Improving Quality of Care Based on CMS Guidelines

Volume 4, Issue 2

Top Issues Affecting Your Practice
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Improving Quality of Care Based on CMS Guidelines
Editor Sue MacInnes, RD, LD Clinical Editor Margaret Falconio-West, RN, APN/CNS, ET, CWOCN, DAPWCA Clinical Team Cynthia A. Fleck, RN, ET/WOCN, CWS, DAPWCA, MBA, FCCWS Janet L. Jones, RN, PHN, ET, CWOCN, DAPWCA Joyce Norman, RN, CWOCN, DAPWCA Elizabeth O’Connell-Gifford, RN, CWOCN, DAPWCA, MBA Carol Paustian, RN, ET, CWOCN, DAPWCA Amin Setoodeh, RN Deb Tenge, RNC, MS, CWOCN, Licensed Administrator Jeannine Thompson, RN, CWOCN Jackie Young, RN, ET, CWCN, DAPWCA Wound Care Advisory Board Mona Baharestani, PhD, ANP, CWOCN, FCCWS, FAPWCA Ann Blackett, MS, RN, COCN, CWCN, CPHQ, CNS Patricia Coutts, RN Pat Emmons, RN, MSN, CNS, CWOCN Cindy Felty, RN, CNP, MSN, CWS, FCCWS Lynne Grant, CNS, MS, RN, CWOCN Teresa Kellerman, MSN, ARNP, WOC/CNS Bette Kussmann, RN, CWCN, COCN Andrea McIntosh, RN, BSN, CWOCN, APN Cathy Milne, MSN, APRN, CS, CWOCN, ANP Laurie Sparks, RN, ET Shelia Thomas, RN, CWOCN Dot Weir, RN, CWCN, COCN, CWS Lynne Whitney-Caglia, RN, MSN, CNS, CWOCN Laurel Wiersema-Bryant, RN, BC, ANP Linda Woodward, RN, OCN, CWOCN Survey Readiness

20 Untangling the Terms 48 Wound Care Competency Day 60 Love Them Two Times

12 22 34 40 45 53 54

Understanding Skin Tears What’s That Noise? Seat Cushions Taking the Fear out of Male Catheterization If the Shoe Fits… Perineal Skin Care for the Incontinent Resident Case Study: Using Olivamine in a Skin Cream to Improve Skin Quality in Diabetic Patients 56 Easing the Pain
Special Features

Page 23

5 6 11 26 31 38 64 74

Top 10 Issues Affecting Your Clinical Practice Today Survey Two Important National Initiatives for Improving Quality of Care Advancing Excellence Campaign Goals The Perils of Ineffective Handwashing The Key to Hand Hygiene Incontinence Anurse in WOUNDerland Sharpening the Saw
Forms & Tools

Page 34

88 89 90 92 94 95

Guidelines for Wound Photography Prevention of Skin Tears – In-Service Outline Bates-Jensen Wound Assessment Tool PUSH Tool 3.0 Quick Guide to Lab Values Foley Catheter Selection Guide
Regular Features

Page 60

4 8 16 51 58

Letter from the Editor News Flash CE-Credit Crossword Puzzle: Understanding Skin Tears Hotline Hot Topic Product Spotlight: Silicones
Caring for Yourself

Page 78

70 78 84 86

Respect “Dr. Marla” Battles Breast Cancer Best Day/Worst Day Recipe: Berries & Cream Pound Cake

© 2007 Medline Industries, Inc. Healthy Skin is published by Medline Industries, Inc. One Medline Place, Mundelein, IL 60060 1-800-MEDLINE (633-5463)

Medline, headquartered in Mundelein, IL, manufactures and distributes more than 100,000 products to hospitals, extended care facilities, surgery centers, home care dealers and agencies and other markets. Medline has more than 700 dedicated sales representatives nationwide to support its broad product line and cost management services. For more information on Medline, visit our Web site,

Improving Quality of Care Based on CMS Guidelines


HEALTHY SKIN I Letter from the Editor
Recently, CMS released the final PPS rule for hospitals. This is a significant policy change that will ultimately improve the quality of care by no longer paying for preventable conditions that are acquired in hospitals. These conditions include pressure sores, UTIs and falls. What do you think will happen next? It’s only a matter of time before reimbursement for LTC and home health are also centered around patient outcomes and more costeffective healthcare by putting the focus on prevention. Patient hand-off between healthcare providers will be a major focus in the future. To that end, we intend to continue to bring you industry news and examples of successful collaborations. We invite you to share your experiences – both good and bad – so that others can learn and benefit. Please feel free to contact me at with anything you would like to share. Once again included in this edition are the key initiatives in home health and long-term care (see Page 6). Notice the icons at the bottom of this page. You will see these icons throughout the magazine whenever an article supports one of these quality goals. Then, on Page 11, follow the crosswalk of national initiatives. The Web site addresses of these organizations are provided so that you can explore the resources available to assist you in your practice. If you would, please take a moment to complete the survey on the following page and tell us your biggest challenges. We want to direct future content to address your pressing concerns by first sharing the results in our next issue and then by tailoring future articles to give you those practical solutions that target your needs. We know that your concerns on the job also include daily interactions with peers and motivating your staff. To that end, we’ve included an article titled “Respect” to remind us of how important it is to manage the interaction between our co-workers and professionals from other healthcare entities. Finally, we are thrilled to feature an article by Dr. Marla Shapiro, the well-known Canadian physician, columnist, TV personality and breast cancer survivor, to inspire us all to remember the importance of our families and friends. Her story is touching and her message a wake-up call to take care of ourselves and to balance our lives between our work, family and self. Best regards,

We all can agree that we should do thing right ... but it is our goal to make it hard for the healthcare worker to do things wrong.

Sue MacInnes, RD, LD

Content Key
We’ve coded the articles and information in this magazine to indicate which National Quality initiatives they pertain to. Throughout the publication, when you see these icons you’ll know immediately that the subject matter on that page relates to one or more of the following national initiatives: • QIO – Utilization and Quality Control Peer Review Organization • Advancing Excellence in America’s Nursing Homes We’ve tried to include content that clarifies the initiatives or give you ideas and tools for implementing their recommendations. For a summary of each of the above initiatives, see Page 6.



We want to hear from you!
Healthy Skin wants to hear what you, our readers, think are the top 10 most important issues in your practice today! And for your time and effort, we will send you an Angel nurse doll. Go to to complete the survey.

Affecting Your Clinical Practice Today

1Simply go to the Internet and type in 2 Click on Top 10 Issues Survey. 3 Rank your top 10 issues and concerns from one to 10.
Issues affecting your practice: Survey Process Reimbursement Wound Care Product Selection Aging Facilities Liability Claims Staffing Resident and Family Satisfaction Staff Development Supply Management Fall Prevention Safety/Risk Infection Prevention Cost Control Pressure Ulcer Prevention Patient Handoff Census Incontinence Pain Management Home Health Nursing Home Wound Clinic Hospital Hospice Other Please select one that best describes your area of practice:
When you have completed the survey, just click enter and your answers will be submitted for calculation. Deadline for submission is October 31, 2007. Check out the results in the next issue of Healthy Skin.

Additional issues:

To take the survey and receive your Angel doll, go to

Two Important National Initiatives for Improving Quality of Care
Achieving better outcomes starts with an understanding of current quality of care initiatives. Here’s what you need to know about national projects and policies that are driving changes in nursing home and home health care.

Origin: Purpose: Goal:

The QIO Statement of Work (SOW) is based on Part B of Title XI of the Social Security Act. The QIO is currently operating within its 8th Round SOW contract cycle, which started in August 2005 and will be in effect until July 2008. In the 8th Round SOW, QIOs are expected to provide assistance to providers that enable them to develop the capacity for and to achieve the vision that every person receives the right care every time. CMS has identified a set of Breakthrough Priorities for improvement. The purpose of these Breakthrough Priorities is partly to improve care, but more importantly to transform the expectations of participants in improvement by making very substantial improvement a fully credible ambition.

Quality Improvement Organization (QIO) Program’s 9th Scope of Work The Centers for Medicare and Medicaid Services’ Office of Clinical Standards will be seeking comments beginning September 2007 on the Quality Improvement Organization (QIO) Program’s proposed 9th Scope of Work. The 9th Scope, which begins on August 1, 2008, will run through July 31, 2011. Information about the 8th Scope of Work is provided at QualityimprovementOrgs/04_9thsow.asp.

Origin: Purpose:

A new coalition-based, two-year campaign initiated on September 26, 2006 to improve quality of life for nursing home residents and staff. A coalition consisting of the Centers for Medicare and 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. 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.


Advancing Excellence The Advancing Excellence in America's Nursing Homes campaign kicked off in the fall of 2006 at a national Nursing Home Quality Summit in Washington, D.C. 5,705 facilities nationwide have committed to work on at least three of the campaign's goals. To download the Advancing Excellence tool kit, go to



Special Features
Check out the Web sites for these initiatives! 8th Statement of Work: Advancing Excellence: American Health Care Association:

Task 1a: Nursing Home Clinical Performance measures • High-risk pressure ulcers • Physical restraints • Management of pain in chronic (long-stay) residents • Management of depressive symptoms Organizational Change and Process Improvement Measures • Conduct annual employee satisfaction surveys • Conduct annual resident satisfaction surveys • Calculate annual CNA turnover rates Task 1b: Home Health Clinical Performance measures • Improvement in bathing • Improvement in transferring • Improvement in ambulation/locomotion • Improvement in management of oral medications • Improvement in pain interfering with activity • Improvement in status of surgical wounds • Improvement of dyspnea • Acute care hospitalization • Discharge to community • Improvement in urinary incontinence

Progress reports will be posted on for both campaigns beginning September 2007

Clinical Goals: Goal 1: Reducing high-risk pressure ulcers Goal 2: Reducing the use of daily physical restraints Goal 3: Improving pain management for longer-term nursing home residents Goal 4: Improving pain management for short-stay, post-acute nursing home residents Operational/Process Goals: Goal 5: Establishing individual targets for improving quality Goal 6: Assessing resident and family satisfaction with quality of care Goal 7: Increasing staff retention Goal 8: Improving consistent assignment of nursing home staff so that residents receive care from the same caregivers

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: Goal 2: Goal 3: Goal 4:

68.6% 42.4% 53.6% 39.7%

Goal 5: 29.7% Goal 6: 65.2% Goal 7: 39.6% Goal 8: 33.5%

As of September 1, goals 1, 3 and 6 have the highest participation rates.

Stay tuned! First year results will be published in the January 2008 issue of Healthy Skin!

Improving Quality of Care Based on CMS Guidelines


CMS Releases Inpatient PPS Final Rule for 2008 Will this impact resident-centered care?
On August 1, 2007, the Centers for Medicare & Medicaid Services (CMS) released the inpatient prospective payment system (PPS) final rule for fiscal year (FY) 2008. The policies and payment rates included in this rule become effective October 1, 2007. The rule adopts eight conditions, including three serious preventable events, for which CMS will not provide higher payments if the selected event occurs while a patient is under the care of the hospital. The changes will take effect for FY 2009 and will include: • Object left in surgery • Pressure ulcers • Air embolism • Vascular catheter-associated infections • Blood incompatibility • Mediastinitis after coronary artery bypass graft • Catheter-associated urinary tract infections • Falls CMS will continue its three-year transition to cost-based relative weights, with two-thirds of the FY 2008 weight based on costs and one-third based on charges. Consider your resident population and the continuum of care with regard to transfers both to and from acute-care settings. A display copy of the document is available at

CMS Issues Revised Guidance for F323 – Accidents & Supervision
The Centers for Medicare & Medicaid Services (CMS) has issued revised guidance for Accidents and Supervision (Tag F323) that became effective on August 6, 2007. The revised guidance combines Tags F323 and F324 into one tag, F323. According to the Survey & Certification Memorandum that accompanies the guidance, the interpretive guidelines clarify areas such as resident supervision, hazard identification and resident risk, falls, unsafe wandering/elopement, environmental assessment of hazards and resident-to-resident altercations. For complete information, please refer to the actual guidance and training materials, available at Supervision: This section includes two behaviors for which a facility may provide supervision: Resident smoking and resident-to-resident altercations. Hazard Identification and Resident Risk: Resident Vulnerabilities: • Falls • Unsafe wandering or elopement • Physical plant hazards • Chemicals and toxins • Water temperature • Electrical safety • Lighting • Assistive devices/equipment hazards • Assistive devices for mobility Deficiency Categorization Actual or potential harm/negative outcome for F323 may include, but is not limited to: • Injuries sustained from falls and/or unsafe wandering/elopement; • Resident-to-resident altercations; • Thermal burns from spills/immersion of hot water/liquids; • Falls due to environmental hazards; • Ingestion of chemical substances; and • Burns related to smoking materials.



Update on

HAIs from CDC:
A new report from the Centers for Disease Control and Prevention (CDC) contains the following updated estimates of healthcare-associated infections (HAIs): An estimated 1.7 million infections and 99,000 associated deaths occur each year • Equivalent to 1 death every 6 minutes • Annually add $5 – $6.7 billion to U.S. healthcare costs • Types of infections: — 32 percent of all healthcare-associated infections are urinary tract infections — 22 percent are surgical site infections — 15 percent are pneumonia (lung infections) — 14 percent are bloodstream infections Hand hygiene is one way to decrease the spread of infection. Learn how to make hand hygiene a success in your facility by reading “The Perils of Ineffective Handwashing” and “The Key to Hand Hygiene” on pages 26 and 31.
Reference: The Centers for Disease Control and Prevention. Estimates of HealthcareAssociated Infections. Available at: Accessed August 23, 2007.

Celebrating the 21st Annual

National Conference, Caesars Palace, Las Vegas, Nevada
Held June 23 to 27, 2007 this year’s conference and exposition had more than 800 in attendance. Kicking off the event was the keynote speaker, Andrea Higham, Director of Corporate Equity and the Johnson & Johnson Campaign For Nursing’s Future, which highlighted “The Promise of Nursing.” This session was not only inspirational; it also set the tone of the conference and emphasized the bright future of nursing. Molly Morand, President of the Morand Group, LLC was once again on hand to deliver her presentation titled “Just Say No to Mandatory In-Services” to a packed audience. “Compassion Fatigue – Preparing Professionals to be Resilient” explored the signs and coping measures for compassion fatigue and offered strategies to assist in developing resiliency. This session was presented by Barbara Rubel, MA, BCETS, CBS, CPBC, Executive Director of the Griefwork Center, Inc. Medline Industries, Inc. introduced their revolutionary educational packaging (EP Packaging) for advanced wound care to all DONs (Directors of Nursing) who attended this meeting. With more than 6,000 members, The National Association Directors of Nursing Administration in Long-Term Care, or NADONA/LTC, is the largest educational organization committed exclusively to nursing and administration professionals in the Long-Term Care and AssistedLiving professions. Mark your calendars for June 21 to 25, 2008 when the 22nd Annual NADONA/LTC National Conference will be held in Nashville, Tennessee at the Gaylord Opryland Hotel and Conference Center.


NADONA/LTC attendees share their knowledge.

How 4 square inches of Puracol Plus changed chronic wound care. Forever.

Look closely. It’s not a bandage. It’s Puracol™ Plus MicroScaffold™, made entirely of pure native collagen.

But apply Puracol Plus and help restore nature’s balance.
This is Puracol Plus MicroScaffold as seen through an electron microscope. Its open, cellular structure allows easy fibroblast migration.2 The high strength of the MicroScaffold2 also assists in establishing a fresh wound bed.

Chronic wounds tend not to heal when unbalanced levels of elastase and MMPs (inflammatory enzymes) destroy the body’s own collagen and growth factors.1

In vitro studies show that Puracol Plus has the ability to reduce the levels of elastase and MMPs from surrounding fluid.2

1. Schultz GS, Mast BA. Molecular analysis of the environment of healing and chronic wounds: Cytokines, proteases, and growth factors. Wounds. 1998;10 (6 Suppl): 1F-9F. 2. Data on file.

Each Puracol package, like every other Medline wound care package, is a 2-Minute Course™ in Advanced Wound Care.

Special Features

Advancing Excellence Campaign Goals:
A cross-reference outlining the clinical and performance goals included in all four National Initiatives in long-term care.
Did you know all of the National Initiatives are closely related?
There are currently four national initiatives striving to improve the quality of long-term care in America: • American Health Care Association’s (AHCA) Quality First - • Nursing Home Quality Initiative’s (NHQI) QIO Goals - • Nursing Home Culture Change Movement - • Advancing Excellence in America’s Nursing Homes - To learn more about each initiative, you are invited to visit each group’s Web site, where they offer detailed information and educational tools.


