Improving Quality of Care Based on CMS Guidelines

What is an
Get Set for
Breast Cancer
Awareness Month
Free CE Inside!
Nurses Leaders
Rate Patient
Your Team
Wound Care Pioneer
Dr. Katherine Jeter
Bikes 3,100 Miles!
Page 94
Volume 9, Issue 2
Join the team!
When it comes to hot topics in long-term care, you’re the experts!
You, our readers, are on the front lines of everything that
happens in the healthcare industry – and we want to hear
from you! Have you ever wished you could write an
article that would be published in a large-circulation
magazine? Nowʼs your chance. Healthy Skin is looking
for writers and contributors. Whether youʼd like to try your
hand at writing or offer suggestions for future articles, we
want to hear what you have to say! You never know– the
next time you open an issue of Healthy Skin, it might be
to read your own article!
Contact us at to learn more!
Content Key
Weʼve coded the articles and information in this magazine to indicate which national quality initiatives
they pertain to. Throughout the publication, when you see these icons youʼll know immediately that
the subject matter on that page relates to one or more of the following national initiatives:
• QIO – Utilization and Quality Control Peer Review Organization
• Advancing Excellence in Americaʼs Nursing Homes
Weʼve tried to include content that clarifies the initiatives or gives you ideas and tools for implement-
ing their recommendations. For a summary of each of the above initiatives, see Pages 6 and 7.
Page 92
Page 32
Page 94
Page 12
Survey Readiness
35 More than Just a Survey Tool
61 A Guide to MDS 3.0 Section H
47 They’re Lurking in the Operating Room and Beyond!
53 ERASE CAUTI Program Helps Hospitals Reduce Catheter Use by
20 Percent
78 PRE-STAGE I: An Obvious, More Descriptive, and Clinically
Impactful Term than “Reactive Hyperemia” or “Blanchable Erythema”
in Describing the State Before Stage I
80 12 Ways to Reduce Hospital Admissions
25 Effects of a Just-in-Time Educational Intervention Placed on Wound
Dressing Packages
32 The Art of Wound Management
38 Assessment and Management of Fungating Wounds
Special Features
5 Medline’s Grant Program
10 Patient Experience is #1
12 Transforming the Health Care Delivery System
15 Answering Your Questions About Accountable Care Organizations
18 The Path Forward for Quality Health Care
23 2011 Nursing Leadership Priorities: The CNO’s Perspective
92 Make Your Facility a Greener Place to Work
94 Congratulations Dr. Jeter and WOCN!
104 Countdown to Breast Cancer Awareness Month
105 Medline Celebrates Six Years of Breast Cancer Awareness
Regular Features
6 Two Important National Initiatives for Improving Quality of Care
8 Breaking News
72 Product Spotlight: Optilock
87 Hotline Hot Topic: Assessing Lower Extremity Wounds
Caring for Yourself
74 If Recent Attacks on Sunscreen Concern You
96 How to Energize Your Team
106 Recipe: Aunt Judy’s Tortilla Roll-Ups
Forms & Tools
108 What Type of Wound Is It?
110 One Needle, One Syringe, Only One Time
111 National Diabetes Fact Sheet, 2011
117 Spinal Injection Procedures Performed without a Facemask Pose Risk
for Bacterial Meningitis
Sue MacInnes, RD, LD
Clinical Editor
Margaret Falconio-West, BSN, RN, APN/CNS,
Senior Writer
Carla Esser Lake
Creative Director
Michael A. Gotti
Clinical Team
Clay Collins, BSN, RN, CWOCN, CFCN,
Lorri Downs, BSN, RN, MS, CIC
Cynthia Fleck, BSN,MBA, RN, CWS, DNC,
Joyce Norman, BSN, RN, CWOCN,
Elizabeth O’Connell-Gifford, BSN, MBA, RN,
Jackie Todd, RN, CWCN, DAPWCA
Wound Care Advisory Board
Christine Baker, MSN, RN, CWOCN, APN
Katherine A. Beam, DNP, RN, ACNS-BC
Patricia Rae Brooks, MSN, RN, ANP, CWOCN
Amparo Cano, MSN, CWON
Jill Cox, CWOCN
Sue Creehan, RN, CWOCN
Donna Crossland, MSN, RN, CWOCN
Barbara Delmore, PHD, RN, CWCN, AAPWCA
Karen Keaney Gluckman, MSN, FNP-BC, APN,
Anita Prinz, RN, MSN, CWOCN, CFNC, COS-C
Mary Ransbury, RN, BSN, PHN, CWON
Denise Robinson, MPH, RN, CHWOCN
Diane Whitworth, RN, CWOCN
Improving Quality of Care Based on CMS Guidelines
Page 105
About Medline
Medline, headquartered in Mundelein, IL, manufactures and distributes more than 100,000 products to hospitals, extended care facilities, surgery centers, home
care dealers and agencies and other markets. Medline has more than 800 dedicated sales representatives nationwide to support its broad product line and cost
management services.
