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The Scoop on

Tom Daschle
on Healthcare
Create a
Improving Quality of Care Based on CMS Guidelines
Volume 6, Issue 3
Join the team!
When it comes to hot
topics in long-term care,
you’re the experts!
You, our readers, are on the front lines of everything that
happens in the healthcare industry – and we want to hear
from you! Have you ever wished you could write an
article that would be 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!
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©2009 Medline Industries, Inc. Healthy Skin is published by Medline Indus-
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Meeting the highest level of national and international quality standards,
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Page 26
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Page 50
Page 10
Survey Readiness
71 Making Sense of Changes to the LTC Surveyor Guidance
33 A Systematic Approach to Pressure Ulcer Prevention
Improves Patient Care, Reduces Costs
42 Legal Issues in the Care of Pressure Ulcers
50 Clean Up Your Act!
57 Tell Me Again Why This Resident Needs a Catheter?
66 Falls in Nursing Homes
26 What is Palliative Care?
31 Frequently Asked Questions: Palliative Care
46 Case Study: The Use of Basement Membrane and
Extracellular Matrix-Containing Urinary Bladder Matrix
56 A Cost Effective Alternative to Urinary Catheterization
78 The Many Benefits of Correctly Sized Incontinence Briefs
Special Features
8 The Quality Summit Highlights
14 Prevention Above All Conference Highlights
19 Public Reporting of Healthcare Errors and Infections
20 Whatʼs Happening in Healthcare Reform
22 They Call it a Nursing Home for a Reason
81 Creative Communication Techniques (English)
82 Creative Communication Techniques (Spanish)
84 FDA Issues Warnings for Diabetic Test Strips
49 The Gangʼs All Here and Theyʼre Ready to Play
Regular Features
6 Two Important Initiatives for Improving Quality of Care
39 Hotline Hot Topic: Support Surfaces
Caring for Yourself
90 How to Communicate More Effectively and
Get More of What You Want
96 Losing Sleep Over Economic Worries?
99 Support Breast Cancer Awareness
Forms & Tools
102 Ten Absolutes: Simplify Daily Tasks and Create
Positive Interactions (English)
104 Ten Absolutes: Simplify Daily Tasks and Create
Positive Interactions (Spanish)
106 Incontinence Product Selection
107 FAQs: Catheter-Associated Urinary Tract Infection
109 How to Handrub?
110 Practice Hospital Bed Safety
115 Pressure Ulcer Pocket Reference Card
Sue MacInnes, RD, LD
Clinical Editor
Margaret Falconio-West, BSN, RN,
Managing Editor
Alecia Cooper, RN, BS, MBA, CNOR
Senior Writer
Carla Esser Lake
Creative Director
Mike Gotti
Clinical Team
Clay Collins, RN, BSN, CWOCN, CFCN,
Lorri Downs, RN, BSN, MS, CIC
Margaret Falconio-West BSN, RN,
Cynthia Fleck MBA, BSN, RN, APN/CNS,
Joyce Norman, RN, BSN, CWOCN,
Elizabeth OʼConnell-Gifford, RN, BSN,
Melissa Rossetta BSN, RN, CWCN
Jackie Todd, RN, BSN, CWCN, DAPWCA
Wound Care Advisory Board
Mary Brennan, RN, MBA, CWON
Zemira M. Cerny, BS, RN, CWS
Patricia Coutts, RN
Cindy Felty MSN, RN, CNP, CWS
Evonne Fowler, RN, CNS, CWON
Lynne Grant, MS, RN, CWOCN
Dea J. Kent, RN, MSN, NP-C, CWOCN
Diane Krasner, PhD, RN, CWCN, CWS,
Andrea McIntosh, RN, BSN, CWOCN, APN
Linda Neiswender, RN, BSN, CPN
Laurie Sparks, WOCN
Lynne Whitney-Caglia, RN, MSN, CNS,
Laurel Wiersema-Bryant, RN, ANP, BC
Deborah Zaricor, RN, CWOCN
Improving Quality of Care Based on CMS Guidelines
Page 66
Improving Quality of Care Based on CMS Guidelines 3
Dear Reader,
It is with a sense of anticipation and genuine excitement
that we launch this edition of Healthy Skin. Never in the
history of this country has there been such an outpour-
ing of debate and discussion on just how health care
should be delivered, paid for and measured. Medline has
been fortunate to have the opportunity on two different
occasions, to bring together top healthcare executives,
first from the long-term care industry, and then from the
acute care industry, to discuss these issues. As a matter
of fact, the first 18 pages of Healthy Skin are dedicated
to these conferences, which were held in Washington,
DC in July and August of this year.
The meeting in July, The Quality Summit, brought
together executives, both clinical and administrative,
from long-term care facilities. We were grateful for the
opportunity to host Dr. Keith Krein, chief medical officer
of Kindred Healthcare; Dr. Andy Kramer, division head of
healthcare policy and research at the University of Col-
orado; Mary Ousley, healthcare consultant and co-chair
of AHCA Survey and Regulatory and Wayne Brannock,
vice president of clinical affairs for Maryland Health En-
terprises, just to name a few. The discussions, including
a presentation by Senate Majority Leader Tom Daschle,
centered around a continuous programof quality assur-
ance. What are the obstacles? What has worked for
these thought leaders to this point? How will the industry
be molded in the future? How can long- termcare better
integrate with both hospitals and home care? And, how
can we all, working together, provide the best care pos-
sible, to all patients all of the time? This was an open
forumdiscussion, mixed with personal experiences, but
centered on defining and offering a plan for executing
quality care.
The meeting in August, Prevention Above All, was geared
toward chief medical officers and chief nursing officers
from over 100 acute care hospitals from across the
country. The emphasis of the conference was on
prevention, specifically covering innovations in the
reduction of catheter-associated urinary tract infections
(CAUTI), hospital-acquired pressure ulcers and ways to
improve hand hygiene practices. The audience was a
powerhouse of talent, but just as dynamic were the
program presenters, which included Tom Daschle, Dr.
Didier Pittet, fromthe World Health Organization (WHO);
Dr. Trent Haywood, chief medical officer from VHA;
Deborah Adler, known for educational healthcare prod-
uct packaging design and Dr. Dale Bratzler, CEO of the
national hospital QIO and representing the Surgical Care
Improvement Project (SCIP) …and these are just a few
of the speakers. We were also honored to host Dr.
Harvey Fineberg, president of the Institute of Medicine,
who discussed comparative effectiveness research and
how it will impact the healthcare industry in the future.
In this publication, we’ve given you a brief overview of
what took place at these conferences, but I encourage
you to also visit to hear for yourself
the issues and potential solutions that are being dis-
cussed in both the long-termcare and acute care arena.
In August, we also announced our Discovery Grant
Award winners, listed on page 15. Medline awarded
over $700,000 in grant money to stimulate research
that will lead to the development of new targeted inter-
ventions aimed at reducing medical risks and potential
harmassociated with hospital-acquired conditions, with
a goal of effecting quality care in all settings. This initial
grant program was so successful that Medline will be
awarding a second round of grant funding. The next
grant application period will be fromNovember 1, 2009
through March 31, 2010.
And that’s just the beginning of this magazine edition.
You also will find an array of information on palliative care,
falls prevention, diabetes care, pressure ulcers, CAUTI,
our kick-off of our year-round breast cancer program,
“Together we can save lives through early detection,” and
much, much more.
All the best to you, until we meet again,
Sue MacInnes, RD, LD