Quality First


Culture Change

Advancing Excellence

Pressure Ulcers Physical Restraints Chronic Pain Post Acute Pain Setting Targets Customer Satisfaction Staff Turnover Consistent Staffing




Improving Quality of Care Based on CMS Guidelines



Reprinted with permission from EPCN



Improving Quality of Care Based on CMS Guidelines


Improving Quality of Care Based on CMS Guidelines







As the primar y supplier to more than 2,700 home health care agencies nationwide, we know what you require from a strong business partner. That is why Medline HomeCare provides innovative solutions for supply management, clinical support and ongoing training, flexible financing and world-class medical products. It’s like a whole team is supporting your staff during every visit. To learn more about Medline’s Total Support Program, call us at 1-800-678-7852 or e-mail us at


Mundelein, S 60060 HEALTHY IL KIN

Medline is a registered trademark of Medline Industries, Inc.

©2007 Medline Industries, Inc.

Improving Quality of Care Based on CMS Guidelines


Crossword Puzzle

Understanding Skin Tears: the “Whys” and “Hows”
hour of To receive one r your CE credit, entene at answers onli niver www.medlineu
1 4 5 6 2 3


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12 13

14 15 16 17

18 19 20


22 1. Register (free) or log in 2. Click Free Courses tab 3. Locate the puzzle and click Learn More, then Begin Course 4. Certificates are available online after puzzle completion



Across 2 Choose dressings that keep the wound optimally moist without causing further _____. 5 Between the epidermis and dermis is the _____ membrane, a moving junction that both separates and attaches the epidermis and the dermis. 6 Keeping the patient well _____ can be the difference between a bruise, a bump and a skin tear. 7 Remember key measures such as cleaning, moisturizing and nourishing the skin with advanced skincare _____. 10 There are several _____ products that can help alleviate the discomfort of skin tears. 11 As skin ages, the rete ridges or pegs begin to _____ between the dermal-epidermal junctions. 13 When injury occurs, there is an increase in _____ absorbed by the skin. 15 Skin tears cause a resident to suffer _____. 16 Certain medications, such as _____, can make the skin more prone to injury. 18 The use of protective sleeves or elastic tubular support bandages can help to _____ dressings in place. 19 The dermis has _____ projections. 20 It is estimated that at least 1.5 _____ skin tears occur in institutionalized elderly each year. 21 One dressing that can handle the initial fluid is a _____ sheet.

Down 1 The dermis and epidermis move as one in _____ young skin. 3 Skin tears occur most commonly in the _____ extremities. 4 It is _____ to look at dressing choices and choose products that allow you to avoid adhesives, decrease dressing changes and maintain a moist wound healing environment. 6 Advancing age and a _____ of previous skin tears put residents at risk for skin tears. 8 To protect the injury during dressing change, indicate the _____ in which the dressing should be removed. The _____ has an irregular shape resembling downward, finger-like projections called rete ridges or pegs. _____ skincare products that deliver endermic nutrition and antioxidants can assist in preventing skin tears. _____ handling of skin tears in important. Dermal-epidermal flattening is typically seen by the _____ decade of life. Hydration and the appropriate _____ are the key objectives to healing and preventing skin tears. Skin tears of _____ origin make up one half of the total skin tear population. Patients and residents who are totally dependent on others for activities of daily living are at the _____ risk for skin tears. Compromised nutrition, fluid volume deficit, confusion, limitations in mobility, lack of independence and ecchymotic skin are all _____ for skin tears.



14 16 17

19 21


Improving Quality of Care Based on CMS Guidelines


Survey Readiness

Can you explain the differences between these commonly confused terms?
Prevalence or incidence?
Prevalence refers to the proportion of a population (such as nursing home residents) who are affected with a particular disease at a given time. Incidence refers to the rate of occurrence of new cases of a particular disease in the population being studied.

Mattress overlay or mattress replacement?
Mattress overlays are pressure-reducing support surfaces placed on top of an existing mattress. They can be filled with air, foam, gel, water or a combination thereof. Mattress replacements, also pressure-reducing support surfaces, are made of high-quality foam or other materials and actually replace the inner-spring mattress directly on the bed frame. They provide pressure relief that is not possible with standard hospital mattresses.3

Avoidable or unavoidable pressure ulcer?
Avoidable pressure ulcer refers to a facility’s failure to do one or more of the following: evaluate the resident’s clinical condition and pressure ulcer risk factors; define and implement interventions that are consistent with resident needs, resident goals and recognized standards or practice; monitor and evaluate the impact of the interventions or revise the interventions as appropriate. Unavoidable pressure ulcers occur despite the facility evaluating the resident’s clinical condition and pressure ulcer risk factors; defining and implementing interventions consistent with resident needs, goals and recognized standards of practice; monitoring and evaluating the impact of the interventions and revised approaches as appropriate.2

Friction or shear?
Friction refers to resistance to movement. Shear refers to disruption of the connection between soft tissue and bone.3

References 1 Merriam-Webster’s Medical Dictionary. Available at: Accessed August 15, 2007. 2 Centers for Medicare & Medicaid Services. CMS Manual System: Pub. 100-07 State Operations. Available at: downloads/R4SOM.pdf . Accessed August 15, 2007. 3 Medline Industries, Inc. The Wound Care Handbook. 2007.




Staff development coordinators frequently ask for in-service on lung sounds and how to document them. Rales, rhonchi and wheezes can be confusing and difficult to describe. Tear out this article to help you understand what you are hearing and what these sounds mean for your patients’ health and care.

What’s that noise?

Your guide to assessing lung sounds

By Ellie Armstrong, LPN

Know what’s normal Large populations of geriatric patients have some type of a respiratory diagnosis. Chronic obstructive pulmonary disease (COPD), emphysema, asthma and congestive heart failure (CHF) can all affect normal lung sounds. It is important to note what patients’ normal lung sounds are, especially since patients with limited mobility are prone to respiratory infections. Assessing patients’ lung sounds on a daily basis can help you know right away when something isn’t “normal.” Assessment should include breath sounds, respiratory rate, heart rate and respiratory pattern. If the patient has a cough, note if it is dry or productive. If the patient has a productive cough, note the color, texture and amount of sputum produced. Also check the patient’s oximetry for a baseline. Hints for listening Auscultation of lung sounds should be done in a quiet environment whenever possible. The patient should be sitting up in bed. If this is not an option, lung sounds may be assessed with the patient lying on their side. Breath sounds are best heard when there is no interference from clothing, so place the stethoscope on the patient’s bare skin. Auscultation should be done on all lobes, moving from left to right for a minimum of two to four breaths. This enables comparison of the lobes to each other and time to listen for abnormal or adventitious sounds.

Improving Quality of Care Based on CMS Guidelines


Bronchial or vesicular? Normal lung sounds are described as bronchial or vesicular. Bronchial sounds are what are heard over the large airways. These sounds have been compared to the sound of air being blown through a tube. They are louder at the expiratory phase. Bronchial sounds can be heard over the tracheal area, over the lung apices and between the scapulas. Vesicular sounds are heard over the chest, away from large airways. These sounds have been compared to the sound of wind blowing through the trees. Vesicular sounds are decreased in patients with COPD and over sites of pneumonia. Absent or diminished? Abnormal breath sounds are classified as absent or diminished. Absent breath sounds are just what the name suggests – they are inaudible. Diminished breath sounds have softer-than-typical loudness. These sounds can reflect reduced airflow to a portion of the lungs, overinflation of a segment of the lungs (such as with emphysema), air or fluid around the lungs and even increased thickness of the chest wall. A decrease in the intensity of sounds in a given area can be the first sign of a disease process. “Adventitious” another word for “abnormal” Rales, rhonchi and wheezes are the most common of adventitious lung sounds. Pleural rubs and stridor are also classified as adventitious, but are less commonly heard. Rales, also called crackles, are caused by the explosive openings of small airways. They have been described as being similar to the crackling sound that wood makes as it burns. Crackles are most commonly heard during the inspiratory phase of breathing, although they can be heard during the expiratory phase also. Crackles are associated with inflammation or infection of the small bronchi, bronchioles and alveoli. Crackles that don’t clear with coughing might indicate pulmonary edema or fluid trapped in the alveoli due to CHF or ARDS. Crackles can be categorized as fine or coarse. Fine crackles are generally higher pitched, less intense and shorter in duration than coarse crackles. Fine crackles are usually heard in the late inspiratory phase. The sound of fine crackles can be simulated by rolling a strand of hair between fingers near the ear.

Coarse crackles are usually louder, lower in pitch and longer in duration than fine crackles. The most common conditions associated with coarse crackles are CHF and bronchitis. Coarse crackles have been described as similar to the sound opening a Velcro® fastener would make. Rhonchi are continuous sounds, as they usually last more than one quarter of a second. Rhonchi can be described as a coarse rattling sound, somewhat like snoring, and are usually caused by secretions in the larger airways. They usually clear with coughing. These sounds can be heard in patients with chronic COPD and acute or severe bronchitis. Wheezes are high-pitched whistling sounds often described as musical. Bronchospasm, airway edema, secretions, endobronchial tumors and compression of the airway can cause this adventitious sound. It might also be heard in patients with CHF due to increased fluid in the peribronchial lymphatics, causing airway compression. Know your resident The lung sounds described above are the most commonly heard lung sounds. Knowing your residents’ normal lung sounds and being able to assess changes will be a valuable tool for their care.

About the author

Ellie Armstrong, LPN, regularly in-services healthcare professionals on the proper way to listen to, describe and document lung sounds in long-term care facilities. She has been an LPN for more than 26 years and currently serves as head of the clinical department at Enos Home Oxygen and Medical Supply, Inc.




October 7 – 10, 2007 Boston, MA, Hynes Convention Center
Make plans now to attend or exhibit at the AHCA/NCAL/MECF 58th Annual Convention and Exposition—where knowledge meets practice. Don’t miss your biggest opportunity to join your fellow quality care providers and leading long term care suppliers to learn, to plan, and to connect with over 3,500 professionals. • Learn how knowledge meets practice by networking with over 3,500 of your peers in sharing ideas, challenges and successes. • Meet over 300 leading suppliers who will show you how knowledge meets practice through an array of products, services and demonstrations. • Hear how knowledge meets practice through our stimulating general sessions and thought-provoking educational seminars.

So join us in Boston, for the premier long term care event of the year!
For more information, visit, or call 202-842-4444

Co-Hosted by

By Scott A. Kale, MD, JD, MS



Special Features

Take a second to think about the average healthcare facility.
Bacteria, viruses and fungi are everywhere. They are on the walls, in the beds and on the sinks. They are on the sheets, the gowns and the books. Although I could go on with this travelogue of the residences of infectious organisms, let’s talk about the one place we least want these creatures lurking – our hands. These creatures are on the hands (and the clothing and jewelry) of the doctors, the nurses, the clerks, the visitors. They are ubiquitous and they are dangerous. What’s the problem? An estimated 103,000 people die every year from healthcare-acquired infections related to poor staff hygiene. This is a greater annual cause of mortality than AIDS, breast cancer and automobile accidents combined. Nearly 75 percent of patient rooms are contaminated with a drug-resistant staphylococcal organism. Fewer than 50 percent of physicians wash their hands between patients, let alone wash them properly. Programs emphasizing hand hygiene have been largely ineffective and beneficial doctor-nurse “debugging” behaviors remain elusive. The increased use of alcohol-based hand rubs (the use of which is standard practice in European hospitals) has improved the rate of handwashing compliance somewhat, but even these products must be used intelligently (before each contact), in the proper volume (3ccs), for the requisite period (18 seconds to 27 seconds, compared to one to two minutes for soap) and over the necessary surfaces (hands and wrists). One would think that medical school training and passing knowledge of germ theory and simple handwashing strategies would conspire to eliminate iatrogenic risks. One would be wrong. Americans are not big handwashers in the first place (only 83 percent wash their hands after using a restroom, for example, and more than 40 percent don’t wash after coughing or sneezing) or they wash incorrectly (for fewer than 20 seconds) when they bother to wash at all.



Improving Quality of Care Based on CMS Guidelines

While they are not diligent or reliable hand-washers, Americans are enthusipass on their shigella (diarrhea), kleb-

facilities because of a willingness of their staffs to follow infection riskcleaning of rooms and equipment, wear disposable gowns and, of course, wash their hands. American healthcare administrators contend that enforcing cleanliness rules is too expensive and difficult. Apparently, it is easier and perversely acceptable to allow one in 20 hospital patients to contract an infection than it is to solve the infection problem with its associated human and financial losses. There has been a visible public movement toward self-protection. DVDs, books and the Internet all tout aggressive methods of keeping yourself – and your loved ones – safe in healthcare facilities. It would appear too few people are taking advantage of them. Perhaps we should enlist patients reduction protocols, obey mandated

astic handshakers, and thereby cordially siella (wound infections), Haemophilus (conjunctivitis), E. coli (urinary tract infections), pseudomonas (infections), bacteroides (infection), Influenza A (pneumonia), Clostridium difficile (colitis), assorted rhinoviruses (upper respiratory infections/colds) and staphylococcus (infection), among other critters. Apparently, physicians and nurses – being typical American workers – have chalked up their own set of dire statistics by disregarding handwashing, as evidenced by the outrageous iatrogenic death rates in hospitals. What’s the solution? So, what can we do? Certainly, the problems associated with ineffective hand hygiene are well recognized. Even the Illinois General Assembly has expressed concern, introducing a bill in February 2007 that would require schoolchildren to wash their hands with antiseptic soap before eating. Politicians, including President Bush, Vice President Cheney, Al Gore and Barack Obama carry hand sanitizers with them at all times to help reduce their risk of infection during glad-handing season (which is now perpetual). Scandinavian countries have been more successful than the United States at reducing deadly infections in healthcare

An estimated 103,000 people die every year from HAIs related to poor staff hygiene.

and their families to help eradicate

infection risk. Residents can speak up doctors to have clean hands before

Influenza A

and tell their caregivers that they want touching them. We have actually created a large blue button printed with “Please wash your hands, my health depends on it” that can be fastened to patient gowns. Residents should also be encouraged to speak these very words to every caregiver with whom they come into contact. A large V.A. study demonstrated that patient-initiated doctor handwashing




on a surgical ward is highly effective at reducing healthcare-acquired infections. We have created an entire kit (“The Advo Kit”) that is given to each patient. It introduces these and other proactive protective behaviors for hospitalized people. Included in our approach is the requirement that the patient provide a “score” for their caregivers. An individual score is recorded for each doctor or nurse. The score reflects the caregiver’s hygiene skills, and the grades are shared with the caregivers. The prospect of being graded will change behavior in the desirable direction. It is my understanding that previous methods have largely failed to change the frequency and intensity of the hand-washing behaviors of our staffs. If it is true that more than 100,000 deaths each year is insufficient motivation to incite a change in hygiene tactics and methods, then something as simple as the proverbial “gold star” or “ A+” issued to caregivers might be. If administrative directives cannot remediate washing performance, perhaps simply honoring patient requests will. All we have to lose by trying a simple method of behavior modification are the germs.
References: 1. Widmer AF. Replace hand washing with use of a waterless alcohol hand rub? Clin. Infect. Dis. 2000;31:136-143. 2. Rotter M. Hand washing and hand disinfection [Chapter 87]. In: Mayhall CG, ed. Hospital epidemiology and infection control. 2nd ed. Philadelphia, Pa: Lippincott Williams & Wilkins, 1999. 3. Chicago Tribune, Metro North section, Thursday, February 15, 2007, page 8. 4.Trick WE, Vernon MO, Hayes RA et al. Impact of ring wearing on hand contamination and comparison of hand hygiene agents in a hospital. Clin. Infect. Dis. 2003 Jun 1;36(11):1383-90.

About the author Scott A. Kale, MD, JD, MS, is in the private practice of internal medicine and rheumatology. He is an attending physician on the staffs of Rush University Medical Center and Saint Joseph hospitals. He is a Fellow of the Institute of Medicine and the immediate past chairman of the board of directors of the DePaul University College of Law’s healthcare policy division. He is also a non-practicing attorney with extensive experience in evaluating medical malpractice, including cases involving decubitus ulcers. His strong interest in medical risk reduction centers on using awareness of past errors to design improved systems of medical care.