Improving Quality of Care Based on CMS Guidelines 3
©2011 Medline Industries, Inc. Healthy Skin is published by Medline Industries, Inc. One Medline Place, Mundelein, IL 60060. 1-800-MEDLINE.
One of these people is my daughter, Molly, a sophomore
at the University of Colorado. Last month, I watched her
swim, bike and run alongside her teammates to win the
2011 USA Triathlon Collegiate National Champi-
onship…over 120 colleges and 1,600 athletes participated.
School colors lined the transition area, teammates
cheered and family and friends took pictures as these
incredibly talented athletes sped by. The spirit, teamwork
and leadership were unbelievably motivating. I was so
proud of her and inspired by her effort and determination.
Another person who inspires me is Dea Kent, CWOCN.
She conducted and wrote the study you’ll find on page
25, titled the “Effects of Just-in-Time Educational Inter-
vention Placed on Wound Packages.” A few years ago,
Dea was at a special launch presentation for Medline’s
newly designed wound care packaging. The packaging
was unique because the design provided “just in time
education,” allowing the bedside nurse to correctly apply
various wound dressing products. After the presenta-
tion, Dea kept thinking that she would really like to test
the packaging to see if it made a difference in helping
the non- wound care specialist in their confidence level
and technique in applying wound dressings. Dea had al-
ways dreamed of doing a clinical study. But, not just any
study, Dea wanted to be published in a peer reviewed
magazine. Wow, what a project…and one she had never
attempted before. She kept telling me, “You, know, I’m
not a PhD, but I know I can do this.”
From start to finish it took several years. But the result
was a multi-centered randomized controlled study, which
was accepted and published in the November/December
2010 issue of the Journal of WOCN. The results were so
compelling that she is also presenting the study at the
upcoming WOCN conference in June in New Orleans.
Dea had a vision and a goal…and she never let herself
waiver regardless of the obstacles she faced along
the way.
All of this leads me to Dr. Jeter’s story. Now this is a truly
inspiring story. At the age of 72, Dr. Jeter biked clear
across the country – 3,100 miles! Oh, and did I mention
that she’s a breast cancer survivor? She achieved this
incredible feat, in partnership with the Wound, Ostomy
and Continence Nurses Society (WOCN) to raise money
to support the continuing education of WOC nurses.
(See the full story on page 94.) How can you not be
inspired by Dr. Jeter, her goal and her achievements?
I’m in awe of her dedication and determination. But it
makes me want to set new goals for myself and achieve
them. I hope it affects you the same way.
Best regards,
Sue MacInnes, RD, LD
4 Healthy Skin
Healthy Skin
Letter from the Editor
fter looking at the photo on the cover of this issue of Healthy Skin, you might think you had
picked up Bicycling Magazine. You didn’t. But there is a good reason Dr. Katherine Jeter is
our featured story. She is one of several people that come to mind who had a vision and a goal.
A goal which at the time may have seemed unthinkable, yet through sheer perseverance,
discipline and determination, they beat the odds. Whether the goal is related to a hobby, a
sport, or your professional career, it is has to be a glorious feeling to set a very hard goal and
to make it!
Improving Quality of Care Based on CMS Guidelines 5
Medline is committing up to $1 million over several years to stim-
ulate the gathering of solid evidence that supports the adoption
of solutions into clinical practice. Review panel members that
represent a breadth of research and practice knowledge will
select grant recipients to be awarded up to $25,000 each for
pilot grants and up to $100,000 each for an empirical study.
