies including any existing pressure ulcers.
Improving Quality of Care Based on CMS Guidelines 25
Skin Changes At Life’s End Continuing Education Questions 1. Why was the SCALE Panel convened? A. To discuss weight loss issues B. To explore the issues surrounding skin conditions associated with dying patients C. To develop new treatments for dry, scaly skin D. None of the above 2. When was the SCALE Final Consensus Statement released? A. February 1, 1972 B. September 30, 2008 C. May 15, 1997 D. October 1, 2009 3. In addition to the 10 consensus statements, the SCALE Final Consensus Statement includes a glossary, a reference list and _________________. A. A dictionary B. A thesaurus C. Several charts/guides for clinical practice D. Free samples of skin care lotion 4. Which approach was used by the SCALE Panel to reach consensus? A. Modified Delphi Method B. Accelerated Apolo Ohno C. Prediction Partnership D. Phase I Delphi Method 5. The SCALE Final Consensus Statement reflects the current evidence and best practices surrounding _______________________. A. Choosing the best bathroom scale B. Sunny Climates And Lifelong Eczema C. Skin Changes At Life’s End D. Treatment of dry skin in long-term care residents 6. The letter “A” in the SOAPIE mnemonic stands for ___________________. A. Answer all questions B. Assess and document etiology C. Accentuate the positive D. All of the above
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7. The 5P enabler for determining appropriate intervention strategies consists of: A. Prevention, Prescription, Preservation, Palliative, Proactive B. Potential, Prescription, Pattern, Palliative, Preference C. Prevention, Perseverance, Panic, Persuade, Preference D. Prevention, Prescription, Preservation, Palliative, Preference 8. Which of the following might cause loss of skin integrity at the end of life? A. Infections B. Binge eating C. Incontinence D. Both A and C 9. Choose the false statement below. A. Expectations around the patient’s end of life goals and concerns should be kept secret. B. Skin changes at life’s end are a reflection of compromised skin (reduced soft tissue perfusion, decreased tolerance to external insults, and impaired removal of metabolic wastes). C. The plan of care and patient response should be clearly documented and reflected in the entire medical record. D. A total skin assessment should be performed regularly and document all areas of concern consistent with the wishes and condition of the patient. 10. Physiologic changes that occur as a result of the dying process may affect the skin and soft tissues and may manifest as observable (objective) changes in skin color, turgor, or __________________, or as subjective symptoms such as localized pain. A. Sensitivity B. Density C. Texture Submit your answers at D. Integrity www.medlineuniversity.com and receive 1 FREE CE credit
1-800-MEDLINE I www.medline.com ©2010 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.
BRINGING IT HOME TO YOU More than 1 million Americans receive home health care services every year.1 Just as every patient is unique, so is every home health care agency. That’s why Medline HomeCare is proud to offer innovative solutions for every segment of your business, designed to fit your specific needs. We provide: • Supply management • Clinical support • Increased productivity • Back office connectivity • Documented cost savings To learn more about Medline HomeCare, call us at 1-800-678-7852. Reference 1 The Centers for Disease Control and Prevention. Home Health Care Patients: Data from the 2000 National Home and Hospice Care Survey. Available at: www.cdc.gov/nchs/pressroom/04facts/patients.htm. Accessed April 12, 2008.
For your free cost-savings analysis, contact your sales representative or call 1-800-678-7852.
©2010 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.
Unraveling the Pressure Ulcer and Wound Care Sections of OASIS-C by Clay E. Collins, RN, BSN, CWOCN, CFCN, CWS
It’s finally here! The long-awaited OASIS-C data collection tool for home care agencies was implemented January 1, 2010, leaving many home care nurses and agencies scrambling to understand the multitude of additions and revisions. These changes could significantly affect agency reimbursement and publicly reported quality measures while also providing essential guidance for surveyors. With this in mind, home care agencies are faced with the daunting task of re-learning and understanding the new OASIS-C document. This article will help you make sense of the changes in the documentation of pressure ulcers and wound care that appear under the section of OASIS-C called “Integumentary Status.” History and background In 1999 the Centers for Medicare and Medicaid Services (CMS) began requiring all Medicare-certified home care agencies to begin collecting and submitting data related to all adult, non-maternity patients receiving skilled nursing services under Medicare and Medicaid. These requirements were documented in the Outcome and Assessment Information Set (OASIS). Over the years, OASIS has undergone changes to improve data collection requirements, refine items for payment algorithms and enhance outcome reporting.
Improving Quality of Care Based on CMS Guidelines 29
Over the past decade CMS has focused on quality improvement and evidence-based practice recommendations from the Institutes of Medicine (IOM), the National Quality Forum (NQF) and the Medicare Payment Advisory Commission (MedPAC). Beginning in 2004, with the revision of long-term care’s F-Tag 314 regarding pressure ulcers and the release of new guidelines to direct surveyors of long-term care facilities, CMS embarked on a journey to bring the providers of longterm care, acute care and home care into a synergistic relationship focused on improving outcomes and the quality of patient care. Next, as a result of the federal Value Based Purchasing (VBP) Initiative, came the implementation of the presenton-admission (POA) indicators for acute care facilities on October 1, 2008. It includes a list of hospital-acquired conditions, including full thickness pressure ulcers (Stage III and IV), which are no longer reimbursable when they occur during a hospital stay.1 In home care, the focus on quality and evidence-based practice has never been more evident than in the new OASIS-C data collection tool. Development of OASIS-C OASIS-C was developed for three reasons: 1. To address issues raised by home care providers 2. To expand home care quality measurement to include care processes
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3. To align and “harmonize” OASIS measures with other care measurement instruments currently being developed across post-acute care settings (i.e., the nursing home Minimum Data Set [MDS] and the Continuity Assessment Record Evaluation [CARE]). Regarding reason #3, pressure ulcer items on OASIS were revised to reflect current pressure ulcer assessment guidelines from the National Pressure Ulcer Advisory Panel (NPUAP) and the Wound, Ostomy and Continence Nurses Society (WOCN) and to collect additional information considered to be essential to care planning (i.e., wound length, width and depth). Home care agencies also are being encouraged to use evidence-based practices, although the care processes included in OASIS-C are not currently mandated in the Home Health Agency (HHA) Conditions of Participation. Home care agencies may choose not to incorporate the care processes included in OASIS-C, but should be aware that since some of the process items will be utilized to support publicly reported measures, failure to incorporate the care processes may be reflected in their Home Health Compare scores. For example, one measure that will be publicly reported on Home Health Compare is: “Percentage of home health episodes of care in which the patient was assessed for risk of developing pressure ulcers at start of care/resumption of care.” The data for this care process will be obtained from a new question added
Agencies are now required to screen patients for risk of developing pressure ulcers. to the OASIS-C, “M1300 - Pressure Ulcer Assessment: Was the patient assessed for risk of developing pressure ulcers?” The goal is clear; CMS expects home care agencies to take an active role in the prevention and treatment of pressure ulcers and expects patients’ wounds to improve. This will challenge agencies to take a closer look at their policies and procedures guiding delivery of care to ensure that they are in line with OASIS-C and the patient care practices being implemented. Staff training and education on wound healing and assessment will be essential in achieving the expertise necessary to accurately complete the questions included in the Integumentary Status section of OASIS-C. The inability to correctly assess, describe and measure wounds could not only result in serious financial implications for a home care agency, but also in poor outcome quality measures. OASIS-C items related to pressure ulcers and other wounds2,3,4,5 With that in mind, let’s take a look at OASIS-C. The first thing you will notice is that the items have been renumbered. The items for Integumentary Status are now numbered M1300 through M1350. For a copy of the Integumentary Status section of OASIS-C, turn to page 86. It will be helpful to follow along with that document as you read this article. Here is a detailed explanation of each item in the Integumentary Status section of OASIS-C: (M1300) Pressure Ulcer Assessment: Was this patient assessed for Risk of Developing Pressure Ulcers? (M1302) Does this patient have a Risk of Developing Pressure Ulcers? These are two new questions added to OASIS-C to capture home care agencies’ use of best practices in the assessment of pressure ulcer risk. Agencies are now required to screen patients for risk of developing pressure ulcers. They are not, however, required to use a standardized, validated risk assessment tool. CMS defines a standardized, validated tool as one that “1) has been scientifically tested and evaluated
with a population with characteristics similar to the patient who is being evaluated and shown to be effective in identifying people at risk for developing pressure ulcers; and 2) includes a standard response scale.” Examples of these types of tools include the Braden Scale and the Norton Scale. In place of the Braden or Norton Scale, agencies may choose to develop their own risk assessment tool or assess patients’ risk based on an evaluation of clinical factors. If an agency chooses this method, then they must also define what constitutes risk. These two questions are to be answered at Start of Care and Resumption of Care. (M1306) Does this patient have at least one Unhealed Pressure Ulcer at Stage II or Higher or designated as “not stageable”? The National Pressure Ulcer Advisory Panel (NPUAP) defines a pressure ulcer as: “Localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction.”6 It is important for the assessing clinician to make an accurate determination of the true causative factors/etiology of a wound to be sure that it truly is a pressure ulcer. If a patient’s wound is not a pressure-related injury, then the correct answer would be “0-No.” If it is determined that the wound is a pressure-related injury, the clinician must have a thorough understanding of the NPUAP staging system, updated February 2007, as well as principles of wound healing. Stage I pressure ulcers involve intact skin, and thus no open wound, so they are not included
The goal is clear;
CMS expects home care agencies to take an active role in the prevention and treatment of pressure ulcers and expects patients’ wounds to improve.
Improving Quality of Care Based on CMS Guidelines 31
in this question. Research regarding wound healing has revealed that partial thickness wounds such as Stage II pressure ulcers heal through regeneration of the dermis and epidermis. Once complete epithelialization occurs, the wound is considered healed and no longer counted as a pressure ulcer. Under M1306, if the patient has a healed Stage II pressure ulcer and no other pressure ulcers, the correct answer would be “0-No.” On the other hand, full thickness wounds such as Stage III and Stage IV pressure ulcers heal differently than partial thickness wounds. Full thickness wounds heal through a process of granulation, contraction and epithelialization, which results in the formation of scar tissue. As a result, full thickness wounds never can be considered “healed.” However, they may be considered “closed” when they have fully granulated, and the wound has been resurfaced with new epithelium. So, if a patient presents with a “closed” (or open) Stage III or IV pressure ulcer or if the patient has an Unstageable pressure ulcer or suspected deep tissue injury, the correct answer to this question would be “1-Yes.” The OASIS-C guidance also directs clinicians to select “1-Yes” if pressure ulcers are known
to exist or suspected to exist, but may not be observable due to the presence of dressings or devices (e.g., casts) that cannot be removed to assess the underlying skin. This question is to be answered at the following points in time: Start of care, Resumption of care, Follow-up and Discharge from agency – not to inpatient facility. (M1307) Date of Onset of Oldest Unhealed Stage II Pressure Ulcer identified since most recent Start of Care (SOC)/Resumption of Care (ROC) assessment This item is designed to identify the oldest Stage II pressure ulcer only and is collected upon discharge from the agency. An ulcer that is suspected of being a Stage II, but is Unstageable, should NOT be identified as the “oldest” Stage II pressure ulcer. With this question, CMS will be able to tell how long this ulcer remained unhealed while receiving services from the home care agency and identify patients who developed a pressure ulcer while under the care of the home care agency. Once again, as previously mentioned, CMS expects to see healing and not deterioration of patients or their wounds while receiving home care services.
Continued on page 34
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Nosocomial pressure ulcers reduced by 50% after 3 months1
Nosocomial pressure ulcers reduced to zero after 8 months1
Estimated cost savings of $6,677.11 per patient
Independent outcomes research1 was conducted in an acute care facility where, after implementation of a prevention program, the only additional change during the reduction period was the focus of improving skin care by using Medline Remedy products* exclusively, as part of a formal skin care regimen. The results were amazing!
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* A silicone-based dermal nourishing emollient (SBDNE) 1. Shannon RJ, Coombs M, et al. Reducing hospital-acquired pressure ulcers with a silicone-based dermal nourishing emollient-associated skincare regimen. Adv Skin Wound Care, 2009;22:461-7. ©2010 Medline Industries, Inc. Medline and Medline Remedy are registered trademarks of Medline Industries, Inc.
CMS expects to see healing and not deterioration of patients or their wounds while receiving home care services. (M1308) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at Each Stage This chart of items requires the clinician to count the number of current open pressure ulcers and their stage. Completion of this item requires a sound understanding of the NPUAP Pressure Ulcer Classification System, available at www.npuap.org/resources.htm. The clinician must be sure that each pressure ulcer meets the requirements of the definition of each stage. Stage I pressure ulcers and any healed (epithelialized) Stage II pressure ulcers are not counted. Likewise, pressure ulcers that are repaired surgically through procedures such as a muscle flap, skin advancement flap or rotational flap, are no longer considered to be pressure ulcers. Instead, the patient now has a surgical wound. Surgical debridement of a pressure ulcer, on the other hand, only removes necrotic tissue, so a surgically debrided wound would still be counted as a pressure ulcer. When counting Stage III and IV pressure ulcers remember, “once a Stage III always a Stage III; once a Stage IV always a Stage IV.” Reverse staging of pressure ulcers is clinically incorrect and inappropriate because the stage only refers to the level of tissue damage. Stage III and IV pressure ulcers, as mentioned previously, heal through granulation, contraction and epithelialization and do not restore the previously damaged underlying layers. So, if a Stage III pressure ulcer means a full thickness tissue loss down to the subcutaneous layer, then this amount of damage will always be present even when the wound has granulated to surface level and has been resurfaced with new epithelium. As a result, if a patient has a previously closed Stage III or IV that reopens, it is still a Stage III or IV (even if it only looks like a Stage II). When attempting to stage a granulating pressure ulcer, challenges arise if the clinician did not see the ulcer at its worst. In this case, the assessing clinician should make every reasonable attempt to determine the original stage of the ulcer at its worst by contacting previous providers (i.e., physician, hospital, nursing home).