Improving Quality of Care Based on CMS Guidelines 29

Your hands will love you even more.
Also available: Sterillium Rub for surgical hand antisepsis

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©2007 Medline Industries, Inc. Medline® is a registered trademark of Medline Industries, Inc. Sterillium® is a registered trademark of BODE Chemie GmbH. NIVEA and Eucerin are registered trademarks of Beiersdorf AG. Sterillium® Comfort Gel® is a registered trademark of Bode Chemie GmbH. *Data on file

Contact your Medline representative or call 1-800-MEDLINE

Special Features

The Key to Hand Hygiene
Have you tried alcohol-based hand gels?
Appropriate hand hygiene is the most important action that can be taken in the battle to prevent cross transmission of nosocomial pathogens to susceptible residents. Transmission of these pathogens can lead to colonization, infection and even death.1 Alcohol-based hand rubs are widely considered to be the most appropriate type of agent for every situation in which hands are not visibly soiled.2 However, several factors need to be considered when determining the best possible protection for residents. Efficacy and dosage Both efficacy and dosage should be considered to selecting an appropriate hand antiseptic. Hands of healthcare workers are mainly colonized with bacteria and yeasts.1 That is why a hand antiseptic should have the optimum efficacy against these pathogens. Alcohol-based gels with 85 percent ethyl alcohol fulfill the efficacy requirements.4 Yet clinicians challenge manufacturers to formulate with emollient technology designed to deliver good skin care and offset concerns they have with the dermal aspects of alcohol use. Another factor is dosage. The efficacy of hand antiseptics is often studied with aliquots of 3 or 5 mL, but the amounts used in clinical practice are largely unknown and it is unlikely that they are as high as 5 mL. Recent unpublished
By Mary Beth Fry, BS, CIC

Improving Quality of Care Based on CMS Guidelines


evidence suggests that an aliquot as small as 2.4 mL might well be sufficient to cover both hands with the preparation and also fulfill U.S. efficacy requirements, especially if the preparation has a high ethyl alcohol content. From a practical point of view, and given the nature of the clinicians’ work environment – where time is short and patient load is demanding – products that can deliver required efficacy with minimal application volume are desirable. Dermal tolerance Handwashing contributes to irritant contact dermatitis on the hands of healthcare workers, which can result in dry and rough skin, redness and loss of integrity of the skin barrier. That is why it is crucial to wash hands only when absolutely necessary. In all other clinical situations, an alcohol-based hand antiseptic should be applied to decontaminate hands. The hand antiseptic should not be sticky and should ideally improve the skin condition, e.g., by reducing skin roughness or increasing skin hydration,4 which can increase the hand hygiene compliance rate.5 If a preparation is unpleasant or uncomfortable to use, it will likely be rejected by healthcare workers. This can result in a low compliance rate and, ultimately, cross transmission of nosocomial pathogens. As a result, while implementing a good hand hygiene program is intended to have a positive impact on infection rates, product selection decisions can lead to the opposite effect if the products are perceived by staff to be damaging to the skin and therefore go unused. Easy access In addition to being effective and gentle on the skin, hand antiseptics must be easily and conveniently available. Pocket bottles and wall dispensers are two simple ways to achieve this. A wall dispenser should be easy to use and

should be functional. In a recent study, only 77 percent of a certain type of wall dispenser were found to be functional after 16 months.6 A malfunctioning or difficult-to-use wall dispenser is likely to discourage healthcare workers to perform hand antisepsis. Pocket bottles provided to staff serve dual purposes. Their availability leads to increased compliance and reduces the amount of “contraband” product brought into facilities without the necessary compatibility testing typically required. Key conclusions Appropriate selection of a hand antiseptic – including taking into account its dispensing technology and packaging configuration – is key in achieving optimum efficacy and comfortable use of hand antiseptics. Meeting these goals will likely have an impact on patient safety.
About the author

Mary Beth Fry, BS, CIC, is currently the infection control coordinator at the University of Illinois Medical Center, Chicago, Ill. She has more than 32 years of experience as a clinical microbiologist and with all aspects of infection control.

References 1. Kampf G, Kramer A. Epidemiologic background of hand hygiene and evaluation of the most important agents for scrubs and rubs. Clinical Microbiology Reviews. 2004;17(4):863-893. 2. Boyce JM, Pittet D. Guideline for hand hygiene in healthcare settings. Recommendations of the healthcare infection control practices advisory committee and the HICPAC/SHEA/APIC/IDSA hand hygiene task force. Morbidity & Mortality Weekly Report. 2002;51:1-45. 3. Kampf G, Rudolf M, Labadie J-C, Barrett SP. Spectrum of antimicrobial activity and user acceptability of the hand disinfectant agent Sterillium Gel. Journal of Hospital Infection. 2002;52(2):141-147. 4. Kampf G, Muscatiello M, Häntschel D, Rudolf M. Dermal tolerance and effect on skin hydration of a new ethanol-based hand gel. Journal of Hospital Infection. 2002;52(4):297-301. 5. Kampf G. The six golden rules to improve compliance in hand hygiene. Journal of Hospital Infection. 2004;56 (Suppl. 2) :S3-S5. 6. Kohan C, Ligi C, Dumigan DG, Boyce JM. The importance of evaluating product dispensers when selecting alcohol-based handrubs. American Journal of Infection Control. 2002;30(6):373-375.



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© 2007 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.

Improving Quality of Care Based on CMS Guidelines



Seat Cushions: Padding Your Pressure Ulcer Prevention Strategy
Cynthia Fleck

Diane L. Holland
BS, PT, CWS, WCC, C. Ped.



XXX Pressure ulcers can occur when a client is lying down or in a seated position. Wheelchairs and other seated surfaces, which are sometimes an afterthought, could be the missing link in a comprehensive care plan that mandates individualized care.

CMS Tag F314 states, “Appropriate support surfaces or devices should be chosen by matching a device’s potential therapeutic benefit with the resident’s specific situation.”1


Frequently asked questions
Why are they called “bedsores” when pressure ulcers also occur in seated individuals? Approximately 68 percent of pressure ulcers occur on the pelvis and are the result of sitting upright.2 Clients who are

two inches of space behind the knees. It is important that the leg rest height is correct so the client’s knees are not positioned too high. Also, a client’s thighs should be adequately supported. This will distribute the pressure load and decrease pressure on the ischial and sacral areas. It is essential to look at issues such as hypertonicity (high muscle tone) and intervene to control and improve positioning. A client with limited range of motion (ROM), such as decreased hip rotation, will compensate with postural changes in the torso. In this case physical therapy or a referral to a positioning professional may be needed for assessment and wheelchair modification. Wheelchairs with sling seat upholstery should be discouraged when clients spend a substantial amount of time in a wheelchair. The sling causes internal rotation of the femurs (legs), adduction (rolling inward) of the lower extremity, a posterior pelvic tilt (sliding down) and a kyphotic trunk (slouched over) posture. Over a period of time this can lead to decreased range of motion, scoliosis and decreased function and weakness in the abdominal and spinal musculature.3,4 What are the different types of wheelchair cushions and which one is the best? There are many pressure redistributing devices on the market that vary in cost and quality. Most of the larger wheelchair

confined to a wheelchair for a significant amount of time during the day are at highest risk. Individuals with comorbidities such as diabetes, renal and respiratory failure, poor hydration and nutritional concerns are also in danger of developing a pressure ulcer. Even a client with good sitting posture can experience skin breakdown. Common locations where pressure ulcers develop when confined to a wheelchair are the sacral area (tail bone) and ischial tuberosities (sitting bones). Skin breakdown may also be related to an individual’s body structure and to the atrophy or loss of muscle from nonuse. Clients can sit in a wheelchair for more than 16 hours a day; therefore, a combination of interventions must be implemented and assessed when ordering a new wheelchair cushion. The primary goal of a wheelchair pressure redistribution device is to evenly spread pressure over a larger area. Pressure by itself does not cause a pressure ulcer; peak pressures that reduce circulation cause them. To help prevent skin breakdown, a wheelchair and wheelchair cushion must fit the client in width, support the thighs and leave


Improving Quality of Care Based on CMS Guidelines


cushion manufacturers offer a range of cushions that differ in pressure redistribution, support and functional needs. A proper assessment and follow up is necessary to determine changes in function that may require modification to the wheelchair and wheelchair cushion. The majority of wheelchair cushions on the market are made out of foam, layers of multi-density foam, gel, a combination of multi-density foam and gel, silicone and varying densities of silicone material and air. The air cushions are either powered or non-powered. There are also custom wheelchair cushions and backs as well. Published studies have compared several types of cushions by judging their ability to prevent skin redness or by measuring interface pressure, which is the pressure


Why do some wheelchair cushions need a piece of wood inserted beneath them? The upholstery in wheelchairs “slings” or “sags” when you sit on it. A cushion will also sag and cause poor positioning by producing internal rotation and adduction of the femurs, which causes torso instability. The wood or solid seat insert will


What should we teach our clients when they are restricted to a wheelchair? This can be a very important piece of the puzzle that healthcare professionals might be missing. Sometimes we offer a client a cushion or pressure redistributing device but offer little to no follow up. Individuals who use a wheelchair and/or a wheelchair cushion need to be taught to move out of the wheelchair and inspect the skin on

decrease the amount of sag in the wheelchair, improving the foundation and the client’s posture. Some wheelchairs have solid frames and do not fold; therefore, a solid wood insert is not needed.

their buttocks. Reinforcement of proper pressure relief techniques and weightshifting every 15 minutes is imperative.9 Cushions wear out, go flat and do not perform optimally forever. We would not dream of purchasing a new automobile and never changing the oil, having a tune-up or checking the tire pressure, right? Yet, often this is what happens after a cushion is purchased. This can mean problems for the user and potential pressure ulcers and other challenges.


I didn’t realize the number of cushions that are available and the various uses for them. Is there any way to make it less confusing? Wheelchair cushions can be confusing and wheelchair positioning and pressure relief is a specialty in its own right.

that occurs when a body comes in contact with a surface or cushion. The overwhelming result of this research indicates that no single cushion is best for all people.5 It depends on the client and their particular needs.

Choice is important because a cushion should last for an extended period of time. Other factors that must be considered when ordering a cushion include continence, transfers, amount of time per day spent in the wheelchair, muscle tone and mobility. Another issue to consider is client compliance and choice. Educating the client on the cushion and evaluating which products improve position, offer effective pressure reduction, optimize function and offer versatility for transfers and daily life are important steps. Your facility’s rehabilitation department or a wheelchair clinic in the community is a good place to start. Look for a Rehabilitation Engineering and Assistive Technology Society of North America (RESNA) certified clinician or technician. To become certified they must study and pass a rigorous exam in this specialty area. Once certified, they are trained in wheelchair assessment and proper wheelchair selection and often utilize special computerized mats to assess a client’s needs.8


What is “bottoming out” and why do

I need to check the cushion all of

the time? It is important to check the cushion every day to determine if it has bottomed out. That may seem excessive but if the client is not “floating” on the surface or suspended, their tissue and bony areas are not being protected. To test for bottoming out, simply don a glove and slide your hand between the client and the cushion. If it is difficult to do, you can place your hand inside a pillowcase to help it slide under the client more easily. There should be about an inch of material (air, gel, fluid, foam, etc.) between the client and the bottom of the surface. Have you ever stayed at a motel and slept on a bed with the springs poking you in the back all night? That is bottoming out.


I have seen egg crate and foam rings used, are they suitable? Foam or air “invalid” rings are not appropriate for pressure reduction.6,7

The ring increases pressure around the sacral region and decreases blood flow, which may cause problems. The ring can also cause deep tissue injury to a high-risk client because the unnatural shape does not conform to the anatomy of the buttocks. Additionally, egg crate cushions offer no pressure relief and can bottom out, causing the client to touch the bottom of the wheelchair and not float on the surface. These products should be avoided.



The client’s skin should be checked for persistent redness each time they are moved. This will measure whether the cushion is doing its job and whether weight shifts or moving the client back to bed should be done more frequently. suppliers who have Certified Rehabilitation Technology Suppliers, or the credential CRTS. These individuals have passed a rigorous credentialing exam and have at least two years of experience. They can be found by visiting the National Registry of Rehabilitation Technology Suppliers (NRRTS) Web site at Another legitimate credential is the Assistive Technology Supplier (ATS), certified by RESNA.12 Clinicians who are Assistive Technology Practitioner (ATP) certified provide analysis of a client’s needs with regard to all areas of seating, positioning and assistive technology. These individuals must possess a minimum of an associate’s degree and three years’ experience in his or her field, such as physical or occupational therapy.
Cynthia A. Fleck, MBA, BSN, RN, APN/CNS, ET/WOCN, CWS, DNC, DAPWCA, FCCWS is a certified wound specialist and dermatology advanced practice nurse, author, speaker, Secretary/Treasurer of the American Academy of Wound Management (AAWM), Member of the Board of Directors of the Association for the Advancement of Wound Care (AAWC), Diplomat of the American Professional Wound Care Association and Vice President, Clinical Marketing for Medline Industries, Inc., Advanced Skin and Wound Care Division. Cynthia can be reached at Diane L. Holland, BS, PT, CWS, WCC, C. Ped is a physical therapist and Certified Wound Care Specialist practicing at Bellevue Hospital in New York City. She was formerly employed at the Hospital for Joint Diseases, Diabetic Foot Center, also in New York City. Diane can be reached at


What are the surveyors looking for and what does CMS state? Key information regarding repositioning and assessment of a client’s skin integrity, especially in the immobile, is emphasized in the CMS Guidance to Surveyors.11 Appropriate support surfaces should be utilized wherever the client’s skin is in contact with a surface area for a prolonged period of time (beds, mattresses, chairs, wheelchairs, etc.). The document further describes the use of sheepskin-type products, pillows and wedges and warns that they should only be used for comfort or reduction of friction, not pressure redistribution. The use of donut-type cushions is not recommended, nor are wheelchairs with sling seats that may not be optimal for prolonged sitting during activities or meals. The following recommendations are quoted directly from the CMS Guidance for Surveyors for Pressure Ulcers.11 — An at-risk resident who sits too long on a static surface may be more prone to get ischial ulceration. — Slouching in a chair may predispose an at-risk resident to pressure ulcers of the spine, scapula, or elbow, (elbow ulceration is often related to arm rests or lap boards). — Friction and shear are also important factors in tissue ischemia, necrosis and pressure ulcer formation.

1 Department of Health and Human Services. Centers for Medicare and Medicaid Services. CMS Manual System Pub. 100-07 State Operations Provider Certification. November 12, 2004. 2 Bryant RA, eds. Acute and Chronic Wounds: Nursing Management. 2nd ed. St. Louis, Mo: Mosby Yearbook, Inc.; 2000. 3 Schmeler M, Byning M. The Lecture Series on Application and Use of Wheelchair Technology Seating Biomechanics Lecture. WheelchairNet. Department of Rehabilitation Science and Technology. Oct.1999. 4 Carison MJ, Payette MJ, Vervena LP. Seating orthosis design for prevention of decubitus ulcers. Journal of Orthotists and Prosthetists. 1995;7(2):51-60. 5 Sprigle S. The match game. Team Rehab Report. May 1992:20-21. 6 Panel for the Prediction and Prevention of Pressure Ulcers in Adults: Pressure Ulcers in Adults: Prediction and Prevention. Clinical Practice Guidelines, No. 3. AHCPR Publication No. 92-0047. Rockville, Md: Agency for Health Care Policy and Research, Public Health Service, U.S. Department of Health and Human Services. May 1992. Available at: Accessed August 21, 2007. 7 Ratliff C, Bryant D. Guideline for Prevention and Management of Pressure Ulcers. WOCN Clinical Practice Guideline Series, No. 2. Wound, Ostomy and Continence Nurses Society. Available at: Accessed August 21, 2007. 8 Fleck CA. Under pressure. Advance for Providers of Post Acute Care. November/December 2004:64-65. 9 Fleck CA. Pressure ulcers: risk, causes and prevention. ECPN. November 2005;105(9):32-40. 10 Fleck CA. The new cms pressure ulcer guidelines. ECPN. January/February 2005:36-42. 11 Department of Health and Human Services. Centers for Medicare and Medicaid Services. CMS Manual System Pub. 100-07 State Operations Provider Certification. November 12, 2004. 12 Rehabilitation Engineering and Assistive Technology Society of North America (RESNA). Available at: Accessed August 21, 2007.


Who can help? Again, clinicians and providers with expertise in seating and positioning should be a part of the team. Look for

Improving Quality of Care Based on CMS Guidelines


References 1 Resnick NM. Improving treatment of urinary incontinence (commentary letter). JAMA. 1998:280(23):2034-35. 2 Mayo Clinic. Types of urinary incontinence. Available at: Accessed August 14, 2007. 3 U.S. Food and Drug Administration. Coping with bladder problems. Available at: Accessed August 14, 2007. 4 Washington State Department of Social and Health Services. Caregivers’ handbook. Available at: Publications/22-277.pdf. Accessed August 15, 2007.

What is urinary incontinence?
Urinary incontinence refers to the inability to control the passage of urine. This can range from the occasional leakage of urine to a complete inability to hold any urine. In fact, urinary incontinence can be broken down into seven types: • Stress incontinence: Occurs when sudden pressure is applied to the bladder, causing urine to leak out. This can happen during exercising, coughing, sneezing, laughing or lifting, for example. • Urge incontinence: Describes the frequent, sudden urge to urinate with little control over the bladder (also known as overactive bladder, spastic bladder or reflex incontinence). • Overflow incontinence: Residents with overflow incontinence cannot completely empty their bladders. This leads to frequent urination or a constant dribbling of urine, or both. • Functional incontinence: This is the most common type of incontinence among elderly residents with arthritis, Parkinson’s disease or Alzheimer’s disease. The limitations these residents have with moving, thinking or communicating make them unable to effectively control their bladders. • Mixed incontinence: Residents experiencing mixed incontinence have two types of incontinence simultaneously, typically stress incontinence and urge incontinence. The causes of the two forms of incontinence are not necessarily related. • Temporary incontinence: Can be caused by severe constipation, infections in the urinary tract or vagina or by certain medications, such as diuretics, narcotics, antihistamines, antidepressants or calcium channel blockers.2

Incontinence can leave your residents feeling embarrassed or alone – but it shouldn’t! In fact, it’s estimated that 25 million Americans will experience transient or chronic incontinence.1 Why not take a moment to review the facts on incontinence? Perhaps doing so will mean that you’ll have just the right words to reassure your residents!