How can we all,
working together,
provide the best
care possible, to
all patients all of
the time?
4 Healthy Skin
Content Key
Weʼve coded the articles and information in this magazine to indicate which national quality initiatives
they pertain to. Throughout the publication, when you see these icons youʼll know immediately that
the subject matter on that page relates to one or more of the following national initiatives:
• QIO – Utilization and Quality Control Peer Review Organization
• Advancing Excellence in Americaʼs Nursing Homes
Weʼve tried to include content that clarifies the initiatives or give you ideas and tools for implement-
ing their recommendations. For a summary of each of the above initiatives, see Pages 6 and 7.
Healthy Skin Letter from the Edi tor
data makes
it clear.
is like
no other.
Independent outcomes research
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!
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.
Medline and Medline Remedy are registered trademarks of Medline Industries, Inc.
To receive a FREE TRIAL of
our effective Remedy skincare products,
contact your Medline sales representative.
Help reduce your risk of liability
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Nosocomial pressure ulcers
reduced by 50%
after 3 months
Nosocomial pressure ulcers
reduced to zero
after 8 months
Estimated cost savings of
$6,677.11 per patient
6 Healthy Skin
Two Important National Initiatives
for Improving Quality of Care
Achieving better outcomes starts with an understanding of current quality
of care initiatives. Hereʼs what you need to know about national projects and
policies that are driving changes in nursing home and home health care.
Origin: The QIO Statement of Work is based upon Part B of the Title XI of the Social Security Act. The Medicare-funded “Ninth
Scope of Work” plan became effective August 1, 2008 and is a three-year work plan.
Purpose: To carry out statutorily mandated review activities, such as:
• Reviewing the quality of care provided to beneficiaries;
• Reviewing beneficiary appeals of certain provider notices;
• Reviewing potential anti-dumping cases; and
• Implementing quality improvement activities as a result of case review activities.
Goal: In the 9th SOW, the QIO Program has been redesigned with a framework for accountability and also in content. The
content now consists of four themes with the goal to help providers, both in long-term care and acute-care facilities,
prevent illness, decrease harm to patients and reduce waste in health care.
Of note: QIOs will be required to help Medicare promote three overarching themes: adopt value-driven healthcare,
support the adoption and use of health information technology and reduce health disparities in their communities.
Under the direction of the Centers for Medicare & Medicaid Services (CMS), the QIO Program consists of a national
network of 53 QIOs located in each of the 50 U.S. states, the District of Columbia, Puerto Rico and the Virgin Islands.
Quality Improvement Organization Program’s 9th Scope of Work Theme
The official Executive Summaries for the 9th SOW Theme are available at:
Origin: A coalition-based, two-year campaign initiated on September 26, 2006 to improve quality of life for nursing home
residents and staff. The coalition has continued the campaign beyond its first-round end of August 25, 2008 for an
additional 2 years (until September 26, 2010).
Purpose: Acoalition consisting of the Centers for Medicare & Medicaid Services (CMS), organizations representing providers,
consumers and government that developed a grassroots campaign to build on and complement the work of 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
QIO Utilization and Quality Control Peer Review Organization
9th Round Statement of Work
Advancing Excellence in America’s Nursing Homes
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: 70.8% Goal 5: 32.1%
Goal 2: 45.4% Goal 6: 62.7%
Goal 3: 54.3% Goal 7: 41.3%
Goal 4: 39.4% Goal 8: 31.3%
Visit this Web site to view progress by state!
*Based on the latest available count of Medicare/Medicaid nursing homes
Improving Quality of Care Based on CMS Guidelines 7
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 perform-
ance 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 28
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
The 9th Scope of Work Content Themes
Clinical Goals: Goal Actual
Goal 1: Reducing high-risk pressure ulcers < 10% 11%
Goal 2: Reducing the use of daily < 5% 3.9%
physical restraints
Goal 3: Improving pain management for < 4% 3.8%
longer-term nursing home residents
Goal 4: Improving pain management for < 15% 20.5%
short-stay, post-acute nursing
home residents
Operational/Process Goals: Goal Actual
Goal 5: Establishing individual targets for > 90% 36.5%
improving quality
Goal 6: Assessing resident and family 22.5%
satisfaction with quality of care
Goal 7: Increasing staff retention 13.9%
Goal 8: Improving consistent assignment 26.6%
of nursing home staff so that
residents receive care from the
same caregivers
Clinical and Operational/Process Goals
Participating nursing homes: 7,434
Percentage of participating nursing homes:* 47.3%
Participating consumers: 2,224
Represents a 7.4% increase in
participation since January 2008.
Average number of goals per
nursing home: 3.8
Quality Summit Shares Center Stage
with Healthcare Reform Debate
Nation’s Capital Site of Medline’s
First Quality Summit for LTC Leaders
The Quality Summit
This summer, while Congress was hotly debating the
merits of healthcare reform, another key meeting was
taking place in our nation’s capital on improving health care
in this country.
Just down the block fromthe capitol building in Washington,
DC, more than 100 thought leaders from skilled nursing
facilities across the country gathered to discuss the
changing healthcare policy landscape, industry trends and
resident-centered quality assurance measures.
Former Senate Majority Leader TomDaschle, architect of the
Obama administration’s healthcare reform efforts, delivered
the keynote address at Medline’s inaugural Quality Summit:
A NewEra of Quality Assurance in Long-TermCare held July
19-21. Senator Daschle praised the content and opportune
timing of the summit.
“The timing of this Medline conference simply could not be
better,” he remarked. “We are in the heart of this special
moment in 2009.” But he also expressed disappointment
in how the reform initiative is addressing the issues in
long-term care. There is “not sufficient awareness and
recognition of the degree to which long-term care fits into
this picture,” Daschle said. “Greater emphasis on wellness,
good chronic care management, reducing administrative
costs and creating a strong technology infrastructure are
also needed,” he added.
Still, Daschle urged participants to lend their voices to the
debate to help craft legislation addressing long-term care
issues. He also emphasized the importance of quality initia-
tives to high value health care, outlining three goals he hoped
reformwould achieve: 1) increased access to health care,
2) cost reductions and 3) improved outcomes through
quality initiatives.
8 Healthy Skin
Continued on Page 10
Special Feature
©2009 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc., abaqis is a registered trademark of Nursing Home Quality, LLC
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.
is the only quality assessment and reporting
system for nursing homes that is tied directly to the QIS,
and its quality assessment modules reproduce the same
forms, analysis and thresholds used by State Agency
surveyors. Rich reporting capabilities on 30 care areas
guide you to what surveyors will be targeting in your facility.
That gives you a unique advantage in preparing for your
survey – and in meeting your resident’s needs.
is sold exclusively through Medline.
Learn more by signing up for a free webinar
demo at
“ How do we improve
our resident and family-
centered quality of care
and prepare for QIS?
We use abaqis.”
Sherri Dahle, RN, DNS
Director of Nursing
Central Healthcare
LeCenter, MN
10 Healthy Skin
Quality Efforts Critical as Acuity Moves Downstream
In open panel discussions, nursing home medical directors,
administrators and chief executives noted the importance of
quality efforts in understanding the increasingly complex
needs of the residents and patients being served by long-
termcare facilities.
With the increasing popularity of home- and community-
based options, which allow seniors to “age-in-place” in less
restrictive settings, a growing number of residents are “com-
ing to the skilled nursing environment at a later point in their
life expectancy and with more multi-morbid conditions,”
explained conference panel member Keith Krein, MD, chief
medical officer at Kindred HealthCare’s Health Services
Division based in Louisville, KY.
Dr. Krein stressed the growing importance and connection
between physician services and quality measures. With
some patients seeking rehabilitation services, and others
requiring chronic or custodial care —all in the same facility—
ongoing quality assurance efforts can help identify the differ-
ences in the care needs because regulatory oversight hasn’t
stayed in synch with this pivotal industry shift, he said.
“Forty years ago, long-term care was mostly custodial in
nature,” Dr. Krein said. “Acute care, rehabilitation and
recovery took place in the hospital environment, as opposed
to the nursing home. Today’s environment increasingly
consists of patients requiring many distinct types of care
all residing in one facility. Quality measures can improve
services and control costs.”
Quality Assurance Tools Key to Excellent
Customer Service
As skilled nursing facilities compete for private-pay rehabili-
tation patients, panelists also spoke about the importance
of improving the perception of the facility not only with state
surveyors, but also with staff, residents, patients and family
members shopping for rehabilitation or custodial care
“Stop looking for revenue from the government. It’s not
going to be there,” advised Barry Bortz, chief executive of-
ficer of Carespring Health Management in Loveland, Ohio.
“Generate outside sources of revenue. To be successful at
generating outside sources of revenue, you have to have
good customer service and you have to have those [quality
assurance] tools in place.”
For its quality assurance program, Bortz said, Carespring
utilizes abaqis, the only quality assessment and reporting
systemtied directly to the Quality Indicator Survey (QIS). The
Centers for Medicare & Medicaid Services (CMS) plan to roll-
out QIS in all 50 states, and to date more than 13 states have
begun implementation.
abaqis, sold exclusively through Medline, is a Web-based
system that enables nursing home providers to identify
quality concerns and focus their improvement efforts using
the same forms, analysis and thresholds used by the state
surveyors in the QIS survey. But abaqis is also designed as
an ongoing quality improvement system to help enhance
customer satisfaction year-round.
The Quality Summit
Improving Quality of Care Based on CMS Guidelines 11
Panelist Wayne Brannock, vice president of clinical affairs for
Maryland Health Enterprises in Ellicott City, MD, said using
abaqis transformed the quality assurance process at his
skilled nursing facility. Just like QIS, abaqis requires
facilities to interview staff members, residents and their
families about specific aspects of care.
During Brannock’s first resident interview, the resident
responded negatively to the QIS question regarding bedtime.
Brannock calls the carefully worded question, “Is this
acceptable to you?” the five magic words.
After receiving the resident’s response, Brannock said,
“That’s the day we changed QA in our company, because
that’s the day that we started actually communicating to
residents,” he recalled. “By asking them what they really
want, we’re finding out what’s acceptable to them, and then
we alter our service to improve their experience.”
Quality Assurance: Truly a Year-Round Initiative
But the panelists pointed out that truly improving quality
involves more than annual state survey preparations and
offers greater rewards than just a successful survey.
“Systematic quality improvement brings confidence, and it
brings trust,” said Mary Ousley, president of Ousley &
Associates in Richmond, KY, and co-chair of the American
Health Care Association Survey and Regulatory. “It brings
confidence in your staff—[confidence] that they really know
what they are doing and that they are part of making change,
and it brings trust internally and externally to the organiza-
tion fromsurvey organizations and finance.”
Ousley explained that incorporating quality measures into
howa facility operates, versus addressing it only in response
to state surveys, was key to ensuring better care for residents
and ensuring that the facility continuously improves.
Nancy Schwalm,
Mary Ousley, Neil L.
Pruitt Jr. and Keith
Krein at Medline’s
Quality Summit,
July 19-21, in
Washington, DC.
12 Healthy Skin
The overwhelming message conveyed by all of the Quality
Summit panelists was that for a nursing home to survive and
thrive, it must focus quality assurance efforts in resident-
centered quality care.
“The whole customer satisfaction movement has come
a long way in long-term care over the last 20 years, and
particularly over the last five – and will be an increasingly
important part of the milieu for years to come,” Krein
explained. “It gets back to person-centered care, it gets back
to culture change and what’s important to each individual,
and obviously we need to embrace that and do more of
it, because it’s only through asking those questions and
understanding whether we are improving the services that
are truly needed, will we improve as time goes on.”
During the Quality Summit, a chief medical officer from one
skilled nursing facility raised the issue of how best to define
quality and whether the term still applied to the latest QIS
survey guidance by CMS and resident-centered care
approaches. Summit speakers Keith Krein, Andrew Kramer,
Mary Ousley and Carmen Shell shared their insights, each
stressing the importance of individualized care and the
evolution of the quality movement.
Keith Krein, MD. Quality starts by
recognizing the “heterogeneity of today’s
nursing centers and the fact that we have
many different types of individuals—
young folks, middle-aged folks, elderly
folks—coming through our doors with
different desires, different needs and
different discharge goals,” said Keith
Krein, MD, chief medical officer at Kindred Healthcare. Dr.
Krein explained that two individuals with the same diagnosis
may request different types of treatment, emphasizing the
importance of taking those differences into consideration
when formulating a treatment plan.
Andrew Kramer, MD. “We need to
work on the definition. The definition of
quality as a standard set of practices that
are forcefully applied in every case
regardless of whether they apply or not is
the wrong definition of quality,” said
Andrew Kramer, MD, division head of
health care policy and research at the
University of Colorado. “You want to try to measure the vari-
ability in care that exists within an organization. Do you adapt
and customize and tailor care to the needs of all the people,
or do you do the same thing every time because that’s the
way it’s supposed to be? Because that ability to vary and tai-
lor care is more about quality than applying that same
structured approach regardless of the individual’s needs. We
have managed over the years to define quality with rigidities
that do not reflect quality.”
Mary Ousley. “The totality of services
that meet or exceed the expectations of
the individual defines quality,” said Mary
Ousley, president of Ousley & Associates,
drawing on the definition crafted by the
American Health Care Association and
Bernie Dana, chair of AHCA/NCAL’s
National Award Board of Overseers.
Ousley stressed that maintenance and environmental serv-
ices may be of greater importance to one resident, while
nursing care and services rank highly for another. Only by
taking the resident’s perception and desires into considera-
tion can a facility truly achieve quality.
Carmen Shell. Carmen Shell, vice
president of clinical services at Morse
Geriatric Center, also stressed the
importance of understanding the specific
goals and expectations of each resident
while creating a workable definition of
quality. “The mistake that we make is
defi ni ng qual i ty for others,” Shel l
explained. “We don’t ask the right questions. That’s one thing
about QIS that is beginning to come full circle, and that is the
right questions are being answered, but sometimes we don’t
listen to the answers. The questions are being asked, and
the questions are getting better and better, but what are the
answers to those questions? And if we really want to effect
change, what are we doing?”
When it Comes to Resident-Centered Quality of Care, One Size Does Not Fit All
Improving Quality of Care Based on CMS Guidelines 13
Survey Says…
To get a handle on the key issues facing our nation’s nursing
homes, the more than 100 long-term care executives at
the Quality Summit in Washington, DC were polled on the
new QIS process and steps their facilities take to prepare
for annual state surveys. Following are some of the poll
questions and responses:
What are the top three things that keep you
up at night?
16% Patient/resident satisfaction
16% State survey
13% Documentation
13% Financial stability
11% Census
8% Lawsuits
8% Nursing shortage
6% Education & training
6% Turnover
Are your survey preparation activities aligned
with your quality assurance initiatives?
80% Yes
20% No
What do you do to prepare for the survey?
60% Mock survey
24% Chart review
16% Attempt to predict sample
How far in advance of the annual state survey
do you begin preparing for it?
43% More than 6 months
40% 3-6 months ahead
17% Less than 3 months ahead
Have any of your buildings been through
a QIS survey?
68% No
32% Yes
Do you feel QIS will improve the quality
of resident care?
46% Yes
18% No
36% I don’t know enough about it yet
Source: Medline Industries, Inc. poll of approximately
110 Quality Summit attendees. Data on file.
Mary Ousley on Quality
Looking back on her decades of
experience in long-term care,
Mary Ousl ey bel i eves the
opportunity is before us today
to take charge of quality.
And her definition of quality
involves far more than keeping
track of QIs and QMs in note-
books, and then analyzing the
data each month. She believes
quality is best achieved by integrating a quality mindset
into everything you do at your facility.
“[ Qual i ty] i s the way you run your busi ness. I t i s
embedded every single day. It is a philosophy of manage-
ment that keeps your facility running,” Ousley said. “It is a
business model that takes into consideration your business
systems, your clinical systems, your human resources
systems. And if you run it any other way, then you won’t
really have a quality management system.”
“Quality management – exactly as it should work
– is about moving an organization forward.”
After beginning her nursing career in acute care, Ousley
reluctantly switched to long-term care when her husband
asked her to serve as administrator for one of their family-
owned nursing homes in Kentucky.
She remembers one particular day at that facility when she
established her personal mantra for long-term care. It was
the day she met a resident named Hazel, whose colorful
past included a position with Bob Hope’s public relations firm.
“It was absolutely amazing to sit and talk with her,” Ousley
said. “What I saw that day really set my path on quality. I no
longer saw older people. I saw people. I learned about the
value inside individuals and how we have to recognize and
honor it in every single thing we do.”
To achieve this, every team member must be onboard,
according to Ousley, who often says the one position she
would eliminate in long-termcare if she could would be the
quality assurance nurse.
“The quality assurance nurse cannot assure quality. It has to
be the team. It has to be the way we manage our facility
every single day. It has to be the leadership we demon-
strate,” Ousley said. “And the individual has to rest in the
center of it – in our hearts – about what we do for quality.”
Prevention Above All Conference,
Washington, DC, August 16-18, 2009
Chief nursing officers, chief medical officers, directors of nursing
and other clinical executives from hospitals across the country
gathered in Washington, DC, August 16-18, 2009, for Medline’s
second annual Prevention Above All Conference. They learned
new strategies for delivering cost-effective, high-quality health
care in today’s uncertain economic climate, as well as evidence-
based solutions for improving patient outcomes.
An impressive agenda
Tying in all that is top-of-mind on Capitol Hill
these days, former Senate Majority Leader Tom
Daschle opened the conference by discussing
the need for a stronger emphasis on primary
care networks and an increased role for nurses
in the prevention movement. Following Daschle
was Institute of Medicine President Harvey
Fineberg, who addressed the overwhelming
benefit of comparative effectiveness research.
He also acknowledged, however, that “compar-
ative effectiveness research alone will not ensure
the adoption of valuable preventive care.”
Emphasis on patient safety
Patient safety was a major focus, and world renowned experts
shared the latest innovations and evidence-based practices in
the prevention of catheter-associated urinary tract infections
(CAUTI), hand hygiene and pressure ulcer prevention.
CAUTI. Medline introduced its new evidence-based system to
help prevent CAUTI. The ERASE CAUTI™ program combines
product and packaging design, education and awareness to
tackle catheter-associated urinary tract infection – a prevalent
hospital-acquired infection.
Hand hygiene. Internationally renowned professor and epi-
demiologist Didier Pittet of Switzerland shared the latest hand
hygiene improvement strategies, including the new standard of
care, alcohol-based hand rubs. Dr. Pittet is a member of the
World Health Organization (WHO) World Alliance for Patient
Safety and lead of the WHO’s First Global Patient Safety
Challenge, “Clean Care Is Safe Care.”
In addition, German epidemiologist Günter Kampf presented
new discoveries and considerations in hand sanitizing tech-
niques. He discussed the recommendation by the WHO that
hand sanitizers should contain 80%ethanol by volume for safe
and effective hand decontamination. However, he noted that
the United States currently recommends only 62%ethanol, far
below the global standards defined by the WHO. Dr. Kampf
works in the department of scientific affairs at Bode Chemie
GmbH & Co. in Hamburg, Germany. He is the author of 119 sci-
entific papers published in international infection control journals.
Pressure ulcers. Pressure ulcer assessment and prevention
remains a major area of concern. Wound care expert Elizabeth
Ayello provided insight on CMS present-on-admission (POA)
indicators as they relate to hospital administrators and clinicians.
Also, two experts in wound care and healthcare law, Kevin
Yankowski, J.D., partner at Fulbright & Jaworsky, LLP and
Caroline Fife, MD, CWS, chief medical officer, Intellicure, Inc.,
addressed the legal implications of caring for patients with
pressure ulcers, sharing ways healthcare professionals can
protect themselves from litigation. Aspects of their presentation
were based on their new white paper, “Legal Issues in the Care of
Pressure Ulcer Patients: Key Concepts for Healthcare Providers.”
SCIP. The Surgical Care Improvement Project continues to
evolve, with two new measures debuting in October 2009. Highly
regarded quality improvement specialist Dale Bratzler, medical
director of the Hospital Interventions Quality Improvement
Organization and SCIP, discussed patient safety in the context
of SCIP and expanded on the upcoming new and revised
SCIP measures.
Event highlights at
For more information on the speakers and event coverage, visit
the Prevention Above All page at
Critical: What We Can Do About the
Health-Care Crisis, authored by former
Senator Tom Daschle, outlines the
healthcare reform strategies that are the
foundation of President Obama’s health-
care initiative. Evaluating where previous
attempts at national healthcare coverage
have succeeded, and where they have
gone wrong, Daschle explains the
complex social, economic and medical
issues involved in reform and sets forth his vision for change.
The book is available for purchase at leading retail
bookstores and online outlets.
14 Healthy Skin
Pilot Grants (funding up to $25,000 each)
Title: Surgical Time Out Assurance Program
Institution: Carilion Clinic, Roanoke, Virginia
Principal Investigator: Deb Copening
Target: Surgical site infection and errors
Title: Descriptive Study of OR Nursing Data Elements (Perioperative
Clinical Processes, and Patient Outcomes)
Institution: AORN (Association of PeriOperative Registered Nurses),
Denver, CO
Principal Investigator: AkkeNeel Talsma
Target: Errors obtained in the perioperative area (OR processing errors
and surgical patient complications)
Title: Multi-institutional trial to test the validity of newly created HAI
definitions and criteria designed especially for behavioral hospital and
health care settings
Institution: Acadia Hospital, Bangor, Maine
Principal Investigator: Thomas Shandera
Target: Healthcare-acquired infections
Title: Pressure Ulcer Assessment Among Ethnically Diverse Patients
Institution: Kaiser Permanente, San Jose Medical Center, San Jose, Calif.
Principal Investigator: Katherine Ricossa
Target: Pressure ulcers
Title: Statewide Maine Infection Prevention Collaborative (MIPC)
Institution: Eastern Maine HealthCare System, Brewer, Maine
Principal Investigator: Erik Steele
Target: Healthcare-acquired infections
Title: Progressive Mobility Among Critically Ill and Critically Injured Patients:
An Examination of Clinical Outcomes Prior to the Implementation of
Standardized Guidelines
Institution: East Tennessee State University College of Nursing, Johnson
City, Tenn.
Principal Investigator: Mona Baharestani
Target: VAP, Pressure ulcers, falls, DVT, PE, catheter-associated
urinary tract infections
Title: Accelerating Pressure Ulcer Prevention Through Regional
Collaboration – Partnership Grant
Institution: The Hospital and HealthSystem Association of
Pennsylvania/Health Care Improvement Foundation Pennsylvania
Principal Investigator: Lynn Leighton and Kate Flynn
Target: Pressure ulcers
Empirical Grants (funding up to $100,000 each)
Title: Cost Effectiveness of a Liquid Skin Protectant in the Prevention of
Heel Pressure Ulcers
Institution: New York Methodist Hospital, Brooklyn, New York
Principal Investigator: Judy A LaJoie
Target: Heel pressure ulcers
Title: Pressure Ulcer Prevention via Early Detection and Documentation
(both pediatric and adult)
Institution: Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
Principal Investigator: Marty O. Vischer
Target: Pressure ulcers
Title: Perioperative Positioning Injuries Program
Institution: Massachusetts General Hospital/Harvard Medical School
Principal Investigator: Jesse M. Ehrenfeld
Target: Perioperative positioning-related injuries
Title: Family Centered Pressure Ulcer Prevention Program
Institution: Grady Health System, Atlanta, Georgia
Principal Investigator: Rhonda Scott
Target: Pressure ulcers
Title: Hand Hygiene Intervention Study
Institution: Englewood Hospital and Medical Center, Englewood,
New Jersey
Principal Investigator: Maryelena Vargas
Target: Hospital acquired infections
Title: A Comprehensive Pressure Ulcer Prevention Program in a
Multi-System Health Care Network
Institution: St. Luke’s Hospital and Health Network, Bethlehem, Penn.
Principal Investigator: Joanne Labiak
Target: Pressure ulcers
2009 Prevention Above All
Discoveries Grants awarded
Dr. Andrew Kramer, professor of medicine at
the University of Colorado, and chair of the
Prevention Above All (PAA) Discoveries Grant
Review Committee, announced the names of
the 2009 grant recipients.
The objective of the PAA Discoveries Grant
program is to stimulate research that will
lead to the development of new targeted
i nterventions aimed at reducing medical risks and harms
associated with hospital-acquired conditions (identified by the
Centers for Medicare & Medicaid Services 2008 IPPS final rule).
All grant applications and proposals were independently
reviewed and approved by healthcare professionals who served
on the grant committee. Grant recipients will be paired with a
research mentor/consultant to develop methods and guide the
conduct of the study, ensuring that a rigorous research process
is followed.
2009 Prevention Above All Discoveries Grant Recipients
Congratulations to the following Prevention Above All Discoveries Grant recipients.
Improving Quality of Care Based on CMS Guidelines 15
Continued on Page 17
Special Feature
©2009 Medline Industries, Inc.
Medline is a registered trademark of Medline Industries, Inc.
Yankowsky and Fife on Preventive Legal Care
With the implementation of new CMS reimbursement
guidelines in October 2008, hospitals have been stepping up
efforts to prevent facility-acquired pressure ulcers. Attorney Kevin
Yankowsky, who represents healthcare facilities and clinicians,
urged Prevention Above All conference participants to implement
preventive legal measures as well.
“In this environment, you’re not looking at pressure ulcer preven-
tion systematically unless you are also taking some time to look
at how you can prevent legal risks and liabilities that arise from
unavoidable pressure ulcers,” Yankowsky said.
Yankowsky and co-presenter Caroline Fife, MD, are members of
the International Expert Wound Care Advisory Panel that recently
released the white paper “Legal Issues in the Care of Pressure
Ulcer Patients: Key Concepts for Healthcare Providers.” (For an
excerpt from the paper, turn to page 42)
Yankowsky, a partner with Fulbright & Jaworsky, LLP, in Houston,
Texas, stressed that healthcare litigation is about how much
money can be made, not about righting bad care. Now that
financial rewards have been limited by widespread tort reform in
many areas of health care, Yankowsky said attorneys are
increasingly taking cases that fall into the category of elder abuse.
Elder abuse is an area that is an exception under many states’
tort reformlegislation, and it still produces monetary awards in the
millions of dollars.
“As avenues to make big money are diminished in other tort
areas,” Yankowsky said, “you are going to see more and more
interest in litigation over pressure ulcers.”
Show Me the Money
Pressure Ulcer Litigation: Civil Liability Awards
Adams v. Valencia Health Care Center (Calif. 2008):
Death from sepsis caused by decubitus ulcers: $2 million
compensatory damage award
Brown v. Menorah Home & Hospital (New York 2007):
Medical malpractice: negligent treatment of decubitus
ulcers: $1.25 million compensatory damage award
Myers v. National Healthcare Corp. (Tenn. 2007):
Wrongful death/medical malpractice: death
from decubitus ulcers: $4.1 million
compensatory damage award:
$28.6 million punitive
damage award
He added that facilities and clinicians who provide excellent care
are at risk for litigation because plaintiff attorneys look for (and
often find) weaknesses in documentation and facility policies that
give the appearance of abuse or neglect.
The following is an excerpt Yankowsky shared from a recent
advertisement for legal services in Texas:
“Developing a bed sore is a clear sign of elder abuse. Bedsores
are a sign of negligence.”
This statement gives the public the impression that if an elderly
individual develops a pressure ulcer, the reason is abuse and neg-
lect, whereas healthcare professionals know otherwise. Pressure
ulcers can develop even under the best of circumstances – and
in spite of excellent care.
“Despite tort reform, and in some cases because of it –
with an aging population and as an unintended consequence of
a lot of these federal reimbursement regulations – the frequency
and severity of your risk from legal consequences is here. It’s
going to stay, and it’s likely to go up.” - Kevin Yankowsky
Co-presenter Dr. Caroline Fife, a physician with experience treat-
ing patients with pressure ulcers, pointed out how the widely
known and accepted pressure ulcer staging system, which labels
pressure ulcers in Stages from I through IV, can give attorneys
and their clients the false idea that pressure ulcers worsen along
a continuum, with the assumption that their progression could
have been stopped along the way.
Fife, an associate professor of medicine at the University of Texas
in Houston, explained how pressure ulcers develop from the in-
side out. Although there usually is extensive tissue damage deep
within the layers of skin from the very beginning, the first appear-
ance of a pressure ulcer often looks like a bruise, known as a
Stage I pressure ulcer. As time progresses, the true result of the
injury deep within the tissue becomes visually apparent, and the
pressure ulcer is labeled a Stage III or Stage IV. Logically and in-
tuitively, it would seem that what began as a minor bruise devel-
oped into a severe, deep, oozing pressure ulcer, when in fact, a
severe injury was there underneath the skin all the time. It just
takes time to show itself visually.
Kevin Yankowsky Caroline Fife
Improving Quality of Care Based on CMS Guidelines 17
Yankowsky and Fife on Preventive Legal Care
“The numeric nature of the [pressure ulcer] staging systemcreates
the impression that the ulceration is worsening, implying negligent
care, when, instead, the injury is evolving along a predictable
path,” Fife said.
How to protect yourself and your facility
Yankowsky outlined ways to remove opportunities for litigation
through careful practices regarding the development of policies
and procedures and patient chart documentation.
He advised creating policies that are guidelines rather than hard
and fast rules, in order to allow clinicians to exercise their profes-
sional judgment.
“Policies and procedures must be drafted not only with an eye
toward improving care, but also with careful consideration of their
potential use by adversaries in future litigation,” Yankowsky advised.
Concerning documentation, Yankowsky said the patient’s chart
is the first thing a plaintiff’s lawyer looks at when researching a
case. He advised evaluating your documentation system with an
eye toward both how it will be used for patient care needs now
and how it will look to litigation adversaries years in the future.
To learn more about preventive legal care, request a copy
of the white paper, “Legal issues in the Care of Pressure
Ulcer Patients: Key Concepts for Healthcare Providers” at
18 Healthy Skin
The results are in the numbers. Be a part of our national
benchmark scorecard to measure your progress and
reduce facility-acquired pressure ulcers.
Hospitals currently enrolled 232
Nursing homes currently enrolled 110
Average test scores Pre-test Post-test
Nursing Assistant 76% 92%
Registered Nurse 77% 96%
Pressure Ulcers
Average Facility-acquired Incidence
Before implementing 6 pressure ulcers (16%)
Medline PUP program
After implementing 3 pressure ulcers (3%)
Medline PUP program
Source: Data on file. Medline Industries, Inc.
Medline’s Pressure Ulcer
Prevention Program Update!
Medline presents a powerful and comprehensive solution
to six of the most common hospital-acquired conditions (HACs).
Preventing HACs is one of the most important issues in
health care today. Simply put, the CMS reimbursement
changes that took effect last October 1 mean healthcare
professionals must eliminate HACs and improve patient
safety —or risk losing Medicare reimbursement dollars.
The good news is that almost all HACs are preventable, and
with Medline’s Prevention Above All, you will have
the knowledge and products to prevent six of the most
common HACs. The program’s multi-layered approach
provides you with targeted evidence-based interventions that
will not only save lives but also improve your bottom line.
The six conditions targeted by Prevention Above All
and their complementary Medline product and program
solutions are:
1. Operating Room and Surgical Errors
Gold Standard Safety Program
2. Hospital-Acquired Infections
Hand Hygiene Compliance Program
3. Pressure Ulcers
Pressure Ulcer Prevention program
4. Harm Avoidance and Patient Satisfaction
Educational Packaging
5. Objects Retained After Surgery
RF Surgical
Detection System
6. Catheter-Associated Urinary Tract Infection (CAUTI)
ERASE CAUTI™Foley Catheter Management System
Hospital-specific public data
Statewide public data
No public data
Voluntary reporting
No reporting
System pending
State Reporting of
Adverse Events
With no national mandatory event reporting systemin
place, the United States is blanketed by a patchwork
of state reporting systems collecting a variety of data
in different ways. The amount of information available
to the public also differs fromstate to state.
Reprinted with permission from Hearst Newspapers. Hearst research by
Olivia Andrzejczak. Graphic by Kyla Calvert. Template by Alberto Cuadra.
Available at
No HAI reporting required
HAI reporting required
Copyright 2008 – Association for Professionals in Infection Control and
Epidemiology, Inc.
Please contact for reprint permission and
update requests. Reprinted with permission.
Mandatory HAI
Reporting in
Only four states currently require long-term care
facilities to report the incidence of healthcare-
acquired infections (HAIs). The states are Oregon,
California, Pennsylvania and Florida, as shown on the
map above.
Public Reporting of Healthcare Errors and Infections
Improving Quality of Care Based on CMS Guidelines 19
Special Feature
Patient-centered research
Therefore, the healthcare research conducted under this
initiative will be patient-centered and apply to the “real
world” in order to help patients, clinicians and other deci-
sion makers assess the relative benefits and harms of
strategies to prevent, diagnose, treat, manage or monitor
health conditions.
In addition, the research should consider and include a
variety of patient populations (e.g., people with disabilities
and chronic illnesses, and different racial and ethnic back-
grounds) for the program to be effective.
Federal Coordinating Council for Comparative
Effectiveness Research
The first step in the comparative effectiveness initiative was
to appoint a management council in March 2009. The Federal
Coordinating Council for Comparative Effectiveness
Research (the Council) is composed of 15 distinguished
leaders from key government healthcare-related agencies,
including the Veterans Health Administration (VHA), Centers
for Disease Control and Prevention (CDC), Centers for
Medicare & Medicaid Services (CMS) and the HHS, among
The Council’s purpose is to coordinate compara-
tive effectiveness research and related health services
research across the federal government with the intent of
reducing duplication and encouraging the complementary
use of resources.
Legislators in the Senate and House have been busy
this year preparing and debating their versions of a
healthcare reform bill. Perhaps one of the bills, or a
hybrid, will be passed by the end of 2009. In the interim,
the launch of a new federally funded healthcare programon
comparative effectiveness research is well underway.
The American Recovery and Reinvestment Act of 2009
allocated $1.1 billion to the U.S. Department of Health and
Human Services (HHS) for this initiative. What is compara-
tive effectiveness? The Institute of Medicine (IOM) defines it
as “the extent to which a specific intervention, procedure,
regimen or service does what it is intended to do under real
world circumstances.”
As HHS describes it, comparative
effectiveness research provides information on the relative
strengths and weaknesses of various medical interventions,
including drugs, devices and procedures.
Comparative Effectiveness Research:
What It Is and How
It Can Help You and
Your Patients
What’s Happening in Healthcare Reform
Goals of Comparative Effectiveness Research (CER)
• Reduce healthcare costs
• Build public interest
• Improve patient care
• Encourage development and use of clinical registries
and data networks
• Increase consistency of treatment provided in different
geographic regions
• Greater ability to tailor interventions to treat patients’
specific needs
• Care based on evidence and best practices
20 Healthy Skin
The Council will oversee the $1.1 billion in funding, of which
$300 million is allocated to the Agency for Healthcare
Research and Quality (AHRQ), $400 million to the National
Institutes of Health (NIH) and $400 million to the Office of
the Secretary.
High-Priority Topics for Federally Funded
Comparative Effectiveness Research
The American Recovery and Reinvestment Act of 2009
called on the Institute of Medicine to recommend a list of
priority topics to be the initial focus of a new national
investment in comparative effectiveness research.
The complete list contains 100 topics, prioritized into four
groups of 25 each. The following is a sampling of topics that
relate to healthcare professional who care for older adults.
They are listed in order from highest to lowest priority,
as indicated by the Institute of Medicine:
• Compare the effectiveness of the different treatments
for hearing loss in children and adults, especially
individuals with diverse cultural, language, medical
and developmental backgrounds.
• Compare the effectiveness of primary prevention
methods, such as exercise and balance training,
versus clinical treatments in preventing falls in older
adults at varying degrees of risk.
• Compare the effectiveness of various screening,
prophylaxis and treatment interventions in eradicating
methicillin resistant Staphylococcus aureus
(MRSA) in communities, institutions and hospitals.
• Compare the effectiveness and costs of alternative
detection and management strategies for dementia
in community-dwelling individuals and their caregivers.
• Compare the effectiveness of pharmacologic and
non-pharmacologic treatments in managing
behavioral disorders in people with Alzheimer’s
disease and other dementias in home and
institutional settings.
• Compare the long-term effectiveness of weight-bearing
exercise and biphosphonates in preventing hip and
vertebral fractures in older women with osteopenia
and/or osteoporosis.
• Compare the effectiveness of diverse models of
transition support services for adults with complex
health care needs (e.g., the elderly, homeless, mentally
challenged) after hospital discharge.
• Compare the effectiveness of different residential
settings (e.g., home care, nursing home, group home)
in caring for elderly patients with functional impairments.
1. U.S. Department of Health and Human Services. Federal Coordinating Council
for Comparative Effectiveness Research: Report to the President and Congress,
June 30, 2009. Available at
alrpt.pdf. Accessed August 3, 2009.
2. Zigmond, J. Healthy choices: industry wonders how $1.1 billion for comparative-
effectiveness research will be applied. Modern Healthcare. March 30, 2009:
3. Institute of Medicine. 100 Initial Priority Topics for Comparative Effectiveness
Research. Available at Accessed August 3, 2009.
Improving Quality of Care Based on CMS Guidelines 21
Special Feature
22 Healthy Skin
They Call it
a Nursing Home For a Reason
Improving Quality of Care Based on CMS Guidelines 23
I remember a television advertisement not too long ago for an
Alzheimer’s drug that has a middle-aged woman narrating about
her fear that she would have had to put her father into a nursing
home if it weren’t for this medication that has allowed himto con-
tinue living with her and her family. It was a warm-hearted ad that
ended with the family having dinner together and laughing.
The main message of the ad was that this medication
works, but the not-so-subtle underlying message is that
we need to do all we can to make sure that our aged
parents do not have to live in the dreaded world known
as “the nursing home.” If we are truly loving children, the
message goes, we will do all we can to make sure our
parents avoid such a hellish existence.
Though the ad is effective, I became bothered by the message
that nursing homes are, without question, negative places in
which to live. I ambothered by this because I knowit isn’t true: My
88-year-old mother has been living in a nursing home for two-and-
a-half years, and her time there has not only been “not negative,”
it has been extremely positive. In fact, it has served to bring her
back to us, her three children and two grandchildren.
My mother was widowed at 74 and continued to live an incredi-
bly active life for the next nine years or so. But then she lost her
ability to drive. And her friends lost their ability to drive, or, in some
cases, they passed away. She then lost her ability to walk unaided
and began to experience urinary incontinence. Finally, she was
diagnosed with early stage Alzheimer’s.
Her world, always so rich with outings, friendship, travel,
and interest in a wide variety of activities, became
smaller and smaller. It happened quickly and seemingly
all at once. She was left with just two regular activities:
a weekly trip to the “beauty shop” where she would get
her hair done and a weekly trip to mass.
One of my two brothers lived with her in the house where we grew
up, but it became clear about three years ago that she needed
more assistance than he was able to give. My husband and I
teach English at a small college in Vermont and we, along with
our two teenaged children, sincerely offered to have my mom
move in with us. She’d always loved visiting us several times a
year since we moved here in 1989, first with my dad and then,
after he passed away in 1994, on her own. But to our offer she
by Janice Gohm Webster, PhD
Brush aside those stereotypes —
long-term care lets families flourish
and loved ones enjoy life
Continued on Page 25
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dinners that are always a treat, the regular concerts given by
people from throughout the community and, of course, the reg-
ular visits fromfamily and friends, and Momhas a richer life than
we would have imagined possible before she moved there.
And some of the best news is that Mom’s Alzheimer’s remains
incipient—most likely at least in part due to her re-engagement
in so many activities lost to her in the last couple of years she
lived at home.
In addition to talking with Momevery day, I amable to visit every
couple of months, and though she is confined to a wheelchair,
she is, in so many ways, the active mom she’s always been.
She’s even able to leave the home for dinner out and overnights
at my brother’s home where my family and I stay when we come
to town. But, as much as she loves getting out and about—just
as she always has—she is never reluctant to return, and that
is both a huge relief and a real comfort to my brothers, my hus-
band, my children, and myself.
Because of the kindness of the nurses, aides, administrators,
and volunteers, and because of relationships with other resi-
dents, the nursing home has really become her home. And, be-
cause she is in great spirits and better health than we ever could
have dreamed of three years ago, I am so thankful that we did-
n’t let the stereotype of a “nursing home” keep our family from
providing Mom with the best care possible. Making this choice
has resulted in these years of her life being not just tolerable, but
truly happy.
How’s that for an advertisement?
About the Author
Janice Gohm Webster, PhD, is an English professor at Cham-
plain College, Burlington, Vermont. For further information, phone
(802) 893-7622 or email
Reprinted with permission from Long Term Living magazine
replied, “Well, I love all of you with all my heart, but honey, what
would I do there?” And although she wasn’t “doing” much in
Michigan anymore, she did have a point. Although her world had
grown small, it was still a world with which she was familiar, in a
town where she’d lived her entire life. She wanted that familiar-
ity and the comfort it provided her.
So there we were. She couldn’t live alone, and she needed more
help than my brothers and I could give her. So, after many
lengthy conversations with each other and with my mom, we all
made the decision that a nursing home was the appropriate
choice. But even knowing this, we made the decision with some
reluctance because we, like so many others, had the impres-
sion that a nursing home was less than one step away fromthe
funeral parlor. And my mom had lived in our family home for 45
years, so leaving was emotional. But nonetheless, we knew it
was the place my momneeded to be. And thankfully, she knew
it as well.
She moved into the nursing home in the summer of 2005, and
almost immediately we knewit was the right choice. Three years
later, I can honestly say that this home has not only provided a
place for my mother to live, it has also provided a place for her
to thrive. For the year or so before moving out of our family
home, I would talk to my mom (we talk on the phone daily) and
she would have very little to say.
“What did you do today Mom?”
“Oh, not much. Watched some TV. Took a nap. Ate a bit.”
I would often cry after hanging up—feeling helpless and
wanting to help. My mother, always a great conversationalist
and easy laugher, now had little to say, was easily distracted,
and seldom laughed.
Now, I look so forward to talking with her every day because I
know she’ll have a lot to say. And once again, every conversa-
tion is punctuated with laughter. She not only has three social
meals a day with friends she’s made since moving in, she also
has daily mass, she continues to get her hair done weekly at a
shop right at the home, she participates in the daily reading/dis-
cussion of the local newspaper, she has physical therapy, and
she plays various games provided on an almost daily basis. Add
to this the monthly birthday parties—replete with cake and ice
cream and various party favors—in honor of all of the residents
celebrating birthdays that month, the monthly “wine and dine”
She moved into the nursing home in the summer
of 2005 and almost immediately we knew it was
the right choice.
In addition to talking with Mom
every day, I am able to visit every
couple of months, and though she
is confined to a wheelchair, she is,
in so many ways, the active mom
she’s always been.
Improving Quality of Care Based on CMS Guidelines 25
Palliative care (pronounced
pal-lee-uh-tiv) is the medical
specialty focused on relief
of the pain, stress and other
debilitating symptoms of
serious illness.
What is
26 Healthy Skin
Palliative care is not dependent on prognosis and can be
delivered at the same time as treatment that is meant to cure.
The goal is to relieve suffering and provide the best possible
quality of life for patients and residents and their families.
To date, there have been few resources to assist caregivers in
learning about and explaining palliative care. Healthy Skin
would like to introduce you to an excellent, Internet-based
resource from the Center to Advance Palliative Care (CAPC).
This article contains excerpts fromthe Get Palliative Care Web
site. Let’s look at what they have to offer.
Ensures quality of life
Palliative care is not a one-size-fits-all approach. Patients have
a range of diseases and respond differently to treatment
options. A key benefit of palliative care is that it customizes
treatment to meet the individual needs of each patient.
Palliative care relieves symptoms such as pain, shortness of
breath, fatigue, constipation, nausea, loss of appetite and dif-
ficulty sleeping. It helps patients gain the strength to carry on
with daily life. It improves their ability to tolerate medical treat-
ments. And it helps them better understand their choices for
care. Overall, palliative care offers patients the best possible
quality of life during their illness.
Palliative care benefits both patients and their families. Along
with symptom management, communication and support for
the family are the main goals. The team helps patients and
families make medical decisions and choose treatments that
are in line with their goals.
Different from hospice
Palliative care is NOT the same as hospice care. Palliative care
may be provided at any time during a person`s illness, even
from the time of diagnosis. And, it may be given at the same
time as curative treatment.
Hospice care always provides palliative care. However, it is
focused on terminally ill patients – people who no longer seek
treatments to cure them and who are expected to live for
about six months or less.
Provided by a team
Usually a team of experts, including palliative care doctors,
nurses and social workers, provides this type of care. Chap-
lains, massage therapists, pharmacists, nutritionists and oth-
ers might also be part of the team. Typically, you get
non-hospice palliative care in the hospital through a palliative
care program. Working in partnership with your primary doc-
tor, the palliative care team provides:
• Expert treatment of pain and other symptoms
• Close, clear communication
• Help navigating the healthcare system
• Guidance with difficult and complex treatment choices
• Detailed practical information and assistance
• Emotional and spiritual support for you and your family
How to get pallative care
There is a three step process provided by the Center to
Advance Pallative Care to access pallative care. Step 1
recommends talking with the doctor. Most of the time,
you have to ask a doctor for a palliative care referral to get
palliative care services. Whether you are in the hospital or at
home, a palliative care team can help you. They provide a list
of some tips to help you talk to the doctor.
We encourage you to access the Center to Advance
Palliative Care at where you will
find much more in-depth information, resources, videos and tools
to help you understand and discuss palliative care.
Improving Quality of Care Based on CMS Guidelines 27
Step 2 is The Palliative Care Provider Directory of
Hospitals, which is a resource to help you locate a hospital
in your area that provides a palliative care program. The
directory is based upon palliative care programs listed in the
American Hospital Association (AHA) Annual Survey.
If you are looking for non-hospital-based palliative care, you
are directed to go to Caring Connections,
a programof the National Hospice and Palliative Care Organ-
ization (NHPCO). It is a national consumer and community
engagement initiative to improve care at the end of life, sup-
ported by a grant fromthe Robert Wood Johnson Foundation.
Step 3 involves meeting with a palliative care team.
At this step you will find a list of questions that should
be addressed during the team meeting to help the patient,
resident and/or family determine if palliative care is appropri-
ate for them.
Is palliative care right for you?
There is an online survey with only four questions that can be
completed by the patient, resident or family member to
determine if palliative care is appropriate based upon individ-
ualized responses.
In addition to the survey, there are direct links to many
resources such as advance directives, cancer societies and
other specialty organizations, financial assistance and many,
many other resources. They include many personal stories,
educational articles, facts and videos that can help everyone
involved in the decision making process obtain the data
needed to make the best decision.
We have also included a list of frequently asked questions that
you can use to learn more about palliative care yourself and
when discussing palliative care with your residents and patients.
Summing it up
The Center to Advance Palliative Care (CAPC) provides
healthcare professionals with the tools, training and technical
assistance necessary to start and sustain successful pallia-
tive care programs in hospitals and other healthcare settings.
CAPC is a national organization dedicated to increasing the
availability of quality palliative care services for people facing
serious illness. Direction and technical assistance are provided
by Mount Sinai School of Medicine.
Reprinted with permission from the Center to Advance Palliative Care. is an Internet-based site
sponsored by the Center to Advance Palliative Care (CAPC) and provided for
general educational and informational purposes only. ©2009 Medline Industries, Inc. Medline is a registered trademark
of Medline Industries, Inc.
See for yourself what a difference Feels Like Home textiles
will make in your facility. Choose any room in your facility
and we will come in with the linen samples for a Feels
Like Home room makeover.
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To learn more about
the Feels Like Home
line, please call
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Feels Like Home