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(M1310) Pressure Ulcer Length, (M1312) Pressure Ulcer Width, (M1314) Pressure Ulcer Depth These three questions are new to OASIS data collection and require the measurement of the largest unhealed Stage III or IV or Unstageable pressure ulcer only. To determine the largest ulcer, measure the length and width of each open Stage III, IV or Unstageable pressure ulcer to determine which has the largest surface area. The instructions direct the clinician how to obtain the measurements: length is measured as the longest length from “head to toe,” width is measured as the greatest width measured perpendicular to the length, and depth is measured from the visible surface to the deepest area of the wound. All measurements are to be recorded in centimeters.
L M1310, M1312 and M1314 require all home care agencies to measure wounds in the same manner to allow CMS to collect data that directly reflects a home care agency’s wound healing efforts as evidenced by either increasing or decreasL ing wound sizes. These items are completed at Start of Care, Resumption of Care and upon Discharge from agency – not to inpatient facility. Measurements may be made using a variety of tools, including a cotton-tipped applicator, disposable measuring device, a camera or other device that calculates measurements. Measurements should always be taken following removal of the dressing and thorough wound cleansing.
The “most problematic pressure ulcer” does not necessarily mean the largest. (M1320) Status of Most Problematic (Observable) Pressure Ulcer For this question, the “most problematic pressure ulcer” does not necessarily mean the largest. The most problematic pressure ulcer could be the largest or the most advanced stage or the ulcer the clinician is having the most problem accessing because of location, difficulty with pressure relief or a variety of other factors. Once the most problematic pressure ulcer is determined, the clinician must then make a determination of the healing status. The Wound, Ostomy and Continence Nurses Society (WOCN) recently issued a new guidance document to assist clinicians in making this determination. It’s available at www.wocn.org/pdfs/GuidanceOASIS-C.pdf. Here are a few items of note: 1. Since Stage II pressure ulcers do not granulate, as previously explained, the only appropriate answer for a Stage II pressure ulcer would be “3-Not healing.” 2. The response “NA-No observable pressure ulcer” only refers to pressure ulcers that cannot be observed due to the presence of a dressing or device that cannot be removed. 3. Unstageable pressure ulcers or ulcers with necrotic tissue (eschar/slough) would either be scored as “2-Early/partial granulation” or “3-Not healing,” depending on the amount of necrotic tissue present. 4. If a patient has only one pressure ulcer, then that ulcer is the most problematic. Stage I pressure ulcers are not considered for this item. (M1322) Current Number of Stage I Pressure Ulcers A Stage I pressure ulcer is characterized by intact skin with non-blanchable redness of a localized area usually over a bony prominence. The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue. This question identifies the presence of Stage I pressure ulcers at Start of Care, Resumption of Care, Follow-up and Discharge.
(M1324) Stage of Most Problematic Unhealed (Observable) Pressure Ulcer This item identifies the stage of the most problematic pressure ulcer that was previously determined in item M1320. Again, a thorough understanding of the NPUAP Pressure Ulcer Classification System is required to correctly answer this item. If the patient has no pressure ulcers or if the most problematic is Unstageable due to the presence of necrotic tissue or unobservable due to a non-removable dressing or device, then the correct answer would be “NA-No observable pressure ulcer.” (M1330) Does this patient have a Stasis Ulcer? (M1332) Current Number of (Observable) Stasis Ulcer(s) These items pertain to stasis ulcers, which are caused by venous insufficiency in the lower leg. It is important for clinicians to differentiate stasis ulcers from other lower leg ulcers, such as arterial ulcers and other types of skin ulcers. This requires the clinician to utilize clinical assessment skills and knowledge of various etiologies of lower leg ulcers. These items are to be completed at Start of Care, Resumption of Care, Follow-up and Discharge from agency – not to inpatient facility. Hint: The WOCN produced a “Clinical Fact Sheet for Assessment of Leg Ulcers” that may be of value in helping with this process. For a copy, turn to page 93 or go to www.wocn.org/pdfs/WOCN_Library/Fact_Sheets/C_QUICK 1.pdf. (M1334) Status of Most Problematic (Observable) Stasis Ulcer This item utilizes the same thought process as item M1320 to determine the most problematic stasis ulcer and describes the healing status of the ulcer dependent on the amount of necrotic tissue and granulation tissue based on the WOCN guidance.
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(M1340) Does this patient have a Surgical Wound? (M1342) Status of Most Problematic (Observable) Surgical Wound This item identifies the presence of any wound caused by a surgical procedure. Scars and keloids are NOT considered surgical wounds. Bowel ostomies and all other ostomies are not considered surgical wounds, either; however, the wound that results after an ostomy reversal procedure is considered to be a surgical wound. As mentioned previously, surgical repair of a pressure ulcer with flap surgery is NOT considered a pressure ulcer and would instead be included under this item. Debridement or skin grafting does NOT create a surgical wound, and these wounds would continue to be considered the same type of wound as previously identified prior to the procedure. The CMS guidance states “For the purpose of this OASIS item, a surgical site closed primarily (with sutures, staples or a chemical bonding agent) is generally described in documentation as a surgical wound until epithelialization has been present for approximately 30 days, unless it dehisces or presents signs of infection.” Surgical sites that have been epithelialized for 30 days should be described as a scar, and should not be included in this item. Surgical wounds also include: Orthopedic pin sites, central line sites, wounds with drains, medi-port sites and other types of implanted infusion devices or venous access devices. A PICC line is NOT considered a surgical wound since it is peripherally inserted. Also EXCLUDED are procedures such as cataract surgery, surgery to mucosal membranes or vaginal gynecological procedures. Item M1342 identifies the most problematic surgical wound and the status of the healing surgical wound based on the WOCN Guidance Document. CMS encourages clinicians to follow the guidance suggested in the WOCN Guidance Document on "OASIS Skin and Wound Status M0 Items" (revised July 2006) in the assessment of surgical wounds. The document is available at www.wocn.org/pdfs/WOCN_Library /OASIS_Guidance_rev_07_24_2006.pdf.
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(M1350) Does this patient have a Skin Lesion or Open Wound, excluding bowel ostomy, other than those described above that is receiving intervention by the home care agency? This final item identifies all other types of wounds or skin lesions other than pressure ulcers, stasis ulcers and surgical wounds that are CURRENTLY receiving intervention. On previous versions of OASIS, clinicians identified the presence of all skin lesions, including moles, scars, etc. With OASIS-C, however, this item now pertains only to lesions that are receiving intervention by the home care agency. PICC lines and IV sites qualify as skin lesions/open wounds under this item. Tracheotomies, urostomies and nephrostomies are also included here if interventions such as cleansing and dressing changes are being provided by the home care agency. Two new care process items, M2250 and M2400, also include items that directly pertain to the use of best practices in the prevention and treatment of diabetic foot ulcers and pressure ulcers. As mentioned earlier, CMS is encouraging home care agencies to use best practice patient care processes, and OASIS-C includes data items to measure the use of these best practices. Clinicians are asked if the plan of care ordered by the physician includes the following: • Diabetic foot care, including monitoring for the presence of skin lesions on the lower extremities • Patient/caregiver education on proper foot care • Intervention(s) to prevent pressure ulcers • Pressure ulcer treatment based on principles of moist wound healing: When determining if the wound care is based on the principles of moist wound healing, the clinician might consider the definition of a moist wound dressing as published in the “AHCPR Treatment of Pressure Ulcers: Clinical Guideline Number 15,” December 1994.7 According to this guideline: – A moist dressing keeps the ulcer bed continuously moist. Wet-to-dry dressings should be used only for debridement and are not considered continuously moist saline dressings. – The dressing needs to keep the surrounding intact (periulcer) skin dry while keeping the ulcer bed moist. – Pressure ulcers require dressings to maintain their physiologic integrity. An ideal dressing should protect the wound, be biocompatible, and provide ideal hydration. The condition of the ulcer bed and the desired dressing function determine the type of dressing needed.
Item M2250 (plan of care synopsis) asks whether the physician-ordered plan of care includes interventions to address seven process measures: vital signs and other clinical findings, diabetic foot care, falls prevention, depression, pain and pressure ulcer prevention and treatment.
Conclusion As you can see, the new OASIS-C incorporates many new ideas and concepts intended to improve patient care. As overwhelming as it may seem, this should be viewed as a great opportunity to improve not only your clinical assessment skills with wounds, but also to improve the care you provide to your patients. With a little time, education and experience, you will feel more confident in assessing your patients, and your patients will feel more confident with you. I encourage you to seek out opportunities to further your knowledge base and never stop learning. References 1. Lyder C & Ayello E. Annual checkup: the CMS pressure ulcer present-on-admission indicator. Advances in Skin and Wound Care. 2009; 22(10):476-484. 2. Highlights of OASIS-C Changes by Section: Train the Trainer Part 2 of 3. Available at: http://www.cms.hhs.gov/HomeHealthQualityInits/02_CMSSponsoredCalls.asp. Accessed January 11, 2010. 3. OASIS-C Development and Impact on Agency Operations. Available at: http://www.cms.hhs.gov/HomeHealthQualityInits/02_CMSSponsoredCalls.asp. Accessed January 11, 2010. 4. OASIS-C Guidance Manual September 2009 for 2010 Implementation. Centers for Medicare & Medicaid Services. Available at: http://www.cms.hhs.gov/homehealthqualityinits/14_hhqioasisusermanual.asp. Accessed January 11, 2010. 5. Wound Ostomy Continence Nurses Society Guidance on OASIS-C Integumentary Items. Available at: http://www.wocn.org/pdfs/GuidanceOASIS-C.pdf. Accessed January 11, 2010. 6. Pressure Ulcers Prevention & Treatment: Clinical Practice Guideline. National Pressure Ulcer Advisory Panel & European Pressure Ulcer Advisory Panel. 2009. 7. AHCPR Treatment of Pressure Ulcers: Clinical Guideline Number 15. December 1994. Available at http://www.ncbi.nlm.nih.gov/bookshelf/br.fcgi?book=hsahcpr&part=A5124. Accessed January 11, 2010.
Clay E. Collins BSN, RN, CWOCN, CFCN, CWS, DAPWCA is a certified wound, ostomy, conti-
nence and foot care nurse through the WOCN Certification Board and a certified wound specialist through the American Academy of Wound Management. He currently serves on the Foot Care Exam Committee for the WOCN Certification Board and is a member of the Wound, Ostomy, Continence Nurses Society, Sigma Theta Tau International Nursing Honor Society and a Diplomat of the American Professional Wound Care Association. He has extensive experience in the home care setting serving as administrator, clinical director and wound program director. He has developed and implemented advanced wound care programs and served as expert reviewer for best practice documents for the WOCN. He is currently a clinical education specialist for Medline Industries, Inc.
Improving Quality of Care Based on CMS Guidelines 37
SURVEY SMARTS An Interview with Dr. Andy Kramer on QIS Facts & Myths
QIS SURVEYS CONDUCTED As of 12/14/2009
California.....................36 Connecticut ..............584 Delaware.......................9 Florida.......................911 Kansas......................328 Louisiana ..................268 Maine..........................29 Maryland .....................56 Minnesota .................333 North Carolina...........186 New Mexico ................44 Ohio..........................278 Vermont ........................9 Washington.................51 West Virginia ...............17 Total ......................3,139
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he transformation of the long-term care (LTC) survey process is under way, with more than 3,100 nursing facilities in 14 states having experienced at least one Quality Indicator Survey (QIS) review. As expected, QIS is bringing much change to the long-term care survey process and a new paradigm in the assessment of care and quality-of-life indicators in LTC facilities.
The QIS is designed to improve consistency in what surveyors pinpoint – and possibly cite – and to facilitate surveyor review of the full range of regulations. The QIS methodology utilizes 162 quality of care indicators—far more than those comprising the QIs/QMs. The QIS calculates rates for each facility for particular care areas and compares them to specified national thresholds, allowing that a certain number of those occurrences could be normal. When a facility’s QIS indicator exceeds the threshold for a particular area, it will likely prompt surveyors to pay close attention to that area during the survey process. Quality Care magazine recently spoke with Dr. Andrew Kramer to learn more about how the QIS is affecting the long-term survey process. Dr. Kramer led the development of the QIS and is currently principal investigator in support of CMS to refine the QIS process and to conduct the training of state survey agencies in the national rollout of QIS.
Dr. Kramer, a noticeable difference in QIS is that it has two stages. Can you briefly describe them? Dr. Kramer: Stage 1 is conducted during the first day and a half of a Quality Indicator Survey. The survey team conducts resident interviews, family interviews, staff interviews, resident observations and chart reviews. At the end of Stage 1, the team of surveyors will compile all of the data they have collected from these assessments. The data will be used to calculate rates that are compared to national thresholds to determine whether Stage 2 investigations for potential compliance concerns are warranted. No compliance decisions are made in Stage 1. Stage 2 is the portion of the survey process in which an in-depth investigation is conducted on behalf of residents within care areas that exceeded thresholds on indicators identified during the Stage 1 process. Compliance decisions are made at the completion of Stage 2.
Does that make QIS surveys longer than traditional surveys? Dr. Kramer: On average, even though QIS includes larger samples of resident and very comprehensive assessments, they generally require about the same amount of time and resources as the traditional survey process. In a specific sense, however, the length of a QIS survey is variable depending on how many care areas are “triggered” in the Stage 1 investigation. If only a few care areas are triggered, the survey could be relatively short. If many care areas are triggered, the survey could be considerably longer. The other factor to consider is that when each new state begins implementing the QIS process, it may take longer than the traditional survey because there is a learning curve for surveyors. As you would expect, efficiency increases substantially once they gain experience with the process.
Surveyors use both a resident’s CPS score and a series of screening questions to determine whether a resident is interviewable.