What causes incontinence?
There are a number of reasons that incontinence develops – and, contrary to what many people think, it’s not a normal part of the aging process. Common causes of incontinence include: • Weak bladder • Weakened muscles around the bladder (common in women who have given birth) • A blocked urinary passageway • Damage to the nerves responsible for controlling the bladder • Diseases that limit movement, such as arthritis3

Reassuring residents that they’re not alone.

Reassuring the incontinent resident
Despite how common incontinence is or what is causing it, residents who are experiencing incontinence might feel embarrassed or ashamed. Here are several tips for comforting them and maintaining their dignity. • Remember that toileting accidents are embarrassing. • Stay calm and reassure the resident that it is OK. • Maintain a matter-of-fact approach, using phrases such as “Let me help you get out of these wet things.” 4



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ear F Male Catheterization
out of
By Victor Senese, RN, CURN

Taking the


his is a true story that took place about 10 years ago. I was paged to see a patient in the hospital for a urethral catheter insertion. I introduced myself to him and he frantically told me, "You’re the third person trying to get this catheter in!" I learned a staff nurse and a resident had already tried and failed to insert a catheter into his distended bladder, and he was not looking forward to my poking around. Half kidding, I told him I am an expert and I can insert this catheter in “one shot.” He took me up on my bet and, sure enough, I was able to insert his catheter in one try.

So, how did I do it? At that time I had been practicing urology nursing for more than a decade and had inserted a lot of urinary catheters. Obviously, I learned a few tricks in the catheterization of males. I am also the nurse called upon when everyone else gives up trying to place the catheter. Here are some simple tips that all nurses can apply to their daily practice. The first thing I do is introduce myself to the patient and inform him I am an “expert” in catheterization. Now, I know everyone isn't an expert, but it helps if the patient thinks you are. I learned early on that nobody wants to be your first patient. Whether you're an expert or a novice, this introduction goes a long way in relaxing an apprehensive patient. Remember, the sphincter is under voluntary control. If a nervous patient tightens up, catheterizations can become a cruel tug-of-war, with the patient’s sphincter often winning. Now that the patient is convinced I know what I am doing, I explain the procedure to him. Most men like to be in control and want involvement in this procedure, so why not get them involved?

Improving Quality of Care Based on CMS Guidelines


When available, I instill 2 percent lidocaine jelly into the urethra. If this is not available or your institution doesn't allow this practice, instill a water-soluble lubricant into the urethra. A cathetertip syringe will work nicely for this. Use about 5 to 10 cc. The lubricant acts to dilate the urethra as well as lubricate the passage. Next, place the catheter into the urethral opening and instruct the patient to relax the muscles in his legs. The sphincter and leg muscles are both skeletal muscles and relaxing the legs will help relax the sphincter. Advance the catheter with a steady pressure. Stop if you meet resistance.

1 2

Catheterization Recommendations
Recommendation #1: If you feel resistance, rest your arm against the patient's leg and ask him to relax. When you feel the leg muscle relax against your arm, push the catheter forward and it will probably slide right in. Recommendation #2: Be sure to insert the catheter up to the balloon’s “Y” port. Don't assume that if you see urine the catheter is in. Examine a Foley catheter and you will notice the drainage islets are in front of the balloon. If you assume the catheter is in because you see urine, you might inflate the balloon in his prostate! Profuse bleeding usually follows this careless act. Recommendation #3:Assess your patient for balloon size. An elderly gentleman can easily pull a 5 cc balloon to his prostate. I usually prefer to use a 30 cc balloon catheter on all males and inflate the balloon to 15 to 30 cc, depending on the patient's level of orientation. Recommendation #4:Tape that tube! The last step is to secure the tube to the patient's leg with tape. This will prevent accidental trauma to the bladder, and is often the most overlooked step in catheterization. Recommendation #5:: A coudé catheter is often disregarded. It is designed with a slight curve at the end to facilitate the passage around an enlarged prostate. If you encounter resistance just before the bladder, the prostate is probably enlarged and a coudé catheter will get you by it easily.

3 4


Occasionally you will not be able to pass a catheter due to strictures or scars found within the urethra. This is when you need to call it quits and request your fellow urologist. If you follow my recommendations you will probably be able to insert urinary catheters into most patients. I still routinely see that patient from the hospital in our office. He has taken to calling me by the nickname "One Shot" and brags to anyone who will listen about that eventful day when I was able to get a catheter into his bladder in one try!

About the author

Victor Senese has been a nurse for 25 years, is a past president of the Society of Urologic Nurses and Associates and is currently employed as a urology nurse clinician in Oak Lawn, Ill.




Foley Catheter
The clinical rationale
According to the CDC, catheter-associated urinary tract infection (CAUTI) is the most common hospital-acquired infection. Each year, more than 1 million patients in U.S. extended- and acute-care facilities acquire such an infection; the risk with short-term catheterization is 5 percent per day. CAUTI is the second most common cause of nosocomial bloodstream infection, and studies suggest that patients with CAUTI have an increased institutional death rate, unrelated to the development of urosepsis. Catheters coated with silver alloy/hydrogel have recently been introduced into practice, and a growing body of literature supports their use in a variety of clinical settings.1

Let us help you fight to eliminate catheter-associated urinary tract infections.

UTIs account for 40 percent of hospital-acquired infections2 80 percent of nosocomial UTIs are catheter-associated (CAUTI)3, 4

Healthcare facilities have adopted prevention strategies to minimize the risk of CAUTI. In addition to emphasizing good practice supported by CDC guidelines, coated catheters are routinely being utilized to improve patient outcomes.
® Silvertouch catheters contain silver; every Silvertouch catheter is coated inside and out with ionic silver. Silver is well recognized as a broad-spectrum antimicrobial effective against gram-positive and gram-negative bacteria, including resistant strains such as MRSA and VRE. ® Silvertouch catheters are more comfortable due to a hydrophilic coating that hydrates quickly and maintains its lubricity for at least a week. ® Silvertouch catheters are latex-free and are 100 percent silicone, so both caregivers and patients are kept safe.
References 1. Rupp M et al. Effect of silver-coated urinary catheters. AJIC. 2004;32(8):445-50. 2. Haley RW, Culver DH, White JW, Morgan WM, Emori TG. The nation-wide nosocomial infection rate. A new need for vital statistics. Am J Epidemiol. 1985;121:159-67. 3. Paradisi F, Corti G, Mangani V. Urosepsis in the critical care unit. Crit Care Clin. 1998;14:165-80. 4. Vincent JL, Bihari D, Suter PM, et al. The prevalence of nosocomial infection in intensive care units in Europe—The results of the EPIC study. JAMA. 1995;274:639-44.

To learn more, contact your Medline representative, call 1-800-MEDLINE or visit
©2007 Medline Industries, Inc. Mundelein, IL 60060 Medline is a registered trademark of Medline Industries, Inc. Silvertouch is a trademark of Medline Industries, Inc.

You’ve made it this far … Let Medline University keep you going Enroll in continuing education courses you can attend at any time, from anywhere you have Web access! Medline University offers more than 50 self-study nursing CE-credit courses. Popular choices include: • Pressure Ulcer Assessment and Documentation • Cleansing and Debriding Wounds • Skin Anatomy • Topical Dressing Selection • Isolation Guidelines for MDROs • Innovations in Hand Hygiene • Developing a Successful Continence Program • Standard Precautions Policy and Procedure An affordable online continuing education resource Visit to learn more.

Special Features

If the shoe fits …

Diabetic feet need special attention

Have you ever worn a pair of shoes only to find your feet hurting because the shoes have caused a blister or other injury? What do you do when this happens? Most of the time you probably do not consider this a problem; you just put on another pair of shoes or a bandage strip. However, if you have decreased sensation to your lower extremities, including your feet, this could be an emergency. Decreased sensation is called neuropathy and is the leading cause of foot wounds in people with diabetes mellitus (DM). By Joyce Norman, BSN, RN, CWOCN

Improving Quality of Care Based on CMS Guidelines


What causes neuropathy? The most common causes for loss of sensation are neuropathies related to diabetes mellitus, but it can also be related to alcoholic neuropathy, herpes, cancer and spinal cord lesions. Neuropathy is a change in sensation as a result of nerve damage that can cause an individual to have no feeling or an increase in pain. The client may describe symptoms such as burning, tingling and unusual pain. Traditional pain medications are often not effective, making other medications, treatments and modalities necessary. Danger ahead Managing a patient with diminished or no sensation can be dangerous and difficult. The patient may be unaware of items in or on their footwear and may continue to wear shoes that cause injuries, have foreign objects in them or that simply do not fit correctly. Because of the lack of sensation caused by neuropathy, the patient does not feel the source of the problem, continues to wear improper footwear until there are apparent signs of injury such as odor, drainage adhering to footwear, or a problem controlling their blood sugar levels. Injury can be avoided The problem with diabetes mellitus is that these complications do not have to occur. Literature indicates that as many as 80 percent of ulcers could be preventable. In fact, they are usually related to poor management of the disease over time. The disease has an impact on many systems. Because of the damage to the small vessels, the eyes, kidneys, heart and peripheral system can be affected. As the complications worsen and an individual loses the ability to feel their feet, diligent monitoring is essential. Someone with DM should have their feet examined at least once a year by a professional healthcare provider. The clinician needs to be trained in

how to determine changes in sensation with the use of a monofilament and other tools. When these subtle changes start to occur, it is appropriate to obtain proper footwear. The footwear should fit well and help to maintain proper alignment of the foot. Beyond neuropathy Another problem that occurs with poorly controlled DM is neuromuscular changes that affect the structure and form of the feet. The toes can start to hammer and have other deformities, and the foot itself can change in appearance and form, which affects the ability of the patient to wear regular shoes. Working with a doctor of podiatric medicine (DPM), orthotist or pedorthotist is important because they can help to accommodate footwear and align the foot so that the changes in structure do not cause ulcers and damage. When orthotics and other accommodations of the footwear are not enough, special shoes may be necessary. Depending on the degree of damage to the foot, the patient may be able to purchase them or they may need to be custom-made. Other features that can help protect the feet are well-fitting footwear with a deep toe box in the shoe to decrease rubbing and reduce undue injury to the foot. The footwear can be a sandal-type or full shoe, with devices built in or attached to help keep pressure off of the affected area. When a client has accommodative foot wear it is not the end of the condition. Footwear needs to be reexamined on a regular basis depending on the wear and amount of damage to the foot. An individual with diabetes should see their healthcare professional at least annually. CMS has recognized the importance of proper footwear and provides coverage under Medicare for one to two shoes per foot per year, insoles or orthotics for better foot alignment up

to three times per year, and podiatric care every 61 days. These benefits help prevent further damage. Inspection & protection The importance of inspecting and protecting diabetic feet cannot be overemphasized. It is important to be aware of the feet, the changes in the feet and what can be done to protect the feet. Simple daily inspection and protection can make a huge difference.



Survey Readiness

Could this help your facility?
By Pat Rodecker, RN, WCC


Nathan Littauer Hospital and Nursing Home, located in Gloversville, N.Y., recently joined with Community Health Center to promote consistent wound care. We began by assembling a team of experts who agreed to work together to make clinical wound care improvements. At the team’s first meeting, a list of products used in each setting was created to cross-reference and ensure consistency when patients transitioned from one setting to another. The primary focus then turned to education. The team insisted that improved wound care education would be necessary to provide appropriate, effective care. To this end, a wound care competency day was planned. The wound care competency day was split into two sections. In the morning, a skincare representative was on hand to educate the clinical nurse specialists (CNSs) on the proper use of skincleansing products. In the afternoon, a lecture on liability and wound care was held. Now that we have given you an idea of how the day was structured, we would like to share what we feel made our wound care competency day a success. Perhaps your own facility would benefit from a similar experience! Skincare Station First was a review of Medline’s Soothe & Cool® No Rinse Hair/Body Wash. We determined that certified nursing assistants (CNAs) wanted residents’ bath water to have suds. Education was provided to the staff indicating that it was not necessary to have suds. A plan was then put in place to provide consistent reminders to reinforce and assist with this practice change. Medline’s Soothe & Cool moisturizing cream had recently been added to our

treatment regimen. We considered this an appropriate setting to reinforce the importance of using it daily to keep the residents’ skin moist. Calazime® Protectant Paste is used on some of our residents and staff had commented that it was thick and hard to remove. To overcome this obstacle, the application of Calazime was demonstrated, stressing that a thin layer was all that was needed. Another exercise included a demonstration with hydrocolloid dressings. Some were shown leaking and another was shown rolled off the ulcer. CNAs were asked which dressings they would report to the nurse for changing. Samples of the various wound care products that we use in our facilities were included at this station with demonstrations on how to apply and remove them. Finally, we reviewed flow sheets that are used for documentation. We ended by answering any specific questions from the staff relating to either a product or specific resident problem. Heel Protection Station The next station was heel protection. Heel pain is a common complaint; therefore we felt is an important subject to address. Padded booties were shown to provide protection from shear; however, they are not appropriate for pressure relief. Heel relieving booties were shown to the staff and application was demonstrated to ensure proper placement of the heel. Staff was reminded to inspect their resident’s feet daily and report concerns to the nurse. Dietary Station The dietary station featured resident food trays. Each person was asked to look at the tray that was presented and then compare it with the next three trays. They were then asked to assess what percentage of the meal was taken. Included in this display was a tray that

Staff completed the following wound care competency questions:

1 2 3 4 5

Name four areas of the body that are at high risk for skin breakdown. Name two reasons that patients would be at high risk for skin breakdown. Name four ways to relieve/prevent pressure ulcers. When would you report to a nurse that your patient needs a dressing change? You are assisting a resident with lunch who typically eats only 25 percent to 50 percent of their meal. Of the following foods, which three should you encourage them to consume first to provide them with the most calories and protein: a. Coffee w/sugar b. Fortified pudding c. Tuna sandwich d. Canned peaches e. Green beans f. 8 oz. whole milk

had spilled milk and food pushed around on the plate but not eaten. Our goal was to see if the staff realized this should not be included in the percentage taken. Dietary personnel included a thorough explanation of the dietary program “every bite counts” (EBC). Certain foods are fortified and the staff was instructed to encourage residents to take these foods first (high calorie and high protein). Play Detective Station The last nursing station was fun. We placed a mannequin in a patient bed

Improving Quality of Care Based on CMS Guidelines


to point out multiple potentials for skin breakdown. Our mannequin was lying on Foley tubing, wearing wet briefs, had on heel booties that were not properly placed, wound drainage on the skin, lying on a bedpan with crumbs in the bed. If that was not enough, the O2 tubing was not padded and the head of bed was elevated to 90 degrees. The turn and position flow sheet at the bedside was not signed. The staff really enjoyed seeing how many things they could find wrong and comparing results with one another as to how well they did. Participants who recognized all of the potentials for skin breakdown were given a small prize. Physical therapy provided a visual display of proper positioning in a wheelchair. This included back and feet positioning. They also stressed the need to reposition at-risk wheelchair residents every hour. The votes are in: “Hands On” Is a great way to learn and review! The day was well attended by nursing home staff. The 11 p.m. to 7 a.m. nursing home staff attended after their shift was over. The 7 a.m. to 3 p.m. staff covered the floor for each other and the 3 p.m. to 11 p.m. shifts attended when they arrived on duty. The hospital staff who attended felt they learned a lot, although we did make a plan to improve their attendance at our next educational workshop. The workshop required about one-half hour for each person to go through all the stations. Setting up did not take too long, either. Resources included a nurse at the three stations, a dietary staff person and someone from physical therapy to be available. The evaluations indicated that staff did increase their ability to identify potential pressure areas on the body and understand how to use the products we have available in our facility. Responses ranged from “good” to “excellent” and the staff said it was worth attending and would like more workshops like this.

Evaluation form

1 2 3 4 5 6

Identify pressure areas of the body. Recognize potential causes of skin breakdown. State how proper nutrition is important to the wound healing process. Identify conditions and report the need for a dressing change to a nurse (CNA). Identify wound ad/or dressing conditions that indicate the need for a dressing change (LPN/RN). Discuss documentation requirements for wound assessment and care (LPN/RN).

About the author

Pat Rodecker, RN, WCC is the clinical coordinator at Nathan Littauer Hospital and Nursing Home.



Janet Jones

Got a question? Call 1-888-701-SKIN (7456)


“I have a partial thickness wound related to incontinence but I can’t get a hydrocolloid to stick in the area. Can you help?”


It is very difficult to get a physical dressing to stick when incontinence

is an issue. Repeated use of a physical dressing is usually ineffective and often leads to additional skin damage such as shearing. The dressing

becomes wet and slides against the skin. Or breakdown from the skin injury occurs because of prolonged contact with the now contaminated dressing. However, it is certainly necessary to cover the injured skin,

protecting it from further assault by urine and stool.