28 Healthy Skin
Better options for cleansing and debriding wounds
Use the right tool for the job.
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Two great options
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Some Methods Are Better Than
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“TenderWet is an excellent choice for debriding wounds,
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Connie Parsons,
1. How do I know if palliative care is right for me?
It may be right for you if you suffer from pain and other symp-
toms due to a serious illness. A coordinated clinical team can
provide care to meet your needs and wishes and your family's
during your illness.
Serious illnesses include but are not limited to cancer, cardiac
disease, respiratory disease, kidney failure, Alzheimer’s, AIDS,
Amyotrophic Lateral Sclerosis (ALS) and multiple sclerosis.
Palliative care can be used at any stage of illness, not just ad-
vanced stages.
2. Who else, besides the patient, can benefit
from palliative care?
Everyone involved! Patients as well as family caregivers are
the special focus of palliative care. Your doctors and nurses
benefit, too, because they know they are meeting their
patients' needs by providing care that reduces suffering and
improves quality of life.
3. Does my insurance pay for palliative care?
Most insurance plans cover all or part of the palliative care
treatment you receive in the hospital, as with other hospital
and medical services. This is also true of Medicare and Med-
icaid. Drugs and medical supplies and equipment may also
be covered. If costs concern you, a social worker or financial
consultant fromthe palliative care teamcan help you with pay-
ment options.
4. Where do people get palliative care?
Palliative care can be offered in a number of places. These
include hospitals, long-termcare facilities, hospices or at home.
5. Can I get palliative care if I am at home?
Yes. After symptoms and pain have been managed and are
under control, you and your doctor can discuss outpatient
palliative care.
30 Healthy Skin
6. What does palliative care involve?
• Pain and symptom control: Your palliative care team
will identify your sources of pain and discomfort.
These may include problems with breathing, fatigue,
depression, insomnia, or bowel or bladder. Then the
team will provide treatments that can offer relief.
These might include medication, along with
massage therapy or relaxation techniques.
• Communication and coordination: Palliative care teams
are extremely good communicators. They put great
emphasis on communication between you, your family
and your doctors in order to ensure that your needs
are fully met. These include establishing goals for
your care, aid in decision-making and seamless
coordination of care.
• Emotional support: Palliative care focuses on the entire
person, not just his or her illness. The team members
caring for you will address any social, psychological,
emotional or spiritual needs you may have.
• Family/caregiver support: Caregivers bear a great deal
of stress too, so the palliative care team supports them
as well. This focused attention helps ease some of the
strain and can help you with your decision-making.
6. What can I expect from palliative care?
You can expect a comfortable and supportive atmosphere
that reduces anxiety and stress. Your specialized plan of care
is reviewed each day by the palliative care team and dis-
cussed with you to make sure your needs and wishes are
being met.
You can expect relief fromsymptoms such as pain, shortness
of breath, fatigue, constipation, nausea, loss of appetite and
difficulty sleeping. Palliative care addresses the whole person.
It helps you carry on with your daily life. It improves your abil-
ity to go through medical treatments. And it helps you better
understand your condition and your choices for medical care.
In short, you can expect the best possible quality of life.
7. Does treatment meant to cure me stop when
palliative care begins?
No. You can get palliative care at any stage of illness, no matter
what your diagnosis or prognosis.
8. Who provides palliative care?
Usually a team of experts, including palliative care doctors,
nurses and social workers, provides this type of care. Chap-
lains, massage therapists, pharmacists, nutritionists and oth-
ers might also be part of the team. Generally, each hospital
has its own type of team.
9. What role does my doctor play?
The hallmark of palliative care is a team approach to patient
care. Your primary doctor will continue to direct your care and
play an active part in your treatment. The palliative care team
provides support for and works in partnership with your pri-
mary doctor.
10. What is hospice care?
Hospice care is for a patient who has a terminal diagnosis and
is usually no longer seeking curative treatment. It focuses on
relieving symptoms and supporting patients who are expected
to live for months, not years. Hospice care is provided in the
home, in a residential setting or in the hospital.
11. Is palliative care the same as hospice care?
No. Hospice care provides palliative care for those approach-
ing the last stages of life.
Palliative care is appropriate for anyone, at any point of a se-
rious illness. It can be provided at the same time as treatment
that is meant to prolong your life.
12. How do I start getting palliative care?
Ask for it! Start by talking with your doctor or nurse. Tell your
family, friends and caregivers that you want palliative care.
Then ask your doctor for a referral.
Improving Quality of Care Based on CMS Guidelines 31
©2008 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.
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Improving Quality of Care Based on CMS Guidelines 33
By Zemira M. Cerny, BS, RN, CWS
Our Hospital:
Chesapeake Regional Medical Center, Chesapeake, VA, was founded in 1976 with
the goal of providing the highest quality health care available to meet the needs of
southeastern Virginia and northeastern North Carolina. The hospital established
several affiliates over the years, and in 1998 they all combined under the same name,
Chesapeake Regional Medical Center. The Medical Center includes:
• A 310-bed inpatient facility
• A 24-hour emergency room
• Rehabilitation services
• Two intensive care units – one is neurological, one is medical
• Sleep Center
• Lifestyle Center
• Obstetrics
• Center for Wound Care and Hyperbaric Medicine
The hospital is a local, independent, community-focused organization offering area
residents what they want: high-quality health care delivered by people who openly
display their concern and compassion.
Our Challenge
When I joined the hospital in April 2008 as the facility’s Wound Care Coordinator,
I learned we had an increasing level of hospital-acquired pressure ulcers. Pressure
ulcers (sometimes referred to as “bed sores”) affect millions of people each year.
A pressure ulcer is an injury to the skin that is caused by pressure. Sitting or lying in
one position without moving puts pressure on the skin and slows down blood flow.
When blood flow slows down, skin and tissue can die and result in a pressure ulcer.
When pressure ulcers occur, they often can be painful, debilitating and potentially
cause serious health issues. They also can add to a patient’s length of stay in the hospital.
The cost savings from preventing pressure ulcers and eliminating additional
treatment is very significant for both the hospital and our patients. According to
the Centers for Medicare & Medicaid Services (CMS), the average cost per patient
per hospital stay for a pressure ulcer as a secondary diagnosis is $43,180, including
nursing time, medication and supplies. (See figure 2 on page 36.)
Chesapeake Regional
Medical Center
Chesapeake, VA
311-bed inpatient facility
Develop a systematic program
to reduce prevalence level of
hospital-acquired pressure ulcers
Conducted 90-day program trial in
ICU2. Reduced ICU2’s pressure ulcer
incidence from 57.1 percent to 0
percent. Overall, the facility’s pressure
ulcer incidence went from 16.2%
in July 2008 to 2.5% in May 2009.
Estimated cost savings for the
hospital were $1,079,500 in nursing
time, pharmaceuticals and supplies.
34 Healthy Skin
In the spring of 2008, our hospital’s ICU2
unit had a pressure ulcer incidence level
of 57.1 percent (incidence is the rate of
new pressure ulcers in a given time period)
with 25 hospital-acquired pressure ulcers.
This number was significantly higher than
the national benchmark of 3.3 percent.
This was the result of inconsistent skin
assessments as well as documentation,
and a general lack of focus about the
value of preventative skin care. Our
program had focused on treating pressure
ulcers after they had already developed
rather than preventing them.
The staff had products available, but
education was limited regarding efficient
use of these products. Ointments and
cleansers were used, but provided no
protective barrier to prevent pressure
ulcer formation. The skincare procedure
also did not include moisturizers, a key
step to an effective skincare program.
We also had very few pressure-relieving
devices such as heel supports and
cushions to help minimize pressure to
vulnerable body parts. Use of reusable
incontinence pads amplified the problem
by keeping moisture close to the patients’
skin for extended periods of time.
Although the high prevalence of pressure
ulcers in our facility was cause for great
concern, the issue took on more immedi-
acy with the impending reimbursement
changes. Beginning in October 2008, the
Centers for Medicare & Medicaid Services
(CMS) no longer reimbursed healthcare
facilities at the higher payment rate
for the costs associated with hospital-
acquired pressure ulcers. With an at-risk
population (elderly patients who are thin
and have diabetes or vascular disease)
of over 50 percent, our staff and senior
administration realized the immediate
need to reevaluate the current pressure ulcer
program and create a new, prevention-
oriented system.
Beginning in May 2008, an interdisci-
plinary wound team and a wound care
advisory panel was developed to create
new protocols and procedures aimed
at reducing pressure ulcer prevalence.
The team consisted of physicians,
nurses, dieticians and a physical therapist.
The panel’s first initiative was to create an
innovative program called the “Wound
Warriors.” The Wound Warriors were
the wound care team’s first line of defense
on each unit. These individuals are nurses
selected based on their interest in wound
care. They receive additional education
about the proper assessment and docu-
mentation involved in the prevention
of pressure ulcers. Each team member
dedicates two shifts per month to
review audits and ensure that the correct
procedures are being followed. They
are also involved in wound rounds with
the interdisciplinary wound team.
Even with the creation of the Wound
Warriors and their focus on pressure
ulcers, a systematic, staff-wide approach
to pressure ulcer prevention, including
standardization and quality products,
was still lacking.
The Solution
In May 2008 we were introduced to
Medline’s Pressure Ulcer Prevention
Program (PUP) through a webinar
presented by the company. The
program, we learned, includes intensive
staff education, skincare products and
hands-on implementation by Medline
staff aimed at reducing pressure ulcer
incidence levels in healthcare facilities.
The program is based on sound wound
care principles backed by excellent
teaching materials. The one potential
hurdle was that, on paper, the program
would increase our supply budget
with the introduction of some new,
but necessary products.
To overcome this initial challenge,
Medline guaranteed that at the end
of the trial period, if our facility did
not reduce our incidence of facility-
acquired pressure ulcers, they would
reimburse us the cost of the products we
used during the trial period. Moreover,
knowing the severity and immediacy
of the pressure ulcer situation at Chesa-
peake, the vice president of nursing was
fully behind the program to do whatever
we could to lower our rates.
We began the program in September
2008 with a 90-day trial in our ICU2
unit, whose total patient census is 14. As
mentioned earlier, but worth repeating,
the unit had a pressure ulcer incidence
level of 57.1% percent with 25 hospital-
acquired pressure ulcers – a disturbingly
high level of pressure ulcers.
The trial was spearheaded by the unit
manager and involved the Medline wound
care specialists, the Wound Warrior and
the charge nurse. In all, there were about
45 ICU2 staff members participating
in the program – 37 licensed nurses and
eight nursing assistants (CNAs).
The program started with an educational
poster displayed in the staff lounge
to bring awareness to the program.
Prior to implementation, a pre-test was
administered to our nurses and nursing
Medline headquarters based in Mundelein, Ill.
Improving Quality of Care Based on CMS Guidelines 35
assistants to assess their baseline level of
treating pressure ulcers. A post-test was
then given about four to six weeks later
to reassess the staff ’s knowledge. The
goal of the program is to pass the test
with a score of 90 percent or higher.
The Medline representatives implemented
an incentive program with small awards
to encourage staff members to review the
materials and complete the tests within
the specified time frame. This system
worked well, and all nursing staff in
ICU2 completed their tests on time.
The staff ’s initial test scores were actually
pretty high – the average CNA score was
85 percent and the nurse’s was 83 percent.
(See figure 1 on back page.)
Medline also supplied and reviewed the
education and training materials with
our staff. The unit manager received a
comprehensive training manual including
a CMS presentation, workbooks,
instructor’s guide, forms and tools and
pre- and post-tests.
The nursing assistant’s workbook
included basic information covering
skin care, patient turning, incontinence
care and nutrition. The nurse’s work-
books covered CMS policy, risk factors,
assessment, skin care, turning, inconti-
nence care, nutrition and documentation.
As a further incentive, everyone who
successfully completes the course and
achieves at least an 80 percent on the
post-test will be presented with a reward
pin to display on their uniform and a
certificate of completion.
The Medline representatives worked
closely with our staff on the education
aspect of the program by reviewing the
format outlined in the workbooks. But
the staff really took it upon themselves
to learn the material through self-training.
Medline conducted intensive inservicing
on the products with our staff – covering
their benefits and how and when to use
them. Product education was a crucial
step in the success of the program. The
main products utilized in the program are:
• Remedy advanced skin care
system, Medline’s exclusive line of
skin care products. The compre-
hensive program includes cleanser
foams, barrier ointments, and
skin repair creams (moisturizers).
The staff also likes the products’
scent and feel, which further
motivates them to use the products
and follow the protocols.
• Ultrasorbs Dry Pads, a superab-
sorbent underpad that wicks
moisture away from the skin for
increased dignity and better skin care.
We also are using more pressure relief
devices for highly vulnerable areas such
as heels and elbows. These devices,
when used properly in conjunction with
the products cited above, help prevent
pressure ulcers in high-risk patients.
The program also offers adult briefs and
low air loss mattresses, but we have not
employed those products as of yet.
The Results
By the middle of October 2008 – about
six weeks into the trial – ICU2’s pressure
ulcer incidence was reduced to 23.1
percent, a reduction of more than half
from where we started. At the end of the
trial, ICU2’s incidence rate was down
to 0 percent. This was in the beginning of
January. A few weeks later, they were still
at 0 percent with February’s facility-wide
prevalence study. The facility’s incidence
rate was 7.5 percent. As of May 13, 2009,
the facility’s rate was down to 2.5 percent,
which is below the national benchmark
of 3.3 percent. What this means in real
numbers is that at the end of the trial we
had virtually no facility-acquired pressure
ulcers, compared to the 25 we had at
the beginning of the trial. This trend
has continued as we report incidence
levels well below the national average.
The staff ’s post-test scores also reflect
these outstanding results. Both the CNA
and nurse’s scores averaged 98 percent!
Moreover, whatever little resistance we
did have from our staff to this new sys-
tem has completely disappeared and has
been replaced by enthusiasm and a great
amount of self-satisfaction for doing an
excellent job. To have your staff believe
in the benefits of the program and see
their efforts result in improved patient
care are essential to the long-term success
of this or any patient care initiative.
Most importantly, senior administration
and materials management have fully
36 Healthy Skin
ABOUT THE AUTHOR Zemira M. Cerny, BS, RN, CWS is
the Wound Care Coordinator at Chesapeake Regional Medical
Center in Chesapeake, VA. Zemira has 10 years specializing in
wound care and is a Certified Wound Specialist through the
American Academy of Wound Management. Zemira’s role is to
oversee wound care in the outpatient and inpatient areas, whereby
allowing for continuity of care across the health care settings. Currently, she is manag-
ing a staff of ten certified Hyperbaric and Wound Care Clinicians.
bought into the program. By showing
them how preventing pressure ulcers
saved $1,079,500, they understood the
full value of the program. (See figure 3 below.)
This savings was determined by multi-
plying 25 – the number of pressure
ulcers acquired in the ICU2 – by
the average cost of a pressure ulcer –
$43,180, as calculated by CMS.
The savings numbers combined with
implications of the the new CMS
inpatient prospective payment system
(IPPS) that no longer reimburses facilities
at the higher payment rate for hospital-
acquired pressure ulcers, presented an
overwhelming case to administration to
implement the program permanently in
the ICU2 and to roll it out facility-wide.
Future Initiatives
The success of the 90-day trial period has
shown us that a systematic approach to
pressure ulcer prevention can eliminate
facility-acquired pressure ulcers. As a
result of this success, we are now in the
early stages of implementing the program
facility-wide and hope to have it in all
our nursing units by the end of June
2009. In order for complete house-wide
prevention, we are anxiously awaiting the
Medline emergency room pressure ulcer
prevention program.
In addition, in the summer of 2009, we
will be seriously assessing Medline’s new
pressure ulcer prevention module for the
operating room. The operating room is a
high-risk environment for pressure ulcers
– according to AORN, the incidence of
pressure ulcers occurring as a result of
surgery may be as high as 66 percent.
This perioperative module includes risk
assessment and prevention methods to
help prevent facility-acquired pressure
ulcers in our surgical patient population.
Pre-Test Scores
Post-Test Scores
Pressure Ulcer Prevention Education Data
Figure 1: Chesapeake Regional Medical Center
Nursing Time
Pressure Ulcer Prevention Program Savings
Figure 3: Chesapeake Regional Medical Center Savings
Total Savings $1,079,500
Nursing Time
Total Costs
Pressure Ulcer Treatment Costs
Figure 2: Pressure Ulcer Costs
*Centers for Medicare & Medicaid Services. Medicare Program; Changes to the Hospital Inpatient Prospective Payment
Systems and Fiscal Year 2008 Rates; Final Rule. Federal Register. 2007;72(162):47130-48175
*Based on reducing the incidence of pressure ulcers from 25 prior to the implementation of the program to zero post-program.
This paper was approved by the Wound Care Advisory Panel and Nurse Manager, the staff of ICU 2, Elaine Griffiths, VP
of Nursing, Angela McPike, VP of Marketing, and Michelle Laisure, Corporate Compliance Officer.
©2009 Chesapeake Hospital Authority. Medline is a registered trademark of Medline Industries, Inc.
% of total treatment cost
Cost per patient/case*