Improving Quality of Care Based on CMS Guidelines 39
You mentioned the surveyor’s learning curve— What do you think is the hardest thing for them to adapt to? Dr. Kramer: Surveyors face two primary adaptations when learning the QIS process. First and most obvious is the intensive use of computer software and technology in the QIS. This isn’t a trivial thing for a lot of them—the adjustment really does take some time to get used to. The other challenge is getting to use the highly structured protocols and larger sample sizes, and the fact that they have tasks that need to be completed within a defined timeframe. So, with all the structured protocols and larger sample sizes, do “zero deficiencies” surveys still occur? Dr. Kramer: Yes. Zero deficiency surveys still occur. Are there certain types of deficiencies that are cited at a higher rate in QIS? Dr. Kramer: A major change resulting from QIS is that Stage 2 in-depth investigations of residents are triggered mostly from resident interviews and observations and family interviews. In contrast, in the traditional survey, most of the investigation is triggered by the QIs/QMs. The QIS results in resident-centered assessments where far more information is derived from residents and families. As a result, F-tags cited at substantially higher rates include quality of life deficiencies such as choices, dignity and activities, which are directly assessed in the resident interview and the resident observation; resident behavior and facility practices relating to abuse, restraints and staff treatment of residents; and quality of care deficiencies relating to providing necessary care for highest practicable well being, weight loss and hydration, and a drug regimen that is free from unnecessary drugs.
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Where Stage 2 “trigger” information comes from: 16% Resident Observation
11% New MDS Indicators
21% Resident Interview
12% Family Interviews 8% Staff Interviews
8% Census Chart
11% Admission Chart
What criteria are used to determine a resident interview candidate? Dr. Kramer: Surveyors use both a resident’s Cognitive Performance Scale (CPS) score and a series of screening questions to determine whether a resident is interviewable. To determine whether a resident can be interviewed, surveyors ask the following questions: 1. Are you from around here, the area, etc? 2. Tell me a little about yourself. 3. How long have you been here? 4. What is the food like here? If the resident provides reasonable answers to these questions, the surveyor marks the resident as interviewable. If the resident provides unreasonable answers, the surveyor marks the resident as noninterviewable. If a surveyor is uncertain, they mark the resident as interviewable and conduct the interview. If they find the responses unreasonable or inconsistent, they are able to change the resident’s status to non-interviewable.
The Quality Indicator Survey is a more resident-centered survey process designed to improve consistency and accuracy, enhance documentation and focus survey resources where they’re needed most.
Can a surveyor add a specific resident that wasn’t chosen randomly by the computer? Dr. Kramer: Yes. After the initial random sample is drawn by the surveyor software tool, the surveyor will reconcile that sample with the facility census. They will ask for a list of residents admitted within the last 30 days and who are still in the facility. If any residents from the initial draw of 40 are no longer in the facility, they will be replaced with one of the newly admitted residents. Surveyors can also “surveyor initiate” a resident into the sample based on resident- or facility-specific information obtained from ombudsman information, off-site complaints, surveyor observation or interviews. How do surveyors go about finding family members to interview? What are they looking for? Dr. Kramer: Surveyors screen all 40 census sample residents and conduct a resident interview with those who are interviewable. Then they select three noninterviewable residents who have a family member or personal representative who is likely to be able to complete a family interview either in person or over the phone before the end of the Stage 1 investigation. They screen the family member or personal representative, asking about their knowledge of and the extent of their relationship with the resident. It is desirable that the family member be familiar with the resident’s care planning, preferences and daily routines when the resident was more inde-
pendent and more able to make choices and express preferences. How will a surveyor handle concerns, not related to a direct question, which are brought up during the resident or family interview? Dr. Kramer: The surveyor will note the concerns in the comments section of the interview and then bring the concerns to the team. If the concerns indicate potential for non-compliance, the surveyor will initiate that resident and applicable care area into the Stage 2 sample. How do you think the QIS will affect residents overall? Dr. Kramer: The Quality Indicator Survey is a more resident-centered survey process designed to improve consistency and accuracy, enhance documentation and focus survey resources where they’re needed most. The QIS can also be used by providers as part of a continuous quality improvement process to review and improve quality-of-life and qualityof-care for residents. QIS will eventually contribute to the objective of aligning the definition of quality among regulatory, provider and consumer constituents. Its resident- and family-centered perspective will have the greatest impact on quality-of-life and quality-of-care for residents.
Improving Quality of Care Based on CMS Guidelines 41
EDUCATIONAL OPPORTUNITIES FOR LONG-TERM CARE PROFESSIONALS
Making Sense of the New Quality Indicator Survey Two free online courses available at www.medlineuniversity.com
The Role of the CNA in Resident-Centered Care and the New Quality Indicator Survey
Understanding the Quality Indicator Survey Designed for: Long-Term Care Administrators
Designed for: Nurses and CNAs You’ll earn: One Administrator Credit You’ll earn: One Continuing Education Credit This course covers:
• How the state survey process has evolved into the new Quality Indicator Survey (QIS) • The importance of the CNA in QIS and resident-centered care
Approved by the National Association of Long-Term Care Administrator Boards (NAB), this course covers:
• How the Quality Indicator Survey (QIS) process evolved to standardize state surveys in accordance with federal guidelines
• The different aspects of QIS, including the resident interview, resident observations and family interviews
• The top six objectives of the QIS
• How the CNA can help improve the overall quality of care in long-term care facilities
• How the QIS differs from traditional state surveys
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• How surveyors in all states are being trained in a structured and consistent manner
LEARN MORE ABOUT THE ONLY INTEGRATED SOLUTION FOR SURVEY READINESS IN NURSING HOMES
Quality Assurance System Webinar
This webinar gives a QIS overview and demonstration on how the abaqis® system can help prepare for both the traditional and QIS survey processes. This demonstration also highlights how abaqis® provides: • Rich reporting capabilities to identify which care areas to target for quality improvement • Root cause analysis on a facility-wide or individual-resident basis, enabling prioritization and focusing of interventions for maximum impact • Emphasis on information reported by residents and families to help identify the needs of residents, aiding your efforts to improve consumer satisfaction Now with the new Stage 2 module featuring: • A dashboard view of triggered care areas based on data collected using abaqis® Stage 1 Suite • Investigative tools to determine deficiencies in triggered care areas
Free Webinar at www.medline.com/abaqisdemo
Improving Quality of Care Based on CMS Guidelines 43
One Nursing Home’s Winning Quality Assurance Strategies By Betty Lou Barron, MSN, MBA Director of Nursing, Bear Creek Nursing Center
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Bear Creek Nursing Center is an 120 bed short-term stay and long-term care health care facility located in Hudson, Florida.
Our Nursing Home Bear Creek Nursing Center is located in Hudson, Florida in the Central West region of the state along the Gulf of Mexico. Our mission is to ensure the highest quality of care to the residents entrusted in our care. Residents and their families are our first priority. Our focus is to help all residents achieve their highest level of function. Bear Creek has 120 licensed beds and offers an array of services including traditional nursing care, which can range from several months to a long-term stay; rehabilitation care and respite care – a short-term program designed to give family members a much needed break from the d e mands of caring for the chronically ill at home. Whether it’s for a w e e k e n d o r a f e w w e e k s , we provide a comfortable, secure medical and social environment.
With the change in the survey process, we knew we not only had to alter the way we prepared for the new QIS, we had to reassess our entire quality assurance approach to focus more on the resident.
Our Challenge Florida was one of the first states to pilot the new Quality Indicator Survey (QIS) for nursing homes. With QIS, we had to change the culture of our nursing home staff. Compared to the traditional survey, QIS is designed to be more consistent and less subjective, with a resident-centered focus. Because QIS is a new and very different process than the traditional survey, our staff was naturally unsure what to expect and how to prepare for the new inspection. The idea of having to change the focus of our quality assurance efforts after having the traditional survey for so many years was unsettling for all of us. Along those same lines, we also realized that our nursing home was managed with an “institutional” mentality, meaning all of our residents were on the same schedule, participated in the same activities, went to bed at the same time, and so on. While we did not know it at the time, this type of system was not the optimal environment for our residents to thrive.
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The Solution With the change in the survey process, we knew we not only had to alter the way we prepared for the new QIS, we had to reassess our entire quality assurance approach to focus more on the resident.
Facility: Bear Creek Nursing Center Location: Hudson, FL Size: 120 licensed beds with an array of services including traditional nursing care, rehabilitation care and respite care Challenge: Prepare for the new Quality Indicator Survey and change the culture of the nursing home staff to be more resident centered.
Back in June 2008, I was introduced to a new quality assurance system for nursing homes called abaqis®. What got me initially interested in abaqis® was that it used the same calculations, thresholds and analysis as the QIS to quickly highlight residents at risk. I wanted something to help take the guess work out of preparing for the survey and make our nursing staff feel confident that what they were doing was helping the resident and enhancing their chances of getting a good survey. The abaqis® Stage 1 Suite examines 125 resident-centered indicators of quality-of-care and qualityof-life that are used to identify care areas for a Stage 2 in-depth investigation and possible citations during a QIS. These indicators are contained in six modules that exactly replicate the QIS assessments conducted on-site during the survey, plus one module that uploads and reviews MDS data. The modules are: • Resident Interview • Family Interview • Staff Interview • Resident Observation • Census Sample Record Review • Admission Sample Record Review • MDS Data
“ Some of the Bear Creek clinical staff who have helped transform the facility into a resident-centered nursing center.
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One of the biggest benefits of abaqis® is that it helps us ask our residents insightful questions about their likes and dislikes, and then it statistically analyzes the data to focus us on our residents’ key issues.
Since abaqis® has become an integral part of our QA system, the patients are noticeably happier now that we are changing things based on their specific feedback. They appreciate that we have become more resident-centered and customer friendly — meaning we are asking what they think about their care and listening to their suggestions and issues.
After I was trained on abaqis ®, I identified 13 key personnel at the facility – our department heads – to train and inservice them on abaqis®. At first, they were reluctant because this new system was a significant departure from what they had been doing in their current QA process and they were uncertain if this was really going to help them prepare for the new inspection. In early February 2009, we started implementing the abaqis® system in our facility. Although abaqis® is a Web-based system that can be accessed from any computer, we have an older facility without wireless capabilities or laptop computers. So, we used a manual process to collect data and then we gave the information to our administrative staff to input into the computer. I divided the data collection responsibilities according to each staff member’s strengths and concentration. For instance, it made sense that our social workers focused on the resident interviews, while the administrative staff concentrated on record reviews. By the end of February, we had completed all the modules, interviews and data analysis for our 112 residents. What we found was that we had 28 areas of concern – areas that abaqis® flagged as red and a possible Stage 2 investigation if we did not correct these deficiencies.
needs and suggestions. One of the biggest benefits of abaqis® is that it helps us ask our residents insightful questions about their likes and dislikes and then it statistically analyzes the data to focus us on our residents’ key issues. It allows us to uncover trends among our residents and see areas where we can change and improve. For instance, we learned that our planned activities were not meeting our residents’ needs. The abaqis® system asks residents for their own suggestions and they came up with movie nights and more activities on weekends and during afternoon shift changes. In fact, we ended up overhauling the entire activities schedule as a result of the feedback we received from the abaqis® interviews. We also discovered the temperature of the food was not to the liking of many of our residents and some of them wanted to eat at different times than when we had them scheduled. Over the next several weeks, we whittled down the number of focus areas to six and then we did a mock QIS survey of the facility at the end of March. Of the six identified areas, four did not get flagged. The two remaining areas of concern we fixed during the next three weeks. With this new QA tool, we felt positive about the progress we were making on improving the quality of our residents’ experiences. Moreover, we became increasingly more confident about the impending Quality Indicator Survey.
Specifically, but not surprisingly, many of the areas of concern came from the resident interviews and their specific
Improving Quality of Care Based on CMS Guidelines 47
The Results On August 30, the official reporting agency, the Agency for Healthcare Administration (AHCA), visited our facility and began our first inspection using the new QIS – and we were ready. The inspection resulted in only four citations. (We had 16 during our mock survey.) According to the team leader of the survey at our facility, we had the fewest areas cited for a Stage 2 investigations he had seen so far. Of the four citations, two were for nurse observations, which are easier issues to resolve than citations resulting from residents complaints about a specific aspect of their care. I truly believe we had such positive feedback because we had abaqis® to prepare us.
Future Opportunities Going forward, abaqis® has become an integral component of our ongoing QA system. We are implementing two of the modules each month, which means we will complete one full survey of all of our residents every quarter. This type of comprehensive quality assurance system impacts our facility in many important and significant ways. It not only decreases our chances for a Stage II investigation, but more profoundly, our residents appear happier and more satisfied with their lives. And, as a result, our CNAs and other staff have increased job satisfaction with the knowledge that they are making a real and valuable contribution in the lives of each resident.
At the conclusion of the survey, several of our staff made the following comments: About the Author
“You were right, the surveyors asked me the same questions that abaqis® asked.” “It really works.” “I see what you mean when you said it was resident-centered.” From the feedback of the surveyors, clearly our staff was less nervous and more prepared for this survey than any other we had had previously, despite the new inspection process. Similarly, since abaqis® has become an integral part of our QA system, the patients are noticeably happier now that we are changing things based on their specific feedback. They appreciate that we have become more resident-centered and customer friendly – meaning we are asking what they think about their care and listening to their suggestions and issues.
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Betty Lou Barron is Director of Nursing at Bear Creek Nursing Center in Hudson, Florida, a 120 bed skilled nursing facility with emphasis on longterm and short-term rehabilitation residents. Betty has been working in the long-term-care industry for almost 10 years in various capacities. She is a Certified Director of Nursing and has earned her certification as an Alzheimer’s trainer for the Department of Elder Affairs. She also has earned a masters degree in nursing and health care administration. Betty is certified with the QIS system. This certification enables her to train and educate other directors of nursing and administrative staff on the QIS process.
“ How do we improve our resident and familycentered quality of care and prepare for QIS?
We use abaqis.” Sherri Dahle, RN, DNS Director of Nursing Central Healthcare LeCenter, MN
The new Quality Indicator Survey (QIS) for nursing homes is more resident-centered, with more information obtained from direct questioning of residents and families. In fact, 60 percent of facilities have had more deficiencies in QIS than in the prior traditional survey, often in regulatory areas such as quality of life that were not as fully investigated in the traditional process.
That gives you a unique advantage in preparing for your survey – and in meeting your resident’s needs. abaqis® is sold exclusively through Medline. Learn more by signing up for a free webinar demo at www.medline.com/abaqisdemo.
abaqis is the only quality assessment and reporting system for nursing homes that is tied directly to the QIS, and its quality assessment modules reproduce the same forms, analysis and thresholds used by State Agency surveyors. Rich reporting capabilities on 30 care areas guide you to what surveyors will be targeting in your facility.