Choose a barrier designed for wet skin (Second Generation Barrier Paste)
A barrier paste designed for wet skin, sometimes called second generation barrier, is an excellent option. Not all barriers are designed for this purpose – look for ingredients such as zinc, karaya, calamine or menthol and indications that read “for wet or weepy skin.” This type of barrier is a very durable paste and will not wash off even with repeated episodes of incontinence, thus creating a “physical dressing.” If turning and repositioning are appropriately done, healing usually occurs without any difficulty.

“... spread the paste as a protective layer.”

Call the Educare Hotline! Medline’s toll-free hotline is supervised by a board-certified enterostomal therapy/ wound, ostomy and continence nurse. Just pick up the phone and call 1-888-701-SKIN (7456).

Helpful hints
Some important tips when using a second generation barrier: > 1. When applying the product it is important not to rub the product in; spread the paste as a protective layer. > 2. It is important when cleansing the area to merely clean off the urine or stool. If any barrier cream residue remains on the skin, merely apply another thin layer of barrier cream on top. > 3. Remember scrubbing can lead to further skin injury. > 4. Cleanse and reapply once or twice a day. > 5. Education is necessary so that the product is utilized correctly.

We’re here to help!

About the Author
Janet Jones, BSN, RN, PHN, CWOCN, DAPWCA is a boardcertified wound, ostomy and continence nurse. She has extensive experience in long-term and home care and has developed wound prevention and treatment programs for many national healthcare groups. She’s also ready to take your call on Medline’s Educare Hotline!

A second generation barrier cream is an excellent option when dealing with superficial injury to the skin and continence issues are a problem.

See you on the Hotline!

A I R - P E R M E A B L E



1 The power of ONE

1 ONEpad

for healthier skin:

1 ONEpad
therapy beds.

for easier care:

The innovative backsheet on allows air to flow through the pad while still acting as a barrier to moisture.* The result is superior skin dryness and comfort.

can be used on both standard beds and air-support

Advanced Technology

1 ONEpad

for lower cost:

are so strong and absorbent that they eliminate the need for multiple pads. They can also reduce the need for draw sheets, linens or reusable underpads. This results in a dramatically lower cost.
*MVTR of 3600 +- 1000 g/m2/24h

Soft, Non-Woven Topsheet – softer against skin for increased comfort Advanced SuperCore® Absorbent Sheet – thermo-bonded to provide better pad integrity and superior skin dryness

AquaShield Film – traps moisture, providing better leakage protection Innovative Backsheet – air permeability means better skin comfort

©2007 Medline Industries, Inc. Medline and Ultrasorbs are registered trademarks of Medline Industries, Inc. SuperCore is a registered trademark of McAirlaid’s Vliesstoffe GmbH & Co.


Perineal Skin Care for the Incontinent Resident
Decision tree for skin care based on the information from Minimum Data Set (MDS) 2.0 continence status. Three >> 1. >> 2. >> 3. simple steps for selecting the best skincare product: Decide where the resident fits into the “continence” definition of MDS 2.0 Section H.1 Assess the resident’s current skin condition Locate the closest description on the grid

Includes use of indwelling urinary catheter or ostomy device that does not leak stool



Bladder – incontinent episodes once a week or less; Bowel – less than weekly

Usually Continent


Bladder – two or more times a week, but not daily; Bowel – once a week

Occasionally Incontinent


Bladder – two or more times a week, but not daily; Bowel – once a week

Frequently Incontinent


Has inadequate control. Bladder – multiple daily episodes; Bowel – almost all the time



Skin Condition: Intact, Reddened or Chapped Skin
Moisturize/ Cleanse Protect

Cleansing wipes or Remedy™ 4-in-1 Cleansers
Remedy Dimethicone Moisture Barrier or Remedy Skin Repair Cream

Remedy Nutrashield

Skin Condition: Dry, Ready-to-Tear Skin
Moisturize/ Cleanse Protect

Remedy 4-in-1 Cleansers
Remedy Dimethicone Moisture Barrier or Remedy Skin Repair Cream

Remedy Nutrashield

Skin Condition: Macerated or Denuded Skin
Fungal Moisturize/ Cleanse Infection Protect

Remedy 4-in-1 Cleansers

Remedy Calazime Protectant Paste

Remedy Antifungal Cream or Powder

Improving Quality of Care Based on CMS Guidelines


Case Study

Using Olivamine* in a Skin Cream to Improve Skin Quality in Diabetic Patients
By Dawn R. Fortna, RN, CDF, CWOCN Ephrata Community Hospital, Ephrata, Pa. PROBLEM Our diabetic population presents with skin issues often resulting in skin injury and increased costs. Autonomic neuropathy causes a decrease in the sweat and oil production, resulting in xerosis. Our goal was to decrease these issues and costs of secondary injuries and improve quality of life for our patients. METHODOLOGY Fifty patients were selected to participate in a skincare product trial. Criteria for inclusion was a diagnosis of diabetes, high risk for skin breakdown and characteristics of xerosis, defined as abnormally dry skin with fine lines, scaling and fissures. Untreated xerosis may lead to itching and scratching, pain and cellulitis. Excluded were confused or non-verbal patients. Skin cream containing Olivamine was applied daily to the patients’ legs and feet, after cleansing, for a period of four weeks. Skin was evaluated weekly for integrity. Pain was documented using a 0-10 pain scale. Patients were queried regarding itchiness. OUTCOMES Olivamine delivers amino acids, antioxidants (hydroxytyrosol), vitamins and methylsulfamethane to the skin. Transepidermal water loss (TEWL) is preserved with dimethicone base, preventing damage from dehydration and decreasing pruritis. CONCLUSIONS A program of cleansing, moisturizing, and protecting the skin with the Olivaminecontaining product improved skin outcomes including skin integrity, prevention of breakdown of fragile skin and decreased pain and itching for patients.

CM is 91-year-old female has had type 2 diabetes for more than 20 years. She presents with xerosis, fine lines, scaling and pain in her legs, which is increased at night (Figure 1a). She describes the pain as “deep pain” and scores it as a number “8” on the scale of 0-10 . Since daily application of the Olivamine-containing product, she has had no xerosis, fine lines and scaling have decreased and her skin appears much healthier. She states that the pain resolves completely for several hours after application of the product (Figure 1b).

Figure 1a

Figure 1b

PM is 63-year-old female has had type 2 diabetes for approximately five years. She also has troublesome venous stasis disease and has an ongoing battle with severe xerosis, scaling and cracking of skin (Figure 2a). She has little sensation in her legs, so pain has not been a major problem. However, since she is using the Olivamine product daily, she states that she has “less of a pulling sensation” on her legs. Daily cleansing, moisturizing and protecting the skin with the Olivamine-containing product has greatly improved the general condition of her skin (Figure 2b).

Figure 2a

Figure 2b

RM is 46-year-old male has had type 2 diabetes for more than 10 years. He has had multiple toe amputations and additional foot surgeries due to osteomyelitis. He presents with a recent surgical incision from amputation of a metatarsal head and is presently under treatment with a podiatrist and WOCN. He has experienced xerosis, scaling and cracking of skin and itching (Figures 3a and 3b). He has noticed marked improvement of his symptoms with daily application of the Olivamine product (Figure 3c).



Figure 3a Figure 3b References 1. Bale S, Harding K, Leaper DJ. An introduction to wounds. London: Emap Healthcare, 2000. 2. Fore J. A review of skin and the effects of aging on skin structure and function. Ostomy Wound Manage. 2006;52(9):24-35. 3. Diabetes mellitus and wound healing. Available at: Accessed June 21, 2005. 4. Holland D, Fleck C. Skin assessment in patients with diabetes. ECPN. 100(4);30-36. 5. Preventing foot complications in patients with diabetes. Available at: Accessed August 22, 2007. 6. Remedy. Available at: remedy. Accessed August 22, 2007. 7. Scarborough-Roessler P. Keeping the foot attached to the leg. Presentation. January 2003. Educators 2000 Plus. 8. Van Gills C, Stark L. Diabetes mellitus and the elderly: special considerations for foot ulcer prevention and care. Ostomy Wound Manage. 2006;52(9):50-56.

Figure 3c


Patients meeting Criteria 47 50 40 26 4

Improved after 4 weeks 47 (100%) 50 (100%) 40 (100%) 22 (84.6%) 4 (100%)

Conclusion All participants in the study exhibited improvement of the initial xerosis, fine lines and scaling of skin while 84.6 percent of those who identified initial itching experienced decreased itching following daily application of the Olivamine product.e participants stated that they noticed immediate results and stated how good the skin felt with application of the product. Upon assessment, the skin integrity appeared to be much improved and no patient in the study had further skin breakdown or infection. Patients experiencing neuropathic pain, of which there were only 4 in the study, all experienced pain reduction of at least 3-4 points on the 0-10 pain scale after application of the Olivamine product. e small number of participants with pain as a major concern is likely due to the number of patients with diabetes and their sensory neuropathy. Many of those with sensory neuropathy have either masked pain or are insensate. ere are obvious limitations to the effect of any product regarding pain in this study. ese results demonstrate that a program of cleansing, moisturizing and protecting the skin with the Olivamine-containing product improved skin outcomes including skin integrity, prevention of breakdown of fragile skin and decreased pain and itching for patients. e quality of life issues are evident by the number of participants who inquired about purchasing the product as a result of their satisfaction with the product’s results.

*Remedy Skin Repair Cream with Olivamine from Medline Industries, Inc. Mundelein, Ill. Remedy is a registered trademark of Medline Industries.

Improving Quality of Care Based on CMS Guidelines


Improving pain management at your facility

In both the QIO’s Nursing Home Quality Initiative and Advancing Excellence in America’s Nursing Homes, clinical performance measures and clinical goals include improvement in pain management. Below are 15 pain management improvement strategies for your team to consider!

1. Design a facility admission tool that includes a question on whether the resident has
any pain.

2. Institute pain screening tools appropriate for cognitively impaired residents and create a
easy-to-carry pocket card.

3. Designate responsibility and accountability to specific staff positions for screening of pain at
admission and periodically thereafter as part of routine interaction with residents.

4. Promote pain as the “fifth vital sign” among all staff – screen for pain just as you would
for breathing.

5. Educate all nursing staff, including CNAs, about pain symptoms in the elderly. 6. Involve the patient and family and stress the importance of their working with staff to assure
appropriate pain management.

7. Test staff members’ competencies in performing pain evaluation. 8. Use standardized evaluation tools, including pain-rating scales, to evaluate residents’
complaints of pain.

9. Develop a procedure for incorporating information obtained during pain evaluation into the
resident care plan.

10. Prescribe pain medications on a regular (versus PRN) basis for individuals with daily pain. 11. Educate all staff, including nurses and physicians, on good pain management and provide
guidelines at each nurses’ desk.

12. Incorporate non-pharmacologic approaches to pain management. (e.g., relaxation, hot or
cold packs, acupuncture, etc.).

13. Conduct regular in-services about pain management, focusing on myths of pain, the elderly
and pain medications.

14. Implement a procedure for contacting and communicating with clinicians (MD, MP or PA)
about residents who continue to have pain after starting treatment.

15. Create a schedule for monitoring pain and response to pain management
(e.g., after each dose of pain medication).
Reference: Nursing Home Improvement Collaborative: Pain Management Handbook. Available at: Accessed August 16, 2007.


© 2007 Medline Industries, Inc. Remedy is a trademark of Medline Industries, Inc. Medline is a registered trademark of Medline Industries, inc.


The Barrier Product for the 21st Century
The inside of an adult incontinent brief is a hostile environment for the skin. Assaulted by urine, fecal enzymes and bacteria, the skin of the incontinent resident needs all the help it can get. Traditionally, this has come in the form of petrolatum barriers, with or without zinc oxide or other ingredients. The paste or film spread over the skin would form a barrier between the skin and the moisture and chemicals trying to break it down. Disadvantages of petrolatum barriers • Greasy/messy • Occlusive to the skin, perhaps preventing normal function of the skin • Pastes that are opaque prevent viewing of the skin • Pastes that are thick can be difficult to clean off • Petrolatum barriers can affect the effectiveness of absorbent incontinence products by clogging the facing Silicone, the petrolatum alternative Silicones have become prevalent in the past 15 years as moisture barriers for incontinence. These inert polymers are strong compounds that are not broken down by water or chemicals. The most familiar is dimethicone, which is combined with an alcohol that evaporates, leaving behind a thin, dry film that protects against moisture, maceration, urine and enzymes. This type of material is still breathable, allowing the skin to act normally. Another advantage to silicone is that it feels smooth, less greasy and lasts longer than traditional petrolatum products, even when washed. Three features of silicone barriers offer distinct advantages over petrolatum barriers, particularly white pastes that include zinc oxide. 1. Very little dimethicone barrier is necessary to spread a thin film over the skin, so a tube will last a long time. 2. Because it is a cream rather than a paste, it glides smoothly over the skin, reducing the pain of spreading a thicker compound that will later have to be scrubbed to be removed. With improved focus on pain reduction in facilities, silicones will become more common. 3. Because most dimethicone barriers are clear once dry, the skin below the barrier can be viewed and monitored without having to be wiped off.



Comfort-Aire™ Disposable Briefs from Medline

Because Their Dignity Matters


e don’t have to tell you how important it is that the disposable brief you chose provides a feeling of confidence and dignity. Nothing matters more. At the same time you’d hope for a solution that works on more than one level. Just one touch and you know Comfort-Aire™ disposable briefs are unique. Extrasoft side panels allow better airflow for enhanced comfort and improved skin care. The comfy outer cover helps prevent irritation. But that’s not all. Comfort-Aire’s enhanced, superabsorbent core keeps skin dry. And dry, healthy skin provides both dignity and comfort. Isn’t that what you want most from a disposable brief ?

Extra-wide, Skin Safe Refastenable Tape Tabs Breathable Side Panels

Enhanced, Super Absorbent Core

Soft Cloth-like Outer Cover

For more information on Comfort-Aire, contact your Medline representative or call 1-800-MEDLINE
©2007 Medline Industries, Inc. Medline is a registered trademark & Comfort-Aire is a trademark of Medline Industries, Inc.

Love Them Times


Products designed for you and your residents

As a professional in the long-term care field, you perform a delicate balancing act every day you’re on the job – taking care of your residents while caring for yourself. Your ultimate goal, of course, is to deliver the best possible care to your residents–but when great products help make that easier, everybody wins! In this edition of Healthy Skin, we’re excited to introduce you to two products whose implementation can benefit all involved!


Survey Readiness
Exuderm® OdorShield™
Resident dignity is a hot topic – and it’s a legal right of all nursing home residents. The Nursing Home Reform Act, part of the Omnibus Budget Reconciliation Act of 1987, established The Residents’ Bill of Rights, among which are “the right to accommodation of medical, physical, psychological and social needs” and “the right to be treated with dignity.”1 Wound malodor, in addition to being commonly associated with chronic and infected wounds, can affect residents socially and psychologically. In extreme incidences, it can even lead individuals to withdraw from social contact, even with family and friends. Yes, a number of odor-absorbing hydrocolloid dressings are available on the market, but Exuderm OdorShield is unique. Unlike any other hydrocolloid, this patented, advanced product is designed to absorb odors from matter that is exuded from wounds. In fact, the odor-absorbing component of Exuderm OdorShield – cyclodextrins – are even used in consumer products such as Febreze® to control odors. This represents a major improvement over traditional charcoal-based, odor-absorbing dressings, which have a limited capacity for odor control. In addition to its odor-absorbing benefits, Exuderm OdorShield has other features of equal benefit to residents and long-term care professionals. Because it is translucent, it allows easy visualization of the wound without removing the dressing. And its smooth satin backing, tapered edge and low-residue formula ensure that it is long-wearing. Ultrasorbs AP are also versatile. Because they are completely But you don’t have to take our word for it – Exuderm OdorShield was recently awarded the 2007 Medical Design Excellence Award (MDEA) in the category “General Hospital Devices and Therapeutic Products.” These awards recognize the achievements of medical device companies responsible for creating innovative products that improve healthcare delivery, increase effectiveness of existing medical practices and ultimately provide enhanced benefits to the patient. Exuderm OdorShield was developed and is manufactured by Avery Dennison Medical™. It is exclusively marketed in the United States by Medline Industries, Inc.
References 1 AARP. The 1987 Nursing Home Reform Act fact sheet. Available at: Accessed August 16, 2007. 2 Van Toller S. Psychological consequences arising from the malodours produced by skin ulcers. Proceedings of 2nd European Conference on Advances in Wound Management.1993;70-71. 3 Resnick NM. Improving treatment of urinary incontinence (commentary letter). JAMA. 1998:280(23):2034-35. 4 Wound, Ostomy, and Continence Nurses Society (WOCN). Guideline for Prevention and Management of Pressure Ulcers. Glenview, Ill.: Wound, Ostomy, and Continence Nurses Society (WOCN); 2003.