©2009 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.
We’ve Made Pressure Ulcer Prevention Easy
Systematic efforts at education, heightened awareness, and specific
interventions by interdisciplinary healthcare teams have demon-
strated that a high incidence of pressure ulcers can be reduced.
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.
Medline’s comprehensive Pressure Ulcer Prevention Program offers
solutions to these challenges.
Pressure Ulcer Prevention Program
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
To join the fight against pressure ulcers and for more
information on the Pressure Ulcer Prevention Program,
please contact your Medline sales representative or call
Join the program
to reduce pressure ulcers.
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.
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
©2009 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.
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Improving Quality of Care Based on CMS Guidelines 39
Support Surfaces
by Jackie Todd, RN, CWCN, DAPWCA
Every day clinicians turn to Medline’s Wound Care Hotline in
search of solutions for their patients’ and residents’ wound and
skin care needs. Some questions are simple; some are more
complex, but at the end of the day the fact remains that the
callers need guidance to find the right solution, and the clinical
education specialists at Medline are there to answer their calls.
A recent caller asked about support surfaces, which play a
multi-faceted role in making a difference in the quality of care
patients receive.
Many factors go into appropriately choosing a support surface.
Developing product selection guidelines specific to a particular
facility and based on patient characteristics may reduce exces-
sive and inappropriate use of specialty support surfaces.
Minimizing the risk for pressure ulcers
Many patients are considered to be at high-risk for pressure
ulcer development due to their injuries, disease processes
and/or the presence of risk factors such as malnutrition and
immobility Although many factors are involved, the primary
cause of pressure ulcers is sustained
compression of the cutaneous and
subcutaneous tissue between a bony
prominence and a surface. When
external pressure is greater than capil-
lary blood-flow pressure, diminished
and impaired blood flow leads to the
death of the tissues.
“Pressure causes pressure ulcers,” and the only variable you
have complete control of is the support surface. Therefore, it is
important to understand the performance characteristics deliv-
ered by various support surfaces. Each redistributes pressure in
a different way and to a different degree. Let’s start with how to
evaluate a support surface’s ability to redistribute pressure.
Pressure redistribution
It would be nice if we had a tool that could predict when tissue
is in danger of dying from pressure. Unfortunately, there are no
tissue viability measurement tools currently available. So, to help
make an informed decision when selecting the most appropri-
ate support surface, you must become familiar with the follow-
ing terms:
• Capillary closing pressure
• Internal cushion pressure
• Interface pressure
These terms may sound confusing, but think about an item you
already know, such as a tire. The surface of the tire, where the
rubber meets the road, is the interface pressure, the air inside
the tire corresponds to the internal cushion pressure, and if there
happened to be a cat in the road, and you accidentally rode
over its tail, there would be capillary
closing pressure in the tail.
Now, if that same cat were not on the
road, but on a soft marsh when the tire
rode over its tail, the tail would sink into
the soft surface and be protected from
the pressure of the tire.
You can use the same theory when thinking of a support surface
for your patient or resident. This would equate to the “immer-
sion” property of the surface, which is the ability to let the pa-
tient’s body sink into the surface. Along with the envelopment
that occurs around the patient’s body as he is immersed into
the surface, the redistribution of weight is maximized across the
surface. This, in turn, minimizes pressure over any given point
and reduces the risk of capillary closure and subsequent
tissue death that results in pressure ulcer formation.
Another key component to remember is that a small amount of
pressure (even while sitting or lying on a surface that provides
Hotline Hot Topic
“Pressure causes
pressure ulcers,” and the
only variable you have
complete control of
is the support surface.
40 Healthy Skin
maximum pressure redistribution) over a long period of time can
do as much damage at the capillary level as a large amount of
pressure over a short period of time.
What does all of this mean? It means that no surface is a magic
potion or silver bullet. Regardless of the support surface used,
patients/residents still need to be turned a minimum of every
two hours or more frequently if tissue tolerance requires it.
Tissue tolerance is the skin’s ability to resist injury due to pres-
sure. Capillary closing pressure for every person is as individual
as a fingerprint. So everyone’s skin can tolerate different
amounts of pressure for different lengths of time before injury
takes place.
Capillary closing pressure is the measurement of pressure on
capillaries (in mmHg) that will cause their collapse or closure.
Capillary closing pressure is the only measurement that has real
value because it reflects intracapillary pressure in the tissues
themselves, not surface pressures outside the body. Capillary
closing pressure can only be measured by invasive techniques
and has been found to be around 32 mmHg
but will be differ-
ent for each patient. The pressure can range from as low as
12 to as high as 40 mmHg.
This information supports the indi-
vidualization of turning schedules to prevent skin breakdown.
How to choose the right support surface
Specialty support surfaces are frequently rented, and those fees
can dramatically add to yearly expenditures for treatment of
pressure ulcers, depending on the sophistication of the tech-
nology used. That’s why capital purchases of surfaces have
become a more appealing choice. Plus, having the right surface
readily available means quicker intervention, which results in bet-
ter outcomes.
So how do you choose the right support surface for your patient
or resident? This is not a “one size fits all” world, and one prod-
uct cannot meet the needs of everyone. When selecting a sup-
port surface, it is best to begin by determining the depth of
tissue destruction and/ or by determining the patient’s level of
risk. You’ll also want to review the support surface features that
can reduce or eliminate shear, friction, moisture and other
factors that contribute to pressure ulcer development.
In addition to keeping these contributing factors in mind, as well
as whether the patient already has existing pressure ulcers and
their anatomical locations, we also must consider pain control
when we decide which support surface the patient requires.
Whether a prevention or treatment surface is needed and
chosen, the need for pain control must be included in the choice
criteria. Turning and repositioning, as well as pressure redistrib-
ution, are key components in pain control for immobile patients.
Comfort and the ability to rest are very important pieces in the
healing process as well, so choosing the surface that meets
all these needs is imperative to positive outcomes.
The right support surface dramatically contributes to the pre-
vention and treatment of pressure ulcers. Combining good skin
care, adequate nutrition, appropriate interventions for all con-
tributing factors and co-morbid conditions makes attaining pos-
itive outcomes a more realizable goal. Positive outcomes result
from “managing the whole patient, not just the hole in the
patient” and getting positive outcomes shows the high quality of
care given, which results in improved quality of life.
1. Warren JB, Yoder LH, Young-McCaughan S. Development of a decision tree for support
surfaces: a tool for nursing. MedSurg Nursing. 1999; 8(4):239-245, 248. Available at http:// Accessed August 28, 2009.
2. Viney C. Mobility Needs In: Nursing the Critically Ill. 1999. Harcourt Publishers Limited:
Edinborough, Scotland. Available at:
resnum=1#v=onepage&q=Capillary%20closing%20pressure%20has %20been%20
found%20to%20be%20around%2032%20mmHg&f=false. Accessed September 4, 2009.
3. Le KM, Madsen BL, Barth PW, Ksander GA, Angell JB, Vistnes LM. An in-depth look
at pressure sores using monolithic silicone pressure sensors. Plastic & Reconstructive
Surgery 1984; 74(6):745-754.
About the author
Jackie Todd RN, CWCN, DAPWCA is the
Clinical Education Specialist for the Atlantic
Region of Medline Industries. She is a member
of the Wound Ostomy and Continence Nurses
Society; a Diplomat in the American Profes-
sional Wound Care Association; and a member
of the Association for the Advancement of
Wound Care. Jackie is a Corporate Advisory
Council member of the National Pressure Ulcer Advisory Panel, serving
on both the Support Surface Standards Initiative and the Deep Tissue
Injury Task Force, and Public Policy Committee. She has served as a
Corporate Advisory Council member to the European Pressure Ulcer
Advisory Panel, a corporate liaison to board members of the Japanese
Pressure Ulcer Society and the Australian Wound Management
Hotline Hot Topic
©2009 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.
More than 1 million Americans receive home health care
services every year.
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 The Centers for Disease Control and Prevention. Home Health Care Patients:
Data from the 2000 National Home and Hospice Care Survey. Available at: Accessed April 12, 2008.
For your free cost-savings analysis, contact your
sales representative or call 1-800-678-7852.
Bringing it home to you
The International Expert Wound Care Advisory
Panel released a 23-page white paper in June
2009 identifying key concepts to help healthcare
professionals with preventative legal care
practices taking into consideration the current
pressure ulcer regulatory and legal environment.
The paper is titled “Legal Issues in the Care of
Pressure Ulcer Patients: Key Concepts for
Healthcare Providers.”
Lawsuits over pressure ulcers are increasingly
common in both acute and long-term settings
with judgments as high as $312 million in a single
Quoting from the paper itself, “Like some
pressure ulcers, litigation over pressure ulcers
may be unavoidable. For this reason, knowing
how to react when it occurs is no less important
than knowing how to minimize the risk of pressure
ulcer lawsuits themselves.”
Read the excerpt on the next page from “Legal
Issues in the Care of Pressure Ulcer Patients:
Key Concepts for Healthcare Providers” for a
nurse’s personal account of what happened
after she was handed a subpoena to report for
a deposition.
For more information and to request a copy of
the entire white paper, visit Medline’s Web site
1. Voss AC, Bender SA, Ferguson ML, et al. Long-term care liability for pressure
ulcers. J Am Geriatric Soc. 2005;53:1587-1592.
2. Ayello EA, Capitulo KL, Fife CE, Fowler E, Krasner DL, Mulder G, et al. Legal
is sues in the care of pressure ulcer patients: key concepts for healthcare
providers. White paper. June 2009.
3. Aronovitch SA. Intraoperatively acquired pressure ulcers: are there common
risk factors? Ostomy Wound Management. 2007;53(2):57-69. Available at Accessed July 29, 2009.
Legal Issues in the Care
of Pressure Ulcer Patients
42 Healthy Skin
Legal Issues in the Care of Pressure Ulcers: Key Concepts for Healthcare Providers
Deposed: A Personal Perspective
By Evonne Fowler, MSN, RN, CWOCN
The unthinkable happened to me.
In my 46 years of nursing, I have always felt
that I was a patient advocate. In fact, I have told
many a patient, “If I were you, I would want me
to take care of you.” I was shocked when I opened
the door one evening and was handed a subpoena
to report for a deposition.
One of the patients I had cared for a few years
ago had brought a lawsuit against the hospital and
I was implicated as one of the wound care specialists
who had rendered service.
I was devastated. I have always done my best
to keep patients in my charge clean, dry, comfortable
and safe. So how did this happen and what does it
mean for me? What would happen next?
I remembered the patient quite well. She was a
very complex and difficult patient. Here’s what my
review of her medical record revealed. She was a
54-year-old morbidly obese (425 lbs.) female who
was admitted to the Emergency Department after
three days of being febrile, unable to eat, experienc-
ing liquid stools and being lethargic. The paramed-
ics had been called to the home earlier, but she had
refused to be taken to the hospital. Later that night,
her daughter was able to persuade her to go to the
Emergency Department. Her admitting diagnosis
was right leg cellulitis. She had a history of multiple
co-morbidities including venous disease, diabe-
tes, morbid obesity, hypertension, chronic anemia,
chronic kidney disease, asthma, and of non-adherent
behavior. She had called the membership services
over 100 times during her years of coverage,
reporting various incidents regarding her care.
A few hours after admission, she was taken
to the operating room, where she had a soft tissue
incision and fasciotomy for compartment syndrome
of the right leg. On post-op admission to the inten-
sive care unit, her initial skin assessment was clear
of bruising or wounds. She developed sepsis, had
an altered mental status with bouts of confusion,
uncooperative behavior, lethargy, difficulty
awakening and agitation; she was verbally abusive
to the staff. Her hospitalization was fraught with
complications, including pneumonia with subsequent
need for intubation. Her behavior became combative.
She pulled out the nasogastric tube and intravenous
lines and had to be placed in restraints.
Eight days after admission, two pressure ulcers
(Stage I and Stage II) were noted in the sacral area.
As per our protocol, photographs were taken. On post
op day 12, the orthopedic surgeon requested a wound
care consultation for recommendations regarding the
management of the open fasciotomy incision. During
the skin assessment, the wound care nurse document-
ed a 9 x 20 centimeter unstageable pressure ulcer
on the sacral area, 75% black, 20% yellow, 5% red.
The patient was on the bariatric air support surface.
The post-op leg wound continued to heal;
however, the sacral pressure ulcer needed multiple
surgical debridements. At the base of the pressure
ulcer, an abscessed area was found. Once the sacral
area was clean, a negative pressure wound therapy
closure device was applied over the wound.
Upon discharge, she spent an additional six
months in a skilled nursing facility for pressure ulcer
management. Eventually, she returned home with
a small open wound. Her lower leg cellulitis had
extended into an eight-month saga due to the com-
plication from the hospital-acquired pressure ulcer.
Now what?
I was a fact witness (required to help relate the
specific facts of this one case) rather than expert
witness (who is usually called in to offer an opinion).
The hospital’s attorney represented me for the
deposition. I was called by the defense and counseled
not to give any opinions.
Improving Quality of Care Based on CMS Guidelines 43
Legal Issues in the Care of Pressure Ulcers: Key Concepts for Healthcare Providers
My attorney sent a file box filled with medical records
for me to review. I was frustrated as I reviewed these
records. Notes were handwritten, difficult to read and
fragmented with different disciplines writing in various
sections. Very few notes were made in the comment
section of the nursing notes. Flow sheets were not com-
pleted. It was challenging to determine if the patient
actually had been turned, cleansed and repositioned
consistently. Although the patient was incontinent of
stool, there were very few episodes of incontinence
noted. Even though I remembered that she was placed
on a special mattress for pressure redistribution, I was
unable to determine this fact from the chart, despite
the fact that a special bed was ordered on day eight.
The Deposition
The attorney for the plaintiff handed me the nurses’
notes for the first seven days of the patient’s
hospitalization and asked me to read the Braden
Score, the integumentary, neuromuscular section,
turning/repositioning section of the flow sheet and
the nurses’ comment section. There was very little
charted in any of the sections. The Braden Score
showed the patient to be at high risk for pressure
ulcer development. I was unable to find a plan of
care in any of the files. Although the hospital had
just implemented a new pressure ulcer program,
none of the new forms or the pressure ulcer trending
were filled out. The attorney had me go through
the chart looking for documentation of instances
of patient non-adherence. I was stunned at the lack
of documentation by both physicians and nurses
about her behavior, the skin and the pressure ulcer
throughout her hospitalization.
The opposing counsel had me read my own charting
for the times I had interacted with the patient and
asked if the doctor had been informed consistently
regarding the skin changes and wound management
of the pressure ulcer. I was embarrassed with my
own charting and lack of information charted. The
photographs taken throughout her hospitalization
were not labeled properly and were out of sequence.
There were no follow-up notes to indicate the patient
or family received education about pressure ulcer
prevention or treatment. There also was no discharge
note detailing the pressure ulcer other than the order
to continue negative therapy.
Lessons Learned
Some of the common complaints registered against
nurses in a lawsuit are failure to follow a standard
of care, failure to communicate, failure to assess and
monitor appropriately, failure to report significant
findings, failure to act as a patient advocate and
failure to document. That certainly applies in this
case. Documentation is essential! Here are the main
lessons I learned from this experience:
- 0n admission, il is impoilanl foi llc wound
care specialist to assess the patient’s skin and
wound and write a detailed, initial, focused
assessment. If a wound is present on admission,
document the wound profile.
- Pocumcnl llc lypc of suppoil suifacc the
patient is on or whenever a support system
change is ordered.
- 1akc a clcai plologiapl of llc wound according
to your organization’s guidelines. For me, that
would mean using a measurement label and a
black marking pen to clearly identify the patient’s
name or initials, medical record number, date
and location of the wound on the photo.
- Rcvicw and follow llc guidclincs iclalcd
to skin and wound care.
- Labcl and placc llc picvcnlion piolocol
standing orders and, if a wound is present,
the wound and skin care treatment standing
orders. Complete the required sections and sign.
- Nolify llc plysician icgaiding llc skin|
wound condition. Based on your findings,
document if the wound is healable or
non-healable and document the interventions
for prevention and treatment of the skin/wound.
- Makc suic you do a follow-up nolc.
- Rccoid in llc disclaigc nolc llc skin
and wound status.
- Rcmcmbci llc powci of woids. Pay
attention to “words not to use.”
After a few months, the case was settled out of court in favor of the patient.
I hope by my sharing my own story of doing a deposition, you will gain from my pain!
44 Healthy Skin
Legal Issues in the Care of Pressure Ulcers: Key Concepts for Healthcare Providers
My attorney sent a file box filled with medical records
for me to review. I was frustrated as I reviewed these
records. Notes were handwritten, difficult to read and
fragmented with different disciplines writing in various
sections. Very few notes were made in the comment
section of the nursing notes. Flow sheets were not com-
pleted. It was challenging to determine if the patient
actually had been turned, cleansed and repositioned
consistently. Although the patient was incontinent of
stool, there were very few episodes of incontinence
noted. Even though I remembered that she was placed
on a special mattress for pressure redistribution, I was
unable to determine this fact from the chart, despite
the fact that a special bed was ordered on day eight.
The Deposition
The attorney for the plaintiff handed me the nurses’
notes for the first seven days of the patient’s
hospitalization and asked me to read the Braden
Score, the integumentary, neuromuscular section,
turning/repositioning section of the flow sheet and
the nurses’ comment section. There was very little
charted in any of the sections. The Braden Score
showed the patient to be at high risk for pressure
ulcer development. I was unable to find a plan of
care in any of the files. Although the hospital had
just implemented a new pressure ulcer program,
none of the new forms or the pressure ulcer trending
were filled out. The attorney had me go through
the chart looking for documentation of instances
of patient non-adherence. I was stunned at the lack
of documentation by both physicians and nurses
about her behavior, the skin and the pressure ulcer
throughout her hospitalization.
The opposing counsel had me read my own charting
for the times I had interacted with the patient and
asked if the doctor had been informed consistently
regarding the skin changes and wound management
of the pressure ulcer. I was embarrassed with my
own charting and lack of information charted. The
photographs taken throughout her hospitalization
were not labeled properly and were out of sequence.
There were no follow-up notes to indicate the patient
or family received education about pressure ulcer
prevention or treatment. There also was no discharge
note detailing the pressure ulcer other than the order
to continue negative therapy.
Lessons Learned
Some of the common complaints registered against
nurses in a lawsuit are failure to follow a standard
of care, failure to communicate, failure to assess and
monitor appropriately, failure to report significant
findings, failure to act as a patient advocate and
failure to document. That certainly applies in this
case. Documentation is essential! Here are the main
lessons I learned from this experience:
- 0n admission, il is impoilanl foi llc wound
care specialist to assess the patient’s skin and
wound and write a detailed, initial, focused
assessment. If a wound is present on admission,
document the wound profile.
- Pocumcnl llc lypc of suppoil suifacc the
patient is on or whenever a support system
change is ordered.
- 1akc a clcai plologiapl of llc wound according
to your organization’s guidelines. For me, that
would mean using a measurement label and a
black marking pen to clearly identify the patient’s
name or initials, medical record number, date
and location of the wound on the photo.
- Rcvicw and follow llc guidclincs iclalcd
to skin and wound care.
- Labcl and placc llc picvcnlion piolocol
standing orders and, if a wound is present,
the wound and skin care treatment standing
orders. Complete the required sections and sign.
- Nolify llc plysician icgaiding llc skin|
wound condition. Based on your findings,
document if the wound is healable or
non-healable and document the interventions
for prevention and treatment of the skin/wound.
- Makc suic you do a follow-up nolc.
- Rccoid in llc disclaigc nolc llc skin
and wound status.
- Rcmcmbci llc powci of woids. Pay
attention to “words not to use.”
After a few months, the case was settled out of court in favor of the patient.
I hope by my sharing my own story of doing a deposition, you will gain from my pain!
What to Do
If This Happens
to You
Although finding out you are being sued can be shocking and
upsetting, it is crucial to stay calm and take some simple
steps to allow for the best possible results.
•Notify your institution and malpractice carrier
immediately for the name of your attorney (counsel).
•DO NOT create notes on your own – separate and apart
from a meeting with your lawyer. These notes could
easily be discoverable in litigation.
•Avoid the temptation to talk to anyone about the case
until you have discussed it with your attorney. Your
attorney will likely advise you to avoid talking to
colleagues about the case; this is important advice.
•Your attorneys or legal department are your resources,
so ask them about terminology or procedures that are
unfamiliar to you.
•As part of the litigation, you may be deposed. You can
be deposed even if the case is not about you. If you face
deposition, meet with your attorney first to go over the
procedure and talk about the sorts of questions the
other attorneys are expected to ask.
•While not all litigation goes to court, sometimes you will
find your self taking the witness stand. Talk to your legal
representatives before testifying in court. It is important
that you understand the procedures and can go over
what you likely will be asked.
Are Your
the Grade?
A recent survey graded physiciansʼ abilities to
recognize, assess and document Stage III and
IV pressure ulcers at a “D” level. Medlineʼs 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 Medlineʼs
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
Contact your Medline sales representative for more
details. You can also learn more about Medlineʼs
Pressure Ulcer Prevention Programs for long-term
care, acute care and perioperative services by visiting
Improving Quality of Care Based on CMS Guidelines 45
46 Healthy Skin
The Next Generation:
The Use of Basement Membrane and Extracellular
Matrix-Containing Urinary Bladder Matrix* in the
Treatment of Chronic Venous Ulcerations
Joseph Gonzalez, DPM
The Foot Wound Institute
Capital Foot & Ankle Centers
Okemos, Michigan
Up to 80 percent of leg ulcers are the result of chronic venous hyperten-
sion, most commonly caused by valvular incompetence.Various prod-
ucts have been proven to be effective for treatment under compression
therapy, including extracellular matrix technology.
Naturally derived, non-crosslinked extracellular matrix, such as those
derived from Urinary Bladder Materials (UBM), are unique among scaffold
technol ogi es that fundamental l y change heal i ng through the
deployment of significant biomolecules. These biomolecules have
the capacity to engage cells involved in natural wound healing, including
progenitor cells that differentiate to fully functional adult cells in site-
specific tissues. Specifically, preclinical research shows that the base-
ment membrane component of the product described here allows
increased activity from a wound healing perspective, as it contains mul-
tiple collagen types, proteoglycans, multiple growth factors, glycoproteins
and anti-infective peptides.
During the healing process, the Basement
Membrane containing Wound Matrix* – the product studied in this case
series – is known to be resorbed and replaced with new tissue where
scar tissue normally would be expected.
The experience at a busy wound center using this novel biomaterial are
presented in a case study series on four patients with chronic venous
ulcers with varying degrees of complexity.
Introduction and Background
Relatively recently, and in parallel with the understanding of the key role
of ECM in wound healing, biomaterial science has evolved allowing the
harvesting and processing of biological tissue into high quality biomate-
rials suitable for regular clinical use. For example, the acellular ECM
isolated from the porcine bladder, or other similar materials isolated from
the intestinal submucosa, are complex multicomponent biomaterials that
have potential for making transformational changes in the practice of
wound healing.
The Wound Center is developing a protocol of using this UBM-derived
Basement Membrane/ECM associated biomolecules to “fill” a tissue
defect, hypothesizing that the complex interplay of the Basement Mem-
brane components will provide the ability to recruit progenitor cells that
may progress on to differentiate into a number of tissue types that fill the
wound as nature intended.
In this study we used the Basement Membrane/ECM material on a
series of venous insufficiency-associated wounds that had resisted all
efforts in healing. Each patient had significant co-morbidities and associ-
ated problems. The objective of the study was to note if the Basement
Membrane/ECM material would change the dynamics of a wound that is
stalled in a pernicious state of equilibrium with no healing observed using
other advanced treatment methods.
Case 2
A 41-year-old male presented to the Wound Center three months status
post ORIF right tibial plateau fracture, ORIF right ankle fracture, and
decompression of compartment syndrome, following a traumatic snow-
mobile accident. The patient’s past medical history is significant for
chronic venous insufficiency as well as hypertension. The surgeons had
attempted skin grafting on the wounds at the same time as the leg skin
grafting with continued areas of non-healing. Upon initial evaluation, the
patient had significant venous edema in the right lower extremity with a
large anterior ankle wound and a small venous wound laterally. Both were
granular, with no signs of infection, yet remained open for three months.
Therefore, Basement Membrane/ECM Wound Matrix was applied, fix-
ated with Steri-strips™ and covered with oil emulsion and a four-layer
compression wrap. The patient returned weekly for dressing changes
and serial debridements, including a debulking of the hypergranular tis-
Case 1
In the context of wound healing, of particular significance is the use of the
Basement Membrane layer in the ECM material.* One of the best sources
of an easily harvestable and reliable acellular Basement Membrane/ECM
is the porcine urinary bladder material or UBM.
A 58-year-old male with a past medical history significant for chronic
venous insufficiency presented to the Wound Center with a large venous
wound on the medial aspect of his right heel. Initially, he was treated with
silver and collagen products and covered with four-layer compression
dressings. After two months of weekly treatment and minimal healing,
he was treated with the Basement Membrane/ECM Wound Matrix
fixated in place with Steri-strips™ and covered with foam and a four-
layer compression dressing. The wound was debrided weekly. In the last
two weeks of healing, the patient was treated with the Basement
Membrane/ECM Wound Matrix and covered with a silver impregnated
foam dressing under the compression wrap. The wound healed in seven
weeks following the initiation of the Basement Membrane/ECM Wound
Improving Quality of Care Based on CMS Guidelines 47
Discussion of Results
A newly available Basement Membrane containing Extracellular Matrix
(ECM) Wound Sheet* has properties that may augment the natural wound
healing process, which is severely compromised in patients with com-
plex co-morbidities. In addition to moist wound healing practices, it is
possible that such complex biomaterials, which have proven ability to re-
cruit wound healing cells, can make a real difference in disturbing the non-
healing equilibrium associated with chronic wounds. It is also possible
that these technologies will be used in the healing of chronic wounds of
the future, now that the concept of “active” wound healing is possible in
a large measure. We believe that the remarkable healing that was demon-
strated on four patients with non-healing venous insufficiency-associated
wounds through the use of the Urinary Bladder Material with Basement
Membrane/ECM components saved significant resources, pain and time.
More research in this area is intended in future.
The use of Urinary Bladder Material derived Basement Membrane/ECM
Wound Matrix is shown to be effective in the treatment of chronic venous
1. Brown B, Lindberg K, Reing J, Stolz DB, Badylak SF. The basement membrane component
of biologic scaffolds derived from extracellular matrix. Tissue Eng. 2006;12(3):519-26.
2. Brennan EP, Reing J, Chew D, Myers-Irvin JM,Young EJ, Badylak SF. Antibacterial activity
within degradation products of biological scaffolds composed of extracellular matrix.
Tissue Eng. 2006;12(10):2949-55.
* MatriStem® is a registered trademark of Acell Incorporated and distributed by Medline
Industries Inc., Mundelein, IL. **Steri-strips™ is a registered trademark of 3M. ***Adaptic®
is a registered trademark of Sandoz AG Corporation.
* MatriStem® is a registered trademark of Acell Incorporated and distributed by Medline
Industries Inc., Mundelein, IL. Steri-strips™ is a registered trademark of 3M. Apligraf® is ????
©2009 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.
sue laterally. Each week, a new piece of Basement Membrane/ECM was
applied and four-layer compression was continued. The wounds were
completely healed after seven weeks; the patient was placed in a custom-
made knee-high compression stocking and discharged.
Case 3
A 66-year-old female presented to the Wound Center 16 weeks status
post ORIF of a right fibula fracture. The initial incision had yet to heal due
to the patient’s chronic venous insufficiency. Her significant past medical
history includes COPD and hypertension. Upon initial presentation the
proximal one-third of her incision remained open with no exposed hard-
ware. X-rays revealed adequate fixation across the fracture with a semi-
tubular plate and screws. The fracture was well-healed and the screws
appeared to be intact with no sign of infection or loosening. Therefore,
Basement Membrane/ECM Wound Matrix was applied, fixated with Steri-
strips™ and covered with oil emulsion and a four-layer compression wrap.
The patient returned weekly for serial debridements and continued appli-
cation of the Basement Membrane/ECM Wound Matrix and com-
pression wrap. The wound healed in three weeks. She was placed in
custom-made knee-high compression stockings and discharged.
Case 4
An 87-year-old male presented to the Wound Center with a new venous
ulceration at the lateral aspect of his left ankle. His past medical history
included recurrent slow-healing, venous wounds as well hypertension.
For the initial two months, he was treated for the ulceration with silver
dressings, collagen and Apligraf
with minimal improvement. Two months
following the application of Apligraf
, he was treated with the Basement
Membrane/ECM Wound Matrix and covered with oil emulsion and a two-
layer compression wrap. The patient returned weekly for serial debride-
ments and treatment with Basement Membrane/ECM Wound Matrix
covered with compression wraps. Six weeks after the initial application of
Basement Membrane/ECM Wound Matrix, the wound was completely
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49 Healthy Skin Improving Quality of Care Based on CMS Guidelines 49
The gang’s all here
and they’re ready to play.
Methicillin-resistant staphylococcus aureus (MRSA), Vancomycin-resistant enterococcus (VRE),
Escherichia coli (E. coli), Extended spectrum-lactamase (ESBL) and Clostridium difficile (C. diff)
could be lurking in unsuspected places at your facility. How much do you know
about these “bad bugs”? Hint: You can find some of the answers by reading
the article on page 50.
1______ In one study, 65 percent of nurses who cared for patients with this type of bacteria
also contaminated their uniforms with it.
2______ Bleach is the only known cleaner proven to kill this “bad bug.”
3______ When this enzyme is produced, it can make microorganisms resistant to
certain antibiotics.
4 ______ This is one of the many types of bacteria found in human and animal feces.
Raw beef is sometimes infected with it, causing illness in humans.
5______ This type of “super bug” is found most often in hospitals.
Choosing from the “bugs” shown above, indicate your answers below.
C. diff
E. coli
A N S W E R S : 1 - M R S A , 2 - C . d i f f , 3 - E S B L , 4 - E . c o l i , 5 - V R E
Special Feature
50 Healthy Skin
Busy, overburdened healthcare facilities,
ever-mutating strains of bacteria and spotty
handwashing compliance – these are just a
few of the reasons behind increasing rates of
healthcare-acquired infection (HAI). But with
multiple and varied contributing factors, it’s difficult
to get a handle on this widespread, worldwide
problem. According to the Centers for Disease
Control and Preventi on (CDC), HAIs account
for an estimated 1.7 million infections and 99,000
deaths in U.S. hospitals each year.
The so-called “bad bugs” behind many HAIs
are so i nsidious, they can be found lurking
practically anywhere within a healthcare facility.
Several new studies show that healthcare
professionals’ scrubs, lab coats and stetho-
scopes are carriers of deadly bacteria such
as methicillin-resistant Staphylococcus aureus
(MRSA) and Clostridium difficile (C. diff) that
easily can be transmitted to patients.
Your Act!
MRSA, C. diff, other harmful bacteria
lurk in unexpected places
ability of isopropyl alcohol, bleach, benzalkonium chloride
swabs and soap and water, isopropyl alcohol was
proven to be most effective to rid the stethoscopes of
S. aureus.
The same study also addressed whether bacteria could
be transferred to human skin from the stethoscope
diaphragm. Micrococcus luteus was inoculated onto a
stethoscope diaphragm, and the study showed that it
did transfer to human skin. The authors concluded that
the transfer of M. luteus to human skin made it likely that
other bacteria could be transferred as well.
Stethoscopes are an extension of the hand in clinical set-
tings and should be cleaned with the same frequency;
that is, after contact with each patient. Cleaning a stetho-
scope takes little time and effort, requires no special
equipment – and it could avoid a deadly infection.
Dirty scrubs
How about your scrubs? Some medical personnel wear
the same uniform to work more than once before laun-
dering, meaning they could be starting their shift with C.
diff, MRSA and who knows what other bacteria already
on their scrubs. A study conducted at the University of
Maryland revealed that 65 percent of medical personnel
admitted to changing their lab coat less than once a
week; 15 percent changed once a month.
workers often touch their own uniforms, potentially
transferring bacteria from the fabric to their patients.
Studies confirm that the more bacteria found on sur-
faces touched often by doctors and nurses, the higher
the risk for the bacteria to be carried to the patient and
cause infection.
Staphylococci and Enterococci
were found to survive for days to months
after drying on fabric.
Improving Quality of Care Based on CMS Guidelines 51
Your Act!
Bacteria-laden stethoscopes
Ill patients are obvious carriers of bacteria, and any sur-
face or piece of medical equipment is a potential vector
for that bacteria. For example, bacterial contamination
of a stethoscope increases markedly after it is used to
examine more than five patients without cleaning.
Several studies, however, suggest that many healthcare
professionals use bacteria-laden stethoscopes, poten-
tially transferring bacteria from patient to patient.
A recent study at one tertiary care center suggests
roughly one third of stethoscopes carried by EMS
professionals harbor MRSA. A microbiologic analysis of
50 stethoscopes provided by EMS professionals in an
emergency department revealed that 16 had MRSA
colonization. Similarly, 16 of the EMS workers could not
remember the last time they cleaned their stethoscope.
For those who did remember, the median time from the
last stethoscope cleaning was one to seven days.
MRSA colonization rates fell considerably in the stetho-
scopes that were cleaned more recently.
Another study cultured 99 stethoscopes on four medical
floors of a 600-bed hospital. All were positive for bacteria
growth. Half of the stethoscopes were cleaned using
ethanol-based cleaner (hand-sanitizing gel) and the
other half were cleaned using isopropyl alcohol pads.
Cleaning with the ethanol gel and isopropyl alcohol pads
significantly reduced the bacteria counts (by 92.8
percent and 92.5 percent, respectively).
A similar study at a large academic medical center took
cultures from 40 randomly selected clinicians’ stetho-
scopes. Staphylococcus aureus was found on 38 per-
cent of them. When comparing the bacteria-removing
Continued on Page 53
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Improving Quality of Care Based on CMS Guidelines 53
In one study, 65 percent of nurses who cared for
patients with MRSA contaminated their uniforms with
Staphylococci and Enterococci were found to
survive for days to months after drying on commonly
used hospital fabrics, such as scrubs made from 100
percent cotton or 60 percent cotton and 40 percent
polyester, as shown in a study conducted by the
Shriners Hospital for Children and the Department of
Surgery at the University of Cincinnati.
Home laundering or professional laundering?
Much debate centers around whether healthcare
professionals should be allowed to launder their own
scrubs at home.
St. Mary’s Health Center in St. Louis, Mo., reduced
infections after cesarean births by more than 50 percent
by providing staff with hospital-laundered scrubs.
Similarly, Monroe Hospital in Bloomington, Ind., which
has a near-zero rate of hospital-acquired infections,
requires all staff to wear hospital-laundered scrubs and
bans them from wearing scrubs outside the hospital
On the other side of the debate, a 1997 state-of-the-art
report (SOAR) compiled by the Association for Profes-
sionals in Infection Control and Epidemiology (APIC)
states, “There is no scientific evidence to suggest that
home laundering versus institutional laundering poses
any increased risk of infection transmission.”
Yet the report also says, “OSHA holds employers
responsible for laundering any clothing, including scrubs
worn by health care workers, that becomes contami-
nated with blood or other potentially infectious body
fluids, regardless of who owns the scrubs.”
The CDC supports home laundering of scrub uniforms
in its Guideline for Isolation Precautions (2007), which
states, “In the home, textiles and laundry from patients
with potentially transmissible infectious pathogens do
not require special handling or separate laundering, and
may be washed with warm water and detergent.”
versely, the state health departments in Pennsylvania
and Massachusetts, among others, recommend that
patients infected with MRSA launder their clothing
at home in hot water and laundry detergent. They also
suggest dryi ng cl othes i n a hot dryer to hel p ki l l
the bacteria.
The CDC’s laundering recommendation is based on the
outcome of two small, limited studies. One of the stud-
ies examined the scrub clothing of 68 labor and delivery
employees. The scrubs were laundered at home in
warm water and detergent and also dried in a clothes
dryer on the hot setting. The authors concluded that
Bleach is the only known cleaner
proven to kill C. diff.
Continued on Page 55
54 Healthy Skin
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Improving Quality of Care Based on CMS Guidelines 55
home-laundered scrub clothing can be worn safely in
labor and delivery units.
What about other areas of
a hospital?
The other study tested the left front shoulders only of 30
home-laundered scrubs and 20 hospital-laundered
scrubs. No pathogenic growth was found on either the
home- or hospital-laundered fabrics.
It could be argued,
however, that the front shoulder of a scrub uniform is one
of the least likely areas to be touched or contaminated.
Fewer bacteria = fewer HAIs
When it comes to preventing HAIs, it’s better to be safe
than sorry. If there’s even a small chance you could be
transferring bacteria to patients, why not take a little extra
time and a small amount of effort to clean up your act?
Hand rub dispensers are conveniently located through-
out most facilities, so go ahead and disinfect your
stethoscope between patients. When you wash your
scrubs, turn those dials to hot, and of course – keep
washing your hands. Pass the word along to colleagues,
and you may be surprised to see your facility’s HAI rates
go down.
1 Estimates of Healthcare-Associated Infections. Centers for Disease Control
and Prevention Web site. Available at Accessed May 13, 2009.
2 Lecat P, Cropp E, McCord G, et al. Ethanol-based cleanser versus isopropyl
alcohol to decontaminate stethoscopes. American Journal of Infection
Control. 2009;37(3):241-243.
3 Merlin MA, Wong ML, Pryor PW, et al. Prevalence of methicillin-resistant
Staphylococcus aureus on the stethoscopes of emergency medical
services providers. Prehosp Emerg Care. 2009;13(1):71-74.
4 Marinella MA, Pierson C, Chenoweth C. The stethoscope. A potential
source of nosocomial infection? Archives of Internal Medicine.
5 McCaughey, B. Hospital scrubs are a germy, deadly mess. The Wall Street
Journal. January 8, 2009:A13.
6 LeTexier, R. Coming clean on home laundered scrubs. Infection Control
Today Web site. Posted October 1, 2001. Available at http://www.infection- Accessed May 11, 2009.
7 Recommended Practices for Surgical Attire in: 2008 Perioperative
Standards and Recommended Practices. Association of PeriOperative
Registered Nurses: Denver, CO.
8 Dix K. Apparel in the hospital: what to wear, where? Infection Control Today
Web site. Posted March 1, 2005. Available at http://www.infectioncontrolto- Accessed May 11, 2009.
9 Belkin NL. Use of scrubs and related apparel in health care facilities.
American Journal of Infection Control. 1997;25(5):401-404.
10 Siegel JD, Rhinehart E, Jackson M, et al. Centers for Disease Control and
Infection. 2007 Guideline for Isolation Precautions: Preventing Transmission
of Infectious Agents in Healthcare Settings. Available at Accessed May
11, 2009.
11 Recommendations on Children with Methicillin-Resistant Staphylococcus
aureus (MRSA) in School Settings. Pennsylvania Department of Health Web
site. Available at Accessed
May 11, 2009.
12 Helpful Reminders About MRSA Infection. Massachusetts Department of
Public Health Web site. Available at:
minders.pdf. Accessed May 11, 2009.
13 Kiehl E, Wallace R, Warren C. Tracking perinatal infection: is it safe to launder
your scrubs at home? MCN Am J Matern Child Nurs. 1997;22(4):195-197.
14 Jurkovich P. Home- versus hospital-laundered scrubs: a pilot study.