©2010 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.
OptiumEZ BLOOD GLUCOSE MONITORING PROVIDES
EASY, ACCURATE & RELIABLE RESULTS Medline’s OptiumEZ monitor, manufactured by Abbott Diabetes Care, minimizes the variables that can affect glucose readings with its patented TrueMeasure® Technology. TrueMeasure Technology screens out common medications that may interfere with the accuracy of blood glucose results. Individual foil wrapping ensures that the test strips are not compromised by humidity, dust or dirt. Advanced Technology Made Simple™ for the Post Acute Care Professional. • No coding required • Simple two-step testing • Results in five seconds • Small blood sample size – 0.6 µl • Easy-to-read display with backlight • Simple 3-button navigation • Test starts only when enough blood is applied– designed to minimize errors, repeat tests and wasted test strips
To learn more about Medline’s Compass Diabetes Resource for Long-Term Care, which includes patient, family and nurse education—including the opportunity to earn 4 CE credits, send an e-mail to [email protected]
©2010 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.
Understanding the New F-Tag 441 Requirements
By Lorri A. Downs, RN, BSN, MS, CIC
If you’re confused about the Centers for Medicare & Medicaid Services (CMS) revised F-Tag 441 requirements regarding shared medical devices – particularly glucose meters – you’re not alone. Although every infection preventionist, healthcare worker, administrator and regulatory surveyor certainly would prefer long-term care facilities to provide dedicated medical equipment for each resident, they also realize this can be cost prohibitive. Therefore, CMS and the CDC guidelines allow for the sharing of durable medical equipment – such as glucose meters – as long as it is properly cleaned and disinfected between every patient use.
Why are the regulatory eyes of CMS looking so closely at cleaning and disinfection? Healthcare-associated infections are a major concern, and germs are commonly transmitted from person to person via medical devices. The new F-Tag 441 states:1
When devices are shared, staff training and education is crucial to ensure proper infection control. One common barrier is lack of clear delegation of equipment cleaning tasks. If the responsibility is left to everyone, often no one ends up performing the cleaning task. Healthcare workers are busy and simply assume another staff member completed this simple but critical task.
“Infections are a significant source of morbidity and mortality for nursing home residents and account for up to half of all nursing home resident transfers to hospitals. Infections result in an estimated 150,000 to 200,000 hospital admissions per year at an estimated cost of $673 million to $2 billion annually. When a nursing home resident is hospitalized with a primary diagnosis of infection, the death rate can reach as high as 40 percent. It is estimated that an average of 1.6 to 3.8 infections per resident occur annually in nursing homes.”
How has F-Tag 441 changed? As mentioned earlier, CMS is especially concerned about infection control due to the rising rates of healthcare-acquired conditions. They have combined all F-Tags related to infection control (i.e., F-Tag 441, 442, 443, 444 and 445) into one location under F-Tag 441 to make these guidelines more accessible. F-Tag 441 is now the “one-stop-shop” for infection control requirements.
Reducing and/or preventing infections acquired through indirect contact with surfaces or medical equipment requires decontamination (cleaning, sanitizing or disinfection) prior to exposing a different resident to the particular piece of medical equipment.
The revisions to F-Tag 441 are based in part on a Centers for Disease Control and Prevention (CDC) report describing separate outbreaks of hepatitis B virus (HBV) linked to the sharing of blood glucose monitoring equipment at long-term care facilities in Mississippi, North Carolina and California.2
Improving Quality of Care Based on CMS Guidelines 51
Investigators suggest that recommendations concerning standard precautions and the reuse of fingerstick devices have not been adhered to or enforced consistently in long-term care settings. The potential for devices to carry bloodborne pathogens and multidrug resistant bacteria and viruses (if the device is not cleaned between every use) is well-documented in the CDC report. For a copy of the report, go to www.cdc.gov/mmwr/preview/mmwrhtml/ mm5409a2.htm. Ultimately the safety of your residents and employees is at the core of most of the rules and regulations surrounding infection control. Yet it can be challenging to keep up with all the regulatory changes. Implementing routine processes will increase your staff’s knowledge and awareness, along with the assurance that clean care really is safer care. How will this regulatory change affect long-term care facilities? Regulatory inspections will be more frequent, and facilities that are 1.) cited with severe non-compliance with the new F-Tag 441 requirements and 2.) fail to implement preventative or corrective measures will no longer be able to participate in Medicare – a financially devastating prospect. Non-compliance is categorized into the following levels according to severity. Note that not cleaning glucose meters between residents falls under the most severe level of non-compliance.
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Severity Level 4 – Immediate jeopardy to resident health or safety: Non-compliance with one or more requirements has caused or is likely to cause serious harm, impairment or death to a resident. Example: “The facility failed to follow standard precautions during the performance of routine testing of blood sugars. The facility did not clean and disinfect the glucometers before or after use and did not use new glucometer lancets on residents who required blood sugar monitoring. This practice of not cleaning and disinfecting glucometers between every use and re-using glucometer lancets created an Immediate Jeopardy to resident health by potentially exposing residents to the spread of blood borne infections for multiple residents in the facility who required blood sugar testing.” 1 Severity Level 3 – Actual harm that is not immediate jeopardy: The negative outcome can include, but may not be limited to clinical compromise, decline or the residents inability to maintain and/or reach his or her highest practicable well-being. Example: “The facility routinely sent urine cultures of asymptomatic residents with indwelling catheters, putting residents with positive cultures on antibiotics, resulting in two residents acquiring antibiotic-related colitis and significant weight loss.” 1 Severity Level 2 – No actual harm with potential for more than minimal harm that is not immediate jeopardy: Non-compliance that results in a resident outcome of no more than minimal discomfort and/or has the potential to compromise the resident’s ability to maintain or reach his or her highest practicable level of well being. The potential exists for greater harm to occur if interventions are not provided. Example: “The facility failed to ensure that their staff demonstrates proper hand hygiene between residents to prevent the spread of infections. The staff administered medications to a resident via a gastric tube and while wearing the same gloves proceeded to administer oral medications to another resident. The staff did not remove the used gloves and wash or sanitize their hands between residents.” 1
New CMS Infe ction Control Requirements for Long-Term Care Facilitie s Listed below are the infection control requirements under F-Tag 441 that long-term care facilities must follow in order to be Medicare providers and receive reimbursement from CMS. 1 “The intent of this regulation is to assure that the facility develops, implements, and maintains an Infection Prevention and Control Program in order to prevent, recognize, and control, to the extent possible, the onset and spread of infection within the facility. The program will: Perform surveillance and investigation to prevent, to the extent possible, the onset and the spread of infection. Prevent and control outbreaks and crosscontamination using isolation precautions in addition to standard precautions. Use records of infection incidents to improve its infection control processes and outcomes by taking corrective actions, as indicated. Implement hand hygiene practices consistent with accepted standards of practice, to reduce the spread of infections and prevent crosscontamination. Properly store, handle, process, and transport linens to minimize contamination.”
References 1. CMS Manual. Interpretive Guidelines for Long-Term Care Facilities Tag F441. Available at: http://www.cms.hhs.gov/transmittals/downloads/ R55SOMA.pdf. Accessed January 21, 2010. 2. Centers for Disease Control and Prevention. Transmission of hepatitis B virus among persons undergoing blood glucose monitoring in long-term care facilities: Mississippi, North Carolina and Los Angeles County, California, 2003-2004. MMWR 2005;54(09): 220-223. Available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5409a2.htm. Accessed January 21, 2010.
Improving Quality of Care Based on CMS Guidelines 53
Ten Tips for Cleaning and Disinfecting Shared Medical Equipment 1 Make a list of every piece of shared medical equipment. (Assign clinical staff to help identify and generate the equipment list.) 2 Assign the cleaning and disinfection responsibility to the type of healthcare worker who will be performing the task within your policy. 3 Communicate this administrative decision to all members of your staff, both written and verbally, and document. 4 Educate and train staff on proper care, maintenance, cleaning and storage of each piece of equipment. At a minimum, provide this education upon initial employment, when the equipment is replaced with a newer model and annually. Document that this training has occurred. 5 Select easy-to-use, EPA-registered hospital grade disinfectants and cleaning products. Make sure the products list which microorganisms and viruses it kills. Common cleaners are sodium hypochlorite (bleach solution) or quaternary ammonium products. However, to help avoid warranty issues or equipment damage, be sure to follow manufacturers’ recommendations regarding which cleaning products to use.
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6 Clean medical device surfaces when visible blood or bloody fluids are present by wiping with a cloth dampened with soap and water to remove any visible organic material, and then disinfect. 7 If no visible organic material is present, disinfect the exterior surfaces after each use using a cloth or wipe with either an EPA-registered detergent/germicide with a turberculocidal or HBV/HIV label claim, or a dilute bleach solution of 1:10 to 1:100 concentration. 8 Note that alcohol also is not an EPA-registered detergent/disinfectant. 9 Disposable professional grade wipes with a short “kill time” (60 seconds after application) can make the time spent cleaning equipment quick and easy. 10 All cleaning should be done in well-ventilated areas with gloves to protect healthcare workers’ hands.
Dispatch® Cleaning Solution for Use on Glucose Meters Dispatch is a liquid cleaner that contains a unique detergent and bleach dilution strength (5500 ppm sodium hypochlorite [NaOCl]) equivalent to the 1:10 bleach solutions recommended by the Centers for Disease Control and Prevention (CDC) for disinfecting. It can be used on hard, non-porous external surfaces such as glucose meters; however, care must be taken to protect the electrical components of the equipment from any contact with liquid. Always remember to turn off electrical equipment prior to cleaning it with a liquid product. Glucose meters should be stored in their carrying case when not in use. After use on a patient, the monitor should be wiped down with Dispatch, left on for one minute, and then wiped off with a fabric cloth or paper towel. More stable than bleach solutions Dispatch is more stable than bleach solutions and more pleasant to use. It remains stable through the expiration date (two years from manufacture), unlike bleach solutions, which begin to deteriorate immediately. It is an excellent cleaner because it contains detergent along with an anticorrosive ingredient that minimizes damage to surfaces and equipment.
Dispatch is available as a liquid or as pre-moistened wipes in a canister. It meets both Universal and Standard Precautions set forth by OSHA and CDC. It is also registered with the EPA. Germicidal efficacy Dispatch kills Mycobacterium bovis (TB) within 30 seconds and the following within 60 seconds: Acinetobacter baumannii, Avian Influenza A, Canine Parvovirus, Enterobacter aerogenes, Enterococcus faecium, Vancomycin resistant (VRE), Escherichia coli, ESBL, Feline Panleukopenia Virus, Hepatitis A Virus (HAV), Hepatitis B Virus (HBV), Hepatitis C Virus (HCV), Herpes Simplex Virus (HSV-2), Human Immunodeficiency Virus Type 1 (HIV-1), Influenza A Virus, Klebsiella pneumoniae, Norovirus, Poliovirus Type 1 (Mahoney), Pseudomonas aeruginosa, Rhinovirus, Rotavirus, Salmonella enterica (formerly choleraesuis), Staphylococcus aureus, Methicillin resistant Staphylococcus aureus (MRSA), Streptococcus pyogenes and Athlete’s Foot Fungus. Dispatch is a registered trademark of Caltech Industries, Inc.
Improving Quality of Care Based on CMS Guidelines 55
Put Bacteria in its Place Microfiber mops minimize infection. According to the CDC, there are an estimated two million incidents related to healthcare-associated infections each year, making infection control one of the highest priorities for healthcare facilities. Thorough cleaning and disinfection of all surfaces, including floors, is one way to reduce infection. Microfiber mops are particularly useful for infection control because they reduce floor surface bacteria by 99 percent.1
Why is Microfiber NICE?
N ew Product to the long-term care market I nfection Control • One wet mop per room reduces cross-contamination, helping with infection control • Due to their size, microfiber mops get into the small pores of the floor, enhancing your cleaning • A positive charge is created on the mop as it is pulled across the floor to attract negatively charged dust and dirt particles • There is a 99 percent reduction in floor surface bacteria after using a micofiber mop1
Cost Savings • Using microfiber mops reduces water and chemical usage 95 percent1
References 1. Environmental Best Practices for Health Care Facilities. Using microfiber mops in hospitals. November 2002. Available at: http://www.epa.gov/region09/ waste/p2/projects/hospital/mops.pdf. Accessed on February 4, 2010. 2. Sustainable Hospitals Project. 10 Reasons for Microfiber Mops. 2003.
• Microfiber mops weigh less than a traditional loop mop, saving money in processing costs • Because microfiber mops will last about 10 times longer than a loop mop,2 there is a lower cost per use
Ergonomics • The lighter weight of a microfiber mopping system compared to a traditional mopping system can significantly reduce the risk of back injuries • The telescoping handle allows the mop to be placed in an ideal ergonomic position for each individual employee
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Order “One Keeper, One Kit” trial pack today and receive 10 FREE MDT217888Z Purple Grabber Mitts as a Gift! Call your Medline representative or 1-800-MEDLINE. Offer ends May 31, 2010. Limit 2 per facility.
©2010 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.