Ultrasorbs® AP
It’s no secret that incontinence can be embarrassing to residents. And with an estimated 25 million Americans experiencing transient or chronic incontinence, it’s incredibly common.3 Some incontinence management products do little to ease embarrassment. Underpads can tear easily, leak or allow wetness to remain in contact with resident skin, potentially leading to irritation or complications to wounds in the sacral area. Ultrasorbs AP from Medline are different. The innovative backsheet on these underpads allows air to flow through the pad while still acting as a barrier to moisture. The result? Superior skin dryness and comfort. In addition, the thermo-bonded SuperCore® wicks moisture away from the skin and locks fluid away, increasing dignity and improving odor control and skin care. According to the Wound, Ostomy, and Continence Nurses Society (WOCN), these results are desirable – and recommended. In their 2003 Guideline for Prevention and Management of Pressure Ulcers, the WOCN recommended selecting “underpads, diapers, or briefs that are absorbent to wick effluent away from the skin.”4 This is great news for the resident, and there are benefits for staff as well. Because Ultrasorbs AP are super strong, they’re resistant to tearing. They’re also extra absorbent–in fact, one Ultrasorbs AP has the absorbing power of three or more standard underpads.

breathable, they can be used on both standard beds and airsupport therapy beds. They’re also suitable for absorbing ongoing fluid loss or anywhere else skin dryness is desired. To learn more about either of these products, contact your Medline representative, visit or call 1-800-MEDLINE.

Improving Quality of Care Based on CMS Guidelines


• Introducing Medline's New Green Tree line of toilet paper and hand towels made of 100 percent recycled material ... because we care. • Medline is doing their share to help the environment. Can we count on you to help? • Ask your Medline rep for more details about this program.
Green Tree is a trademark of Medline Industries, Inc

Call 1-800-MEDLINE

Cool tips
Aluminum • By recycling one aluminum can per day, we can save enough energy to operate a television set for three hours. Automobiles • Three major items from our automobiles cause problems in landfills: oil, tires and car batteries. Recycle motor oil with local oil and lube shops so that it can be used in commercial operations as fuel. If your local recycling facility accepts tires, the rubber can be used for playgrounds, flooring, asphalt or burned as fuel. Car batteries contain lead and sulfuric acid – but all elements can be reused in new batteries. • Share a ride with coworker or friend and you’ll cut your emissions in half. Electronics • Put your computer in sleep mode when you are not using it. • Do not add electronic waste to landfills. A computer monitor, for example, might be 6 percent lead by weight. Glass • Recycle glass – the energy saved from one glass bottle will light a 100-watt light bulb for four hours. Energy • Keep the temperature of your water heater at home down to 120 degrees Fahrenheit. It will be hot enough for everyday use but will keep energy usage lower. • Invest in a programmable thermostat to make adjustments for you when you are not home or when you are sleeping at night. • Unplug an underutilized freezer or refrigerator. Paper • Think before you print a document – do you really need a paper copy? If so, is there an economy print mode on your printer that will use less ink? • Paperless billing – having statements sent to your email address and paying your bills online eliminates paper, stamps, envelopes, etc. Trees • Plant a tree. If every American family planted one tree, more than a billion pounds of greenhouse gases would be removed from the atmosphere every year.

Cool tips

Improving Quality of Care Based on CMS Guidelines

by Jeannine Thompson
BSN, RN, CWOCN Clinical Education Specialist



Special Features
Among Alice’s challenges: 1. A locked door and an unobtainable key. 2. Tweedle Dee and Tweedle Dum who were more concerned about themselves
than with listening to what Alice had to say.

3. Magical mushroom pieces without instructions. 4. The Mad Hatter and the March Hare’s tea party, where they celebrated
un-birthdays instead of birthdays, wasting Alice’s time.

5. A forest full of confusing signs. 6. Gardeners who had Alice help paint white roses red to cover-up
their mistakes.

Do you remember the story of Alice in Wonderland?
Alice wanted to find the white rabbit. So, without thinking, she jumped into a deep hole. Alice encountered many challenges and detours during her quest to find the white rabbit.

7. The queen who blamed Alice for everything bad that had happened to her. 8. A court hearing where the witnesses were of no help to Alice.
Ultimately, Alice never did catch the white rabbit.

Anurse in WOUNDerland: The clinician’s Alice in Wonderland
Like Alice, Anurse can jump into wound care without thinking. And, also like Alice, Anurse may encounter many challenges and detours during her quest to provide an optimal moist wound healing environment to promote the closure of a pressure ulcer.

1. An unobtainable “key” dressing needed for healing. 2. Associates who care more about their own agendas than listening to what
Anurse has to say.

3. Wound care products that lack instructions for use. 4. Healthcare professionals who practice unconventional wound care instead
of care based on clinical research, which can cause Anurse to waste her time.

5. Literature that can be confusing. 6. Associates who want to cover up sub-optimal care. 7. State and federal surveyors who may not see the whole picture. 8. Associates who are of no help in court.
Ultimately, the pressure ulcer does not heal. During Alice’s adventure, she meets a very wise Cheshire cat. Being lost, she asks the cat which way she should go. “That depends upon where you want to go,” responds the cat. Alice says, “It really doesn’t matter.” To which the cat replies, “Then it really doesn’t matter which way you go.”

In pressure ulcer care, the “where do you want to go?’’ question represents wound closure and how Anurse reaches that goal does

Improving Quality of Care Based on CMS Guidelines


matter – physically, financially and emotionally.
Alice didn’t have a global positioning system to help her get from her home to the rabbit, but Anurse does. All Anurse has to do is use the reliable and validated pressure ulcer healing tools that have been provided to her.

Anurse can no longer waste her time with the Mad Hatter and March Hare and not reach the goal in a reasonable amount of time. Becoming aware that the pressure ulcer has not progressed at the time of discharge, end of the certification period, when the state surveyors review the charts or when the lawyers appear at the facility is unacceptable.

How can you show healing?
Validated assessment tools that use objective data to monitor pressure ulcer progression can help determine if a specific treatment modality is appropriate. Anurse knows the three phases of wound healing are inflammatory, proliferative and

Using the GPS system model, Anurse inputs the starting and ending destinations and the best way to get there in the plan of care. If the wound does not progress as planned, the GPS system alerts Anurse immediately. Anurse is already proficient in assessment, planning and implementation, but what about timely evaluation? Pay for Performance (P4P) is here. Poor healthcare practices will no longer be paid for. Documentation must indicate that Anurse’s treatment modality is appropriate for the pressure ulcer and that the pressure ulcer is progressing positively.

maturation. Anurse also knows that the inflammatory phase typically begins on day one and lasts for five days, the proliferative phase typically begins on day five and lasts until day 25, and the maturation phase typically begins on day 25 and lasts up to18 months. In general, a clean pressure ulcer with adequate blood supply and innervation should show evidence of stabilization or some healing within two to four weeks. However, many pressure ulcer healing rates are like Alice’s white rabbit, who states “I’m late, I’m late for a very important date,” thus making them chronic ulcers, which can linger for weeks, months and even years. Validated tools for monitoring pressure ulcer healing have existed since 1997. The Pressure Ulcer Scale for Healing (PUSH), the Sussman Wound Healing Tool (SWHT) and the Bates-Jensen Wound Assessment Tool (formerly known as the Pressure Sore Status Tool (PSST)) can be Anurse’s pressure ulcer GPS. If Anurse uses a monitoring tool on a routine basis, usually weekly, to assess the progression of the pressure ulcer, she will know if the wound is progressing through the inflammatory phase as expected. If the tool indicates slow to no progression, Anurse knows that she needs to notify the doctor that a change to the plan of care might be necessary to promote healing and move the wound out of the inflammatory phase. As the assessment continues to be charted using a monitoring tool, Anurse can determine if the pressure ulcer is progressing through the proliferative phase. If the pressure ulcer is not progressing, Anurse will contact the physician to change the plan of care to promote collagen synthesis, formation of new blood vessels, formation of granulation tissue and epithelialization. If a pressure ulcer is not progressing and the clinician decides to continue the current plan of care, the rationale for the decision should be documented.

PUSH Tool 3.0
A useful tool for monitoring the change of a pressure ulcer over time is the PUSH tool, developed by the National Pressure Ulcer Advisory Panel (NPUAP). To use the PUSH Tool, the pressure ulcer is assessed and scored on the following three elements:

1. Length x Width is measured and scored from 0 to 10 2. Exudate Amount is scored from 0 (none) to 3 (heavy) 3. Tissue Type is assessed and scored from 0 (closed) to 4 (necrotic tissue)



Each element is assigned a number, which is then added together to obtain a total score. That score is placed on the Pressure Ulcer Healing Graph. Changes in the score over time provide an indication of the changing status of the ulcer. If the score decreases, the wound is improving or healing. If the score increases, the wound is deteriorating. References
Anna and Harry Borun Center for Gerontological Research. The Bates-Jensen Wound Assessment Tool Page. Available at: e_ulcer_prevention/pubwat.pdf. Accessed August 15, 2007. National Pressure Ulcer Advisory Panel. The PUSH Tool page. Available at: Accessed August 15, 2007. Sussman C, Swanson G. Utility of the sussman wound healing tool in predicting wound healing outcomes in physical therapy. Advances in Wound Care. 1997;10(5):74-77.

Sussman Wound Healing Tool (SWHT)
Developed by Sussman and Swanson in 1997, this two-part tool measures pressure ulcer wound healing. The focus of the tool is to track a change in tissue status and wound measurement, assess whether the wound is healing and track the impact of physical therapy technologies for wound healing. Part I of the tool assesses 10 variables that address wound tissue attributes. The attributes are classified as “good for healing” or “not good for healing.” The scoring system is simply marked with a “1” if the attribute is present and “0” if the attribute is absent. Part II evaluates wound depth and location and measures the phases of wound healing.
To obtain a copy of the Sussman Wound Healing Tool, contact Aspen Publishers, Inc.

Bates-Jensen Wound Assessment Tool
Formerly known as the Pressure Sore Status Tool (PSST) This tool was developed by Barbara Bates-Jensen to enhance the communication between healthcare clinicians regarding pressure ulcers. Thirteen assessment parameters are measured on a scale of 1 to 5. Two additional parameters are measured with a simple check system. The tool will help Anurse track individual categories as well as an overall score. Once the numbers are recorded and the scale is complete, a total is calculated using all 13 parameters and then placed on a linear chart. Data is collected on a routine basis, usually weekly. The results are compared to previous assessments and treatment plans can be adjusted accordingly. In the movie version of her story, Alice states, “Well, I went along my merry way, and I never stopped to reason. I should have known there’d be a price to pay, some-day. Someday. I give myself very good advice, but I very seldom follow it. Will I ever learn to do the things I should?” Healthcare professionals have been publishing evidenced-based wound care research for 40 years. If a nurse continues to practice old, ineffective treatments, she too may find herself in trouble just like Alice. With P4P, healthcare professionals are charged with improving patient outcomes with efficient, effective, economical pressure ulcer care. To learn more about these wound monitoring tools, please refer to pages 90 to 93 in the Forms & Tools section of this magazine.

The End

Improving Quality of Care Based on CMS Guidelines


Medline and MyZiva open the door to Online Educational Opportunities...and a whole lot more
Medline, the number one provider of healthcare supplies and equipment to the long-term care market, and MyZiva, a leading online educational and informational resource with more than 10,000 registered users, have joined forces to provide enhanced educational oppor tunities to the entire nursing home industry and a whole lot more! As representatives of nursing homes from around the nation can attest, MyZiva offers a broad spectrum of education, information, tools and resources to nursing home professionals and their staff, including corporate compliance templates, easily retrievable federal regulations, a searchable national nursing home database and more. MyZiva brings the clinical component of its educational offerings to a new level through its relationship with Medline. Together, they offer more than 150 courses on wound care, pressure ulcers, infection control, incontinence, respiratory care and more. Benefits to education subscribers include an array of professional credits, including administrator CEs. To learn more about the MyZiva/Medline educational and informational initiatives, as well as its minimal cost, visit or call 1-866-238-2845.



Choose from any of the more than 150 online CEU-accredited courses...
Administrator Credit
Abuse and Neglect (2) T Accidents and Falls (3) T Administration and Management (2) T Bariatrics (3) T Behavior Management (3) T Care Planning (2) T Corporate Compliance (3) T Deficiencies, Sanctions and Appeals (2) T Drug Therapy (2) T Elopement and Unsafe Wandering (2) T Emergency and Disaster Preparedness (2) T Employee Health and Safety (2) T Ergonomics (3) T Food Service (2) T Hazard Communication (2) T HIPAA (2) T Hydration in the Long-Term Care Setting (2) T Infection Control (4) T Medical Records (2) T Medicare (4) T Nutrition (2) T Pain Management (2) T Pressure Ulcers and Skin Care (2) T Public Relations and Marketing (2) T Quality Assurance (2) T Quality Indicators and Quality Measures (2) T Reporting Requirements (3) T Resident Assessment/MDS (3) T Restraints (2) T Risk Management (3) T Safety (2) T Sexual Harassment (2) T SNF Prospective Payment System (PPS) (2) T Survey Process (2) T Urinary Incontinence and Use of Urinary Catheters (2) T Wound Care (2)

Certified Activity Professional Credit
Behavior Management (2) T HIPAA (2) T Therapeutic Recreation and Activities (2)

Certified Dietary Manager Credit
Abuse and Neglect (2) T Emergency and Disaster Preparedness (2) T Employee Health and Safety (2) T Ergonomics (2) T Food Service (2) T Hydration in the Long-Term Care Setting (2) T Infection Control (2) T Nutrition (2) T OSHA (2) T Purchasing and Inventor y Control (1) T Quality Assurance (2) T Risk Management (2) T Sexual Harassment (2)

Licensed Practical Nurse Credit
Abuse and Neglect (2) T Accidents and Falls (3) T Administration and Management (2) T Behavior Management (3) T Care Planning (2) T Constipation and Fecal Impaction (2) T Corporate Compliance (3) T Drug Therapy (2) T Elopement and Unsafe Wandering (2) T Emergency and Disaster Preparedness (2) T Employee Health and Safety (2) T Ergonomics (3) T Hazard Communication (2) T HIPAA (2) T Hydration in the Long-Term Care Setting (2) T Infection Control (4) T Medical Records (2) T Medicare (4) T Nutrition (2) T Pain Management (2) T Pressure Ulcers and Skin Care (2) T Privacy and Confidentiality (2) T Quality Assurance (2) T Quality Indicators and Quality Measures (2) T Reporting Requirements (3) T Resident Assessment/MDS (3) T Restraints (2) T Risk Management (3) T SNF Prospective Payment System (PPS) (2) T Sur vey Process (2) T Urinar y Incontinence and Use of Urinar y Catheters (2) T Wound Care (2)

Registered Dietetic Technician Credit
Constipation and Fecal Impaction (2) T Food Ser vice (2) T HIPAA (2) T Hydration in the Long-Term Care Setting (2) T Infection Control (4) T Nutrition (2) T Pressure Ulcers and Skin Care (2) T Quality Assurance (2) T Risk Management (2)

Registered Dietitian Credit
Constipation and Fecal Impaction (2) T Food Ser vice (2) T HIPAA (2) T Hydration in the Long-Term Care Setting (2) T Infection Control (4) T Nutrition (2) T Pressure Ulcers and Skin Care (2) T Quality Assurance (2) T Risk Management (2)

Registered Professional Nurse Credit
Abuse and Neglect (2) T Accidents and Falls (3) T Administration and Management (2) T Behavior Management (3) T Care Planning (2) T Constipation and Fecal Impaction (2) T Corporate Compliance (3) T Drug Therapy (2) T Elopement and Unsafe Wandering (2) T Emergency and Disaster Preparedness (2) T Employee Health and Safety (2) T Ergonomics (3) T Hazard Communication (2) T HIPAA (2) T Hydration in the Long-Term Care Setting (2) T Infection Control (4) T Medical Records (2) T Medicare (4) T Nutrition (2) T Pain Management (2) T Pressure Ulcers and Skin Care (2) T Privacy and Confidentiality (2) T Quality Assurance (2) T Quality Indicators and Quality Measures (2) T Reporting Requirements (3) T Resident Assessment/MDS (3) T Restraints (2) T Risk Management (3) T SNF Prospective Payment System (PPS) (2) T Sur vey Process (2) T Urinar y Incontinence and Use of Urinar y Catheters (2) T Wound Care (2)

Improving Quality of Care Based on CMS Guidelines


R-E-S-P-E-C-T. This word is a familiar mantra vocalized years ago by Aretha Franklin and repeated by those of us in need of just that – a little respect. As healthcare professionals, we practice daily respect for our patients and their given situations. It is a normal part of our role within that relationship. But have you ever wondered if your professional peers fully appreciate the presence (or absence) of respect within professional relationships? Too frequently battle lines are drawn between acute, long-term care, home care, hospice and physician’s office staff,