• To stimulate research that will lead to the development of
new targeted interventions aimed at improving patient safety
and decreasing healthcare-acquired conditions
• To test the costs and effectiveness of interventions and
programs designed to improve the quality of care and
increase patient safety.
• To disseminate practical, evidence-based solutions within
and across healthcare facilities, leading to improved
patient safety.
These awards are designed to assist healthcare providers in
developing and testing creative solutions or interventions for
reducing or preventing healthcare-acquired harms. Recipients of
grant award will be paired with a research mentor/consultant
through the grant program to develop methods and guide the
conduct of the study, ensuring that a rigorous research process
is followed. These studies can be small pilot studies aimed at
developing and testing the feasibility of new solutions or larger
evaluation studies to more fully test the cots, effectiveness or dis-
semination of evidence-based solutions. Please note that at this
time, the programis only accepting submissions fromhealthcare
providers based in the United States, Canada or Mexico.
Award Process
1. In response to our request for applications (RFA), providers
will submit a letter (limited to 3 pages) of intent providing the
following information:
• The patient safety event that the study will address
• Whether the applicant is proposing a pilot study
($25,000 limit) or empiric study ($100,000 limit)
• The proposed patient safety solution
• The objective of the study
• The proposed approach to the study (enough detail to
understand how the patient safety solution will be
implemented and how the investigator plans to measure
the impact of the intervention)
• Expected output of the study
• Plan for submission of institutional review board (IRB)
approval of the proposed study or documentation to
show that the study is exempt IRB federal requirements
2. In addition, the applicant should submit the following with
the letter (not included in the 3-page limit):
a. Brief biography about the individuals involved (limited
to one page each), which includes any experience about
the area of study focus.
b. Budget estimate (limited to one page), including the major
expenditure categories.
3. Only one application from a healthcare provider will be
considered. Institutions cannot submit more than one
4. The review committee will review all LOIs received after the
June 30, 2011 deadline. Accepted letters will be assigned to
the most appropriate research mentor, who will contact the
applicant and work with him or her to develop the letter into
a full proposal of 5-7 pages in length, including a complete
budget. Proposal and budget guidelines will be sent after
the approval of the letter of intent.
Most of the projects that are chosen for full proposal
submission will be funded; however, this process may
involve a subsequent resubmission a revised proposal
so that the funded research plan is clear.
5. Pilot grants will generally be up to six months in duration with
a budget of no more than $25,000. Empirical studies can be
up to $100,000 and last up to a year in duration. Pilot study
grantees can go on to submit an empirical study grant at the
successful conclusion of the pilot project, or applicants can
apply for a full empirical study grants based on their initial
letter of intent if they have an existing practice with some
evidence base that they wish to evaluate.
6. The final report for a pilot grant study should be a brief
paper written for a Medline publication (Healthy Skin, The
OR Connection or Infection Prevention Now) whether or not
the study is successful. The final report for an empirical study
is a paper to be submitted for publication in a peer-reviewed
E-mail your request for application to:
Supporting the Adoption of Solutions
into Everyday Practice
2011 Submission Dates May 1- June 30, 2011
Speo|a| Feature
6 Healthy Skin
Two Important National Initiatives
for Improving Quality of Care
Achieving better outcomes starts with an understanding of current quality
of care initiatives. Hereʼs what you need to know about national projects and
policies that are driving changes in nursing home and home health care.
Origin: The QIO Statement of Work is based upon Part B of the Title XI of the Social Security Act. The Medicare-funded
“Ninth Scope of Work” plan became effective August 1, 2008 and will remain in effect through July , 2011.
Purpose: To carry out statutorily mandated review activities, such as:
• Reviewing the quality of care provided to beneficiaries;
• Reviewing beneficiary appeals of certain provider notices;
• Reviewing potential anti-dumping cases; and
• Implementing quality improvement activities as a result of case review activities.
Goal: In the 9th SOW, the QIO Program has been redesigned with a framework for accountability and also in content. The
content now consists of four themes with the goal to help providers, both in long-term care and acute-care facilities,
prevent illness, decrease harm to patients and reduce waste in health care.