MCN Am J Matern Child Nurs. 2004;29(2):106-110.
15 Diarrhea-causing bacteria common in hospitals. Health News. Available at
mon_in_ us_hospitals. Accessed May 13, 2009.
16 Denny D. Monroe Hospital’s low infection rates draw national interest.
January 19, 2009. Bloomington Herald Times. Available at http://www.hear-
17 Wenzel R, Edmond MB. The impact of hospital-acquired blood stream
infections. Emerg Inf Dis. 2001;7(2):174-177.
Change your habits for infection prevention
• Keep isopropyl alcohol wipes or ethanol-based
hand cleaner available and wipe down your
stethoscope after each patient encounter.
• Wear street clothes to work, and then change
into clean scrubs every day. Keep an extra set
on hand and change mid shift if your scrubs
get visibly dirty or notably splattered with any
substance possibly containing bacteria. Change
back into street clothes before leaving the facility
to avoid carrying bacteria into your car, public
places and your home. If you wear a lab coat,
keep a clean supply at your facility and change
into a new one each day.
• If your facility allows you to launder your own
uniforms at home, be sure to use hot water (110
to 125 degrees F or 43.33 to 51.67 degrees C)
with 50 to 150 parts per million of chlorine
(Note: Bleach is the only known cleaner
proven to kill C. diff.)
Above all, drying laundered
linen in a hot clothes dryer plays the most
significant role in eliminating bacteria.
56 Healthy Skin
A cost-effective alternative
to urinary catheterization
Knowing catheter-related urinary tract infections (UTIs)
are the most common of all hospital-acquired infec-
tions, Alan F. Rothfeld, MD, was looking for alternatives to
catheterizing patients at Hollywood Presbyterian Medical
Center (HPMC), a 434-bed hospital in Los Angeles.
Rothfeld noted that new incontinence management products
offer less costly and more effective alternatives to catheteri-
zation. Restore ultra-absorbent disposable briefs, manufac-
tured by Medline, stay dry and hold significantly more urine
per day.
In order to document whether using disposable briefs in place
of urinary catheters would decrease UTIs, Rothfeld led a six-
month study, from January to October 2008, at HPMC’s ICU
step-down units. The study observed the use of Restore
briefs during two three-month periods in two separate units of
the hospital with a total of 60 beds, averaging 83 percent
50 Percent Reduction in UTIs
There were five hospital-acquired UTIs during the three-month
control period, indicating an infection rate of 3.2 per 1,000
catheter days. During the three-month intervention period,
there were only two hospital-acquired UTIs, with an infection
rate of 2.4 per 1,000 catheter days.
Infections during the intervention period fell from an average of
1.06 per 1,000 patient days to 0.45. “The reduction in
infections was mainly due to the decrease in catheter use
rather than other changes in patient care,” Rothfeld
explained, noting that catheter use during the intervention
period fell from 330 to 190 per 1,000 patient days.
According to Rothfeld’s findings, catheters are needed in only
about half the cases in which they are used.
Before beginning the study, Rothfeld developed the
following indications for the use of urinary catheters:
1. Written orders for hourly urinary output
2. Inability to void spontaneously (usually due
to obstruction)
3. Active urinary tract infection with Stage 3 or 4
pressure ulcer
If a patient had none of these indications, no catheter was
requested. If a patient had a catheter already, a request to the
physician for discontinuance was initiated.
An anonymous questionnaire conducted at the end of the
study revealed the disposable briefs were a welcome alter-
native among physicians and nurses. “In fact, no patient
reported decreased comfort and most of the staff was sup-
portive of this program, indicating it increased overall satis-
faction among nursing personnel,” Rothfeld said.
Ditch the foleys, adopt diapers to address UTIs. Infection Control Today Web
site. Posted March 10, 2009. Available at
ager/printerfriendly.aspx?article=23711. Accessed May 22, 2009.
Rothfeld AF & Stickley A. A Program to Reduce Nosocomial Urinary Catheter
Infections at an Acute Care Hospital [manuscript]. Hollywood Presbyterian
Medical Center; 2009.
Restore is a registered trademark of Medline Industries, Inc.
TI w
ith U
of Incontinence
by Lorri Downs, RN, BSN, MS, CIC
Have you ever thought about or questioned if the
catheter you were inserting was really necessary and
clinically indicated? It has become critically important that
we evaluate the need for urinary catheterization and no longer
insert catheters for convenience or because that is what we
always do. What’s more, did you know that requests from
nurses to place a urinary catheter for nursing convenience are
not uncommon?
The 1997 APIC/SHEA position paper on urinary tract infections
in long-term care identifies CAUTI as the most common infec-
tion in long-term care residents, with a bacteriuria prevalence
without indwelling catheters of 25 to 50 percent for women and
15 to 40 percent for men. With this already elevated presence
of bacteriuria, usage of indwelling urinary catheters can be
expected to result in higher CAUTI rates with an associated risk
of CAUTI-related bacteremia, unless appropriate prevention
efforts are implemented.
New guidelines and recommendations tell us that we should
determine if there is an approved medical indication for
catheterization. This means that we evaluate and reconsider
the common practice of inserting indwelling catheters. This
evaluation may change how we have always done things.
The Centers for Medicare & Medicaid Services
(CMS), as a result of the Medicare Modernization
Act of 2003 and the Deficit Reduction Act
of 2005, has identified CAUTI as a
Tell Me Again Why This Resident
Needs a Catheter?
Improving Quality of Care Based on CMS Guidelines 57
Continued on Page 59
CAUTI Prevention: How Do You Rate?
1. At my facility, we practice timely removal
of urinary catheters.
a. Always
b. Sometimes
c. Never
2. I follow strict aseptic technique when
inserting a catheter.
a. Always
b. Sometimes
c. Never
3. At my facility, we educate catheterized
residents about urinary tract infections.
a. Always
b. Sometimes
c. Never
4. At my facility, we keep track of how long
catheters are kept in patients.
a. Always
b. Sometimes
c. Never
5. Before placing a catheter, I assess whether
the patient really needs it, and I document
the assessment in the medical record.
a. Always
b. Sometimes
c. Never
What’s your score?
a _____ x 5 = _______
b _____ x 3 = _______
c _____ x 0 = _______
TOTAL _______
How do you rate?
25 Perfect score! Keep up the great work and educate others.
17 – 23 Great job. Read below for more helpful tips.
8 – 14 You’re doing OK. Read “Tell Me Again Why This Resident Needs a Catheter?”
to find out more about CAUTI prevention AND earn a free CE!
0 – 5 Lots of opportunity to improve practices at your facility. Medline can help! Also review the strategies below.
We invite you to join the Race to ERASE CAUTI! With 100,000 nurses working together, we can do it!
CAUTI FACTS Evidence-Based Prevention Strategies
• The MOST effective way to prevent CAUTI is to AVOID inappropriate catheterization.
• Greater attention is REQUIRED to avoid inserting catheters in patients unnecessarily.
• Limiting urinary catheter use and, when a catheter is indicated, minimizing the duration the catheter remains
in place, are primary strategies for CAUTI prevention.
• Alternatives to catheterization should be considered.
• Documentation must include: indications for catheter insertion, date and time of catheter insertion,
individual who inserted catheter, date and time of catheter removal.
• Insertion using aseptic techniques and sterile equipment.
• Handwashing is the FIRST and most important preventive measure.
• Education must include appropriate indications for catheter placement and the possible alternatives to
indwelling catheters.
• Educating the patient can reduce readmissions
and help to achieve higher patient satisfaction scores.
• SHEA/IDSA guidelines advise against the routine use of silver-coated or antibacterial urinary catheters
to prevent CAUTI.
3, 4
1. Expert discusses strategies to prevent CAUTIs. Infection Control Today Web site. June 1, 2005. Available at
Accessed July 10, 2009.
2. Catheter-related UTIs: a disconnect in preventive strategies. Physician’s Weekly. 25(6), February 11, 2008.
3. Lo E, Nicolle L, Classen D, Arias A, Podgorny K, Anderson DJ, et al. SHEA/IDSA practice recommendation: strategies to prevent catheter-associated urinary tract infections in acute
care hospitals. Infect Control Hosp Epidemiol. 2008;29:S41–S50.
4. Gould CV, Umscheid CA, Agarwal RK, Kuntz G, Pegues DA, et al. Guideline for Prevention of Catheter-Associated Urinary Tract Infections 2008. Draft. Centers for Disease Control
and Prevention. Available at Accessed July 10, 2009.
5. Gokula RM, Hickner JA, Smith MA. Inappropriate use of urinary catheters in elderly patients at a midwestern community teaching hospital. Am J Infect Control 2004;32:196-199.
6. Stokowski, LA. Preventing catheter-associated urinary tract infections. Medscape Nursing Perspectives. February 3, 2009. Available at Accessed July 6, 2009.
58 Healthy Skin
healthcare-associated infection (HAI) that can reasonably
be prevented through the application of evidence-based
practice. CMS reported in the 2008 Federal Register
that in 2007 there were 12,185 CAUTIs, costing $44,043
per hospital stay. CAUTI is one of 10 hospital-acquired
conditions (HACs) for which CMS will no longer provide
reimbursement if it occurs during hospitalization.
Brand-new CAUTI prevention guidelines
As a result of this data, leading industry experts, including
the Association for Professionals in Infection Control and
Epidemiology (APIC), the Society for Healthcare Epidemiol-
ogy (SHEA), the Centers for Disease Control and Prevention
(CDC), the Joint Commission and many others have joined
together to outline strategies and guidelines to prevent
catheter-associated urinary tract infections in acute care
The CDC’s Draft Guideline for Prevention of
Catheter-Associated Urinary Tract Infections 2008 (released
in June 2009) identifies new guidelines and recommenda-
tions to prevent CAUTI.
Barriers to CAUTI prevention
Three distinct barriers to the prevention of CAUTI become
evident when analyzing the problem. In the long-term care
environment the presence of a catheter predisposes the
resident to symptomatic and asymptomatic bacteriuria.
Now, compound this problem with the fact that many nurses
do not routinely perform aseptic technique and may not be
aware when contamination occurs. In fact, during most
observations of nurses, we have seen inconsistent practice
in setting up a sterile field and inserting indwelling
catheters aseptically. It is perfectly clear that in many health-
care settings, three barriers to CAUTI prevention occur
routinely – too many catheters are inserted, catheters stay
in too long and contamination occurs upon insertion.
CAUTI reduction strategies
To help you further realize the magnitude and role
nurses play in preventing CAUTI, let’s look at some
additional statistics. Did you know that the hospital emer-
gency department (ED) has the highest percentage of
catheter placements?
In the ED, documentation of the rea-
son for catheter placement is poor, and a written physician
order is frequently lacking. Without a physician order, physi-
cians are unaware that the patient has a catheter.
physicians do not know that a catheter has been inserted,
it is no wonder that an order for timely removal is lack-
ing, and catheters stay in longer than medically necessary.
Automatic stop orders and nurse-driven protocols, which
allow nurses to remove catheters without a physician order
when the patient no longer meets established criteria, can
help with the timely removal of catheters.
Common catheter practices in healthcare settings
Adding to the problem, inappropriately placed catheters are
more often forgotten about.
In 56 percent of hospitals there
is no system to keep track of which patients have catheters,
and 74 percent of hospitals do not keep track of how long
the catheter is in place.
Shocking as this may be, let’s
see if any of these common situations occur at your facility.
1. Do you assess patients to determine if the standing
order to insert an indwelling catheter is medically
2. When a patient comes to your facility with an
indwelling urinary catheter or when you insert one,
do you regularly evaluate the need to keep the
catheter in place?
3. Do you date and time when the catheter was
inserted? This critical step helps clinicians remove
catheters in a timely manner.
Nurses are positioned to significantly impact the reduction
and elimination of catheter-associated urinary tract infec-
tions by removing catheters when patients do not meet the
approved indications. Take a peek at Table 1, which lists
when indwelling urinary catheters should and should not
be used.
Too many indwelling urinary catheters are inserted
It has been estimated at up to 50 percent of the
indwelling urinary catheters are unnecessarily placed.
Improving Quality of Care Based on CMS Guidelines 59
60 Healthy Skin
What is a nurse to do? If your patient has no alternatives,
and you must insert a urinary catheter, is there anything
you can do to help prevent catheter-associated urinary
tract infections? Absolutely!
CAUTI prevention methods
a. Alternatives to urinary catheter use
- Do not allow routine urinary catheter placement when
certain criteria are not met.
- Consider alternatives to indwelling urethral catheters,
such as intermittent catheterization, condom catheters,
briefs and absorbent underpads.
b. Appropriate urinary catheter use
- Use indwelling catheters only when medically necessary.
- Do not use catheters for the management of incontinence.
c. Aseptic insertion of urinary catheters
- Use aseptic insertion technique with appropriate hand
hygiene and gloves.
- Allow only trained healthcare providers to insert catheters.
d. Proper urinary catheter maintenance
- Properly secure catheters after insertion.
- Maintain a sterile closed drainage system.
- Maintain good hygiene at the catheter-urethral interface.
- Maintain unobstructed urine flow.
- Maintain drainage bag below level of bladder at
all times.
- Use portable ultrasound bladder scans to detect
residual urine amounts.
- Do not change indwelling catheters or urinary drainage
bags at arbitrary fixed intervals.
e. Timely removal
- Remove catheters when no longer needed.
- Document indication for urinary catheter on each day
of use.
- Use reminder systems to target opportunities to re
move catheters.
The above list was combined from
recommendations in the CDC
Guidelines and 2008 APIC CAUTI
Elimination Guidelines.
Putting it all together to
Until recently, catheter-associ-
ated urinary tract infections
have received little attention
compared to many of the
other types of HAIs. However,
research and best practices for
the prevention of CAUTI are
readily available. Despite the
link between urinary catheters
and urinary tract infections in
hospitals and other healthcare
settings, a recent survey of
U.S. hospital practices identi-
fied that no strategy is consis-
tently or universally used in
Table 1. Appropriate Indications for Indwelling Urethral Catheter Use
Patient has acute urinary retention or obstruction
Need for accurate measurements of urinary output in critically ill patients
Perioperative use for selected surgical procedures:
• Patients undergoing urologic surgery or other surgery on contiguous structures
of the genitourinary tract
• Anticipated prolonged duration of surgery (catheters inserted for this reason
should be removed in PACU)
• Patients anticipated to receive large-volume infusions or diuretics during surgery
• Operative patients with urinary incontinence
• Need for intraoperative monitoring of urinary output
To assist in healing of open sacral or perineal wounds in incontinent patients
Patient requires prolonged immobilization (e.g., potentially unstable thoracic or
lumbar spine)
To improve comfort for end of life care if needed
Indwelling catheters should not be used:
• As a substitute for nursing care of the patient or resident with incontinence
• As a means of obtaining urine for culture or other diagnostic tests when the
patient can voluntarily void
• For prolonged postoperative duration without appropriate indications
• Routinely for patients receiving epidural anesthesia/analgesia
Note: These indications are based primarily on expert consensus.
Improving Quality of Care Based on CMS Guidelines 61
U.S. hospitals to prevent these infections.
Literature reports numerous organizations that have imple-
mented successful strategies to reduce CAUTI. These or-
ganizations have utilized multidisciplinary teams to implement
evidence-based changes in practice; have incorporated
practice changes into the routine standard of care; and
have performed ongoing or periodic review of progress to
reinforce successful strategies.
Develop a CAUTI prevention program for your facility
If your organization does not have a CAUTI elimination
program, or you are not getting the results you had hoped
for, start by assessing whether an effective organizational
program exists. Work with your infection preventionist and
other key multidisciplinary stakeholders to develop your
Questions to consider to help you get started
with your own CAUTI prevention program:
• Are there policies or guidelines that define criteria
for insertion of a urinary catheter?
• Has the organization established criteria for when
a catheter should be discontinued?
• Is there a process to identify inappropriate usage
or duration of urinary catheters?
• Is there a program or guidelines to identify and remove
catheters that are no longer necessary? (e.g., physician
reminders, automatic stop orders or nurse-driven
• Are there policies or guidelines for use of a bladder
scanner to detect urinary retention prior to insertion
of a catheter?
• Are there mechanisms to educate care providers
about use and care of urinary catheters?
• Overall Assessment: Is there an effective
Contamination occurs during insertion
Most nurses are aware of the importance of aseptic technique but it can take extra time.
Heavier nursing workloads contribute to poor compliance with aseptic technique.
Start the race to erase CAUTI by educating your resi-
dents and staff about CAUTI. Ensure all staff practice aseptic
technique and remove catheters in a timely manner.
Join the RACE to ERASE CAUTI! Talk about prevention,
rai se awareness, then i mpl ement sol uti ons i n your
organi zation.
1. Ribby KJ. Decreasing urinary tract infections through staff development, outcomes, and
nursing process. J Nurs Care Qual. 2006; 21:272-276.
2. An APIC Guide to the Elimination of Catheter-Associated Urinary Tract Infections 2008
(CA-UTI) p. 5-6, 8-9, 22, 35 -41 The Association of Professionals in Infection Control
and Epidemiology.
3. Stokowski, LA. Preventing catheter-associated urinary tract infections. Medscape
Nursing Perspectives. February 3, 2009. Available at Accessed July 6, 2009.
4. Centers for Medicare & Medicaid Services. Proposed Changes to the Hospital IPPS
and FY2009 rates; Available at
Accessed July 24, 2009
5. Lo E, Nicolle L, Classen D, Arias A, Podgorny K, Anderson DJ, et al. SHEA/IDSA
practice recommendation: strategies to prevent catheter-associated urinary tract
infections in acute care hospitals. Infect Control Hosp Epidemiology. 2008; 29:S41–S50.
6. The CDC Guideline for Prevention of Catheter-Associated Urinary Tract Infections 2008,
7. 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;
8. Saint S, Kowalski CP, Kaufman SR, Hofer PH, Kauffman CA, Olmsted RN et al.
Preventing hospital–acquired urinary tract infection in the United States: a national study.
Clinical Infectious Diseases. 2008; 46(2):243-250.
62 Healthy Skin
Improving Quality of Care Based on CMS Guidelines 63
True or False (circle one)
1. CAUTI is the most common infection in long-term
care residents. T F
2. The emergency department has the highest percentage
of catheter placement. T F
3. Usage of indwelling urinary catheters can be
expected to result in higher CAUTI rates. T F
4. Assistance in pressure ulcer healing for incontinent
patients is an approved indication for urinary
catheterization. T F
5. Allowing only trained healthcare providers to insert
catheters is one method for preventing catheter-
associated urinary tract infections (CAUTI). T F
6. A recent survey of U.S. hospital practices identified
that no strategy is consistently or universally used to
prevent CAUTI. T F
7. CAUTI is one of 10 hospital-acquired conditions for
which the Centers for Medicare & Medicaid Services
(CMS) will no longer provide reimbursement if it
occurs during hospitalization. T F
8. Nurses rarely request to place a urinary catheter for
nursing convenience. T F
Multiple Choice
9. Which of the following is not an approved indication
for urinary catheterization?
a. To improve comfort during end-of-life care.
b. Management of acute urinary retention and
urinary obstruction.
c. The patient requires prolonged immobilization.
d. The patient is incontinent and requires two or
three linen changes per shift.
10. Which of the following are techniques for proper
urinary catheter maintenance?
a. Properly secure catheters after insertion.
b. Maintain unobstructed urine flow.
c. Both a and b.
d. Change indwelling catheters or urinary drainage
bags at arbitrary fixed intervals.
11. CMS reported in the 2008 Federal Register that in
2007 there were ______CAUTIs.
a. 800,000
b. 56,296
c. 1,877
d. 12,185
12. It has been estimated that up to ____ percent of
indwelling urinary catheters are unnecessarily placed.
a. 85
b. 10
c. 50
d. None of the above
13. Which of the following is a successful strategy
implemented by healthcare organizations to
reduce CAUTI?
a. Redesign patient care areas
b. Utilize multidisciplinary teams to put
evidence-based changes in practice
c. Serve cranberry juice to patients
d. Deploy rapid response teams (RRTs)
14. Which of the following organizations did not
participate in outlining strategies and guidelines
to prevent CAUTI?
a. American Medical Association (AMA)
b. Centers for Disease Control and Prevention (CDC)
c. Association for Professionals in Infection Control
and Epidemiology (APIC)
d. The Joint Commission
15. What percent of hospitals do not keep track of how
long the catheter is in place?
a. 25%
b. 10%
c. 36%
d. 74%
CE Questi ons
Tell Me Again Why This Resident
Needs a Catheter?
Submit your answers at
and receive 1 FREE CE credit
Point and click to
The new ERASE CAUTI program combines design,
education and awareness to tackle catheter-associated
urinary tract infection – the number one hospital-acquired
The innovative one-layer tray design guides the clinician
through the process of placing a catheter to ensure
aseptic technique.
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
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
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.
Ask your Medline representative about the new ERASE
CAUTI Program or call 1-800-MEDLINE (633-5463).
Open up the
innovative one-layer
catheter tray and
see the intuitive
design for
Click here for
details on nursing
education materials
that promote
Visit this section
to join 100,000
nurses in the
Race to ERASE
1. Catheter-related UTIs: a disconnect in preventive strategies.
Physicians Weekly. 25(6), February 11, 2008.
Each year, an average nursing
home with 100 beds reports
100 to 200 falls.
About 1,800
older adults living in nursing
homes die each year from
fall-related injuries.
Those who experience non-
fatal falls can suffer injuries,
have difficulty getting around
and have a reduced quality
of life.
Continued on page XXX
in Nursing Homes
66 Healthy Skin
How big is the problem?
• In 2003, 1.5 million people 65 and older lived in
nursing homes.
If current rates continue, by 2030
this number will rise to about 3 million.
• About 5% of adults 65 and older live in nursing
homes, but nursing home residents account for
about 20% of deaths from falls in this age group.
• Each year, a typical nursing home with 100 beds
reports 100 to 200 falls. Many falls go unreported.
• As many as 3 out of 4 nursing home residents fall
each year.
That’s twice the rate of falls for older
adults living in the community.
• Patients often fall more than once. The average is
2.6 falls per person per year.
• About 35% of fall injuries occur among residents
who cannot walk.
How serious are these falls?
• About 1,800 people living in nursing homes die each
year from falls.
• About 10% to 20% of nursing home falls cause
serious injuries; 2% to 6% cause fractures.
• Falls result in disability, functional decline and reduced
quality of life. Fear of falling can cause further loss of
function, depression, feelings of helplessness, and
social isolation.
Why do falls occur more often in nursing homes?
Falling can be a sign of other health problems. People in
nursing homes are generally more frail than older adults
living in the community. They are generally older, have
more chronic conditions, and have difficulty walking. They
also tend to have problems with thinking or memory, to
have difficulty with activities of daily living, and to need
help getting around or taking care of themselves.
All of
these factors are linked to falling.
What are the most common causes of nursing
home falls?
• Muscle weakness and walking or gait problems are
the most common causes of falls among nursing
home residents. These problems account for about
24% of the falls in nursing homes.
• Environmental hazards in nursing homes cause 16%
to 27% of falls among residents.
Such hazards
include wet floors, poor lighting, incorrect bed height,
and improperly fitted or maintained wheelchairs.
• Medications can increase the risk of falls and
fall-related injuries. Drugs that affect the central
nervous system, such as sedatives and anti-anxiety
drugs, are of particular concern.
• Other causes of falls include difficulty in moving from
one place to another (for example, from the bed to
a chair), poor foot care, poorly fitting shoes, and
improper or incorrect use of walking aids.
How can we prevent falls in nursing homes?
Fall prevention takes a combination of medical treatment,
rehabilitation, and environmental changes. The most
effective interventions address multiple factors.
Interventions include:
• Assessing patients after a fall to identify and address
risk factors and treat the underlying medical
• Educating staff about fall risk factors and prevention
• Reviewing prescribed medicines to assess their
potential risks and benefits and to minimize use.
• Making changes in the nursing home environment to
make it easier for residents to move around safely.
Such changes include putting in grab bars, adding
raised toilet seats, lowering bed heights, and installing
handrails in the hallways.
• Providing patients with hip pads that may prevent a
hip fracture if a fall occurs.
• Using devices such as alarms that go off when
patients try to get out of bed or move without help.
Exercise programs can improve balance, strength,
walking ability, and physical functioning among nursing
home residents. However, it is unclear whether such
programs can reduce falls.
Each year, a
typical nursing
home with 100
beds reports
100 to 200 falls.
Many falls go
Improving Quality of Care Based on CMS Guidelines 67
Do physical restraints help prevent falls?
• Routinely using restraints does not lower the risk of
falls or fall injuries. They should not be used as a fall
prevention strategy.
• Restraints can actually increase the risk of fall-related
injuries and deaths.
• Limiting a patient’s freedom to move around leads to
muscle weakness and reduces physical function.
• Since federal regulations took effect in 1990, nursing
homes have reduced the use of physical restraints.
• Some nursing homes have reported an increase in
falls since the regulations took effect, but most have
seen a drop in fall-related injuries.
Reprinted with permission from the Centers for Disease Control,
National Center for Injury Prevention and Control, Division of
Unintentional Injury Prevention
1 Rubenstein LZ. Preventing falls in the nursing home. Journal of the American
Medical Association 1997;278(7):595–6.
2 Rubenstein LZ, Josephson KR, Robbins AS. Falls in the nursing home. Annals of
Internal Medicine 1994;121:442–51.
3 National Center for Health Statistics. Health, United States, 2005. With Chartbook
on Trends in the Health of Americans. Hyattsville (MD): National Center for Health
Statistics; 2005.
4 Sahyoun NR, Pratt LA, Lentzner H, Dey A, Robinson KN. The changing profile of
nursing home residents: 1985–1997. Aging Trends; No. 4. Hyattsville (MD): National
Center for Health Statistics; 2001.
5 Rubenstein LZ, Robbins AS, Josephson KR, Schulman BL, Osterweil D. The value of
assessing falls in an elderly population. A randomized clinical trial. Annals of Internal
Medicine 1990;113(4):308–16.
6 Thapa PB, Brockman KG, Gideon P, Fought RL, Ray WA. Injurious falls in
nonambulatory nursing home residents: a comparative study of circumstances,
incidence and risk factors. Journal of the American Geriatrics Society 1996;44:273–8.
7 Rubenstein LZ, Robbins AS, Schulman BL, Rosado J, Osterweil D, Josephson KR.
Falls and instability in the elderly. Journal of the American Geriatrics Society
8 Bedsine RW, Rubenstein LZ, Snyder L, editors. Medical care of the nursing home
resident. Philadelphia (PA): American College of Physicians; 1996.
9 Ejaz FK, Jones JA, Rose MS. Falls among nursing home residents: an examination
of incident reports before and after restraint reduction programs. Journal of the
American Geriatrics Society 1994;42(9):960–4.
10 Ray WA, Taylor JA, Meador KG, Thapa PB, Brown AK, Kajihara HK, et al. A
randomized trial of consultation service to reduce falls in nursing homes. Journal
of the American Medical Association 1997;278(7):557–62.
11 Mustard CA, Mayer T. Case-control study of exposure to medication and the risk of
injurious falls requiring hospitalization among nursing home residents. American
Journal of Epidemiology 1997;145:738–45.
12 Ray WA, Thapa PB, Gideon P. Benzodiazepenes and the risk of falls in nursing
home residents. Journal of the American Geriatrics Society 2000;48(6):682–5.
13 Tinetti ME. Factors associated with serious injury during falls by ambulatory nursing
home residents. Journal of the American Geriatrics Society 1987;35:644–8.
14 Cooper JW. Consultant pharmacist fall risk assessment and reduction within the
nursing facility. Consulting Pharmacist 1997;12:1294–1304.
15 Cooper JW. Falls and fractures in nursing home residents receiving psychotropic
drugs. International Journal of Geriatric Psychology 1994;9:975–80.
16 Kannus P, Parkkari J, Niem S, Pasanen M, Palvanen M, Jarvinen M, Vuori I.
Prevention of hip fractures in elderly people with use of a hip protector. New England
Journal of Medicine 2000;343(21):1506–13.
17 Nowalk MP, Prendergast JM, Bayles CM, D’Amico MJ, Colvin GC. A randomized
trial of exercise programs among older individuals living in two long-term care
facilities: the FallsFREE program. Journal of the American Geriatrics Society
18 Vu MQ, Weintraub N, Rubenstein LZ. Falls in the nursing home: are they
preventable? Journal of the American Medical Directors Association 2005;6:S82–7.
In 2000, the total direct cost of all fall injuries for people 65
and older exceeded $19 billion.
The financial toll for older
adult falls is expected to increase as the population ages,
and may reach $54.9 billion by 2020 (adjusted to 2007
How big is the problem?
• One in three adults 65 and older falls each year.
• Of those who fall, 20% to 30% suffer moderate to
severe injuries that make it hard for them to get
around or live independently and increase their
chances of early death.
• Older adults are hospitalized for fall-related injuries
five times more often than they are for injuries from
other causes.
How are costs calculated?
The costs of fall-related injuries are often shown
in terms of direct costs.
• Direct costs are what patients and insurance
companies pay for treating fall-related injuries.
These costs include fees for hospital and nursing
home care, doctors and other professional services,
rehabilitation, community-based services, use of
medical equipment, prescription drugs, changes
made to the home, and insurance processing.
Costs of
Falls Among
Older Adults
68 Healthy Skin
• Direct costs do not account for the long-term effects
of these injuries such as disability, dependence on
others, lost time from work and household duties,
and reduced quality of life.
How costly are fall-related injuries among
older adults?
• In 2000, the total direct cost of all fall injuries for
people 65 and older exceeded $19 billion: $0.2 billion
for fatal falls, and $19 billion for nonfatal falls.
• By 2020, the annual direct and indirect cost of fall
injuries is expected to reach $54.9 billion (in 2007
• In a study of people age 72 and older, the average
health care cost of a fall injury totaled $19,440, which
included hospital, nursing home, emergency room,
and home health care, but not doctors’ services.
How do these costs break down?
Age and sex
• The costs of fall injuries increase rapidly with age.
• In 2000, the costs of both fatal and nonfatal falls were
higher for women than for men.
• Medical costs in 2000 for women, who comprised
58% of older adults, were two to three times higher
than for men.
Type of injury and treatment setting
• In 2000, traumatic brain injuries (TBI) and injuries to
the hips, legs, and feet were the most common and
costly fatal fall injuries, and accounted for 78% of
fatalities and 79% of costs.
• Injuries to internal organs caused 28% of deaths and
accounted for 29% of costs from fatal falls.
• Hospitalizations accounted for nearly two thirds of
the costs of nonfatal fall injuries, and emergency
department treatment accounted for 20%.
• On average, the hospitalization cost for a fall injury
was $17,500.
• Fractures were both the most common and most
costly type of nonfatal injuries. Just over one third of
nonfatal injuries were fractures, but they accounted
for 61% of costs—or $12 billion.
• Hip fractures are the most frequent type of fall-related
fractures. The cost of hospitalization for hip fracture
averaged about $18,000 and accounted for 44% of
direct medical costs for hip fractures.
Reprinted with permission from the Centers for Disease Control,
National Center for Injury Prevention and Control, Division of
Unintentional Injury Prevention
1 Stevens JA, Corso PS, Finkelstein EA, Miller TR. The costs of fatal and nonfatal falls
among older adults. Injury Prevention 2006;12:290–5.
2 Englander F, Hodson TJ, Terregrossa RA. Economic dimensions of slip and fall injuries.
Journal of Forensic Science 1996;41(5):733–46.
3 Hausdorff JM, Rios DA, Edelber HK. Gait variability and fall risk in community-living
older adults: a 1-year prospective study. Archives of Physical Medicine and
Rehabilitation 2001;82(8):1050–6.
4 Hornbrook MC, Stevens VJ, Wingfield DJ, Hollis JF, Greenlick MR, Ory MG.
Preventing falls among community-dwelling older persons: results from a randomized
trial. The Gerontologist 1994;34(1):16–23.
5 Alexander BH, Rivara FP, Wolf ME. The cost and frequency of hospitalization for
fall-related injuries in older adults. American Journal of Public Health 1992;82(7):1020–3.
6 Rizzo JA, Friedkin R, Williams CS, Nabors J, Acampora D, Tinetti ME. Health care
utilization and costs in a Medicare population by fall status. Medical Care
7 Roudsari BS, Ebel BE, Corso PS, Molinari, NM, Koepsell TD. The acute medical care
costs of fall-related injuries among the U.S. older adults. Injury, Int J Care Injured
8 Barrett-Connor E. The economic and human costs of osteoporotic fracture. American
Journal of Medicine 1995;98(suppl 2A):2A–3S to 2A–8S.
Improving Quality of Care Based on CMS Guidelines 69
Falls are a major concern in nursing homes. In fact, about
1,800 people living in nursing homes die each year from falls.
About ten to 20 percent of nursing home falls cause serious
According to the Centers for Disease Control and Prevention
(CDC), fall prevention entails a combination of medical treatment,
rehabilitation and environmental changes.
Some of the environmental interventions you can put into place
include installing grab bars, adding raised toilet seats, providing
patients with hip pads that may prevent a hip fracture, and
using alarms that go off when patients try to get out of bed or
move without help.
All of these safety-enhancing products are
available from Medline.
Bath Safety Products
Medline carries a wide variety of bath safety products, includ-
ing grab bars, raised toilet seats and more. Our rugged steel
grab bars are easy to grip and help reduce the risk of acci-
dents. Raised toilet seats consist of a plastic, add-on seat
cover that elevates a low toilet by six to seven inches to reduce
strain on both patients and assisting caregivers.
Pressure-Sensing Safety Alarms
When used properly, patient alarms can alert caregivers when
a resident at risk for falls is on the move. Medline’s patient
alarms come packed with some of the most sought-after tech-
nological features, including auto-sensing without the need for
an on/off switch, as well as nurse call system compatibility.
This is just a small sampling of Medline’s fall prevention
products. For further information on these and more
products and to receive a free on-site fall prevention
preparedness assessment, contact your Medline
representative or call 1-800-MEDLINE (1-800-633-5463).
1 Centers for Disease Control and Prevention.
Falls in Nursing Homes. Available at:
Accessed September 3, 2009.
Fall Prevention
Interventions to keep residents right side up.
The new guidelines enhance instructions to surveyors on how to
evaluate compliance with areas such as resident choices about
daily schedule, (including when to get up, go to bed, eat and
bathe) visitation issues, homelike environment, food procure-
ment and expand significantly on guidance related to lighting.
The following is a summary of the new guidelines. Beginning
June 18, 2009 surveys are being conducted with a sharpened
focus on elements of quality of life.
Because some of the changes require significant facility remod-
eling and capital expenditures, CMS realizes these modifications
are not feasible immediately. CMS recommends that facilities
view those changes as goals to strive toward.
Access and Visitation Rights - F172
Facilities must provide 24-hour access to
non-relative visitors who are visiting with the
consent of the resident. These other visitors
are subject to “reasonable restrictions,” such
as those imposed by the facility to protect
the security of all the facility’s residents:
• Keeping facility locked at night
• Denying access or providing limited and supervised
access to a visitor if that individual has been found to be
abusing, exploiting or coercing a resident
• Denying access to a visitor who has been found to have
been committing criminal acts such as theft
• Denying access to visitors who are inebriated
and disruptive
Making Sense of Changes
to the LTC Surveyor Guidance
The Centers for Medicare & Medicaid Services (CMS) issued a new survey and
certification letter June 12, 2009, that revises and clarifies requirements related
to quality of life and environment.
Summary of
CMS requirements
for a homelike
Improving Quality of Care Based on CMS Guidelines 71
Survey Readiness
Married Couples, Roommates - F175
In the same way that married couples are
allowed to share a room, all nursing home
residents may choose to room with any
other resident, male or female, provided
that a room is available and the payment
source is the same for each resident or pri-
vate funding is available.
Dignity - F241
• Encouraging and assisting residents
to dress in their own clothes rather
than hospital-type gowns.
• Promoting resident dignity in dining,
including the avoidance of:
– Bibs instead of napkins (except by
resident request)
– Staff standing over residents while assisting them to eat
– Staff interacting or conversing only with each other rather
than residents, while assisting residents
– Using labels to classify groups of residents
(e.g., “feeders”)
• Maintaining an environment free from signs posting
confidential clinical or personal information about residents
• Grooming residents in the way they wish to be groomed
(e.g., removing facial hair, allowing residents to wear
clothing styles of their choice)
• Keeping residents sufficiently covered while in public areas
(e.g., while en route to bathing areas)
• Responding in a dignified manner to residents with
cognitive impairments (i.e., refraining from challenging or
disputing a resident’s intent, even if it is irrational). For
example, if a resident with dementia says she needs to
meet her children at the school bus, go ahead and walk
outside with her, and then converse with her about her
children until the behavior dissipates.
Self-Determination and
Participation – F242
As already mentioned under this section,
the resident has the right to:
• choose activities, schedules and
health care consistent with his or
her interests
• interact with members of the
community both inside and outside the facility
• make choices about aspects of his or her life in the
facility that are significant to the resident
Clarification has been added that the facility is responsible for
actively seeking information from the resident regarding signifi-
cant interests and preferences in order to provide necessary
assistance to help residents fulfill their choices.
Schedules: Residents have the right to have a choice over their
schedules, consistent with their interests, assessments and
plans of care. Types of “schedules” include those concerning
daily waking, eating, bathing, healthcare appointments and the
time for going to bed at night.
Individual Routines Improve Outcomes
According to individuals who helped with the revisions
to Tag F242, allowing residents to follow their own sched-
ules and routines results in:
• Residents sleeping better when they are allowed to
wake and go to bed according to their own schedule;
this also translates to a better mood
• Better healing
• Better appetite
• Reduced agitation
• Fewer falls
• Fewer pressure ulcers
• Better transitions from subacute care settings
Source: “Creating Home: The New Quality of Life Revisions to LTC
Surveyor Guidance” Webinar Series. June 10 & 11 and June 17 & 18, 2009.
Presented by Pioneer Network, American Association of Homes and Services for
the Aging (AAHSA) and American Health Care Association (AHCA).
72 Healthy Skin
Continued on Page 74
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Accommodation of Needs – F246
The facility is responsible for evaluating
each resident’s unique needs and prefer-
ences and ensuring that the environment
accommodates the resident to the extent
reasonable and does not endanger the
health or safety of individuals, including
other residents. This includes adapting
the resident’s bedroom and bathroom furniture and fixtures
as necessary to ensure that the resident can (if able):
• Open and close drawers and turn faucets on and off
• See himself or herself in the mirror and have toiletry
articles within reach at the sink
• Open and close bedroom and bathroom doors and
operate room lighting
• Perform other desired tasks, such as turning a table
lamp on and off or using the call bell
Additional areas regarding accommodation of needs
include providing:
• Reasonably sufficient electric outlets to accommodate
resident’s need to safely use his or her electronic
personal items
• Comfortable seating for residents in their bedroom
• Adequate task lighting in resident’s bedroom to
accommodate resident’s chosen activities
• Accommodation of resident’s preference for the
arrangement of furniture to the extent space allows,
including facilitating resident choice about where to
place his or her bed (with roommate’s consent)
• Varying types and sizes of furniture in common areas
to accommodate individual resident’s preferences
and needs for seat height, depth, firmness and arms
that assist in arising to a standing position
• Staff interaction in a way that takes into account the
resident’s physical limitations, assures communication
and maintains respect, (e.g., getting down to eye level
to speak with a resident who is sitting)
Safe, Clean, Comfortable and
Homelike Environment – F252
For the purpose of this requirement,
“environment” refers to any area in the
facility that is frequented by residents,
including (but not limited to) the residents’
rooms, bathrooms, hallways, dining
areas, lobby, outdoor patios, therapy
areas and activity areas. A determination of “homelike” should
include the resident’s opinion of the living environment.
The intent of the word “homelike” is to provide an environment
as close to that of a private home as possible. The concept of
creating a home setting includes eliminating institutional odors
and practices to the extent possible. The following practices
also decrease the institutional character of the environment:
• Eliminating overhead paging and canned music
• Dining room meals served on regular dishes without trays
• Storing medications securely in cabinets or resident rooms
rather than using medication carts
• Limiting the use of audible chair and bed alarms to avoid
startling the resident
• Using less institutional-looking furnishings
• Eliminating large, centrally located nurses stations
Kind, Caring Staff
+ Knowing Me as an Individual
= Quality Care
Source: “Creating Home: The New Quality of Life Revisions to LTC Surveyor
Guidance” Webinar Series. June 10 & 11 and June 17 & 18, 2009. Presented
by Pioneer Network, American Association of Homes and Services for the
Aging (AAHSA) and American Health Care Association (AHCA).
A complete copy of the surveyor guidance summarized in this
article is located at: CMS Manual System Pub. 100-07, Provider
Certification. Transmittal 48. June 12, 2009. Revisions to Appendix
PP, “Guidance to Surveyors of Long Term Care Facilities.”
Continued on Page 76
CMS Manual System
Department of Health &
Human Ser vices (DHHS)
Pub. 100-07 State Operations
Provider Certification