Caring for Yourself

By Teresa Kellerman, RN, WOC, ARNP

each of whom has at times voiced less than kind opinions about the care provided by their contemporaries. Sadly, this also takes place within one’s own nursing unit and between units of the same facility. Nursing professionals have long prided themselves on excellent patient care and, especially, on prevention of pressure ulcers. Many of us were “raised” in a nursing culture where a pressure ulcer is the mark of less-thanadequate nursing care. Finger pointing and blaming for skin breakdown or wound development has become common behavior, often because we cannot appreciate and respect the challenges encountered within other environments and the severity of the patient’s condition. We should honestly ask ourselves, “What care provider does not strive for optimal outcomes for his or her patients?” Wound care specialists, encounter wound and skin issues on a daily basis. Many of these cases are considered to be somewhat commonplace (skin tears, excoriation secondary to incontinence, etc.). For many wound, ostomy and continence nurses (WOCN), certain scenarios and

Respect means to feel or show honor or esteem for someone or something; to consider the well-being of; or to treat someone or something with courtesy. Showing respect is a basic law of life.
cases are etched into our minds because of the significance of the details or the absurdity of the situation. I received a call from a frantic nurse who had just received a 40-year-old male from an area long-term care facility. She proceeded to tell me about the horrible neglect that this man must have endured. She was certain that this facility should be reported to the state authorities. She was confident that this patient had multiple pressure ulcers from poor nursing care. Upon examination of the patient’s condition, I determined that his tissue injuries were not pressure ulcers; location and quality of these lesions, as well as the

The Sacred Tree

Improving Quality of Care Based on CMS Guidelines


admitting circumstances regarding them provided valuable information and explained the complexity of this scenario. With the history provided by the patient’s mother, it became apparent that this patient had necrotizing fascitis, a condition that nursing has no control over. The patient, in fact, had been admitted from a surgeon’s office for emergent surgery to address the rapidly progressing necrosis. The response of this nurse, prior to adequate patient history and examination, assumed that the patient’s integumentary condition was directly related to his level of nursing care. This patient was a fragile, blind diabetic with renal failure. He had a previous below-the-knee amputation, an extremely high white blood cell count, poorly controlled blood glucose levels secondary to his infection and severely limited sensation. The nursing staff who had previously taken care of him had in fact contacted the patient’s primary care physician multiple times within the past week to report their growing concerns regarding his condition. Without accurate information and without benefit of doubt, clinicians might presume that a patient has suffered at the hands of a caregiver. Effective communication When critical information is not shared between care providers, we might fill in the blanks with inaccurate facts, leading to faulty solutions or hostile rationalization. In the previous example, no documentation from the originating facility had accompanied the patient. Nothing beyond an order set for admission was provided by the surgeon’s office. Multiple calls made to the extended-care facility resulted in the requested documentation to gain more insight into the situation. An emotional circumstance was compounded with a labor-intensive effort to support the patient and to prepare him for surgery later that same evening. Hand-offs Currently, one of the the Joint Commission’s national patient safety goals is improvement of hand-off communication. Emphasis should be placed upon the hand-off of patient-specific information between caregivers or

Respect for ourselves guides our morals; respect for others guides our manners.

Laurence Sterne

the transition between care settings. This particular issue provides an opportunity to practice the professional provision of much-needed care-related information. It acknowledges respect for the care provided by the sending and receiving facility and staff. National Patient Safety Goal 2E is “to implement a standardized approach to ‘hand off ’ communications including an opportunity to ask and respond to questions. [Ambulatory, Assisted Living, Behavioral Health Care, Critical Access Hospital, Disease-Specific Care, Home Care, Hospital, Lab, Long Term Care, Office-Based Surgery].”1 Improved communication and relationships Foremost, we must practice respectful behaviors toward our nursing peers. We would expect and accept nothing less for ourselves, would we? As a profession, we must assume that all caregivers practice within the same standard of care until proven otherwise. If we observe otherwise, then communication becomes even more critical. And, when we observe firsthand that a standard of care has not been met, we can report true and supported cases of neglect. Healthcare communities must develop a standardized means of communication. Transfer forms need to be thorough and contact information should be provided in the event that follow-up questions arise. You might consider forming a community task force to address concerns and build a positive, open relationship with your nursing colleagues. Provision of appropriate information is crucial. With regard to a patient’s integument and/or wound care needs, the current treatment, skin and/or wound status and related interventions for these issues should be the minimum data to accompany the patient. Current medications and lab values, medical history and previous treatments for skin/wound needs will supplement the aforementioned.



Colleagueship is the bond between people who share a profession … it springs from a respect of each individual for each other and for themselves …


Maybe you need more R-E-S-P-E-C-T in the workplace.

Within the Midwest community where I practice, a coalition was formed to address pressure ulcer prevention involving acute, rehab, long-term, health department, home and hospice care entities. A noted need and subsequent goal of this group was to improve communication and care between services with regards to pressure ulcer issues. Open dialogue has occurred and recognition of the need for further work has been established. But, as with any quality improvement initiative, identification of the problem must be done. All involved parties must acknowledge and accept responsibility for the needed change(s). Solutions must be discovered collaboratively with the focus of best outcomes for patients while maintaining respectful interaction and behaviors.
About the author

Julie Morath

The warning signs of no R-E-S-P-E-C-T:

• You feel fatigued in the morning when you get up and have to face another day on the job. • You are no longer laughing or having fun at work. • You feel lethargic and empty on the job. • You have become uncharacteristically irritable. • You feel overwhelmed all the time. Even routine tasks feel like enormous challenges to be overcome. • You have trouble concentrating. • You feel emotionally drained and "used up" at the end of the workday. • Physical problems may include sleeplessness, chronic fatigue or loss of appetite. • Lack of respect among co-workers or employees and managers. • Lack of control over one's workload, schedule and deadlines. • A feeling that one's ideas are not valued or listened to. • Absence of feedback, so employees cannot see or appreciate the results of their efforts. • Conflict between employees, or between employees and management. • Anxiety about job security, or the possible consequences of failure at a job task or project. • Let others know you are having difficulty and ask for help. Be specific in your requests. • If you believe you are nearing the burnout stage, seek professional guidance and support. • Cut back on responsibilities. If you feel the main issue is overload of work, identify which tasks can be eliminated or delegated to others. • Focus on what you can control. Distinguish between things in your personal and work life that you can control, and those you cannot. • Take care of yourself with a balanced diet, rest and exercise. • Don't take work home with you. • Pace yourself at work. Take mini-breaks. Reference: Galt V New study sheds light on preventing . burnout. Globe and Mail. August 12, 2006.

The causes

Teresa Kellerman, MSN, ARNP, CNS, CWCN, COCN, OCN, is an oncology CNS and WOC nurse at St. Francis Health Center in Topeka, Kan. She is a member of many professional organizations, including Wound, Ostomy and Continence Nurses Society (WOCN); Oncology Nursing Society (ONS) and the Greater Kansas City Clinical Nurse Specialist Group. References The Joint Commission. The FAQs for The Joint Commission’s 2007 National Patient Safety Goals page. Available at: Accessed August 10, 2007.

The remedies



Special Features


"Why can't I get my employees to do the things we ask them to do?" Most healthcare organizations, regardless
of size, location or profitability, all struggle with the same issues. One common issue is getting employees and physicians to do what they are supposed to do.

In our work with departmental and unit level managers, one of the questions we get asked most often is, "Why can't I get my employees to do the things we ask them to do?" Other versions of this question are, "I am having trouble getting them to do (fill in the blank), what advice do you have for me?" or, "How can I instill a sense of personal accountability in my staff?" Those of you that have worked with me in our Leadership Development Institutes know that I believe in simplicity and formulas. My motto is "Keep it simple, follow the formula!" This concept guides my answers to managers who ask these questions. When answering, I tell managers there are essentially only four reasons for nonperformance. The key is to determine which of the four reasons apply in each case and then provide the remedy for that reason. Reason #1: The employee does not know they are supposed to do the job in a specific way. This is always the first question to ask in any instance of nonperformance. I advise the manager to go to the employee and say, "Tell me what you are supposed to do in this situation." Note how closely their answer matches your mental vision of what is supposed to happen in the given situation.

Improving Quality of Care Based on CMS Guidelines


In our work with management teams we often hear, "Everyone knows they are supposed to do this, it is just common sense." I think you will be surprised how often your vision differs from that of your staff. In fact, the common sense you think everyone has might not be common at all. Correcting this miscommunication will fix many of your nonperformance challenges. Reason #2: They know what they are supposed to do, but do not know how to do it. This is essentially an issue of training. In this circumstance, employees want to perform, they just do not know how because they have not been trained properly. Once you are sure they know what they are supposed to do, the next question to ask is, "Am I sure they have been trained to do it the way I want them to do it?" We are always surprised at the number of institutions that add instructional language to their policy and procedures manual and then assume that training has been done regarding application or compliance with the new requirements. Managers must give their staff the tools to be able to comply with the requirements of the job. Remember that telling is not training. Just telling an employee they should "do it this way" is not sufficient. Effective training includes four elements: 1. Explanation 2. Demonstration 3. Practice 4. Reinforcement and feedback If what you consider training does not include these four elements, the employee has not been trained properly. Reason #3: They know what they are supposed to do, but do not have the physical and/or mental capacity to perform it. In other words, no matter how much training you give them, they are unable to do the job. This is often the most misdiagnosed reason for nonperformance. Experts estimate that up to 80 percent of the time supervisors are incorrect when they determine this is the reason for nonperformance. Therefore, if you are positive the employee knows what they are supposed to do, and you are absolutely

sure they have received plenty of constructive training to do it, and they are still not doing it, ask "Does this person have the mental and/or physical capacity to do this job?" The answer may be the employee does not have the capacity to do the job effectively with the amount of training you are willing to provide to them. Alternatively, you might have made a hiring mistake and the person is not suited for the job you are asking them to do. Reason #4: They know what to do, how to do it and they have the capacity to do it, but choose (for many reasons) not to do it. This is willful noncompliance. The noncompliance may stem from these thought patterns: • My way is better • Your way will not work • I do not want to change • I am unable to do it because of institutional obstacles • I do not want to do it • I will not be supported if I do it The manager must determine why the employee is not performing and address the reason immediately. This response involves three components: 1. Provide convincing information that the organization's way is better than the employee's way 2. Provide positive rewards for good performance 3. Provide negative consequences for nonperformance Knowing and using these four reasons for nonperformance have helped me tremendously during my military career and in cofounding and leading two successful businesses. Whenever I have been confronted with nonperformance I ask myself, "Which of the four reasons is the cause?" If it is reason #1 or #2, I provide training to fix the problem. If it is reason #3, it is best to let the employee go as soon as possible. We do not do the employee or the organization any favors by keeping them in a job they are not capable of performing. If it is reason #4, and I am unable to change the



employee’s behavior through positive rewards or negative consequences, again it is best to let that employee go as soon as possible. Effective management of staff is not magic. It is taking specific actions to obtain the behaviors from employees that benefit the organization. It is the things managers do that influence people's performance. If managers do not do the right things at the right times, or in the right sequence, performance outcomes will not be satisfactory. Use these reasons for nonperformance to help you do the right things, in the right sequence, to obtain the performance you want.

Stephen W. Harden LifeWings President
LifeWings Partners LLC was founded by a former U.S. Navy Top Gun instructor and commercial airline pilot. The firm specializes in applying aviation-based teamwork training and safety tools to help healthcare facilities save patients' lives and reduce costs. LifeWings has helped more than 70 facilities nationwide provide better care to their patients.
Reference: Harden SW. Sharpening the saw: a message from the president. The Pulse. June 2007.

Improving Quality of Care Based on CMS Guidelines


battles breast cancer

Dr. Marla”

By Marla Shapiro, MD



Caring for Yourself

I felt like my identity was being stripped away.”
It was a routine mammogram, but when the X-ray was done, the radiologist asked for a magnified view of my right breast. She needed to get a better look at something. I wasn't anxious. I knew that this was fairly routine. If the breast tissue is dense, the X-ray film can be difficult to interpret. But when she came back, the news wasn't good. She tried to be reassuring, but her eyes were fixed on the floor as she suggested that I undergo a biopsy. I could feel the fear rising. I knew I was in trouble. After all, I was a doctor too. But on that day, Friday, Aug. 13, 2004, without warning, I switched roles and became a patient. It was foreign territory for me, and now, having spent 14 months there, I have to admit the journey has not been easy. The biopsy led to surgery that ultimately confirmed I was suffering from invasive breast cancer. In many ways, where Dr. Marla ended and just Marla began was poorly defined. My profession was inextricably woven into the very fabric of who I was – someone taught to be a clear thinker and problem solver whose decisions are based on evidence, even if it's just the best that science can offer at the moment. And when it comes to cancer, the evidence is staggering. According to the National Breast Cancer Foundation, women in the United States develop breast cancer more than any other type of cancer, except skin cancer. It also has the second highest rate of cancer death in females. An estimated 200,000 women will be diagnosed with breast cancer this year and it will lead to the deaths of more than 40,000 of them. However, this disease does not only affect women. The NBCF also notes that approximately 1,700 men are diagnosed with breast cancer each year. It will kill roughly 450 of them. As a doctor, you learn to respect those numbers and screen as effectively as you can, be it clinical examination, diagnostic tests or lifestyle counseling. As a patient, your life is changed forever. And mine has. As well as the feelings everyone has when faced with a life-threatening diagnosis, I had to deal with the fact that, thanks to my appearances both on [Canadian morning news show] “Canada AM” and on [health and lifestyle program] “Balance,” my own show, I am a public figure.

Improving Quality of Care Based on CMS Guidelines


Just what this meant was driven home the day I went for my first oncology appointment. As my husband, Bobby, and I stood at the reception desk in Toronto's Sunnybrook Hospital, we could see that “Balance” was playing on the television set in the waiting room. People behind us began to wonder out loud if "that woman standing there" was Doctor Marla and if "she" had cancer. I wanted to turn around and scream, "I may have cancer, but I'm not deaf." And yet I realized at the same time that I'd have to say something about what I was going through. Keeping it a secret was the last thing I wanted. My goal was to deliver a message: Fight and hope. I wanted to support my family and friends with encouraging words. So, when I wrote the first of my weekly columns for The Globe and Mail's health page almost exactly a year ago, I introduced myself to readers with the news of my recent diagnosis. I also explained that I did not want the disease to define me, but clearly it has in many ways, some perceptible and some not. I am not the same woman who walked through the doors of mammography that fateful day. For one thing, the treatment meant that I couldn't practice medicine. I did not want to abandon this role I felt so comfortable with – I felt like my identity was being stripped away. But chemotherapy wipes out your whiteblood-cell count and makes you a sitting duck for any infection; to keep working in such a situation would have been like doing the tango in a minefield. I forced myself to keep up with “Canada AM” and my other media commitments. I needed to hold on to

Marla – with her hair starting to grow back – and her family.

a piece of me that was old and familiar. But most of my energy went into fighting the disease. People ask if this fight has gone better for me because I'm an informed patient. I really don't know. In so many ways, it has been easier because I understand the language and the uncertainty. But in other ways, I know too much and yet not enough. It is very hard ever to feel reassured. The treatment of breast cancer is tailored to the individual and based on where you are when you're diagnosed. But even then, there are many options and no black and white, no right answer. As I navigated through the maze of diagnosis and treatment options, I realized that, despite my knowledge, I was totally unprepared. It felt like I was running a race. There are so many decisions that have to be made – and made quickly. The various treatment options were outlined, along with the potential benefits and side effects, but ultimately I had to make the choices that I hoped were right for me. And these choices hinged on the fact that my tests could not confirm

whether the areas where the cancer had invaded my body were related to or independent of each other. As a result, I was offered chemotherapy – although I could have refused that option. After that, I had to decide between radiation and mastectomy, therapies that were considered equally effective even if they are clearly so different. So no one could tell me how to run the race. It's something you have to figure out yourself: what treatments are right for you, what your comfort level is, what risks you're willing to take. It's a race I had to run alone. Or so I thought. When my husband and I told our two older children, daughters Jenna and Amanda, I minimized my concern. But when I was to start chemotherapy, I could not shield them from the obvious side effects I would have to endure. We waited a while to tell nine-year-old Matt, and thought we had done a good job of protecting him. But children are perceptive, and he soon sensed that something was wrong. Which frightened him because our



silence suggested there was something that he could not talk about.