Of note: QIOs will be required to help Medicare promote three overarching themes: adopt value-driven healthcare,
support the adoption and use of health information technology and reduce health disparities in their communities.
Under the direction of the Centers for Medicare & Medicaid Services (CMS), the QIO Program consists of a national
network of 53 QIOs located in each of the 50 U.S. states, the District of Columbia, Puerto Rico and the Virgin Islands.
Quality Improvement Organization Program’s 9th Scope of Work Theme
The official Executive Summaries for the 9th SOW Theme are available at:
Origin: A coalition-based, two-year campaign initiated on September 26, 2006 to improve quality of life for nursing home
residents and staff. The coalition has continued the campaign beyond its first-round end of August 25, 2008 for an
additional 2 years (until September 26, 2010).
Purpose: Acoalition consisting of the Centers for Medicare & Medicaid Services (CMS), organizations representing providers,
consumers and government that developed a grassroots campaign to build on and complement the work of existing
quality initiatives including Nursing Home Quality Initiative (NHQI), Quality First and the culture change movement.
Goal: To ensure that continuous quality improvement is comprehensive, sustainable and consumer-focused, the coalition
has adopted goals that seek to improve clinical care, incorporate nursing home resident and family satisfaction
surveys into continuing quality improvements and increase staff retention to allow for better, more consistent
care for nursing home residents.
Participating providers will commit to focusing on at least three of the eight measurable goals, including at least one clinical goal and
one operational process goal. Current participants may choose to continue with the same goals, add additional goals or change goals
for the next two-year campaign.
QIO Utilization and Quality Control Peer Review Organization
9th Round Statement of Work
Advancing Excellence in America’s Nursing Homes
Stay tuned for
details on 10th Round
Statement of Work
Improving Quality of Care Based on CMS Guidelines 7
Trends in Goal Selection
Each nursing home participating in Advancing Excellence selects a minimum of three goals (outlined above).
The goals – and the percentage of participating nursing homes that have selected them – are listed below.
Goal 1: 70.9% Goal 5: 32.1%
Goal 2: 45.3% Goal 6: 62.8%
Goal 3: 54.2% Goal 7: 41.2%
Goal 4: 39.6% Goal 8: 31.3%
Visit this Web site to view progress by state!
*Based on the latest available count of Medicare/Medicaid nursing homes
Theme #1: Beneficiary Protection Activities will focus on
nine Tasks:
1. Case reviews
2. Quality improvement activities (QIAs)
3. Alternative dispute resolution (ADR)
4. Sanction activities
5. Physician acknowledgement monitoring
6. Collaboration with other CMS contractors
7. Promoting transparency through reporting
8. Quality data reporting
9. Communication (education and information)
Theme #2: Patient Pathways/Care Transitions Activities
will focus on three Tasks:
1. Community and provider selection and recruitment
2. Interventions
3. Monitoring
Theme #3: Patient Safety Activities will focus on six
primary Topics:
1. Reducing rates of health care-associated methicillin-resistant
Staphylococcus aureus (MRSA) infections
2. Reducing rates of pressure ulcers in nursing homes and hospitals
3. Reducing rates of physical restraints in nursing homes
4. Improving inpatient surgical safety and heart failure treatment
in hospitals
5. Improving drug safety
6. Providing quality improvement technical assistance to nursing
homes in need
Theme #4: Prevention Activities will focus on nine Tasks:
1. Recruiting participating practices
2. Identifying the pool of non-participating practices
3. Promoting care management processes for preventive services
using EHRs
4. Completing assessments of care processes
5. Assisting with data submissions
6. Monitoring statewide rates (mammograms, CRC screens, influenza
and pneumococcal immunizations)
7. Administering an assessment of care practices
8. Producing an annual report of statewide trends, showing baseline
and rates
9. Submitting plans to optimize performance at 18 months
There will be two periods of evaluation under the 9th SOW. The first
evaluation will focus on the QIO's work in three Theme areas (Care
Transitions, Patient Safety and Prevention) and will occur at the end
of 18 months. The second evaluation will examine the QIO's perform-
ance on Tasks within all Theme areas (Beneficiary Protection, Care
Transitions, Patient Safety and Prevention). The second evaluation will
take place at the end of the 28
month of the contract term and will be
based on the most recent data available to CMS. The performance
results of the evaluation at both time periods will be used to determine
the performance on the overall contract.