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Changing the Catheter Culture at Your Facility Connie M. Yuska, MS, RN, CORLN
Recently my husband was hospitalized following a 10-foot fall at work. We were thankful his injuries were not life-threatening, but he did have bilateral ankle and heel fractures. Given the immobility we knew was ahead, I was discussing the treatment plan with a good friend who is a nurse. One of her first questions was, “They are going to put in a catheter aren’t they?” My reply was, “I certainly hope not. I don’t want him to get a catheter-associated infection. That is the last thing we need with everything else that’s going on!” This conversation verified what I have experienced for the majority of my career both as a staff nurse and as a chief nursing officer. More likely than not if a patient was incontinent or having difficulty getting to the bathroom, one of the first requests would be an order for a urinary catheter. The nurses believed that their primary intervention of catheter insertion would maximize the patient’s comfort and avoid skin breakdown. Today we know that urinary tract infection is the most common healthcare-associated infection (HAI); 80 percent of these infections are attributable to an indwelling urethral catheter.1 One in four patients receives an indwelling urinary catheter at some point during their hospital stay and up to 50 percent of these catheters are placed unnecessarily.2,3 So, how do you change the culture at your facility if nurses still want to place a catheter? We all know that changing an organization’s culture can feel like turning a cruise ship around in a wild and stormy sea. The perception of nurses traditionally has been that putting a catheter in an incontinent patient is the best standard of care. We have to change that perception. As we begin to collect data, the evidence is showing that avoiding catheterization protects the patient from acquiring a catheter-associated urinary
Improving Quality of Care Based on CMS Guidelines 59
tract infection. And we know that too many indwelling urinary catheters are inserted. We also know that indwelling urinary catheters stay in too long.4
Components of Successful Culture Change Successful culture change consists of many components. The following are some key strategies you can try at your facility, including use of the new Guideline for Prevention of Catheter-Associated Urinary Tract Infections 2009, education and training, engaging front-line staff, a reward program, and finally, being creative, having fun and tracking progress. The Centers for Disease Control and Prevention (CDC) Guideline The Healthcare Infection Control Practices Advisory Committee (HICPAC) of the CDC recently published the Guideline for Prevention of Catheter-Associated Urinary Tract Infections 2009. This is an excellent reference to review prior to initiating a catheter reduction program at your facility. The document contains recommendations on appropriate urinary catheter use and proper techniques for urinary catheter insertion and maintenance. In addition, the guideline outlines strategies for quality improvement and surveillance programs and summarizes recommendations for an administrative infrastructure to support a CAUTI prevention program.5
Education and training A logical place to start is by designing a comprehensive education and training program. Having a program that provides the supporting framework for education also helps to organize and publicize the initiative. Medline’s ERASE CAUTI program will give you all the tools you will need. The ERASE CAUTI Program for nurses (RNs and LPNs) is a two-part educational program. Part One is a step-by-step product training program on the ERASE CAUTI catheter tray and insertion methodology. Part Two includes the following four modules: Module 1: Indications and Alternatives to Catheterization Module 2: Aseptic Technique and Proper Insertion of a Foley Catheter Module 3: Care and Maintenance, Signs and Symptoms of CAUTI Module 4: Competency Validation In addition, current practice guidelines, sample policies and procedures and competency validation tools are included. You have the opportunity to initiate the training at orientation when a new employee joins your organization. This “sets the stage” for the catheter culture in your facility. You are setting the expectation that your staff will keep an incontinent patient clean and dry without exposure to the unnecessary risk of acquiring a catheter-related urinary tract infection. Then during your annual competency reviews for your staff, you can reinforce the training and the new “catheter culture.” This gives you a greater chance of hardwiring the change into your culture and ensuring that your staff’s new viewpoint on catheterization is sustained. Engaging front-line staff It is also important to identify staff nurse champions at the beginning of the program. Enlisting their help through a formalized assignment is one good way to generate enthusiasm and support for the new program. Staff nurses have very good ideas and often know the best answer if we remember to include them! Getting them involved in the literature review and in planning the staff education roll-out will solidify their role as “champions” in the Race to ERASE CAUTI! Reward program In sustaining any long-term change, it is extremely important to recognize achievement. Staff work very hard, and
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their efforts need to be recognized. Another part of the ERASE CAUTI Program is a reward component. Everyone who successfully completes the course and achieves at least an 80% on the post test receives one CE credit, a certificate of completion and a pin to display on their ID badge or uniform. The pin recognizes individual achievement and provides an opportunity for the staff to talk about the program with patients, families and other healthcare professionals, keeping the program top-of-mind. Being creative, having fun and tracking progress Since this is a Race to ERASE CAUTI, encourage your staff to post statistics regarding the decline in catheter- associated infections. Nursing units in hospitals or hospitals in systems can make this a fun, competitive event that results in better patient care. Finally, celebrate when an individual or the entire facility crosses the finish line of achieving zero catheter-associated urinary tract infections.
A Happy Ending Although my husband did not have any incontinence, he was non-weight bearing and thankfully, none of the nurses actually asked that a catheter be placed prior to surgery. He did have a catheter placed during surgery, but it was taken out within 24 hours! The hospital staff did follow the Guideline for Prevention of Catheter-Associated Urinary Tract Infections 2009, which states “for operative patients who have an indication for an indwelling catheter, remove the catheter as soon as possible postoperatively, preferably within 24 hours, unless there are appropriate indications for continued use.”5 I am happy to report that my husband was discharged from the hospital to a rehabilitation facility, and he was able to come home for Thanksgiving. This year I was very thankful that he was in a hospital with an up-to-date catheter culture, and he is on the road to recovery!
References 1. Lo E, Nicolle L, Classen D, Arias A, Podgorny K, Anderson DJ, et al. SHEA/IDSA practice recommendations: strategies to prevent catheter-associated urinary tract infections in acute care hospitals. Infect Control Hosp Epidemiol. 2008;29:S41-S50. 2. Saint S, Kaufman SR, Thompson M, Rogers MA, Chenoweth CE. A reminder reduces urinary catheterization in hospitalized patients. Jt Comm J Qual Patient Saf. 2005;31(8):455-462. 3. Stokowski, LA. Preventing catheter-associated urinary tract infections. Medscape Nursing Perspectives. February 3, 2009. Available at: http://www.medscape.com/viewarticle/587464-4. Accessed July 6, 2009. 4. Sulzback-Hoke, Linda M. “Ask the Experts.” Critical Care Nurse. 2002,22:84-87. Available at: http.//ccn.accnjournals.org/cgi/content/full/22/3/84. Accessed July 24, 2009. 5. Guideline for Prevention of Catheter-Associated Urinary Tract Infections 2009, Healthcare Infection Control Practices Advisory Committee, Centers for Disease Control. Available at: http://www.cdc.gov/ncidod/dhqp/pdf/guidelines/CAUTI_Guideline2009final.pdf.
About the author
Connie Yuska RN, MS, CORLN began her career as a nurse in the specialty of otorhinolaryngology. Her clinical experience includes both inpatient and outpatient care of head and neck oncology patients, and she is certified in otorhinolaryngology and head-neck nursing. She has held clinical manager and director of nursing positions in a large academic medical center and also has experience in the home care setting as the vice president of operations for a large academically affiliated home care agency in the Chicago area. Connie later joined the executive suite as the chief nursing officer of a large community hospital in Chicago, and she is currently a vice president of clinical services for Medline. In all of her leadership roles, she has been responsible for ensuring the delivery of high quality, safe and cost-effective nursing care. Connie is a 2003 graduate of the J&J/ Wharton Nurse Executive Program. She is member of the Board of the Illinois Organization of Nurse Leaders and a member of the American Organization of Nurse Executives. In 2005, she was inducted into the 100 Wise Women Program sponsored by Deloitte & Touche. In addition, she has published several articles and chapters in oncology journals and textbooks.
Improving Quality of Care Based on CMS Guidelines 61
We didn’t just design a new tray, we designed a way to make it hard for healthcare workers to do the wrong thing. The new ERASE CAUTI program combines design, education and awareness to tackle catheter-associated urinary tract infection – the number one hospital-acquired infection.1
Design The innovative one-layer tray design guides the clinician through the process of placing a catheter to ensure aseptic technique.
Education The acronym ERASE is easy to remember, reminding the clinician to:
Evaluate indications – Does the patient really require a catheter?
Read directions and tips – Follow evidence-based insertion techniques
Aseptic techniques – Key design solutions support aseptic technique
Open up the innovative one-layer catheter tray and see the intuitive design for yourself.
Secure catheter – A properly secured catheter will reduce movement and urethral traction
Educate the patient – Printed materials tell the patient how to reduce the likelihood of infection
Awareness Join the Race to ERASE CAUTI! The current state of health care demands that nurses play a leading role in identifying and implementing CAUTI risk reduction strategies. Help us reach our goal to introduce 100,000 nurses to the ERASE CAUTI system. To sign up for a FREE webinar, “Innovation in the Prevention of CAUTI,” go to www.medline.com/erase/webinar.asp.
©2010 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.
Education Click here for details on nursing education materials that promote evidence-based practice.
Awareness Visit this section to join 100,000 nurses in the Race to ERASE CAUTI.
Reference 1. Catheter-related UTIs: a disconnect in preventive strategies. Physicians Weekly. 25(6), February 11, 2008.
Safe Handling of Residents Which Technique Would You Use? Safe handling of residents affects both the caregiver and the resident. Poor technique can result in resident injury or displeasure in addition to caregiver injury. Nursing is consistently listed as one of the top ten occupations for workrelated musculoskeletal disorders, with incidence rates of 13.5 per 100 nurses in nursing home settings.1 Manual handling also can be a causal factor in resident falls. Imagine you are asked to assess the following residents and help develop a care plan for safe patient handling and transfer, while also considering the caregivers’ risk of injury. Find the best matches below. 1. ____ Mrs. Brown is non-weight-bearing, weighs 475 pounds, and is transferred between bed and recliner. 2. ____ Judy, 205 pounds, has limited upper body strength, is partial weight-bearing, and needs help transferring from bed to chair and from chair to commode.
A. Manual stand-assist lift B. Low friction lateral transfer device with 2-person assist C. 600-pound patient lift
3. ____ Always active, Chuck recently had a stroke and has trouble standing on his own. He is partial weight-bearing and has some upper body strength.
D. 1 person and gait belt
4. ____ Mr. Anderson is non-weight-bearing, weighs 162 pounds, and is transferred between bed, commode and wheelchair.
F. 2-person assist with gait belt
5. ____ Mrs. Horton is bedbound, 185 pounds, and is completely non-weight bearing. She is transferred laterally from bed to shower gurney. 6. ____ 90-pound Ella is fully weight-bearing, uses a walker for part of the day, but in the afternoon uses a wheelchair. She is unsteady transferring between the two. 7. ____ Mrs. Grant, 180 pounds, is on a unit that has no lift. She is partially weight-bearing and needs assistance between bed, toilet and chair. 8. ____ Mr. Kent, 185 pounds, remains in bed much of the day. He is often is found on the lower half of the bed and needs repositioning regularly.
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E. 400-pound power stand-assist lift
G. 2-person assist with drawsheet H. 400-pound patient lift
Answers: 1C, 2E, 3A, 4H, 5B, 6D, 7F, 8G Please note that the answers provided here are not hard-and-fast rules. We realize there are many different ways to safely and effectively lift and handle residents, depending on individual circumstances. Reference: 1. U.S. Department of Labor. Bureau of Labor Statistics. Survey of Occupational Injuries and Illnesses, 2001.
PERFORMANCE UNDER PRESSURE The Legal Side of Pressure Ulcer Prevention mong the tools of the healthcare trade are medicines, dressings, instruments, nutritives and durable equipment. The tools of the legal trade are words. When these two professions meet, it’s words that become the focus of attention. The outcome of a medical litigation is highly dependent on the words used in a care setting, arguably as important as the care delivered itself.
The concept of the importance of words in a clinical setting was discussed at the Medline “Prevention Above All” conference in Washington, D.C. by Kevin W. Yankowsky, JD, a partner in the Health Law–Health Litigation department of Fulbright & Jaworski LLP and Caroline Fife, MD, CWS, Director of Clinical Research at the Memorial Hermann Center for Wound Healing and Associate Professor– Division of Cardiology at the University of Texas Health Science Center. They explained the potential for trouble when words are turned against their original user. Perhaps nowhere is a facility’s choice of words more important than in the policies and procedures it creates and expects its employees to follow. “The road to litigation is paved with well-intentioned policies,” explained Mr. Yankowsky. “Policies and procedures are kept in libraries by plaintiff’s attorneys. They’re shared electronically online.” The implication is that a facility’s own policies may be used to support a judgment against itself and its workers. Though policies and procedures are not law, a skillful lawyer can hold them up as standards. Because they’re the facility’s own words, they can be very powerful.
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In their single-minded pursuit of improved clinical care, policy drafters often fail to consider the legal implications of words they choose to insert in policies. Even more dangerously, they often fail to appreciate the plain, common sense meanings lay people give to those words when they are jurors in a professional liability trial. For example, never, always, equal, complete and immediately are absolute words. Absolutes should be used cautiously, as they imply a binary, black or white, yes or no state. Suppose one particular two-hour turn of a bariatric resident over a four-day period was not done until three hours had passed. If your policy stated that residents with certain risk factors for pressure ulcers must be turned every two hours, have you delivered substandard care because of that one incident? Actually, this scenario captures two potential problems – the imperative must and the implied linkage between a policy and standard of care. In nearly all jurisdictions, jurors in a healthcare liability lawsuit will be asked to decide whether
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the “standard of care” was violated. Typically, “standard of care” in a medical legal context is unique to each resident, very factually specific and generally no more than what would be reasonable care under the same or similar circumstances. However, a policy incorrectly identified as the definition of the standard of care can fundamentally change this important question. When a policy is labeled the “standard of care” a jury can be asked to simply consider whether or not every exact detail of the policy, as written, was followed. Put another way, the focus shifts to whether the policy was strictly adhered to instead of whether clinically appropriate care was delivered. A policy should be a guideline that recognizes the uniqueness of each resident, which allows the sound judgment of the healthcare team to be exercised and provides flexibility in implementation. When “standard of care” is too closely bound to a policy, the answer to policy adherence is too closely bound to the assessment of appropriate care.
The word stage means a point in a progression or series of events. When we think of stages, we usually consider them moving through a usual set order, such as stages of development or grief. Staging a pressure ulcer, however, does not fit with that widespread understanding of the term. “There is the misconception that if you have a Stage III or IV, it must have begun as a Stage I,” Dr. Fife explained. “Therefore it follows that had it been identified at Stage I, the Stage IV would never have happened. If that’s true, the fact the Stage IV is there must mean that there was negligent care.”
[silence]” One of the most dangerous words in precipitating litigation may well be no words at all. “We really need to think about … what drives residents to attorneys,” explained Mr. Yankowsky. “Sometimes it’s greed. Certainly sometimes it’s grief. Sometimes it’s anger. Most of the time … it’s a search for answers.”