Once told, he was obviously relieved, and being so young, he soon came up with every conceivable question. He found it curious that I would lose my hair. (Actually, I did too.) He wanted to know if cancer would just go away, like a cold does. When we told him it was something that had to be beaten, he walked around for days, boxing imaginary demons in the air. Also, suddenly I was home a lot. My children have grown up in a busy household with a mother who leaves early and often comes home late. And while they knew that I was always "there for them," it wasn't always a physical presence. Being there for car pools, events and homework often required a juggling act. My newfound free time allowed me to rediscover my kitchen. I started baking and cooking so much that, after a while, the kids complained they were gaining weight even as I was

I realized that, despite my knowledge, I was totally unprepared.”
move through life, I suddenly realized that they had the exact same fears. And while I felt I could force myself to deal with anything, I could barely cope with their pain and fear. Try as I might, I could not make it go away. But as time went by, I found there were things I could do. The email and letters of support and concern I received were overwhelming. I am eternally grateful to the women who came forward to share their stories. I did not have to be alone. Then one day my husband asked me why, if one in nine of us has breast cancer, does Canada not have more bald women running around? The answer is that we are here but often silent. We carry on. We wear our wigs. We move forward as best we can, considering so little is said about how nothing in life prepares you to deal with a curve ball like this. But when I was invited to go to Vancouver to appear on “Vicki Gabereau,” I wondered about leaving the wig at home. The truth was that I was wearing it only on “Canada AM.” In real life, I walked around bald. I gave speeches bald, went to dinner bald. But I knew that this was different: national television without a wig. I decided that this was who I was in real life, and so I headed off to the West Coast wearing just my little black hat to keep me warm.

gradually disappearing into the side effects of my treatment. Thanksgiving last year came right after my first round of chemotherapy, and I was unbelievably sick. Nothing had prepared me for how ill I would be. I felt like a toxic waste dump. I couldn't move, I couldn't eat. Home from school for the weekend, the girls were confronted with just how ill I had become. The fear in their eyes hit me like a ton of bricks. Clearly this wasn't just about me. This was their fight too. As I tried to suppress my dark thoughts about not being around to see them marry, have children and

Marla with Amanda, one of her two daughters...

and with her son, Matt.

Improving Quality of Care Based on CMS Guidelines


Laughing with chocolate breasts before her bilateral mastectomy.

As I sat in makeup and Vicki came in to say hello, she stopped and, in her typical way, said: "You look different, Mama." She smiled, I smiled and off we went to do the interview. She was frank and curious and asked tough questions. I was totally comfortable in my own skin – and totally unprepared for what happened next: Letters came from women saying they had taken off their wigs after seeing the show. I realized then that many people had thought I was sailing through my fight with cancer, that somehow I had the inside track. In reality, on many levels, it was exactly the opposite: I am no different from anyone else in the same situation. It soon became apparent to me that I had a story to share – and it wasn't as much about the medicine and scientific advances as it was about the impact on my family, my life and all the things we don't talk about. When I spoke to CTV about making a documentary, the network was protective of me and said it was my decision, but I felt strongly that I wanted to do this. A crew more or less moved in and followed me around. My family and friends and physicians were open

and honest, and the result is called Run Your Own Race. Today, my chemotherapy is behind me. The surgeries I elected to have rather than radiation are over, and I have gone back to my office and a career I love. So how have I changed? In many ways, I am the same – juggling a zillion work balls and loving the return. But in so many other ways, I am different. The only word I can think of to describe it is mindful. I am so much more mindful of the decisions I make, my family, my children and how I choose to live my life. My children would say that my values have changed, and perhaps they are wiser than their mother, who has finally learned to match her emotional and her time commitments. There are those who insist that I have inspired them with my so-called courage, when, in fact, they have inspired me with their stories. It doesn't take courage to fight when there is no other option. I am not alone. You are not alone. Together, we all make a difference. Based on an article originally appearing in The Globe and Mail, October 2005.

About the author For years, well-known medical contributor Dr. Marla Shapiro has waded through the constant barrage of medical research and has disseminated the most sensible medical information you need to make smart healthcare decisions. She completed medical school at McGill University and trained at the University of Toronto for her Master’s of Health Science in Community Health and Epidemiology. She concluded her specialty training in Community Medicine receiving her Fellowship in Community Medicine from the Royal College of Physicians and Surgeons of Canada. She is an Associate Professor in the Department of Family and Community Medicine at the University of Toronto and is in private practice. In 1993 she joined City TV in Toronto, Ontario as the medical expert on the nationally syndicated show “Cityline.” Shortly thereafter she became the medical expert for “City Pulse” and CP24 News. In 2000, she left City to become the health and medical contributor for CTV's “Canada AM.” In addition to her weekly appearances on “Canada AM,” she is seen on “Newsnet” and as the medical consultant on CTV’s “News with Lloyd Robertson.” 2003 saw the exciting addition of “Balance: Television for Living Well.” Dr. Shapiro hosted this exciting daily health and lifestyle show. It is seen across North America and has sold internationally. Dr. Shapiro is the recipient of the 2005 Media Award from the North American Menopause Society for her work in expanding the understanding of menopause, and won the Society of Obstetricians and Gynaecologists of Canada/Canadian Foundation for Women's Health Award for Excellence in Women's Health Journalism in 2006 for her documentary Run Your Own Race.



Tips for Early Detection
The most important thing any woman can do to fight breast cancer is to practice tips for early detection. Many women are not familiar with the territory, so here are some early detection tips, signs and symptoms from the National Breast Cancer Foundation, included as reminders. Three recommended screening methods • Breast Self-Exam – Studies show that regular (monthly) breast self-exams, combined with an annual exam by a doctor, improve the chances of detecting cancer early. • Breast Physical Exam (By a doctor) – This should be done on an annual basis and in conjunction with breast self-exams. • Mammograms – The National Cancer Institute, the American Cancer Society and the American College of Radiology now recommend annual mammograms for women over 40. Symptoms and signs • A new or persistent lump or a thickening in or near the breast or possibly in the underarm area • A change in the size or shape of your breast • Discharge from either of the nipples that has not occurred before • Changes in the color or feel of your breast, areola or nipples, which might consist of dimpling, puckering or a scaliness of the skin. It’s critical to carry out regular breast self-examinations – this way, you will be able to detect any of these signs or symptoms. If you find something that you feel is abnormal, arrange an appointment to see your doctor.
Reference Symptoms and diagnosis. Available at: Accessed August 21, 2007.

A Must-Read
Life in the Balance is Dr. Marla Shapiro’s inspirational account of her battle with breast cancer from diagnosis to surgeries to chemotherapy and her agonizing decision to have both breasts removed. It is also the personal story of how her family handled the news and came together to achieve newfound balance in their lives. This is a book for anyone whose life has been touched by cancer or who knows someone who has. Order your copy at one of these online retailers:

Improving Quality of Care Based on CMS Guidelines


BEST day
Everyone has them, but often we do not take time to reflect and learn from whatever made the day either the best or the worst we’ve encountered. Many lessons could be learned from taking a few minutes to sift through details and analyze data so that we can choose to either replicate or eliminate the factors that contributed to the success or demise of a given workday. Below are some situational examples to stimulate your mind and help you start thinking about your own best and worst days!


“When I interview people for nursing jobs, I’m very clear that this is not a place of joy and happiness all the time. Now that I’m older and I have some experience, I feel it’s an honor to be there at the time of death. But it takes a piece of you every time. Usually, I’m more happy after work than sad. I sometimes miss the lights and sirens, but I wouldn’t trade my worst day here for my best day at any other job.” “You never know what a day will bring. It’s strangely comforting to work in a nursing home. There’s a rhythm to it…the housekeepers are cleaning the same area when you arrive each morning, the cafeteria has chicken strips again for lunch.”


Caring for Yourself

“Ironically, the best day I ever spent in my eight years in hospital PR was also the worst. Our local high school had a shooting this past spring and the victim was brought to the hospital. The entire Communications Department, save me, was out of the office at a seminar three hours away. Being a part-time writer, I had to step up and do interviews with national news agencies, over the phone with NPR, etc., which was a huge learning experience. And we were the heroes, because our staff saved this kid’s life (he was shot four times, three in the torso). But not soon after, his mom is in the paper trashing the hospital for not covering his bills, etc. The good and the bad. That’s working in a hospital for me.” “Hospitals are messy places where good and bad things happen, making public relations a constant juggling act. Think about it…you have a young male motorcycle accident victim arriving in the trauma unit who is not likely to survive (bad) but the thought that his organs might just bring life to many others is the opportunity (good). Or the hospital is planning a major expansion of facilities to better serve its community (good) but an unfortunate incident happened to a patient who also happened to be a family member of a local businessman with lots of money (bad).”

We want to hear from you!

Improving Quality of Care Based on CMS Guidelines 85

Please email stories about your best and worst days at work to We will share many of the responses in future issues of Healthy Skin!

Caring for Yourself

Berries Cream
8 oz. cream cheese 3 sticks margarine 3 cups sugar 1 tsp. vanilla extract Pinch of salt 6 eggs 3 cups flour 1 large tub of whipped topping 2 packages of strawberries (sliced), 1 small package of each - blueberries, raspberries and blackberries


Pound Cake

Grease and flour 10-inch tube pan. Preheat oven to 325º F

Cream the first 5 ingredients together. Then add the 6 eggs (1 at a time) and 3 cups flour. Blend. Then spoon batter into pan. Bake 1½ hours. Once the cake is cooled, take a knife and slice the cake into two layers. Spread 1⁄3 of the whipped topping on the bottom layer of cake. Top with a layer of strawberries and sprinkle with the other berry options. Dab some additional whipped topping on top of the berries and cap off with the top layer of the cake. Spread the remaining whipped topping on top of the cake. Add an additional layer of strawberries, then decorate with blueberries, raspberries and blackberries. Cool in the refrigerator and serve.

• ComfortEase™: A poly-rich heavyweight fabric that offers durability, wick-dry comfort and a crisp look at a great price. • AngelStat®: A 50/50 moderate-weight cotton/ poly blend makes these scrubs soft yet durable. • Encore: These soft, lightweight scrubs are both comfortable and economical.
Custom embroidery is available on all items! To learn more about the complete line of Medline scrubs, contact your Medline sales representative or call 1-800-MEDLINE.

Medline continues to revolutionize scrubwear

Ciel Blue

Mariner Blue


Caribbean Blue






Rich Purple


Midnight Blue

Jade Green



Colors shown are ComfortEase™ colors. Please contact you Medline rep for AngelStat® and Encore colors

Forms & Tools

Table of Contents
Guidelines for Wound Photography Prevention of Skin Tears – In-Service Outline Bates-Jensen Wound Assessment Tool PUSH Tool 3.0 Quick Guide to Lab Values Foley Catheter Selection Guide 88



92 94 95

This section of Healthy Skin is all about making it easier for you to do your job. It contains practical information and ideas to help you provide the best possible care for your residents while following current guidelines and standards of practice. The charts, forms and systems you'll find here are intended to be used. If you see something you like, feel free to tear it out and make it your own!

Improving Quality of Care Based on CMS Guidelines


Forms & Tools Guidelines for Wound Photography
General tips • Digital photos are always preferred. • Grid or disposable camera shots are not acceptable. • Need three completed case studies with a beginning, middle and end photo. Patient selection • Approach each resident as if their wounds will become a poster/case study. • Get in the habit of using good photography techniques every time to improve your photo outcomes. • Allow time to compose your shot and your patient. Permission Be sure to obtain a photo permit as required by your agency or facility. Frequency Photos should be taken at admission, weekly thereafter and at wound closure. All efforts should be made to protect patient privacy with regard to HIPAA compliance. Preparing for your shoot Lighting Use natural light (no flash) whenever possible. Be careful that the sun does not wash out the subject or distort the surface texture. If the light source is behind you, make sure your body does not create a shadow. Background Your objective is to showcase the wound on a solid background. Drape the patient in a dark blue or black cloth, which helps to absorb the flash and decrease the reflection off the patient’s skin. Avoid white because it will cause many cameras to have trouble focusing. Shiny blue underpads that reflect the flash should also be avoided. Composition • Avoid clutter in the background (i.e., printed clothing or towels). • A ruler labeled with the date, length, width and depth of the wound(s) must be present in each photo. • The resident must be positioned in the same manner for each set of photos so that progress can be seen. • Take the photo from the same angle each time. It’s best to have the camera pointing perpendicular to the wound instead of down from the top. • Taking all of the photos at the same time of the day will help with consistency in lighting. • Camera movement is the most common cause of photo blurriness. Stand firm with your feet shoulder width apart and tuck your elbows tight to your sides to prevent any shaking. • Take a minimum of four shots at each visit per wound site: > Location shot at four feet > Two-foot close-up – 90 percent person and 10 percent background > Two-foot with zoom – highlight tissue texture, drainage > Preview shots taken to ensure that pictures are clear and visible Additional photos of wound care procedures that highlight dressing removal, amount and absorption of drainage, product performance, pre- and post-irrigation wounds and dressing application steps are all of interest and might be useful in a poster presentation. Most of us are frugal when it comes to taking photos. Be liberal! The beauty of digital photography is that you can delete what you do not like. It’s better to have a lot of photos and choose the best back at the computer.



Forms & Tools Prevention of Skin Tears – In-Service Outline

Young adult skin

Old skin

Effect of Aging on the Skin Epidermal cells thin and divide slower Dermis thins (overall appearance of skin is thinner) Less collagen production (more visual wrinkling) Elastin fiber wear (less elasticity to skin) Decrease sebum product, natural skin oils (skin is drier) Decrease sweat glands (skin is drier) Rete ridges flatten (makes skin more fragile) Decrease number of melanocytes (“aging spots”) while size of individual melanocytes increases Decrease subcutaneous fat Risk Factors History of previous skin tears Compromised nutrition Fluid volume deficit Confusion Mobility limitations Bruised skin Medications that cause thinning of skin

Prevention Strategies Long sleeves Gentle adhesives Pillows Careful use of transfer equipment Proper nutrition (internal and topical) Appropriate hydration Treatment Options Nonadhesive oil emulsion gauze Hydrogel sheet Transparent film Silicone faced dressings Wound closure strips

Improving Quality of Care Based on CMS Guidelines




“Reprinted with permission from Barbara Bates-Jensen

Improving Quality of Care Based on CMS Guidelines


Forms & Tools



Forms & Tools

Improving Quality of Care Based on CMS Guidelines


Forms & Tools

Quick Guide to Lab Values
Taking a look at your residents’ lab values can tell you a lot about why their wounds might not be healing properly. For starters, lab values can indicate insufficient nutrients, oxygen and cellular components. The information below can help you evaluate lab values and identify health problems commonly associated with values above and below the normal ranges.* Red blood cells (RBC) Normal values • Males: 4.7 to 6.1 M/µL • Females: 4.5 to 5.4 M/µL RBCs contain hemoglobin, which allows the transport and exchange of oxygen and carbon dioxide to tissues. Below normal range • Anemia • Lymphomas, leukemia • Cirrhosis • Dietary deficiency: iron, vitamin B12 • Fluid overload • Hemorrhage • Normal pregnancy • Renal disease Above normal range • Congenital heart disease • Severe chronic obstructive pulmonary disease (COPD) • Severe dehydration: severe diarrhea or burns White blood cells (WBC) Normal value • 5.0 to 10.0 K/mm3 WBCs fight infection and react against foreign bodies or tissue. If the body makes poor or malformed cells, wound healing slows or halts and the wound might be left in a state of chronic inflammation. Below normal range • Autoimmune disease • Bone marrow failure • Dietary deficiency: iron, vitamin B12 • Drug toxicity

Above normal range • Infection • Non-marrow cancers • Dehydration • Inflammation • Trauma, stress or hemorrhage • Tissue necrosis Hemoglobin (Hb or Hgb) Normal values • Males: 14 to 18 g/dL • Females: 12 to 16 g/dL Hemoglobin transports oxygen and carbon dioxide. Below normal range • Anemia • Bone marrow failure • Cirrhosis • Dietary deficiency • Hematalogic cancers • Hemorrhage • Prosthetic valves Above normal range • Congenital heart disease • Severe dehydration: severe diarrhea, burns • Severe COPD Total protein Normal value • 6 to 9 gm/dL Protein is the building block of many body components, including muscle, skin, hair, internal organs and blood. Below normal range • Burns • Inflammatory diseases • Malnutrition • Protein-losing processes • Overhydration Above normal range • Dehydration

*List is not comprehensive. Reference: Medline Industries, Inc. The Wound Care Handbook. 2007



Forms & Tools

Foley Catheter Selection Guide
The longer a resident is kept on a catheter, the higher their risk of developing a catheter-associated urinary tract infection (CAUTI) climbs. In addition to CAUTI, these residents are also in danger of developing other complications, such as leakage, encrustation and blockage. You can help reduce catheter complications and CAUTI by selecting the appropriate catheter. Use your answers to the questions below to select the catheter that best fits each resident’s needs. Does patient have latex allergy or sensitivity? Yes • Latex-free Foley catheter • 100 percent silicone Foley catheter No • Latex-free Foley catheters • 100 percent silicone Foley catheters • Coated latex Foley catheter

Does patient have history of recurrent UTI? Yes • Latex-free Foley catheters No • Latex-free Foley catheters • 100 percent silicone Foley catheters • Coated latex Foley catheters

Does patient have frequent blockage/encrustation? Yes • Latex-free Foley catheters • 100 percent silicone Foley catheters No • Latex-free Foley catheters • 100 percent silicone Foley catheters • Coated latex Foley catheters

Is it anticipated that the patient will have the catheter for more than ten days? Yes • Latex-free Foley catheters • 100 percent silicone Foley catheters No • Latex-free Foley catheters • 100 percent silicone Foley catheters • Coated latex Foley catheter



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

Ta ke a lo o k
For more information regarding our Educational Packaging contact your Medline representative, or call: 1-800-MEDLINE
©2007 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc. MKT 207289/L IT 558/25M/J BK5

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