Centers for Medicare &
Medicaid Services (C MS)
Transmittal 48

Date: JUNE 12, 2009

SUBJECT: Revisions to Appendix PP, “ Guidance to Surveyors of L ong Term
Care Facilities”

I. SUMMARY OF CHANGES: This instruction revises Appendix PP, “Guidance to
Surveyors” f or several regulatory Tags, howev er, the regulatory language is unchanged.
Tag F255, “Private Closet Space” is deleted a
nd the regulatory language is m oved to Tag



Disclaimer for manual changes only: The revision date and transmittal number apply
to the red italic ized ma terial only. Any other material was previously published an d
remains un changed. However, if th is revision contains a ta ble of con tents, you will
receive the new/revis ed information only, and not the entire table o f contents.

II. CHANGES IN MANUAL INSTRUCTI ONS: (N/A if manual not updated. )
(R = RE VISED, N = NEW, D = DELETED) – ( Only One Per Row. )

R Appendix PP/ §483.10(j)/Access an d Visitation Rights/Tag F172
R Appendix PP/§483.10(m )/Married Couples/Tag F175
R Appendix PP/§483.15(a)/Dignity/Tag F241
R Appendix PP/§483.15(b)/Self-Determ ination and Participation/Tag F242
R Appendix PP/§483.15(e)(1)/Accomm odation of Needs/Tag F246
R Appendix PP/§483.15(e)(2)/Notice Before Room or Roomm ate Change/Tag
R Appendix PP/§483.15(h)/Safe, Clean, Comf ortable and Hom elike Environm ent/
Tag F252
D Appendix PP/§483.15(h)(4)/Privat e Closet Space/Tag F255
R Appendix PP/§483.15(h)(5)/Adequate a nd Comfortable Lighting/Tag F256
R Appendix PP/§483.35(i)/Sanitary Co nditions/Tag F371
R Appendix PP/§483.70(d)(2)(iv)/Resident Room
s/ Tag F461

Appendix PP/§483.70(f)/Resident Call System
/Tag F463

III. FUNDING: Medicare contractors shall implement these instructions w ithin
their current operating budgets.

Medline Healthcare Furnishings
Even though your residents might have a new address, it’s
important that they still feel like they’re at home. Let Medline
show you all the ways we can make your facility a more
welcoming, comfortable place to live.
We’ve been supplying quality healthcare products for more
than 40 years and we know what you need and want. With that
in mind, we’ve developed versatile furnishing collections with
the quality and durability you need and the stylish look and feel
that you love. We offer great furnishings for your:
• Lounge
• Living rooms
• Reception area
• Dining room
• Resident rooms
Visit to explore all of our
furnishing options. While you’re there, don’t forget
to try our Living Spaces Virtual Designer, a handy
online tool that can help you create your own resident
rooms – free of charge! Of course, our Interiors
Specialists are waiting to help you as well.
Bringing You Closer to Home

©2009 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.
76 Healthy Skin
Widespread change to your facility to accommodate new sur-
veyor guidelines can take time, effort and money. But small
changes can begin right away for little cost. Here are some
ways to begin taking smaller steps toward change.
First, be sure to tour your entire facility, taking a good look at
all areas used by residents. Next, take a group of residents
around, and get their input. Note light levels at different times
of the day, glare levels from sunshine coming through
windows and from shiny floors. Think about ease-of-use for
residents with low vision and limited hand dexterity. Ask
residents about difficulties they may have (i.e., opening doors,
seeing where they are going, using a faucet).
The following are simple changes that can be made in specific
areas of your facility.
• Install extra brackets in closets to make closet rods
moveable to accommodate both the resident standing
and the resident in a wheelchair
• Replace standard drawer handles with easy-to-use ones
• Add grippers to door knobs or switch to long handle knobs
• Replace standard table lamp switches with
easy-to-use ones
• Add night lights along the path to the bathroom
• Use flip-up grab bars
• Select easy-to-use faucet handles
• Tilt down sink mirrors to accommodate residents
using wheelchairs
• Add storage space near sinks
• Use contrasting color for baseboard or wall so residents
can distinguish where the floor ends and the wall begins
• Stop using shiny floor wax
• Determine if it is time to replace pictures and decorations
in hallways to enhance visual interest
Common areas
• Ask tall and short residents to sit on and get up from
furniture. Is it time to do some furniture replacement?
• Consider different seat heights for people of different sizes
• Would a “get up” pole or trapeze help?
Dining areas
• Can residents using wheelchairs get the arms of their
chair under the dining table?
• Stop using trays; provide table service using china
and glassware
• Use oversized linen napkins or heavy paper napkins
instead of adult bibs
Household kitchens within facility
• Install cabinet and drawer hardware that is large and
easy to use
• Install an adjusting system for kitchen cabinets
Notice Before Room or Roommate Change
• Being sensitive that a move or change of roommate can
be traumatic for some residents
• Notifying residents of changes in advance to help ease
the transition
• Allowing time for residents to grieve the loss of their
previous room or roommate
Quick Ways to Adapt Your Facility to Residents’ Needs
Source: Schoeneman K & Bowman C. Quick fixes for the environment. Pioneer Network Conference, 2008.
Available at /Data/Documents/Quick_Fixes_for_the_Environment.pdf.
Accessed August 31, 2009.
Improving Quality of Care Based on CMS Guidelines 77
Adequate and Comfortable
Lighting – F256
Lighting is important, as residents often
have issues with eyesight. As people age,
the eyes usually change, requiring more
light. Adequate lighting design includes
these features:
• Sufficient lighting with minimal glare
• Even light levels in common areas
and hallways
• Use of daylight as much as possible
• Elimination of glare caused by high-gloss flooring,
waxes and uncovered windows
• Task lighting for reading and other activities
requiring concentration
• Night lights to help residents find their way to the
bathroom at night
• Dimmer switches or the use of pen lights to allow
nurses to care for residents at night without
disturbing roommates
• Floor and baseboard to be in contrasting colors to
enable residents with impaired vision to determine the
horizontal plane of the floor
• Use of contrasting colors for bathroom walls and toilets
so residents with impaired vision can distinguish the toilet
fixture from the wall.
• Use of dishes that contrast with the table or tablecloth
to help residents with impaired vision see their food.
Sanitary Conditions – F371
• Clarification: Food procurement
requirements are not intended to
restrict resident choice. All residents
have the right to accept food brought
to the facility by any visitor(s) for
any resident.
Resident Rooms – F461
• Allowable window sill height shall not
exceed 36 inches
• Resident’s clothing to be kept sepa-
rate from the clothing of roommate(s)
• Closet space to be arranged so the
resident can reach hanging clothing
and items on closet shelves
• The term “closet space” is not
necessarily limited to a space installed into the wall.
Compliance may be attained through the use of storage
furniture such as clothing wardrobes. Out-of-season items
may be stored outside the resident’s room.
Interiors by Medline
Living Spaces Room
Makeover Contest
Enter to win a resident
room makeover!
First Place Winner: Receives free remodel of a semi-private
resident room with a value of $4,000.
Second Place Winner: Receives a free remodel excluding the
furniture in the room with a value of $500.
How to Enter
Send us a picture of your resident room most in need of a
makeover. Include a paragraph explaining what it will mean to
you to win the competition. Send your paragraph and picture
to or mail to Interiors Division, Medline
Industries, Inc. One Medline Place, Mundelein, IL 60060.
Entries must be received by December 31, 2009.
For more information on Medline Interiors and to try our Virtual
Room Designer free of charge, visit
Contest Details
A panel of judges will choose the winners based on the picture
and the response describing what it would mean to win the
competition. No purchase is necessary.
Medline will take before and after pictures of the makeovers at
each winner’s facility. We will require the consent of the winners
to take the photos and use the name of the facility for marketing
The Many Benefits of Correctly Sized
Incontinence Briefs
Today’s adult incontinence products come in many forms and sizes
to meet individual needs. They are helpful in promoting healthy skin
and maintaining the overall health of individuals who are incontinent.
The most frequently used products are briefs and protective
underwear (pull-ups). The level of incontinence, gender, fit and use
are all factors in product selection. Sizing is important for correct fit,
leakage control and to help prevent skin damage.
Improper sizing can lead to problems
Frail skin can be damaged in a number of ways by an inappropri-
ately fitted brief. A brief that is too small can lead to friction and
pinching, which can result in skin damage. Briefs that are too large
can cause even more problems. Products that are oversized create
increased pressure over the entire groin and delicate perineal area
when the wearer is “wrapped” in excess layers of product. Ill-fitting
garments do not fit snugly and are not able to quickly wick away
moisture from urine, which can cause skin maceration. Skin mac-
eration in turn can lead to further damage and potential infection.
Bigger ≠ better
A myth that compounds the sizing problem is that bigger is “better”
or “easier to apply.” Larger products do not hold more urine or
feces. And the risk of damage to skin from an improperly fitted gar-
ment far outweighs the ease of applying an oversized product.
Larger sized products are often packed with fewer pieces per pack-
age, taking up more storage space than smaller products. They are
by Claire Sweeney, BS, MSN, RN
78 Healthy Skin
Improving Quality of Care Based on CMS Guidelines 79
also more expensive. Incontinence products can represent up to
one third of a facility’s budget, so correct selection and sizing can
have a huge impact on an institution’s bottom line, as well as the
care of its residents.
The importance of a properly fitted brief
• Proper fit can help prevent leakage, which in turn, protects
the skin.
• An overly large brief may be exposing more skin surface area
than necessary to urine and fecal material, which poses a risk
to the skin.
• Improperly fitting briefs require more frequent changing,
which can be expensive and time-consuming.
• A properly fitting brief is more comfortable for the wearer.
• Those who wear briefs are apt to be less sensitive about the
touchy issue of “diapers” if the garment is somewhat discreet
under clothing.
Who’s in charge of incontinence care?
Incontinence care program responsibilities are often divided among
several departments in a facility. Oftentimes nurses assess, central
supply and /or environmental services orders (and sometimes
delivers) supplies, and nursing assistants and caregivers actually
apply the products.
All departments need to work as a team to ensure the correct prod-
uct is available and used for a resident when necessary. It might be
more convenient to order only large and extra large products due
to ease of ordering and storage limitations, however, this practice
will not meet the Centers for Medicare & Medicaid Services (CMS)
guidelines that call for the provision of “individualized interventions.”
People come in all shapes and sizes, and appropriate sizing
of product promotes dignity, self-esteem, healthier skin, and
Three Easy Steps for Better Sizing
Step 1: Measure across the front of the body; from hip bone
to hip bone and over the abdomen. Or measure from thigh
to thigh, if that area appears to be larger.
Step 2: Double the measurement from Step 1 and add
two inches.
Step 3: Match the final measurement with the manufacturer’s
size chart.
1. Managing incontinence. In Pressure Ulcer Prevention Program - Nurse.
Mundelein, Ill.: Medline Industries; 2008.
Determine Sizing of Absorbent Product
Adult brief
Small: Green backing 20"–32" (51cm – 81cm)
Medium: White backing 32"– 42" (81cm – 107cm)
Regular: Purple backing 40"–50" (102cm – 127cm)
Large: Blue backing 48"–58" (122cm – 147cm)
X-Large: Beige backing 59"–66" (150cm – 168cm)
XX-Large: Green backing 60"–69" (152cm – 175cm)
Bariatric: Beige backing 65"–90" (165cm – 229cm)
Determine and document the size by selecting the larger
of the hip or waist measurement, or use sizing matrix
reference based on gender/weight:
Gender: M F
Hip measurement
Waist measurement

Knit pants
Medium/Large: 20"– 60" (51cm – 152cm)
Blue/Brown waistband
X-Large: 45"– 70" (114cm – 178cm)
Green waistband
XX-Large: 50"– 75" (127cm – 191cm)
Purple waistband

Disposable mesh pants
Medium 28"– 40" (72cm – 102cm)
Large: 30"– 45" (76cm – 114cm)
X-Large: 32"– 48" (81cm – 122cm)
XX-Large: 38"– 58" (97cm – 147cm)

About the Author
Claire Sweeney, BS, MSN, RN, has 22 years
of nursing experience, primarily in geriatric set-
tings, assisted living and long term care and
her main areas of interest include infection
control and pressure ulcer management.
Need additional help with sizing? Ask your Medline representative
to arrange for a nurse to visit your facility for hands-on instruction.
Comfort-Aire™ Disposable Briefs
One touch and you know Comfort-Aire disposable briefs are
unique. Velvety soft side panels allow airflow for enhanced
comfort and skin care. The comfortable outer cover helps
prevent skin irritation.
One look and you can see the advantages. The wider hook
tape tabs make it easier to grasp and won’t stick to skin or
gloves, and the compressed packaging is easier to handle.
One try and you’ll understand. Comfort-Aire’s enhanced, super-
absorbent core keeps skin dry, which helps to keep it healthy.
Comfort-Aire. The right choice for
ultimate patient comfort and protection.
For more information about Comfort-Aire,
contact your Medline representative or call
us at 1-800-MEDLINE.
Just one touch...
Extra-wide, skin-safe
refastenable tape tabs
Soft cloth-like outer cover
Enhanced, super-absorbent core
Breathable side panels
Improving Quality of Care Based on CMS Guidelines 81
Communication Techniques
Take the stress out of relating to people with Alzheimer’s
by Jo Huey
The following tool, “Ten Absolutes,” was developed while providing
direct care for persons with Alzheimer’s disease. It was designed
to gi ve care provi ders a way to posi ti vel y i nteract, focusing on
the completion of personal care and important health issues such
as nutrition and hydration. “Ten Absolutes” is equally useful in providing
the tools for relaxed interaction with a person with Alzheimer’s or a
related disorder.
If you find yourself on the “Absolutely Never” side, don’t despair. Simply
move to the right side of the list and things will improve. For a more
detailed version of this tool, turn to page 102.
Absolutely Never!!!!!!! Instead
1. Argue Agree
2. Reason Divert
3. Shame Distract
4. Lecture Reassure
5. Say “Remember” Reminisce
6. Say “I Told You” Repeat/Regroup
7. Say “You Can’t” Do What They Can
8. Command/Demand Ask/Model
9. Condescend Encourage/Praise
10. Force Reinforce
©Huey 1996
About the author
Jo Huey is a world-renowned specialist in helping family
caregivers work through the maze of emotions and skills
needed to assist an Alzheimer’s patient. She is also
author of two books: Alzheimer’s Disease: Help and
Hope and Don’t Leave Momma Home with the Dog.
To learn more, visit
Special Feature
82 Healthy Skin
de Comunicación
Elimine el estrés de su relación con personas con Alzheimer
por Jo Huey
La siguiente herramienta, “Diez Absolutos” fue desarrollada mientras
se proporcionaba cuidado directo a personas con la enfermedad de
Alzheimer. Fue diseñada originalmente para dar a los proveedores de
cuidados de salud una forma de interactuar positivamente, centrán-
dose en completar tareas de cuidado personal y salud importantes,
tales como nutrición e hidratación. “Diez Absolutos” es igualmente
útil para proporcionar las herramientas para una interacción relajada
con una persona con enfermedad de Alzheimer u otra parecida.
Si se encuentra usted en el lado del “Absolutamente Nunca”, no
desespere. Simplemente pase al lado derecho de la lista y las cosas
mejorarán. Para una versión más detallada de esta herramienta, vaya
a la página 104.
Absolutamente Nunca!!!!!!! En vez de ello
1. Discuta Esté de acuerdo
2. Razone Desvíe
3. Avergüence Distraiga
4. Sermonee Tranquilice
5. Diga “Recuerda” Rememore
6. Diga “Te lo dije” Repita/Reagrupe
7. Diga “No puedes” Haga lo que ellos pueden
8. Ordene/Demande Pregunte/Modele
9. Sea condescendiente Estimule/Alabe
10. Fuerce Refuerce
©Huey 1996
Sobre la Autora
Jo Huey es una especialista de renombre mundial en ayudar a cuidadores
de familia a abrirse paso entre el laberinto de emociones y habilidades
necesarios para ayudar a un paciente con Alzheimer. También es autora
de dos libros: Enfermedad de Alzheimer: Ayuda y Esperanza y No Dejes
a Mamá en Casa con el Perro. Para más información,
How 4 square inches of Puracol Plus
changed chronic wound care.
This is Puracol Plus Micro-
Scaffold as seen through an elec-
tron microscope. Its open,
cellular structure allows easy fi-
broblast migration.
The high
strength of the MicroScaffold
also assists in establishing a
fresh wound bed.
Each Puracol package, like
every other Medline wound care
package, is a 2-Minute Course