All of these assumptions are false. The current NPUAP (National Pressure Ulcer Advisory Panel) pressure ulcer staging system indicates only the depth of tissue damage at the time the ulcer is assessed – it implies nothing about progression. Furthermore, our current understanding of how stage 3 and 4 ulcers develop is that they form from the inside out, the way an apple rots. As a result, tissue damage has already occurred at the level of the muscle by the time skin changes are apparent.
Two typical scenarios lead to litigation. The first is a resident or family who had questions that were simply not answered. The second is a question that was answered incompletely, inappropriately, unhelpfully or dismissively.
When communicating with residents and their families about pressure ulcers, using the staging system, while clinically correct, may be more confusing than helpful. Spending time to educate them – about the development of wounds from the inside out, about the skin as an organ that can fail and about the healing process may save you from trying to educate a jury later on those same points.
The role of the apology is a topic of debate. Apologizing is not new; it has been almost universally taught in homes and classrooms and liberally applied on sporting fields and in department stores. In a clinical setting, though, it is a relatively new phenomenon.
Of course, you should only answer questions appropriate to your clinical expertise and specific knowledge of the resident’s case. Otherwise, a three-part response is called for: Acknowledge the question and its importance, name the person who can address their question, and promptly notify that person by calling them or leaving them a detailed message—and note the action in the chart.
“If you don’t provide the answers, your adversary will,” Yankowsky cautioned, “and once they go to the plaintiff’s attorney, the game’s up. You’re past the point of being able to prevent the legal risk.”
Current thinking is that this practice may be efficacious, but words can be tricky when attached to an apology. Unintended and unexpected messages may be communicated. A nurse wishing to communicate sympathy by saying, “I’m sorry,” may mean, “I’m sorry this has happened to you,” but the resident may hear an admission of guilt for substandard care. Like many good treatments, apologies must not be dispensed without cautious, conscious consideration.
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Prevention Above All Preventative medical care and preventative dentistry are concepts we understand conceptually and whose effectiveness we can prove empirically. The concept of preventative legal care for healthcare facilities and practitioners is not as widely adopted. Understanding the potential pitfalls of simple words and responding appropriately is one facet of a comprehensive preven-
tative legal care approach. Far from being an underhanded way of deflecting blame for poor health care, it is an open and honest way to improve health care while preventing litigation that is preventable and protecting oneself against litigation that may be unpreventable.
Available beginning March 22, 2010
1 Contact Hour
LEGAL IMPLICATIONS OF PRESSURE ULCERS Join us for this webcast presentation as two industry experts bring you critical information on how the utilization of the nursing process and proper documentation are vital components in maintaining the standard of care and avoiding litigation. Dr. Caroline Fife is the Chief Medical Officer of Intellicure, Inc. and is an Associate Professor within the Department of Medicine, Division of Cardiology at the University of Texas Medical School at Houston and Director of Clinical Research at the Memorial Hermann Center for Wound Healing and Hyperbaric Medicine. She has served on the Boards of the American Academy of Wound Management and the Association for the Advancement of Wound Care. She is the co-editor of the textbook, "Wound Care Practice" and is the author of many scientific papers. Kevin Yankowsky is a partner in the health law litigation group of Fulbright & Jaworski L.L.P.’s Houston office. A true trial lawyer, Kevin’s trial practice encompasses virtually all types of civil litigation facing the healthcare industry. In addition to his extensive courtroom experience, he advises on Joint Commission investigations, hospital committee and medical peer review matters.
To pre-register for this special webcast visit www.medlineuniversity.com
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JOIN THE PROGRAM TO REDUCE PRESSURE ULCERS We’ve made pressure ulcer prevention easy. Systematic efforts at education, heightened awareness and specific interventions by interdisciplinary healthcare teams have demonstrated that a high incidence of pressure ulcers can be reduced.1 The main challenges to having an effective pressure ulcer prevention program are: lack of resources; lack of staff education; behavioral challenges; and lack of patient and family education.2 Medline’s comprehensive Pressure Ulcer Prevention Program offers solutions to these challenges. The Pressure Ulcer Prevention Program from Medline will help you in your efforts to reduce pressure ulcers in your facility. The program includes: • Education for RNs, LPNs, CNAs and MDs • Teaching materials for you to help train your staff • Practical tools to help reduce the incidence of pressure ulcers • Innovative products supported by evidence-based information that results in better patient care
This has been a great learning experience for our staff and for our facility as a whole. I am thankful Medline had this program and that we were able to access it. I can’t imagine recreating this wheel!” Katrina “Kitty” Strowbridge, RN Quality Improvement Coordinator St. Luke Community Healthcare Network Ronan, Montana
For more information on the Pressure Ulcer Prevention Program, contact your Medline representative, call 1-800-MEDLINE or visit www.medline.com/pupp-webinar to register for a free informational webinar.
References 1 Holmes A, Edelstein T. Envisioning a world without pressure ulcers. ECPN. 2007;122(8):24-29. 2 CMS Roundtable, Omni Hotel, Chicago, Ill. March 10, 2008. ©2010 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.
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Caring for Yourself
Habits of Very Happy People By Wolf J. Rinke, PhD, RD, CSP
Economy sputtering; swine flu getting everyone upset; lots of changes at my facility, and you want me to be happy? You’re kidding, right? Actually not! Because no matter how bad things seem to be, it’s important to remind ourselves that Abraham Lincoln was absolutely right when he said, “Most people are about as happy as they make their minds up to be.” Happy people are not happy because they are endowed with the happiness gene—although researchers tell us that accounts for about half of one’s potential for happiness—happy people are happy because they realize that happiness is something they control by doing certain things every day. So here are nine things you can do that will make you happier:
1. Love what you do I find it ironic that many people deny themselves the joy of their work. Somehow they assume that work is a dirty four letter word and that they must escape it as soon and as fast as possible so that they can get home and plop down in front of the TV. (This by the way, is a great way to become more unhappy and depressed.) I suspect it is because they have not found what they love to do. The key word here is love—not like— because once you find what you love to do you will not ever have to “work” another day in your life. (By the way, it took me 36 years to find what I love to do, so don’t give up your search, because when you find your passion, the quality of your life will improve dramatically.) If you would like help with this, read my book Make It a Winning Life: Success Strategies for Life, Love and Business.
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2. Chase your dreams Happiness is often a byproduct of something that we are going after—something that juices us. Think of children. When are they the happiest? About two weeks before the Christmas or Hanukkah holidays, or when they have ripped all the presents open? Once we have clearly-defined, specific, firein-the-belly goals, we get turned on, and we become happy. In other words, if your goal is to be happy—that’s what many people in my seminars tell me—you won’t necessarily be happy. You get happy from traveling the journey or reminding yourself that you are doing something that improves the quality of someone else’s life. Chasing your dreams cranks up your internal body chemistry to such an extent that it energizes you to achieve extraordinary results and may keep or may even make you healthy. Want proof? A good example is Lance Armstrong, who after being diagnosed in 1996 with an advanced form of testicular cancer that had metastasized to his brains and lungs, was given only about a 50 percent chance of survival. After receiving aggressive cancer therapy, including brain and testicular surgery and extensive chemotherapy, he went on to win the Tour de France—cycling’s most prestigious and grueling race—seven times in a row from 1999-2005. (The previous record was winning it five times.) And just when everyone thought he was down and out, he returned to competitive racing after four years of “retirement” to finish third in the 2009 Tour de France. Not bad for someone who at age 38 is considered old in the punishing sport of competitive cycling.
3. Nourish an attitude of gratitude A difficulty for many successful people is that they perpetually look up the mountain, never down. To feel a sense of gratitude you must have goals—look up the mountain—but also take the time to reflect on all that you have already achieved and accumulated—look down the mountain. If you need a bit of help with this, take advantage of the next holiday season. Instead of buying gifts for people who already have more than they will ever need, rally the whole family and serve a meal at a homeless shelter. Or visit a third world country. For example, when I used to speak in the Pacific Rim, my sense of gratitude was always renewed. Typically the client booked me in a five-star hotel, which makes any of our five star hotels pale in comparison. One of the hotels in Jakarta even had a marble driveway. Not concrete, not flagstones— marble. When I looked out of my 29th story window I saw many other super-modern high-rise buildings. I also saw a garbage dump several blocks away swarming with people – people who were living on the dump in cardboard “houses” and foraging for scraps. Stop right now, and be grateful for all the love and abundance that surrounds you.
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4. Love someone deeply Barbra Streisand was absolutely right, “people who love people are the luckiest people in the world.” Start by developing a strong bond and lifetime relationship with a significant other. Having been happily married to my “Superwoman” for 41 years, I can attest that she by far is my biggest source of joy and happiness. (She got that name because she is a one-in-a-million mate, mother, business partner and confidant.) If you don’t have such a relationship, make it one of your top three fire-in-the belly goals, because such a partner becomes increasingly more important as you enter the later passages of your life. Extend that same love to your family and your close friends. The greater your circle of loving relationships, the greater your happiness.
5. Treat your “bodymind” like a temple Neuroscientist and pharmacologist Dr. Candance Pert, who discovered the opiate receptor – the cellular binding site for endorphins in the brain – calls our body and mind the “body-mind” because her work has unequivocally demonstrated that the mind and the body are one. Her work also shows that thoughts are things – things that manifest themselves in the body and in your life. So if you think “bad” or negative thoughts, then that will have a negative impact on your body. And of course the reverse is true. Since the mind can have only one thought at a time, get in the habit of monitoring your thoughts and selftalk by asking, “Is what I’m thinking about right now negative?” (The worst is hate.) If it is, it will move you away from happiness and optimum health. On the other hand, positive thoughts, such as love, kindness and appreciation will move you in a positive direction. This is so powerful that we now have a whole science concerned with this phenomenon—
psychoneuroimmunology, or PNI for short. (Want to know more? Read Dr. Pert’s books: Molecules of Emotions: The Science Behind Mind-Body Medicine and Everything You Need to Know to Feel Go(o)d.)
6. Laugh more That’s right – go ahead and laugh right now. Can’t seem to get it going? Go to the bathroom, stick your tongue out, wiggle your nose and make the silliest face you can possibly come up with and get yourself to laugh. If you need more help, join a laughter yoga club, popularized in India, and now available all over the world including the United States (http://www.laughteryoga.org). Or consult with a “certified laughter leader.” (Hey, I’m not making this stuff up!) A good way to nurture this is to laugh more at yourself. It will cause you to take yourself less serious—which is a great start because you are not nearly as important as you think you are. (I’m including myself in that statement; so don’t get bent out of shape). Laughter has innumerable benefits. It turns on your endorphins and other internal “drugs” that are far more powerful than anything you can ingest—legal or illegal. In fact, it is so powerful that the late Norman Cousins used it as an “anesthetic” to combat pain associated with his incurable disease.
7. Give more of what you want A shortcut to happiness is making other people feel happy. Why? Because life is like a mirror—whatever you give—is what you get. Make people happy and you will be happier. Hate people and you will live in a hateful world. Love people the way they are, and you will experience more love. You catch my drift. Actually you already knew that. And that’s why you are much more anxious to give a gift than get one. Happiness certainly does not come from things. Otherwise the happiest people on
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Be sure to never give up hope, no matter how bleak it gets. And even more important, be sure not to confuse inconveniences with problems. earth would be lottery winners. They are not. In fact lottery winners often become discouraged and depressed because they become so obsessed with “stuff” that most are broke three years after they have won the jackpot. “Superwoman” and I have come to the realization that less is more. That is to say, the more stuff we have, the more problems and stress we have. That’s why we evaluate every new opportunity by asking ourselves whether taking advantage of the new opportunity will add to the quality of our lives. If the answer is yes, we go for it. If the answer is no, we don’t.
8. Develop a Positive Explanatory Style Professor Marty Seligman, of the University of Pennsylvania, who has had a tremendous influence on getting psychologists to focus on the good—what he has dubbed “positive psychology”— wrote a number of powerful books addressing this topic (http://www.authentichappiness.sas.upenn.edu/seligman.aspx). His research has demonstrated that we can learn to be more optimistic by developing a “positive explanatory style” (PES). The way you do that is by focusing on the good stuff, especially when bad things happen to you. In other words you learn to fake it until you make it. Research has shown that people who have developed PES, as opposed to a Negative Explanatory Style (NES) are able to evaluate “reality” more clearly—just the opposite of what most people assume. Process “bad” news more effectively, and you are more likely to accept what can’t be changed and move on. In short, PES enables you to inoculate yourself against the negative attitude “virus” and his big cousin—depression.
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9. Keep Hope Alive Hope is an incredibly powerful emotion. Without it not only do you become unhappy—you die. No one has told that story more powerfully than Dr. Victor Frankl in his book Man’s Search for Meaning, in which he details the role of hope in surviving the German concentration camps. So be sure to never give up hope, no matter how bleak it gets. And even more important, be sure not to confuse inconveniences with problems. Because many of the “problems” that we get ourselves all worked up about are inconveniences, not tragedies. When you are in the middle of one of these, a great diagnostic is to ask yourself: “How will I feel about this five years from now?” And then act accordingly. To deal more effectively with the real tragedies—which will come—turn to the source of hope and inspiration that works for you. It may be religion, spirituality, meditation or listening to a great motivational speech. (Just had to sneak that in there.) It will help you keep hope alive and make you more optimistic and happier. © 2009 Wolf J. Rinke Dr. Wolf J. Rinke, PhD, RD, CSP is a keynote
speaker, seminar leader, management consultant, executive coach and editor of the free electronic newsletters Make It a Winning Life and The Winning Manager. To subscribe go to www.WolfRinke.com. He is the author of numerous books, CDs and DVDs including Make it a Winning Life: Success Strategies for Life, Love and Business; Winning Management: 6 Fail-Safe Strategies for Building High-Performance Organizations and Don’t Oil the Squeaky Wheel and 19 Other Contrarian Ways to Improve Your Leadership Effectiveness. All are available at www.WolfRinke.com. His company also produces a wide variety of quality, pre-approved continuing professional education (CPE) selfstudy courses including Beat the Blues: How to Manage Stress and Balance Your Life, on which this article is based, available at www.easyCPEcredits.com. Reach him at [email protected]
Snug-fitting sheets for healthier skin. SoftSpan sheets with spandex fit snugly on the bed to comfort and protect the skin. A patented blend of cotton, polyester and spandex provides softness and a non-abrasive surface, along with better air circulation for skin health.