in Advanced Wound Care.
Look closely. It’s not a bandage. It’s Puracol


, made entirely of pure native collagen.
Chronic wounds tend not to heal when unbalanced levels
of elastase and MMPs (inflammatory enzymes) destroy the
body’s own collagen and growth factors.
But apply Puracol Plus and help restore nature’s balance.
In vitro studies show that Puracol Plus has the ability
to reduce the levels of elastase and MMPs from
surrounding fluid.
1. Schultz GS, Mast BA. Molecular analysis of the environ-
ment of healing and chronic wounds: Cytokines, proteases,
and growth factors. Wounds. 1998;10 (6 Suppl): 1F-9F.
2. Data on file.
Special Report
Elevated blood glucose readings
are possible with some types
On August 13, 2009, the FDA issued a notification alerting
healthcare professionals about the possibility of falsely
elevated blood glucose results in patients who are receiving
therapeutic products containing certain non-glucose sugars.
The false readings occur when the tested blood reacts to
diabetic test strips containing GDH-PQQ (glucose dehydro-
genase pyrroloquinoline quinone).
Continued on Page 86
84 Healthy Skin
Medline’s OptiumEZ monitor, manufactured by Abbott
Diabetes Care, minimizes the variables that can affect
glucose readings with its patented TrueMeasure
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
©2009 Medline Industries, Inc.
Medline is a registered trademark of Medline Industries, Inc.
TrueMeasure is a registered trademark and Advanced Technology Made
Simple is a trademark of the Abbott Group of Companies.
For more information, please contact
your Medline sales representative or
call 1-800-MEDLINE.
OptiumEZ Blood Glucose Monitoring provides
86 Healthy Skin
GDH-PQQ glucose monitoring measures a patient’s blood glu-
cose value using methodology that cannot distinguish be-
tween glucose and other sugars. Certain non-glucose
sugars, including maltose, xylose and galactose, are found in
certain drug and biologic formulations, or can result from the
metabolism of a drug or therapeutic product.
The concern is that if a healthcare professional treats a patient
with insulin based on a falsely elevated glucose reading,
inappropriate dosing and administration of insulin could result
and potentially cause hypoglycemia, coma or death.
• Avoid using GDH-PQQ glucose test strips in healthcare
facilities. If your facility currently uses GDH-PQQ glucose
test strips, NEVER use them on patients who are receiving
interfering products or from whom or about whom
you cannot obtain information regarding concomitant
medication use, e.g., patients who are unresponsive or
cannot adequately communicate. Interfering products
containing non-glucose sugars include:
– Extraneal (icodextrin) peritoneal dialysis solution
– Some Immunoglobulins: Octagam 5%, Gamimune
N 5%, WinRho SDF Liquid, Vaccinia Immune
Globulin Intravenous(Human), and HepaGamB
– Orencia (abatacept)
– Adept adhesion reduction solution (4% icodextrin)
– BEXXAR radioimmunotherapy agent
– Any product containing, or metabolized into maltose,
galactose or xylose.
Use ONLY laboratory-based glucose assays on these
• Determine whether patients are receiving interfering
products on admission and periodically during their
stay at your facility.
• Educate staff and patients about the potential for falsely
elevated glucose results in the presence of certain
non-glucose sugars when using GDH-PQQ glucose
test strips.
• Consider using drug interaction alerts in computer
order entry systems, patient profiles and charts
to alert staff to the potential for falsely elevated
glucose results.
• Periodically verify glucose meter results with laboratory-
based glucose assays if you are using GDH-PQQ test
strips in patients who are not receiving interfering products.
The FDA’s recommendation is to avoid using
GDH-PQQ glucose test strips
The following products on the market use the reagent
• Roche
Comfort Curve strips that are
used on The Inform
, Complete
, Advantage
Voicemate™ meters
• The Accu-Chek Aviva, Compact, Go and Active test
strips Abbott
FreeStyle Flash, Freedom and Lite meters*
• HDI True Test strips that work on the True Result
and True2go meters.
Test strips currently on the market may be distributed under
multiple trade names. In addition, manufacturers of GDH-PQQ
test strips currently on the market may subsequently change
to non-GDH-PQQ methodology. Therefore, healthcare
providers (and patients) should refer to device labeling or
consult with test strip manufacturers to confirm the type of
methodology used.
* In late August 2009 Abbott submitted 510(k) applications to
the FDA for new FreeStyle and FreeStyle Lite test strips, which
will use GDH-FAD chemistry designed to minimize interference
from common non-glucose sugars. Abbott’s current Optium
system provides you with choices that can help you manage
the individual needs of your patients with diabetes.
1. U.S. Food and Drug Administration. FDA Public Health Notification: Potentially Fatal
Errors with GDH-PQQ* Glucose Monitoring Technology. Available at: http://www.fda.
176992.htm. Accessed September 9, 2009.
2. Abbott Diabetes Care. Letter to healthcare providers, September 1, 2009.
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,
Medlineʼs 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
Contact your Medline sales representative for more
details. You can also learn more about Medlineʼs
Pressure Ulcer Prevention Programs for long-term
care, acute care and perioperative services by visiting
Improving Quality of Care Based on CMS Guidelines 87
Think green with environmentally conscious
products for all areas of your facility.
These Medline products are either:
Recycled, recyclable, biodegradable or made from easily
renewable materials
Reduced in size to take up less space when shipped,
saving fuel and reducing carbon monoxide emissions
Free from environmentally harmful chemicals or pollutants
Reusable, to reduce waste in landfills
Minimally packaged
Enviro ISO gown
Reusable surgical gowns
Reusable ISO gowns
Reusable briefs and underpads
Diagnostic Equipment
Blood pressure cuffs (reusable)
Environmental Services
Disinfectant products
Eco floor mats
Eco floor mops
General cleaners
Hard surface germicidals
Microfiber cleaning cloths
Microfiber mops
Recycling sorting containers
Reusable hamper bags
Super-concentrated detergents
and lubricants
Touchless sensor faucets
and flushers
Tile, grout and bathroom
Toilet paper, facial tissue
and hand towels
Trash liners
Upholstery cleaner
Food Service
Biodegradable paper cups
Recyclable plastic cups and straws
Patient utensils
Infection Control
Advanced Bowie Dick test
Bio-zolve pre-soak instrument spray
Sterilization containers
Latex-Free Surgical Products
Anesthesia breathing bags
Anesthesia circuits
Anesthesia masks
Anti-fog solution
Band bags and equipment covers
Bone wax
Disposable safety scalpels
Electrosurgical disposables
(tips, ground pads, pencils
and tip cleaner)
Esmark bandages
Insufflation tubing and needles
Light handle covers
Sharps safety products (magnetic
drapes, transfer trays, scalpel
Skin markers
Suture boots
Thermoform molded trays
Tube holders (amnio hook,
umbilical cord clamp, umbilical
cord clamp cutter)
Vessel loops
Connecting tubes
Drain bags
Eco-friendly foam positioners
Oxygen concentrator
Peak flow units
Reusable nebulizer cups
Silver Foley catheters
Suction catheters
More Ways to Go Green
• Make it a habit to turn off the
lights when leaving any room
for 15 minutes or more.
• Think before you print. Could
this document be read or stored
online instead?
• Make it a policy to purchase
supplies made from recycled
• Bring your own mug instead
of using paper cups at work.
• Brighten up your workplace
with live plants, which absorb
indoor pollution.
Environmentally conscious Medline products
Ask your Medline rep for details
on ordering these products.
Source: The Sierra Club,
©2009 Medline Industries, inc. Medline is a registered trademark of Medline Industries, Inc.
By Wolf J. Rinke, PhD, RD, CSP
Do you have problems with communication in
your facility and at home? Whenever I ask that
question of my audiences virtually all hands go up.
Why? Because we are all terrible communicators.
Here are 12 specific strategies that will help you
communicate more effectively and get more of
what you want.
1. Reality Test
Most of us assume words have meaning. They do not! The
fact is all of us speak a different “language” because we all
have different values, beliefs and life experiences that impact
how we interpret everything. For example, what does the
word “fast” mean to you? If you’ve been dieting, it probably
means “to not eat.” If you are an amateur photographer, you
might be thinking of the speed of film. If you do a lot of laun-
dry, you might be thinking of how stable a color is. If you like
to race, you might think of the speed of a vehicle. And the list
goes on.
90 Healthy Skin
To get around this, do a reality test, especially when a shared
understanding is critical. Here are several examples. When
your spouse tells you how much you irritate him, summarize
your conversation: “Sweetheart, let me just make sure that
you and I are on the same page. What I heard you say was .
. .” At the end of a complicated instruction to one of your pa-
tients: “Now Miss Eager, we went over a lot of technical in-
formation. To make sure you will be able to follow my
instructions, please repeat what you heard me say.”
2. Get Really Good at Asking Questions
As an executive coach, I’ve learned the benefits of asking
questions. Here is what questions can do:
• Put you in control of the conversation. Questions elicit
an almost Pavlovian response in the listener to find
an answer.
• Establish rapport. Questions demonstrate interest, which
causes others to like you. And people who like you
are more likely to comply with your wishes and requests.
• Build trust. Eliciting ideas from others causes them to
feel that you care about them, which helps build trust.
How to Communicate More Effectively and Get More of What You Want
Caring for Yourself
Improving Quality of Care Based on CMS Guidelines 91
• Achieve deeper understanding. When you ask questions,
you will help the other party focus on what you want
them to focus on.
• Provide for greater buy-in, higher motivation and
compliance. Questions allow individuals to come up
with their “solution,” and invariably their level of
commitment will increase.
3. Avoid Fundamental Attribution Errors
Someone is late for an appointment, and we perceive that
they don’t care or they are sloppy, when in fact they may
have had an accident. In psychology this is referred to as
making a fundamental attribution error. I refer to it as “we
are very good at running our own movies,” meaning that we
attach all kinds of meanings to behavior we observe that has
nothing whatsoever to do with the person’s actions.
I see this all the time in my coaching practice.
A manager tells me, “My boss does not care about me.”
I ask, “How do you know?”
“Well, he never tells me anything.”
I ask, “How do you mean?”
“Well, most of the time I find out stuff through
the grapevine instead of from my boss.”
I ask, “Have you ever asked him to keep you in the loop?”
“No, but you know, that is a very good idea.
I should really do that.”
My consistent advice is deceptively simply but extremely
powerful: If in doubt, check it out.
4. Utilize Adult Language
According to Eric Berne and Thomas Harris, of the transac-
tional analysis (TA) fame, all of us utilize three different internal
“recordings” that represent our “ego states”: child, parent
and adult.
The child ego state refers to the behavior pattern, thoughts
and feelings we learned as children. They include helpless-
ness, blaming and emotional expressions such as “I can’t
help it,” “Don’t blame me,” “It’s your fault,” etc. Nonverbal
cues of the child ego state include whining, whistling, laughing,
teasing, expressing dejection, pouting, nail biting, moving
restlessly and looking rebellious, nervous or sad.
Our parent ego state was developed by observing parents
and other authority figures. When we are in a parent role we
tend to be very judgmental, critical, controlling, comforting or
nurturing, and use such phrases as “You can’t do that,” “You
have to,” “Always,” “Never,” etc. Nonverbal cues include
finger pointing, looking at your watch while communicating,
finger tapping, pressing lips tight, grinding teeth, checking
up on others, scowling, sneering, patronizing or expressing
The third internal recording is that of the adult. An adult is a
fact finder, information seeker, analyzer and logical problem
I see this all the time in my coaching practice.
A manager tells me, “My boss does not care about me.”
I ask, “How do you know?”
“Well, he never tells me anything.”
I ask, “How do you mean?”
“Well, most of the time I find out stuff through the grapevine
instead of from my boss.”
I ask, “Have you ever asked him to keep you in the loop?”
“No, but you know, that is a very good idea.
I should really do that.”
92 Healthy Skin

6. Listen Actively
Even though it’s been said by the prolific author Anonymous,
“It is better to remain quiet and be thought a fool than to
speak and remove all doubt,” most of us are very good at re-
moving all doubt. One reason is that most of us are very
good at “talking and telling” instead of “listening and learn-
ing.” To become an active listener, remind yourself that there
must be a reason that we were born with only one mouth
and two ears.
The better you get at listening, the more you’ll find out what
the other party really wants. Once you know that, you are
communicating from a position of strength. Your husband
says: “For our next vacation I want to go to Phoenix.” Un-
fortunately you are tired of Phoenix. Instead of telling him
why Phoenix is a bad idea, ask questions to find out what he
really wants. “Please tell me what you would like to do in
Phoenix?” He might say, “I want to play golf where the air is
warm and dry.” Now you can put your thinking caps on to
identify lots of places that will meet both of your needs. Here
are several related strategies:
• When someone asks a question, keep your mouth shut
until the other person has finished speaking. Do this even
though you know the answer when the other person
begins to speak. Remember, when the mouth is
engaged, the ears are out of gear.
• Show the person speaking that you are listening actively
by totally focusing all of your mental energy on what the
other person is saying, not only with her words but also
her body. You can achieve that by making strong eye
contact, leaning slightly forward and using your body
language to acknowledge the message and
the messenger.
solver. When you use your adult recording, you ask why?
what? when? where? who? how? and say such things as “I
made a mistake,” “I changed my mind,” “I don’t know,”
“I don’t understand,” “It’s my opinion,” “Let me check on
that,” and “What can we learn from this?” When you are in
this ego state, you tend to be clear, calm and non-judg-
mental. Your nonverbal expressions include straight but
relaxed posture, comfortable eye contact and a friendly face
that says, “I’m interested in what you have to say. I’m alert,
thoughtful and attentive.”
Communication effectiveness is dramatically enhanced
when you express yourself in an adult ego state, especially
when both you and the other party are playing the same
recording. Since it is difficult to change other people,
I strongly urge you to get in the driver’s seat of your trans-
actions by using adult language whenever you are commu-
nicating. If you would like more help with this, read my How
to Maximize Professional Potential CPE program available
5. Accept 111 Percent Responsibility
for the Entire Communication Process
Most of us are experts at playing the blame game. Have you
noticed that when there is a breakdown in communication,
it’s almost always the fault of someone or something else,
but seldom the person who is making the excuses! To make
this point, ask someone who arrives late for a meeting,
“Would you have been on time if $1,000 were riding on it?”
The typical answer is “Of course!”
To achieve dramatic improvements in your communication
effectiveness, I strongly recommend that you buy 111 per-
cent into the following axiom: If it is to be, it is up to me. (This
one works for all aspects of your life, so do try this at home.)
It is better to remain quiet and be thought a fool
than to speak and remove all doubt,”
— Anonymous
Improving Quality of Care Based on CMS Guidelines 93
• Listen to the “music” as well as the words. In order to
really understand what’s being communicated, it’s
important that you hear more than the words, which
you can achieve by tuning into the mood, atmosphere
and emotional tone that put the words into context.
• Demonstrate empathy by getting inside the other
person’s thoughts and feelings. This can be expressed
by saying “I see,” “I understand,” “I follow you,” “I’m with
you,” and so on.
• Take off your mask and be yourself. This engenders
trust, and trust is essential to effective communication.
• Before ending your communication, summarize and do
a reality test, as previously discussed.
7. Express Yourself in Positive Terms
When we speak, we can say things negatively or positively.
For example, you can say, “I don’t have an answer for that,”
or “I can answer that the next time we get together.” Which do
you think is easier to understand? Research has demon-
strated that positively worded statements are one-third eas-
ier to comprehend than their negative counterparts. The
reason is that human beings are unable to move away
from the reverse of an idea. Instead, we move toward that
which we visualize in our minds. Don’t believe it? Let me ask
you not to think of a green snake. What did you just think of?
A green snake, right? You see, none of us can move away
from the reverse of an idea. Take advantage of this phenom-
enon by expressing yourself in positive terms.
8. Master the PIN Technique
The PIN technique is a powerful way to reframe your percep-
tions and turn the negatives into positives. Here is how it
works. When you are confronted with anyone or anything that
would cause you to react negatively, PIN it. For example, your
team member says, “Boss, you know how morale has gone
down the tube? Let’s close the hospital and go on a cruise.”
Instead of NIPing anything “weird,” focus your mental energy
first on the:
P - Positive. Ask yourself what could be positive about your
employee’s suggestion: “Well at least she seems interested in
making things better.” After you’ve done that in your mind’s
eye, next evaluate the …
I - Interesting or Innovative. Ask what could be interesting
or innovative about your team member’s suggestion. “Maybe
there is a need for more celebration around here.” Once
you’ve evaluated that, and only after you’ve exhausted all the
Ps and Is, then ask yourself: “What is the downside, or the…”
N - Negative. Because in communication, just like in life,
nothing ever goes one way, there is yin and yang, health and
sickness, life and death, high stock market and low stock
market and the list goes on. PINing it will enable you to eval-
uate both the upside and downside of every conversation.
However, if you NIP comments, ideas or suggestions in the
bud, it’s like closing the proverbial shade, which prevents you
from seeing opportunities.
9. Convey Integrity at All Times
People prefer to deal with communicators they can trust,
rather than those they have to second-guess. The fact is that
without trust, relationships die and your ability to communi-
cate is severely compromised. So be sure to be congruent,
which means that your body language, vocal patterns and
pitch support what you’re saying. And the way to achieve that
is to “tell it like it is,” even though it shows that you are not
omnipotent. Also be aware of self-defeating phrases some
To turbo-charge your communication
effectiveness, pretend that all people you
communicate with have printed across
their forehead a big bold sign that reads
94 Healthy Skin
people use habitually without being aware of their implica-
tions. For example, avoid saying, “Let me be absolutely
honest with you.” If you say that to me, I’m thinking: “What are
you normally?”
10. Strive For Win-Win
When you are communicating be on the lookout for things
that will be beneficial to the other party. For example, if you are
talking with a team member, instead of saying “You have to
yada, yada, yada,” use: “How can I help you with . . .?” When
you are talking to patients, instead of saying, “According to
hospital policy you have to . . .,” use, “What options can we
think of that will . . .” This attitude shows that you are inter-
ested in helping the other person get what he wants, which
in turn will make him more receptive to helping you get what
you want.
11. Always Strive to Make the Other Person
Right—Never Wrong
Whatever you do, avoid arguing. People who argue will lose
the “battle” because it causes the other person to become
defensive. So what’s a better approach? Make the other per-
son right. My Superwoman and I have taken this to another
level. Anytime we find ourselves getting into conflict, one of
us will raise his/her hand with all five fingers extended, which
stands for: “You are right about that.” (One finger for each
word.) So you don’t sound like a parakeet, use other phrases
that make the other person right, such as: “That is a very
interesting idea;” “I’ve never thought of it that way;” “This
seems very important to you,” etc. So make it a habit to agree
with people and you will find that you will get much better
results with far less resistance. (For other powerful techniques
read my Win-Win Negotiation CPE program, available at
12. Make Them Glad They Communicated
with You
To turbo-charge your communication effectiveness, pretend
that all people you communicate with have printed across
their forehead a big bold sign that reads MAKE ME FEEL
IMPORTANT! This phrase will remind you to always focus on
their needs first, because once they get the feeling you want
to help them, most people will do whatever they can to
reciprocate, which in the long run will help you get more of
what you want.
Dr. Wolf J. Rinke, 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 He is the
author of numerous books, CDs and DVDs including 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 available
at His company also produces a wide variety
of quality pre-approved continuing professional education (CPE)
self-study courses including his latest The Power of Communication:
How to Increase Your Personal and Professional Effectiveness
on which this article was based. It is available at www.easyCPE- Reach him at
Improving Quality of Care Based on CMS Guidelines 95
Losing Sleep
Over Economic
You’re Not
More Americans are losing sleep because of finan-
cial worries. Declining home values, dwindling savings
and fear of layoffs are forcing more people to seek help for
insomnia and a host of other sleep disorders.
Nearly 30 percent of Americans say they lose sleep at
least a few nights a week, according to a national “Sleep
in America” poll conducted by the National Sleep Foun-
Sleep specialists say the survey results mirror patient con-
cerns in their medical practices lately. “We’ve been seeing
this clinically for months, a very sharp increase in insom-
nia due to stress,” said Joseph Ojile, CEO and founder of
Clayton Sleep Institute in St. Louis.
Losing sleep goes deeper than just feeling tired. People
who slept poorly were also almost twice as likely to eat
high-sugar and high-carbohydrate foods, and they
smoked or used tobacco more often than better sleepers.
And we’re more tired than ever. The average adult needs
seven hours and 24 minutes of sleep, but most report
getting just six hours and 40 minutes on a typical week-
day, according to the poll. One in five surveyed said they
get fewer than six hours of sleep on average. The number
of Americans who report they get the recommended eight
hours has declined since 2001.
Lack of sleep can have devastating health consequences.
A 1999 study at the University of Chicago showed that
restricting sleep to just four hours per night for a week left
healthy young adults with the glucose and insulin read-
ings of diabetics.
96 Healthy Skin
If you’re having trouble sleeping lately, here are some ways to help
get your inner clock back on track.
• Go to bed and get up at about the same time every day,
even on the weekends. Sticking to a schedule helps
reinforce your body’s sleep-wake cycle.
• Don’t eat or drink large amounts before bedtime.
Eat a light dinner at least two hours before sleeping.
• Avoid nicotine, caffeine and alcohol in the evening.
These are stimulants that can keep you awake. Avoid caffeine
for eight hours before your planned bedtime. And although
often believed to be a sedative, alcohol actually
disrupts sleep.
• Exercise regularly. Regular physical activity, especially
aerobic exercise, can help you fall asleep faster and make your
sleep more restful. However, for some people, exercising right
before bed may make getting to sleep more difficult.
• Make your bedroom cool, dark, quiet and comfortable.
Adjust the lighting, temperature, humidity and noise level
to your preferences. Use blackout curtains, eye covers,
earplugs, extra blankets, a fan or white-noise generator,
a humidifier or other devices to create an environment
that suits your needs.
• Sleep primarily at night. Daytime naps may steal hours
from nighttime slumber.
• Children and pets are often disruptive, so you may need
to set limits on how often they sleep in bed with you.
• Start a relaxing bedtime routine. Do the same things
each night to tell your body it's time to wind down. This
may include taking a warm bath or shower, reading a
book, or listening to soothing music.
• Go to bed when you’re tired and turn out the lights.
If you don’t fall asleep within 15 to 20 minutes, get up and
do something else. Go back to bed when you’re tired. Don’t
agonize over falling asleep. The stress will only prevent sleep.
• Check with your doctor before taking any sleep
medications. He or she can make sure the pills won’t
interact with your other medications or with an existing
medical condition. Your doctor can also help you
determine the best dosage.
• Nearly everyone has occasional sleepless nights.
But if you have trouble sleeping on a regular or frequent basis,
see your doctor. You could have a sleep disorder, such
as obstructive sleep apnea or restless legs syndrome.
1. Layton MJ. More people are seeking help for insomnia and sleep disorders.
The Ledger. March 29, 2009; p. N25. Available at:
nia-and-Sleep-Disorders. Accessed August 17, 2009.
2. Marcus MB. Economy doing a number on people’s sleep. USA Today. March 1, 2009.
Available at:
N.htm. Accessed August 17, 2009.
3. Mayo Clinic. 10 tips for better sleep. Available at
health/sleep/HQ01387. Accessed August 17, 2009.
Tips to Help You Get Your ZZZs
Improving Quality of Care Based on CMS Guidelines 97
Caring for Yourself
A world without breast cancer is in our hands.
Medline’s Generation Pink latex-free, third-generation
synthetic 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.
For more information on Medline’s exam gloves,
please contact your Medline sales representative
or call 1-800-MEDLINE.
Improving Quality of Care Based on CMS Guidelines 99
Breast Cancer
Month October 2009
Medline Breast Cancer Awareness Campaign
Celebrates Five Years
“Together We Can Save Lives”
Five years ago, Medline began a mission to promote breast
cancer awareness beyond the standard 31 days of public
awareness each October. We launched a year-round breast
cancer campaign called “Together We Can Save Lives
Through Early Detection,” which supports breast cancer
education and early detection. Since the launch of the
campaign, Medline has donated more than $450,000 to
the National Breast Cancer Foundation (NBCF). For more
information on the NBCF, visit
In partnership with NBCF, Medline
has helped fund grants to hospitals
and other healthcare organizations
that offer free mammograms to
women in need. Through this part-
nership, Medline continues its mis-
sion to give back to customers and
their communities, help promote the
early detection of breast cancer and
ultimately save lives. We hope this
campaign will help spread the word –
early detection and mammograms save lives!
New Breast Cancer Awareness Web Page
Medline has just launched a new Web page dedicated to breast
cancer awareness and the “Together We Can Save Lives”
campaign. Raising breast cancer awareness among nurses is
one of our key goals, as it is the leading cause of death for
women ages 40-55. The average age of a nurse is 46.
The Web page contains background on the breast cancer
campaign, AORN breakfast forum special event details with
photo galleries and keynote speaker bios. Visit today at
Pink Ribbon Products
Medline Industries, Inc. also promotes breast cancer
awareness by displaying the pink ribbon logo on products.
By purchasing a pink ribbon product from Medline, you are
helping to support Medline’s $100,000 annual contribution
to the NBCF.
Some of the products include pink exam gloves, the pink
ribbon rollator, pink ribbon bouffant caps and breast cancer
awareness scrubs and other apparel. Ask your Medline
rep for details or visit
Caring for Yourself
1. In the Shower
Fingers flat – move gently over
every part of each breast.
Use your right hand to examine
left breast, left hand to examine
right breast. Check for any lump,
hard knot or thickening. Carefully
observe any changes in your
2. Before a Mirror
Inspect your breasts with your
arms raised high overhead. Next,
place your arms at your sides.
Look for any changes in contour
of each breast; a swelling, a
dimpling of skin, or changes
in the nipple.
Then rest palms on hips and
press firmly to flex your chest
muscles. Left and right breasts
will not match exactly. Few
women’s breasts do match.
3. Lying Down
Place pillow under right shoulder,
right arm behind your head.
With fingers of left hand flat,
press right breast gently in small
circular motions, moving vertically
or in a circular pattern covering
the entire breast.
Use light, medium and firm pressure. Squeeze nipple,
check for discharge and lumps. Repeat these steps on
your left breast.
Recommendations for Routine
Mammography Screening
Age 40: A baseline mammogram as a standard for future
40-49: a mammogram every one or two years, depending
on previous findings
50 and older: a mammogram every year
Compliments of Medline’s “Together We Can Save Lives
Through Early Detection” campaign. To learn more go to
Breast Self-Examination
• Each year, more than 211,000 American women learn
they have breast cancer.
• The chance of a woman having invasive breast cancer
sometime during her life is about 1 in 8. The chance
of dying from breast cancer is about 1 in 35.
• About 192,370 estimated cases of breast cancer for
women and about 1,910 estimated cases of
breast cancer for men will be diagnosed in 2009.
Of these, 40,170 cases for women and 440 cases
for men will result in death.
• Nearly 90 percent of women diagnosed with breast
cancer will survive their disease at least five years.
• The chance of getting breast cancer goes up as a
woman gets older. Most cases occur in women
over 60.
• Women 40 and older should have a mammogram
every one to two years. Mammograms are the most
effective way to detect breast cancer.
• Breast cancer death rates are falling, probably as a
result of early detection and improved treatment.
American Cancer Society,
National Cancer Institute,
100 Healthy Skin
Improving Quality of Care Based on CMS Guidelines 101
The following pages contain practical tools for implementing
patient-focused care practices at your facility.
Positive Interactions
English ............................................................102
Spanish ............................................................104
Incontinence Product Selection........................106
CAUTI FAQs ....................................................107
How to Handrub? ............................................109
Practice Hospital Bed Safety............................110
Pressure Ulcer
Pocket Reference Card ....................................115
102 Healthy Skin
Absolutely Never!
1. Argue
“You know your mother has been dead for years. You cannot
wait for her to eat dinner” “You have lived in this house for 25
years, you are home”
2. Reason
“You did not take a bath today, and you need to take a bath
because we have an appointment with the doctor. Then we
are going to go to lunch with Jane, and then we are going to
get you a new pair of shoes, and why are you walking off
when I am talking to you? We have to go in here and get your
bath and we have to hurry.”
3. Shame
“How can you accuse John of stealing after all he has done
for us?”
4. Lecture
“You have got to go back to bed and get some sleep. You
have been up half the night and why on earth did you empty
these drawers? Who is supposed to clean up this mess?
I suppose tomorrow you will want to sleep all day and we
won’t be able to go to Carol’s house and help with the
children. I am just too tired to deal with this, so you have to
get in bed and go to sleep right now. We can’t continue like
this. No one can live this way. We both have got to get
some sleep.”
5. Say “Remember”
“Do you remember who this is?” “What did you have for lunch
today?” “Did Mary visit today?” “When did Jeanne come
to visit?”
6. Say “I told you”
“I just told you that we are not going to the bank today. It is
Sunday, and the bank is closed. How many times do I have
to tell you we are not going to the bank. It is Sunday.”
Do This Instead!
“I haven’t seen your mother today. If I see her, I will tell her you
are looking for her. While we are waiting, let’s have a bite to eat.
I want to go home, too. While we are waiting, let’s have a bite
to eat.”
“Please come in here with me. Oh, I know you aren’t going to
take a bath. Let me help with that shoe. Oh, I know you aren’t
going to take a bath. Just slide this off over your arm. Oh, I know
you aren’t going to take a bath. How does this water feel? It
seems warm enough. Oh, I know you aren’t going to take a
bath. Just step right in here.”
“John is here to help us find your wallet. Let’s have a cup of
coffee and get started.”
“I can’t sleep either. Let’s go to the bathroom. I need something
to drink.” (Offer a drink.) “Try to lie down again.” (Pat the bed.)
“No? How about some cookies and milk?” “Try to lie down
again.” (Sit beside bed and pat the bed.) “Doesn’t that feel
good?” (Stay until settled or asleep. Rub their hand, forehead
or arm.)
“Hi, Tom. This is Sarah. She is visiting me from Elmhurst
Elementary PTA. I had the nicest lunch today. Mary is such a
pleasant person and she visits often. I hoped I would get here
before Jeanne’s visit.”
“Wouldn’t you know it is too late for church, and we have to go
to the bank tomorrow. Since it is Sunday, let’s have fried chicken.
Yes, we will go to the bank when it opens tomorrow.”
© Huey 1996
Forms & Tools Posi ti ve Interacti ons
Ten Absolutes: Simplify Daily Tasks
and Create Positive Interactions
Improving Quality of Care Based on CMS Guidelines 103
Absolutely Never!
7. Say “You can’t”
“You can’t wear two shirts. You can’t pick that up with your
hands. You can’t eat that like that. You can’t put your sweater
on your legs. You can’t put your shoe on your shoe. You can’t
go outside; it’s raining. You can’t keep putting things in the
wrong place. You can’t go home; you are home.”
8. Command/Demand
“You have got to change your clothes. Sit down right here
and stop walking around. This doesn’t belong to you. Now
give it back. Why would you take those when we didn’t pay
for them? You have to leave your clothes on; we’re in a
public restroom. We are in a hurry. You need to do this
right now.
9. Condescend
“Did you have any problem with him today? Be sure he takes
his medicine; he spit it out this morning. I hope you don’t have
trouble today. It took me 20 minutes just to get him into the
car. He has been looking for his mother all morning.”
10. Force
“Now you are going to take a bath because you haven’t had
one for two weeks. These nice people are here to help us.
Give that to me right now; it’s not yours. If you don’t give it
back, we will have to take it from you. You may not go into this
room. You must come out of this room right now.”
Do This Instead!
Do What They Can
“Try this one. It looks nice. See how this spoon works. Isn’t this
fun?” Try this one. Try it over here. We need to find the umbrella.
This looks nice here. I want to go home, too.”
“This is pretty. Do you want to try it on? Sit with me a minute.”
(Pat the chair.) “This is nice. May I see it? Do you want to
buy those? See if you will be warmer with this. How about
going here?”
“I’m sure you were your sweet, wonderful self today. Dad will
help you with his medication today; it has been hard to swallow.
We are having a challenging day today, and Dad will help you a
lot. He is especially interested in his mother today.”
“I know you already took a bath. Come right in here. I know you
don’t want a bath. Let’s take off this shoe. I know you don’t want
to take a bath. This lady is helping out, and it is OK. That is re-
ally pretty. May I see it? Do you like this? Would you like to have
it? Isn’t this a nice room; would you like to have a cup of coffee?”
© Huey 1996
From: Alzheimer’s Disease: Hope and Help by Jo Huey
Reprinted with permission.
Posi ti ve Interacti ons Forms & Tools
104 Healthy Skin
Absolutamente Nunca
1. Discuta
"Tú sabes que tu madre ha estado muerta por años. No
puedes esperarla para cenar" "Has vivido en esta casa 25
años, estás en casa"
2. Razone
"No te bañaste hoy, y necesitas bañarte porque tenemos una
cita con el doctor. Luego vamos a almorzar con Jane, y luego
vamos a comprarte un nuevo par de zapatos, y ¿por qué te
alejas cuando te estoy hablando? Tenemos que entrar y
bañarte, y tenemos que darnos prisa."
3. Avergüence
"¿Cómo puedes acusar a John de robar después de todo
lo que ha hecho por nosotros?"
4. Sermonee
"Tienes que volver a la cama y dormir un poco. Has estado
despierto la mitad de la noche y ¿por qué vaciaste estos
cajones? ¿Quién crees que va a limpiar este lío? Supongo
que mañana querrás dormir todo el día y no podremos ir a la
casa de Carol y ayudar con los niños. Simplemente estoy
demasiado cansada para ocuparme de esto, así que tienes
que ir a la cama y dormirte ahora. No podemos seguir así.
Nadie puede vivir así. Ambos tenemos que dormir un poco."
5. Diga "Recuerdas"
"¿Recuerdas quién es esta persona?" ¿Qué almorzaste
hoy?" "¿Te visitó Mary hoy?" "¿Cuándo vino Jeanne de
6. Diga “Te lo dije”
"Te acabo de decir que no vamos a ir al banco hoy. Es
domingo, y el banco está cerrado. ¿Cuántas veces tengo
que decirte que no vamos a ir al banco? Hoy es domingo."
¡Haga Esto!
Esté de acuerdo
"No he visto a tu madre hoy. Si la veo , le diré que la estás bus-
cando. Mientras esperamos, comamos algo. Yo también quiero
ir a casa. Mientras esperamos, comamos algo."
"Por favor entra aquí conmigo. Oh, Sé que no te vas a bañar.
Déjame ayudarte con ese zapato. Oh, sé que no te vas a bañar.
Desliza esto por tu brazo. Oh, sé que no te vas a bañar. ¿Cómo
se siente esta agua? Parece lo suficientemente tibia. Oh, sé que
no te vas a bañar. Pisa justo aquí."
"John está aquí para ayudarnos a encontrar tu billetera.
Tomemos un café y empecemos."
"Yo tampoco puedo dormir. Vamos al baño. Necesito algo de
beber." (Ofrezca algo de beber.) "Trata de recostarte de nuevo."
(Palmadas en la cama.) "¿No? ¿Qué te parece unas galletas y
leche?" "Trata de recostarte otra vez." (Siéntese al lado de la cama
y dé palmaditas en ésta) "¿No se siente rico?" (Quédese hasta
que esté tranquilo o dormido. Frote su mano, frente o brazo.)
"Hola, Tom. Esta es Sarah. Ella me está visitando de la
Asociación de Padres de Familia de Elmhurst. Tuvimos un
almuerzo muy agradable hoy. Mary es una persona muy
agradable y nos visita con frecuencia. Yo esperaba llegar
aquí antes de la visita de Jeanne."
"No sabes que es demasiado tarde para ir a la iglesia, y
tenemos que ir al banco mañana. Dado que es domingo,
comamos pollo frito. Sí, iremos al banco cuando abra mañana."
Formas y Herramientas Interacci ones Posi ti vas
Diez Absolutos: Simplifique las Tareas
Diarias y Cree Interacciones Positivas
Improving Quality of Care Based on CMS Guidelines 105
Absolutely Never!
7. Diga "No Puedes"
"No puedes usar dos camisas. No puedes recoger eso con
tus manos. No puedes comer así. No puedes poner tu abrigo
en tus piernas. No puedes poner tu zapato en tu zapato. No
puedes salir, está lloviendo. No puedes seguir poniendo
cosas en el lugar equivocado. No te puedes ir a casa, estás
en casa".
8. Ordene/Demande
"Tienes que cambiarte de ropa. Siéntate aquí y deja de dar
vueltas. Esto no te pertenece. Ahora devuélvelo. ¿Por qué
tomaste esto cuando no lo pagamos? Tienes que dejarte
la ropa puesta, estamos en un baño público. Estamos apura
dos. Necesitas hacer esto de inmediato.
9. Sea condescendiente
"¿Tuviste algún problema con él hoy? Asegúrate que tome
su medicina; la escupió esta mañana. Espero que no tengas
problemas hoy. Me tomó 20 minutos simplemente meterlo
en el auto. Ha estado buscando a su madre toda la mañana".
10. Fuerce
"Ahora vas a bañarte porque no te has bañado en dos
semanas. Esta buena gente está aquí para ayudarnos. Dame
eso de inmediato, no es tuyo. Si no lo devuelves, te lo tendré
que quitar. No puedes entrar en esta habitación. Debes salir
de esta habitación de inmediato".
Do This Instead!
Haga lo que Puedan
"Pruébate esto. Se ve bien. Ve cómo funciona esta cuchara. No
es divertido?" Prueba ésta. Pruébalo aquí Necesitamos encontrar
el paraguas. Esto se ve bien aquí. Yo también quiero ir a casa."
"Esto es bonito. ¿Te lo quieres probar? Siéntate conmigo un
minuto." (Toque la silla.) "Esto está bien. ¿Puedo verlo? ¿Quieres
comprarlos? Ve si estás más abrigado con esto. ¿Qué tal si
vamos aquí?"
"Estoy seguro que fuiste muy dulce y maravilloso hoy. Papá te
ayudará con su medicina hoy, ha sido difícil de tragar. Estamos
teniendo un día difícil hoy, y Papá te ayudará un montón. Está
especialmente interesado en su madre hoy".
"Sé que ya te bañaste. Ven aquí. Sé que no quieres bañarte.
Quitemos este zapato. Sé que no quieres bañarte- Esta dama
está ayudando, y está bien. Esto es muy bonito. ¿Puedo verlo?
¿Te gusta esto? ¿Te gustaría tenerlo? Qué habitación tan bonita.
¿Te gustaría una taza de café?"
© Huey 1996
De: Enfermedad de Alzheimer: Esperanza y Ayuda, por Jo Huey.
Reimpreso con permiso.
Interacci ones Posi ti vas Formas y Herramientas
Forms & Tools Inconti nence Product Sel ecti on
Incontinence Product Selection
Protective Belted
Undergarments Liners
Pads Liners
Moderate volume of urine
up to one cup or 250cc
• Stress, urge, mix or
transient incontinence
• Can walk with or
without assistance
• Dementia
Slight volume of urine less
than half a cup or 100cc
• Stress incontinence
• Can walk with or
without assistance
• Urinary incontinence
Moderate volume of urine
up to two cups or 500cc
• Urge, overflow or bowel
• Bedridden
• Difficulty walking or
Heavy Plus
Moderate volume of urine
more than two cups or 500cc
in 4 hours
• Overflow or bowel
• Contracted, bedridden
• Difficulty walking or
• Loose stool
High Capacity
106 Healthy Skin
ŶĞLJƐ ;ǁŚŝĐŚ ĮůƚĞƌ ƚŚĞ ďůŽŽĚ ƚŽ ŵĂŬĞ ƵƌŝŶĞͿ͘ CĞƌŵƐ ;ĨŽƌ ĞdžĂŵƉůĞ͕ ďĂĐƚĞƌŝĂ
Žƌ ǁŚŝůĞ ƚŚĞ ĐĂƚŚĞƚĞƌ ƌĞŵĂŝŶƐ ŝŶ ƚŚĞ ďůĂĚĚĞƌ͘
ͻ 8ƵƌŶŝŶŐ Žƌ ƉĂŝŶ ŝŶ ƚŚĞ ůŽǁĞƌ ĂďĚŽŵĞŶ ;ƚŚĂƚ ŝƐ͕ ďĞůŽǁ ƚŚĞ ƐƚŽŵĂĐŚͿ
ͻ lĞǀĞƌ
What are some of the things that hospitals are doing to prevent catheter-
ͻ ÞƵƫŶŐ Ă ƚĞŵƉŽƌĂƌLJ ĐĂƚŚĞƚĞƌ ŝŶ ƚŽ ĚƌĂŝŶ ƚŚĞ ƵƌŝŶĞ ĂŶĚ ƌĞŵŽǀŝŶŐ ŝƚ ƌŝŐŚƚ
ĂǁĂLJ͘ 1ŚŝƐ ŝƐ ĐĂůůĞĚ ŝŶƚĞƌŵŝƩĞŶƚ ƵƌĞƚŚƌĂů ĐĂƚŚĞƚĞƌŝnjĂƟŽŶ͘
Catheter care
ǀĞŶƚ ŐĞƌŵƐ ĨƌŽŵ ŐĞƫŶŐ ŝŶƚŽ ƚŚĞ ĐĂƚŚĞƚĞƌ ƚƵďĞ͘
Ž kĞĞƉ ƚŚĞ ďĂŐ ůŽǁĞƌ ƚŚĂŶ ƚŚĞ ďůĂĚĚĞƌ ƚŽ ƉƌĞǀĞŶƚ ƵƌŝŶĞ ĨƌŽŵ ďĂĐŬŇŽǁ-
ŝŶŐ ƚŽ ƚŚĞ ďůĂĚĚĞƌ͘
ƚŚŝŶŐ ǁŚŝůĞ ĞŵƉƚLJŝŶŐ ƚŚĞ ďĂŐ͘
ͻ uŽ ŶŽƚ ƚƵŐ Žƌ ƉƵůů ŽŶ ƚŚĞ ƚƵďŝŶŐ͘
ͻ uŽ ŶŽƚƚǁŝƐƚŽƌ ŬŝŶŬ ƚŚĞ ĐĂƚŚĞƚĞƌ ƚƵďŝŶŐ͘
CAUTI FAQs Forms & Tools
Improving Quality of Care Based on CMS Guidelines 107
Comfort Gel
Your hands will
love you even
©2009 Medline Industries, Inc. Medline
is a registered trademark of Medline Industries, Inc.
is a registered trademark of BODE Chemie GmbH.
NIVEA and Eucerin are registered trademarks of Beiersdorf AG.
Comfort Gel
is a registered trademark of Bode Chemie GmbH.
Contact your
Medline representative
or call 1-800-MEDLINE
*Data on file
Available in three
packaging styles
to suit any need,
including a touchless
dispensing option.
Do more with less
Sterillium Comfort Gel delivers greater efficacy than other alcohol-based hand antiseptics*
by virtue of its ethyl alcohol concentration, and it does more for your infection control efforts
by using up to 50 percent less volume per application.* Independent in vitro testing demonstrated
that Sterillium Comfort Gel achieves reductions of ≥ 5 log10 (≥ 99.999 percent) on a broad
range of nosocomial pathogens.*
Add comfort for compliance
Sterillium Comfort Gel’s incredible bactericidal effect doesn’t matter if the product isn’t being used!
You’ll want to reach for Sterillium Comfort Gel again and again because it includes a balanced blend
of moisturizing emollients that leverages technology shared with BODE Chemie by its parent
company Beiersdorf AG, makers of well-known skincare products NIVEA
and Eucerin
The result is a product proven to increase skin hydration by 14 percent in just two weeks.*
Increased efficacy. Incredible comfort. Improved compliance.
Sterillium Comfort Gel.
Also available:
Sterillium Rub
for surgical hand
Apply a palmful of the product in a cupped hand, covering all surfaces; Rub hands palm to palm;
Right palm over left dorsum with
interlaced fingers and vice versa;
Palm to palm with fingers interlaced; Backs of fingers to opposing palms
with fingers interlocked;
Rotational rubbing of left thumb
clasped in right palm and vice versa;
Rotational rubbing, backwards and
forwards with clasped fingers of right
hand in left palm and vice versa;
Once dry, your hands are safe.
How to Handrub?
Duration of the entire procedure: 20-30 seconds
May 2009
1a 1b 2
3 4 5
6 7 8
All reasonable precautions have been taken by the World Health Organization to verify the information contained in this document. However, the published material is being distributed without warranty of any kind,
either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World Health Organization be liable for damages arising from its use.
WHO acknowledges the Hôpitaux Universitaires de Genève (HUG), in particular the members of the Infection Control Programme, for their active participation in developing this material.
Handrub Forms & Tools
Improving Quality of Care Based on CMS Guidelines 109
1 / F DA Cons umer Heal t h I nf or mat i on / U. S . Food and Dr ug Admi ni s t r at i on J UNE 2009
Consumer Health Information
CDRH reports that about 2.5 mil-
lion hospital beds are in use in the
United States. The center regulates
these beds as medical devices.
“Many of today’s hospital bed
models are quite complex. Patients
and health care professionals should
understand how to use them prop-
erly, and manufacturers must provide
adequate instructions for use,” says
Todd, who works in CDRH’s Office
of Surveillance and Biometrics.
Beware of Entrapment
The main risk is entrapment, which
occurs when a patient is caught in
spaces in or around the bed rail,
mattress, or bed frame. Entrapped
individuals can become strangled.
Practice Hospital
Bed Safety
ospital beds are
found in nearly
all patient care
settings or environments,”
says Joan Ferlo Todd, RN, a
senior nurse-consultant at the
Food and Drug Administration’s
(FDA) Center for Devices
and Radiological Health
(CDRH). “They are used not
only in hospitals, but also in
outpatient care centers, long-
term care facilities, and in
private homes.”
Hospital Bed Entrapment Zones
An FDA guidance characterizes the head, neck, and chest as key
body parts at risk of entrapment, and identifies seven potential
“zones of entrapment” where special care is required:
1. within the rail
2. under the rail, between the rail supports or next to a single rail
3. between the rail and the mattress
4. between the rail, at the ends of the rail
5. between split bed rails
6. between the end of the rail and the side edge of the head or
foot board
7. between the head or foot board and the mattress end
Forms & Tools Practi ce Hospi tal Bed Safety
110 Healthy Skin
Continued on Page 112
Caregivers appreciate the ability to maneuver Medline’s
Alterra 1232 hi-low bed no matter the height. Staff aren’t
forced to use the lowest or highest setting to move the bed.
Risk managers value the built-in battery back-up system
that comes with each Alterra 1232 bed for no additional cost.
This feature keeps the bed functioning in a power outage.
Residents love the comfort and style of the Alterra 1232
hi-low bed by Medline.
Additional features:
• Optimal hi-low range of 26” to 7.25”
• Built-in motor stop keeps the bed from applying more
pressure in the event that something gets caught in the
head or foot section
• Interest-free payment plan of 3, 6 or 12 months
To learn more about the Alterra 1232 hi-low
bed, contact your Medline representative or
call 1-800-MEDLINE.
height of
height of

Custom head/footboards and staff control also available
Rest Assured
2 / F DA Cons umer Heal t h I nf or mat i on / U. S . Food and Dr ug Admi ni s t r at i on J UNE 2009
Consumer Health Information
“Patient entrapment is uncommon,”
says Todd, “but when it occurs, it’s
often fatal.”
Between 1985 and 2009, FDA
received reports of 803 incidents of
patients caught, trapped, entangled,
or strangled in hospital beds. The
reports included 480 deaths, 138
nonfatal injuries, and 185 cases where
staff intervened to prevent an injury.
Most of the affected patients were
frail, elderly, or confused.
“Not all patients are at risk for
entrapment, and not all hospital beds
pose an entrapment risk,” says Todd.
“But health care facilities, as well as
patient caregivers, are urged to take
a careful look at hospital beds. They
need to determine if there are large
openings that present an entrapment
risk, and to take steps to minimize
this risk.”
Any type of rail or grab bar attached
to a bed, as well as the fit of the
bed mattress, should be assessed
for entrapment risks, she adds. “It is
important to view the hospital bed
as a system,” she says. “Not all mat-
tresses or bed rails are suitable with
any given bed frame.”
FDA regulates hospital beds through
post-market activities such as analyz-
ing reports of product problems and
adverse events, says Todd. “Although
the agency does not regulate the
design of the beds, it offers safety
guidance to industry.”
FDA is a member of the Hospital
Bed Safety Workgroup (HBSW), a
partnership among the medical bed
industry, national health care organi-
zations, patient advocacy groups, and
federal agencies.
In 2006, FDA with collaboration
from HBSW issued “Hospital Bed
System Dimensional and Assessment
Guidance to Reduce Entrapment,” rec-
ommendations for manufacturers of
new hospital beds and for facilities
with existing beds, including hos-
pitals, nursing homes, and private
“The guidance may also be used
by health care facilities,” says Jay A.
Rachlin, director of CDRH’s Divi-
sion of Health Communication in
the Office of Communication, Edu-
cation, and Radiation Programs. “It
offers useful information for health
care facility staff.”
Rachlin says the guidance, along
with other educational products from
FDA and the HBSW, have improved
patient safety. “Manufacturers have
redesigned their bed frames and
their side rails to reduce the risk of
Entrapment Zones
The guidance characterizes the head,
neck, and chest as key body parts at
risk of entrapment. It also identi-
fies these seven potential “zones of
entrapment” in hospital beds:
1. within the rail
2. under the rail, between the rail
supports or next to a single rail
3. between the rail and the mattress
4. between the rail, at the ends of
the rail
5. between split bed rails
6. between the end of the rail and
the side edge of the head or foot
7. between the head or foot board and
the mattress end
Rachlin says that proper fitting
rails can be useful. However, health
care professionals and patients need
to assess whether rails are necessary
in each instance. “In addition to
entrapment, there are other potential
hazards associated with bed rail use,
including serious injuries from falls
when patients climb over rails, and
having patients feel isolated or unnec-
essarily restricted,” he says.
Fire Prevention
Fire is a rare safety risk associated
with motorized hospital beds. “Fires
are due mostly to a lack of mainte-
nance,” says Todd. “There are electri-
It is important to view the hospital bed as
a system. Not all mattresses or bed rails are
suitable with any given bed frame.
OJO Images
Forms & Tools Practi ce Hospi tal Bed Safety
112 Healthy Skin
3 / F DA Cons umer Heal t h I nf or mat i on / U. S . Food and Dr ug Admi ni s t r at i on J UNE 2009
Consumer Health Information
cal shorts due to frayed or strained
wires, motors overheat, or dust or
other materials from the hospital fall
into the motor casing.”
She suggests these steps to cut the
risk of fire incidents:
- Inspccì ìlc hcd's powci coid foi
- Don'ì connccì ìlc hcd's powci
cord to an extension cord or to a
multiple-outlet strip.
- Inspccì ìlc ßooi hcncaìl ìlc hcd
for buildup of dust and lint, which
could clog the motor.
- Inspccì ìlc hcd conìioI pancI
covering for signs of damage
where liquids could leak in.
- Clcck cquipmcnì foi signs of
overheating or physical damage.
- Kccp Iincns and cIoìlcs awav
from power sources.
Home Use
Todd says there have been very few
reports of safety incidents with hos-
pital beds used in private residences.
“This may represent underreport-
ing by consumers,” she says. “The
reporting system for these incidents
is set up for health care facilities, but
consumers and home patients can
still report medical device incidents
to FDA through its MedWatch pro-
She adds that hospital beds used
at patients’ homes are usually pre-
scribed devices. “They’re not required
to be prescribed, but the beds are
usually very expensive to rent or buy,
and most patients get them for home
through health plans.”
It is important to ask that the bed
meet the guidelines in the FDA guid-
ance to reduce the risk of entrapment.
Some hospital beds used at home may
require patient or caregiver training,
Todd says. “It depends on the com-
plexity of the bed.”
Safety Tips
CDRH offers the following safety tips
for home use of hospital beds:
- Clcck ìlc moìois, cspcciaIIv foi
dust and debris.
- Ensuic ìlaì cacl componcnì-ìlc
bed frame, mattress, rails, and any
addcd acccssoiics-piopciIv fiìs
together. Make sure the mattress is
the correct size for the bed frame
so unsafe gaps are not present. If
you see an opening let a health
care professional know or call the
- Wlcn in douhì, consuIì ìlc hcd
frame manufacturer to determine
if a component or accessory is com-
patible with your bed frame.
- Usc iaiIs cauìiousIv. Paìicnìs slouId
not try to climb around or over the
rails to get out of bed.
What is a Hospital Bed?
Todd says that there is no standard
definition for hospital beds, a fact
that consumers shopping for such a
bed need to be aware of.
“A bed becomes a hospital bed
when it meets the requirements for
being a medical device,” she says.
CDRH defines a medical device as
“an instrument, apparatus, imple-
ment, machine, contrivance, implant,
in vitro reagent, or other similar arti-
cle that is intended for use in the diag-
nosis of disease or other conditions,
or in the cure, mitigation, treatment
or prevention of disease.”
“There are beds sold in retail stores
that don’t meet the definition of med-
ical devices under the law, but which
may have some of the characteris-
tics of a hospital bed,” says Todd.
“These beds may have features such
as height-adjustment mechanisms or
adjustable positions for the back and
knee, or be fitted with snap-on rails.
But they’re not regulated by FDA.”
She says that such beds fall under
the jurisdiction of the U.S. Consumer
Product Safety Commission. “If these
beds are used with any type of rail,
consumers should adhere to the same
safety recommendations in place for
hospital beds.”
This article appears on FDA’s
Consumer Update page (www.fda.
default.htm) which features the latest
on all FDA-regulated products.
For More Information
Hospital Bed Safety
Preventing hospital bed fires
Safety Brochure: Bed Rails in
Hospitals, Nursing Homes, and
Home Health Care
MedWatch, for reporting adverse
Some hospital beds used at home may
require patient or caregiver training.
Practi ce Hospi tal Bed Safety Forms & Tools
Improving Quality of Care Based on CMS Guidelines 113
©2009 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.
Improving Quality of Care Based on CMS Guidelines 115
Pressure Ul cer Pocket Reference Forms & Tools
Pressure Ulcer Staging
A pressure ulcer is a 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. These stages should only be used
for pressure ulcers.
SUSPECTED Deep Tissue Injury (DTI) Purple or maroon
localized area of discolored intact skin or blood-filled blister due
to damage of underlying soft tissue from pressure and/or shear.
The area may be preceded by tissue that is painful, firm, mushy,
boggy, warmer or cooler as compared to adjacent tissue.
STAGE I Intact skin with non-blanchable redness of a localized
area usually over a bony prominence. Darkly pigmented skin
may not have visible blanching; its color may differ from the
surrounding area.
STAGE II Partial-thickness loss of dermis presenting as a
shallow open ulcer with a red pink wound bed, without slough.
May also present as an intact or open/ruptured serum-filled
STAGE III Full-thickness tissue loss. Subcutaneous fat may be
visible but bone, tendon or muscle are not exposed. Slough may
be present but does not obscure the depth of tissue loss. May
include undermining and tunneling.
STAGE IV Full-thickness tissue loss with exposed bone, tendon
or muscle. Slough or eschar may be present on some parts of
the wound bed. Often includes undermining and tunneling.
UNSTAGEABLE Full-thickness tissue loss in which the base
of the ulcer is covered by slough (yellow, tan, gray, green or
brown) and/or eschar (tan, brown or black) in the wound bed.
©NPUAP 2007 Adapted from National Pressure Ulcer Advisory Panel’s Pressure Ulcer Staging Classification.
©2009 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.
Interactive courses & 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.
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.
And for facilities participating in the Pressure
Ulcer Prevention and Hand Hygiene programs,
all materials, pre- and post-tests are now conve-
niently located online at
Visit the redesigned
today, and let us know what you think!
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