Call your Medline representative or 1-800-MEDLINE to trial two dozen SoftSpan fitted sheets for the same price you’re paying for your current sheets.
Independent laboratory studies1 showed that SoftSpan fitted sheets had 260% stretch in the width and 98% stretch in the length, compared to a regular knit sheet, which has 104% stretch in the width and 45% in the length. Regular woven sheets have no stretch at all. More stretch means a tighter, smoother fit, and no wrinkles. Mayo Clinic and other healthcare experts recommend keeping the bottom sheet pulled tight to prevent wrinkles and bunching, which can cause pressure that contributes to skin breakdown.2,3
References 1. Diversified Testing Laboratories, Inc. ASTM D 6614-07, “Standard Test Method for Stretch Properties of Textile Fabrics – CRE Method.” July 29, 2009. Data on file. 2. Mayo Clinic. Bed sores (pressure sores). Available at http://www.mayoclinic.com/health/bedsores/DS00570. Accessed on February 5, 2010. 3. Oregon Department of Human Services. Pressure Sores: A Self-Study Course. 2008. Available at: http://www.oregon.gov/DHS/spd/provtools/nursing/study-guides/pressure_sores.pdf3.
©2010 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.
Thank You! Providence St. Vincent Medical Center F rom th e h i g h e s t l e v e l s o f y o u r o r ganization down through your entire staff, we could not have picked a better partner for the “Pink Glove Dance,” video project. Thank you for taking part in a cause that touches us all.
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Boosting Hearts, Minds and Support for Breast Cancer Awareness
A YouTube™ Sensation
One early November morning, when the OR staff of Providence St. Vincent Medical Center was approached by Medline to take part in a little breast cancer awareness video they were doing, little did they know what an impact their participation would soon make. A little more than a month later, over six million people across the globe have seen the “Pink Glove Dance” video. The YouTube video phenomenon has been featured on CNN, ABC World News with Charles Gibson, Fox & Friends - Fox News Network’s national morning show, and literally more than 100 local TV newscasts across the country. News stories about the video also span the Internet, from the Huffington Post to the AOL home page. People can’t stop talking about this video, which showcases more than 200 hospital workers from the medical center in Portland, OR. dancing in Medline’s pink gloves. Phone calls, cards and e-mails are flooding both the hospital and Medline. And more than 10,000 people have posted comments about the video on YouTube. It has entertained and inspired laughter and, for many, it has evoked memories of their own battle with breast cancer or battles faced by loved ones. One viewer wrote: “Wonderful! This brought tears to my eyes as I am a survivor 13 years out and it reminded me of the wonderful staff at Yale Oncology unit. Thank you to all in the medical field. Please be sure to share this with those who are going through treatments. I am sure this will be helpful.” – mamakawecki55 Another said: “Given the type of work that they do, it is good to see them having fun for a good cause. Remember they are the ones who care for those with cancer.” – seaglassfriends
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Birth of an Idea Why would perfectly sane and incredibly busy hospital workers agree to dance in a YouTube video? The short answer is to get people talking about breast cancer. But there’s more to the story. It all began at Medline’s Corporate office when employees were brainstorming ideas to promote their new Generation Pink™ glove (launched in October). To further support Medline’s ongoing breast cancer awareness campaign (visit www.medline.com/breast-cancer-awareness for details), they had already implemented a promotion to donate $1 of every case purchased to the National Breast Cancer Foundation to fund mammograms for individuals who cannot afford them.
The next few days were a blur of action. The hospital sent out a call for employee volunteers to dance in the video. Back at Medline, the wheels were in motion. Jay Sean’s hit song “Down” was selected for the video and discussions took place to coordinate which areas of the hospital would be filmed, the number of staff participating in each shot and the overall plan of events.
But they needed a big idea to help spread the word. So, they asked, “What if we were to video healthcare workers dancing in pink gloves? Could we produce a viral video?” Little did they know. . . The first step was finding the right hospital to partner with Medline to create the video. The Providence Health System, a 26-hospital system in the northwest area of the country, proved to be the perfect choice. The health system suggested Medline work with Providence St. Vincent Medical Center in Portland, which not only was willing to give full access to each area of the facility for the video shoot, but also shared Medline’s passion for breast cancer awareness.
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The Making of the Video A week later, Medline product manager Emily Somers was at the hospital with a few boxes of pink gloves and the film crew. More than 200 employees of all ages, departments and skill levels answered the call to participate. “We had so many people who said, ‘You know, this disease has touched my life. I want to be a part of it,’” said
I am very honored that Medline and Providence St. Vincent Medical Center used my song “Down” to promote and support Breast Cancer Awareness. I like that such a fun and light hearted approach was taken to create awareness for a serious disease that can be cured if caught early. – Jay Sean
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Martie Moore, the chief nursing officer at Providence St. Vincent Medical Center. The filming took two days and Emily taught the volunteers basic dance moves to showcase the pink gloves. “In an environment filled with sickness and gloom, the caregivers brought incredible energy to the making of the video, expressing their great heart and spirit,” Emily said. From lab technicians and the kitchen help to surgical teams, they all let loose, dancing throughout the hospital.
Monte Crawford, “the mop man,” has become one of the more popular figures in the “Pink Glove Dance” video.
Touching People Around the World Thousands of people across the globe have posted inspiring comments about the video — even singer Jay Sean responded by posting a link to the video on his website. On his Facebook page he wrote, "The vid is awesome … medicine will always be close to my heart and this is such a worthy and important cause. So maybe I could have been a doctor and a singer at the same time after all then? Just brilliant."
17,000 Screaming Pink-Gloved Fans
Emily Somers, Medline product manager – and the choreographer of the “Pink Glove Dance” – teaches the lab staff of Providence St. Vincent some dance moves during the shooting of the video.
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To further spread the “Pink Glove Dance” message, more than 17,000 passionate fans recently wore Medline’s pink gloves at a live concert held in Chicago. With 34,000 pink gloved hands swaying back and forth to a live performance by Jay Sean singing his hit song “Down,” the arena took on a surreal appearance of a dense forest of pink trees waving in the wind. It was an unbelievable sight that brought tears to the eyes of many in the audience.
A world without breast cancer is in our hands. Medline’s Generation Pink latex-free, third-generation vinyl exam gloves have the comfort, barrier protection and price you love. Even better, when you choose Generation Pink gloves, you’re helping Medline support the National Breast Cancer Foundation.
Other ways to show your support: Become a Facebook fan at: facebook.com/ medlinebreastcancerawareness
Watch the “Pink Glove Dance” video at: YouTube.com/watch?v=OEdvfyt-mLw
For more information on Medline’s exam gloves, please contact your Medline representative, call 1-800-MEDLINE or visit www.medline.com.
©2010 Medline Industries, Inc. The cross-fingered pink glove hand image is a trademark of Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.
“ • National news – ABC, CNN, FOX, MSNBC • 17,000 fans donning pink gloves during a live performance of Jay Sean’s hit song, “Down”
Pink Glove Dance Video Goes Viral!
” • Over 6 million views on YouTube • Over 10,000 comments on YouTube • More than 120 TV news stories across the country
Support The Cause. Help fund free mammograms! When you choose Generation Pink Gloves, a portion of the proceeds will be donated to the National Breast Cancer Foundation to fund free mammograms for women who cannot afford them. Depending on who you are (an individual or a facility), there are two sites to choose from when ordering gloves. • Individuals visit www.scrubs123.com • Healthcare facilities visit www.medline.com/breast-cancer-awareness • If you wish to donate directly to the National Breast Cancer Foundation, visit the NBCF website www.nationalbreastcancer.org.
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Cheesy Potatoes (12 servings) • 16 oz. bag frozen hash brown potatoes (cubed or shredded) • 16 oz. container sour cream • 1 can cream of chicken soup • ½ c. chopped onion • 8 oz. bag shredded cheddar cheese
Topping: • 2 c. corn flakes • ¾ stick melted butter or margarine
Directions: Mix together all ingredients and place in a baking dish. Top with crushed corn flakes mixed with the melted butter. Cover with foil and bake at 350 degrees F for 30 minutes. Remove the foil and bake an additional 20-30 minutes. Hint: To cut down on salt and fat, use low-sodium soup and reduced fat cheese and sour cream. Shipping employee Dennis Shannon has worked at Medline’s Allentown, Penn. warehouse for 10 years. In his spare time, he enjoys cooking and entertaining. He said at his house, “I do the cooking and my wife does the baking, so it works out well.”
Servings: 12 Calories: 296 Fat: 12.7 g Sodium: 407.7 mg Fiber: 1.2 g
The Shannons regularly host parties at their home, where they have a fully outfitted game and entertainment room. Dennis said his cheesy potatoes dish is a big favorite with guests. “It’s easy and inexpensive to make, and people really like it.” Dennis offers another quick, easy and inexpensive recipe that’s also a big hit at parties: Spread a thin layer of chiveflavored cream cheese onto a flour tortilla and then layer it with a slice of turkey breast lunch meat, a piece of red leaf lettuce and pimentos. Roll it up and cut into slices for an attractive and delicious snack.
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©2010 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.
FORMS & TOOLS
The following pages contain practical tools for implementing patient-focused care practices at your facility. OASIS-C Integumentary Status ........................................86 H1N1 (Swine Flu) Patient Handout (English) ..................................89 Patient Handout (Spanish) ................................91 Leg Ulcers Clinical Fact Sheet: Quick Assessment of Leg Ulcers ......................................................93 Infection Prevention and Control Long-Term Care Audit ........................................95 Bariatrics Bariatric Assessment: Home Care/Long-Term Care Facility ....................................................101 Improving Quality of Care Based on CMS Guidelines 85
Forms & Tools
OASIS-C Integumentary Status
This checklist is part of the new OASIS-C guidance from the Centers for Medicare & Medicaid Services. OASIS-C went into effect at the end of 2009. For a step-by-step explanation of this portion of OASIS-C, turn to the article on page 29.
OASIS-C INTEGUMENTARY STATUS (M1300) Pressure Ulcer Assessment: Was this patient assessed for Risk of Developing Pressure Ulcers? 0 - No assessment conducted [ Go to M1306 ] 1 - Yes, based on an evaluation of clinical factors, e.g., mobility, incontinence, nutrition, etc., without use of standardized tool 2 - Yes, using a standardized tool, e.g., Braden, Norton, other (M1302) Does this patient have a Risk of Developing Pressure Ulcers? 0 - No 1 – Yes (M1306) Does this patient have at least one Unhealed (non-epithelialized) Pressure Ulcer at Stage II or Higher or designated as "not stageable"? 0 - No [ Go to M1322 ] 1 – Yes (M1307) Date of Onset of Oldest Unhealed Stage II Pressure Ulcer identified since most recent SOC/ROC assessment: __ __ /__ __ /__ __ __ __ month / day / year UK - Present at most recent SOC/ROC assessment NA - No new Stage II pressure ulcer identified since most recent SOC/ROC assessment
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OASIS-C Integumentary Status
Forms & Tools
OASIS-C INTEGUMENTARY STATUS (cont’d.) (M1308) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at Each Stage: (Enter “0” if none; enter “4” if “4 or more”; enter “UK” for rows d.1 – d.3 if “Unknown”) Stage description – unhealed pressure Number Present Number of these that were ulcers present on admission (most recent SOC / ROC) a. Stage II: Partial thickness loss of dermis presenting as a shallow open ulcer with red pink wound bed, without slough. May also present as an intact or open/ruptured serumfilled blister. b. Stage III: Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscles are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. c. Stage IV: Full thickness tissue loss with visible bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling. d.1 Unstageable: Known or likely but not stageable due to non-removable dressing or device d.2 Unstageable: Known or likely but not stageable due to coverage of wound bed by slough and/or eschar. d.3 Unstageable: Suspected deep tissue injury in evolution. Directions for M1310 and M1312: If the patient has one or more unhealed (non-epithelialized) Stage III or IV pressure ulcers, identify the pressure ulcer with the largest surface dimension (length x width) and record in centimeters: (M1310) Pressure Ulcer Length: Longest length “head-to-toe” | ___ | ___ | . | ___ | (cm) (M1312) Pressure Ulcer Width: Width of the same pressure ulcer; greatest width perpendicular to the length | ___ | ___ | . | ___ | (cm) (M1314) Pressure Ulcer Depth: Depth of the same pressure ulcer; from visible surface to the deepest area | ___ | ___ | . | ___ | (cm) (M1320) Status of Most Problematic (Observable) Pressure Ulcer: 0 - Re-epithelialized 1 - Fully granulating 2 - Early/partial granulation 3 - Not healing NA - No observable pressure ulcer
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Improving Quality of Care Based on CMS Guidelines 87
Forms & Tools
OASIS-C Integumentary Status
OASIS-C INTEGUMENTARY STATUS (cont’d.) (M1322) Current Number of Stage I Pressure Ulcers: Intact skin with non-blanchable redness of a localized area usually over a bony prominence. The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue. 0 1 2 3 4 or more (M1324) Stage of Most Problematic (Observable) Pressure Ulcer: 2 - Stage II 3 - Stage III 1 - Stage I [Go to M1330 at SOC/ROC/FU ] NA - No observable pressure ulcer
4 - Stage IV
(M1330) Does this patient have a Stasis Ulcer? 0 - No [ Go to M1340 ] 1 - Yes, patient has one or more (observable) stasis ulcers 2 - Stasis ulcer known but not observable due to non-removable dressing [ Go to M1340 ] (M1332) Current Number of (Observable) Stasis Ulcer(s): 1 - One 2 - Two 3 - Three 4 - Four or more (M1334) Status of Most Problematic (Observable) Stasis Ulcer: 1 - Fully granulating 2 - Early/partial granulation 3 - Not healing (M1340) Does this patient have a Surgical Wound? 0 - No [ Go to M1350 ] 1 - Yes, patient has at least one (observable) surgical wound 2 - Surgical wound known but not observable due to non-removable dressing [ Go to M1350 ] (M1342) Status of Most Problematic (Observable) Surgical Wound: 0 - Re-epithelialized 1 - Fully granulating 2 - Early/partial granulation 3 - Not healing (M1350) Does this patient have a Skin Lesion or Open Wound, excluding bowel ostomy, other than those described above that is receiving intervention by the home health agency? 0 - No 1 - Yes
88 Healthy Skin
Forms & Tools
H1N1 Patient Handout
H1N1 (Swine Flu) What is H1N1 flu?
H1N1 influenza, or swine flu, is a respiratory illness caused by type A influenza viruses. This virus was originally referred to as “swine flu” because it was thought to be very similar to flu viruses that normally occur in pigs (swine) in North America. H1N1 flu was first detected in people in the United States in April 2009. How does H1N1 flu spread? H1N1 flu is contagious and is spreading between people. This virus may be transmitted in similar ways that other flu viruses spread, through coughing or sneezing. A person may be able to infect another person one day before symptoms develop and for seven or more days (longer for children) after becoming sick. It is possible that someone may become infected by touching something with the virus on it and then touching his mouth or nose. Eating pork does not cause swine influenza.
What are the symptoms of H1N1 flu? The symptoms of H1N1 flu include fever, cough, sore throat, runny or stuffy nose, body aches, headache, chills and fatigue. Diarrhea and vomiting may also be associated with H1N1 flu. Most people with the virus have recovered without needing treatment, but hospitalizations and deaths have occurred.
H1N1 Symptoms • Headache • Fever • Fatigue
What should I do if I think I have H1N1 flu? If you have flu symptoms, stay home and avoid contact with other people to avoid spreading your illness. It is recommended that you stay home for at least 24 hours after your fever is gone, or if possible, until your cough is gone. If you have severe illness or you are at high risk for flu complications, contact your health care provider. He or she will determine whether testing or treatment is needed.
Seek emergency medical care for any of the following warning signs:
• Body aches
• Runny or stuffy nose • Sore throat • Cough
• • • • • •
• Difficulty breathing or shortness of breath • Pain or pressure in the chest or abdomen • Sudden dizziness • Confusion • Severe or persistent vomiting • Flu-like symptoms improve but then return with fever and worse cough
Fast breathing or trouble breathing Bluish skin color Not drinking enough fluids Not waking up or not interacting Being so irritable that the child does not want to be held Flu-like symptoms improve but then return with fever and worse cough • Severe or persistent vomiting
Text courtesy of NursingCenter.com. Images courtesy of Anatomical Chart Company. Lippincott Williams & Wilkins | Wolters Kluwer Health Businesses.
Improving Quality of Care Based on CMS Guidelines 89
Forms & Tools
H1N1 Patient Handout
How is H1N1 flu treated? The CDC recommends the use of oseltamivir (brand name Tamiflu) or zanamivir (brand name Relenza) to treat and/or prevent swine influenza. These antiviral medications may also prevent serious complications. For treatment, antiviral drugs work best if star ted within 2 days of symptoms.
What can I do to prevent H1N1 flu? You can reduce your risk of contracting and spreading swine influenza and other influenza viruses by: • Coughing or sneezing into your arm; avoiding close contact with people who have respiratory symptoms such as coughing or sneezing
• Not touching your eyes, nose, or mouth because this is how germs get into your body
• Staying home when you're sick and getting as much rest as possible
• Keeping surfaces and objects (especially tables, counters, doorknobs, toys) that can be exposed to the virus clean
• Washing your hands often with soap and water for 15-20 seconds; using alcohol-based hand cleansers is also acceptable
• Practicing other good health habits, including getting plenty of sleep, staying active, drinking plenty of fluids, and eating healthy foods
Lisa Morris Bonsall, MSN, RN, CRNP
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Text courtesy of NursingCenter.com. Images courtesy of Anatomical Chart Company. Lippincott Williams & Wilkins | Wolters Kluwer Health Businesses.
Check with your healthcare provider to see if the H1N1 vaccine is right for you.
Forms & Tools
H1N1 Español por los Pacientes
Virus de la influenza A subtipo H1N1 (anteriormente llamado de la «gripe porcina») ¿Qué es la gripe por H1N1? La gripe por H1N1, originalmente llamada «gripe porcina», es la enfermedad respiratoria que causa la infección por el virus de la influenza A subtipo H1N1. A este virus originalmente se le llamó virus de la «gripe porcina» puesto que se pensó que era muy similar a los virus que causan gripe en los cerdos (porcinos) en Norteamérica. El virus de la influenza A subtipo H1N1 fue detectado por primera vez en humanos en los Estados Unidos de Norteamérica en abril del 2009. ¿Cómo se propaga la gripe por H1N1? La gripe por H1N1 es contagiosa y se propaga de persona a persona. El virus puede propagarse de manera similar a otros virus de la gripe; a través de la tos o de los estornudos. Una persona puede infectar a otra un día antes de presentar síntomas y durante siete o más días (más tiempo en los niños) después de haber enfermado. Existe la posibilidad de que una persona se infecte al tocar una superficie contaminada con el virus si esta persona luego se pone las manos sobre la boca o nariz. Comer carne de cerdo no causa gripe por H1N1.
¿Cuáles son los síntomas de la gripe por H1N1? Los síntomas de la gripe por H1N1 incluyen fiebre, tos, dolor de garganta, nariz con mucosidad o tupida; dolor en el cuerpo, dolor de cabeza, escalofríos y fatiga. La mayoría de las personas que han tenido el virus se han recuperado sin necesitar tratamiento, pero ha habido otras que han necesitado hospitalización, y también otras que han muerto.
Síntomas de A(H1N1) • Dolor de cabeza • Fiebre • Fatiga
¿Qué debo hacer si pienso que tengo gripe por H1N1? Si usted piensa que tiene síntomas de gripe quédese en casa y evite entrar en contacto con otras personas para no propagar la enfermedad. Es recomendable quedarse en casa por lo menos durante 24 horas después de que le haya pasado la fiebre, o si es posible, después de que le haya pasado la tos. Si está gravemente enfermo, o si pertenece a un grupo de alto riesgo para desarrollar complicaciones, entre en contacto con su proveedor de atención médica. Él determinará si es necesario que le hagan análisis o que tome tratamiento.
• Escalofríos • Nariz con mucosidad o tupida • Dolor de garganta • Tos • Dolores corporales
Busque atención médica de urgencias si presenta cualquiera de los siguientes signos (señas) de alarma:
• • • • • •
• Dificultad para respirar o sensación de «falta de aire» • Dolor o sensación de presión en el pecho o en el abdomen • Mareo súbito • Confusión • Vómito intenso o persistente • Los síntomas como de gripe mejoran pero luego reaparecen con fiebre y tos más fuerte.
Respiración acelerada o dificultad para respirar Tonalidad morada en la piel No está tomando suficientes líquidos No se despierta o no responde a las acciones Está tan irritable que no quiere que lo alcen Los síntomas como de gripe mejoran pero luego reaparecen con fiebre y tos más fuerte. • Vómito intenso o persistente
Texto por cortesía del centro NursingCenter.com. Imágenes por cortesía de Anatomical Chart Company. Lippincott Williams & Wilkins | Wolters Kluwer Health Businesses.
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Forms & Tools
H1N1 Español por los Pacientes
¿Cómo es el tratamiento para la gripe por A(H1N1)? Los Centros para el Control y la Prevención de Enfermedades de los EE. UU. (CDC) recomiendan el uso de oseltamivir (nombre de marca Tamiflu) o de zanamivir (nombre de marca Relenza) para el tratamiento y la infección, o solamente para prevenir la infección por el virus de la influenza A(H1N1). Estos medicamentos antivíricos también pueden prevenir complicaciones graves. Para el tratamiento, los medicamentos antivíricos funcionan mejor si se comienzan a usar en un lapso de dos días después de que comienzan los síntomas.
¿Qué puedo hacer para prevenir la gripe por A(H1N1)? Usted puede disminuir su riesgo de contraer gripe por A(H1N1) y de propagar otros virus de la influenza de la siguiente manera:
• Tosiendo o estornudando sobre su brazo y evitando el contacto cercano con personas que presentan síntomas respiratorios tales como tos o estornudos.
• No tocándose los ojos, nariz o boca, pues ésta es la manera como los gérmenes llegan hasta nuestro cuerpo.
• Quedándose en casa cuando está enfermo y descansando el mayor tiempo que pueda.
• Manteniendo limpias las superficies y objetos (especialmente mesas, mesones, cerraduras de puertas) que puedan estar expuestos al virus.
• Lavándose las manos con frecuencia con agua y jabón durante 15 a 20 segundos o usando un limpiador para las manos con base en alcohol.
• Practicando otros hábitos saludables; incluso dormir bastante, mantenerse activo, tomar líquidos en cantidad y comer alimentos saludables.
Escrito por Lisa Morris Bonsall, MSN, RN, CRNP Traducido por Marcela D. Pinilla, M.H.E., M.T. (ASCP)
Texto por cortesía del centro NursingCenter.com. Imágenes por cortesía de Anatomical Chart Company. Lippincott Williams & Wilkins | Wolters Kluwer Health Businesses.
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Verifique con su proveedor de atención médica para determinar si la vacuna contra el virus de la influenza A(H1N1) es adecuada para usted.
1 5 0 0 0 C o m m e r c e Pa r k wa y, S u i t e C
Mount Laurel, NJ 08054
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NAILS Onychomycosis; dystrophic nails; paronychia, hypertrophy
SURROUNDING SKIN Normal skin tones Trophic changes Fissuring or callus formation Edema: with erythema may indicate high pressure Temperature: warm
WOUND Base: pink/pale; necrotic tissue variable; Depth: variable Edges well deﬁned Exudate: usually small to moderate Wound shape: usually rounded or oblong and found over bony prominence
SURROUNDING SKIN Pallor on elevation Dependant rubor Shiny, taut, thin, dry, Hair loss over lower extremities Atrophy of subcutaneous tissue Edema: variable; atypical Temperature: decreased/cold Infection: Cellulitis Necrosis, eschar, gangrene may be present
SURROUNDING SKIN Venous dermatitis (erythematic, weeping, scaling, crusting) Hemosiderosis (brown staining) Lipodermatosclerosis; Atrophy Blanche Temperature: normal; warm to touch Edema: pitting or non-pitting; possible induration and cellulitis Scarring from previous ulcers, ankle ﬂare, tinea pedis Infection: Induration, cellulitis, inﬂamed, tender bulla
Advanced age Alcoholism Chemotherapy Diabetes Hansen’s Disease Heredity HIV, AIDS and related drug therapies Hypertension Impaired glucose tolerance Obesity Raynaud’s Disease, Scleroderma Smoking Spinal Cord Injury and neuromuscular diseases
Altered pressure points/sites of painless trauma/repetitive stress Dorsal and distal toes Heels Inter-digital Metatarsal heads Mid-foot (dorsal and plantar) Toe interphalangeal joints
Quick Assessment of Leg Ulcers
WOUND Base: Pale; granulation rarely present; necrosis, eschar, gangrene (wet or dry) may be present Depth: may be deep Margins: edges rolled; punched out, smooth and undermining Exudate: minimal Infection: frequent (signs may be subtle)
Areas exposed to pressure or repetitive trauma, or rubbing of footwear Lateral malleolus Mid tibial Phalangeal heads Toe tips or web spaces
Arterial Disease Cardiovascular Disease Diabetes Dyslipidemia Hypertension Increased pain with activity and/or elevation IIntermittent Claudication Obesity Painful Ulcer Sickle Cell Anemia Smoking Vascular procedures/surgeries
WOUND Base: ruddy red; yellow adherent or loose slough; granulation tissue present, undermining or tunneling are uncommon Depth: usually shallow Margins: irregular Exudate: moderate to heavy Infection: less common
Advanced Age CHF Lymphedema Obesity Orthopedic Procedures Pain reduced by elevation Pregnancy Previous DVT with Phlebitis Pulmonary Embolus Reduced mobility Sedentary Lifestyle Traumatic Injury Vascular Ulcers Work History
Quick Assessment of Leg Ulcers
Malleolus Medial aspect of leg superior to medial malleolus
Venous Insufﬁciency (STASIS)
Clinical Fact Sheet
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Revised: November 24, 2009
Mount Laurel, NJ 08054
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Cautious use of occlusive dressings
INFECTED WOUND/DRY OR MOIST NECROSIS Referral for potential surgical debridement/antibiotic therapy OPEN WOUND/NON-NECROTIC Moist wound healing; Non-occlusive dressings Aggressive treatment of any infection
Use dressings that maintain a moist surface, absorb exudates and allow easy visualization
MEASURES TO ELIMINATE TRAUMA Reduction of shear stress and ofﬂoading of neuropathic wounds (bedrest, contact casting, orthopedic shoes) Use of assistive devices to provide support, balance and additional ofﬂoading Appropriate footwear Tight glucose/glycemic control Aggressive prevention/treatment of infection (debridement of callus and necrotic tissue; pharmacologic treatment when appropriate) Revascularizaton if ischemic Complications: Cellulitis, osteomyelitis, gangrene, Charcot fracture
DRY, NON-INFECTED, NECROTIC WOUND Keep dry
MEASURES TO IMPROVE TISSUE PERFUSION Revascularization if possible Medications to improve RBC transit through narrowed vessels Lifestyle changes (avoid tobacco, caffeine, restrictive garments, cold temperatures) Hydration Measures to prevent trauma to tissues (appropriate foot wear) Maintain legs in neutral or dependent position Pressure reduction for heels and toes
1 5 0 0 0 C o m m e r c e Pa r k wa y, S u i t e C
Goals: absorb exudates, maintain moist wound surface
30mm Hg compression at ankle‘ **See WOCN Clinical Practice Guideline for Compression Therapy
Surgical obliteration of damaged veins Elevation of legs Medications Exercise Education Compression therapy to provide at least
NON-INVASIVE VASCULAR TESTING Capillary reﬁll: Normal
NON-INVASIVE VASCULAR TESTING Capillary reﬁll: Delayed (more than 3 seconds) ABI