Focus for the 9th Scope of Work
– Move away from projects that are “siloed” in specific care settings
– Focused activities for providers most in need
– New emphasis on senior leadership (CEOs, BODs) involvement
in facility quality improvement programs
The 9th Scope of Work Content Themes
Clinical Goals: Goal Actual
Goal 1: Reducing high-risk pressure ulcers <10% 11%
Goal 2: Reducing the use of daily < 5% 3%
physical restraints
Goal 3: Improving pain management for < 4% 3%
longer-term nursing home residents
Goal 4: Improving pain management for <15% 19%
short-stay, post-acute nursing
home residents
Operational/Process Goals: Goal Actual
Goal 5: Establishing individual targets for > 90% 36.5%
improving quality
Goal 6: Assessing resident and family 22.5%
satisfaction with quality of care
Goal 7: Increasing staff retention 13.9%
Goal 8: Improving consistent assignment 26.6%
of nursing home staff so that
residents receive care from the
same caregivers
Clinical and Operational/Process Goals
Participating nursing homes: 7,481
Percentage of participating nursing homes:* 47.6%
Participating consumers: 2,233
Average number of goals per
nursing home: 3.8
8 Healthy Skin
HHS announces new patient
safety partnership
The Department of Health and Human Services (HHS)
recently introduced Partnership for Patients, a collaboration
with hospitals and others to reduce hospital-acquired condi-
tions (HACs) and preventable hospital readmissions. The
initiative will use $1 billion in Patient Protection and Affordable
Care Act funding to test models of safer care delivery, pro-
mote best practices and help Medicare patients at high risk
for readmission safely transition fromthe hospital to other care
settings. By 2014, participants hope to reduce HACs by 40
percent and preventable readmissions by 20 percent to save
up to $35 billion across the health care system.
Medicare patients spending less
time in the hospital at end of life
Medicare beneficiaries with severe chronic illness spent fewer
days in the hospital at the end of life in 2007 than they did in
2003, and were less likely to die in a hospital and more likely
to receive hospice care, according to a study released by the
Dartmouth Atlas Project. However, Medicare patients were
more likely to be treated by 10 or more doctors in the last six
months of life in 2007 (36.1 percent) than they were in 2003
(30.8 percent), and the average number of intensive care days
for these patients increased to 3.8 from 3.5.
AHRQ issues findings from
hospital culture of safety survey
The Agency for Healthcare Research and Quality (AHRQ) just
released the latest findings from its Hospital Survey on
Patient Safety Culture, a tool to help hospitals evaluate their
efforts to create a culture of safety. The voluntary survey looks
at 12 areas, including communication openness; handoffs
and transitions; management support for patient safety;
organizational learning/continuous improvement; staffing;
supervisor/manager expectations and teamwork. The results
were based on data from 1,032 U.S. hospitals.
Areas of strength:
• teamwork within units
• supervisor/manager expectations
Areas for potential improvement:
• non-punitive response to mistakes
• handoffs/transitions
Source: American Hospital Association
• Average reduction in facility-acquired
pressure ulcers: 70.5%
• Average annual savings: $306,000
How does it work?
With a compelling combination of products
and education:
1. Medline’s strategic product bundle, including
skin care and incontinence products
2. Medline’s free educational program for
nurses and nursing assistants, including
4 CE credits for nurses plus online,
interactive competencies
©2011 Medline Industries, Inc. Medline is a registered
trademark of Medline Industries, Inc.
1. Medline Industries, Inc. Data on file.
If you are interested in:
Implementing a program that allows you
to achieve these results and sustain them
over time
Reducing the incidence of pressure ulcers
at your facility
Learning more about Medline’s Pressure
Ulcer Prevention Program
Get results with
Medline’s Pressure Ulcer Prevention Program
800 facilities have joined the program.
Are you one of them?
Download a QR Code Reader app
Launch the QR app
Scan this QR Code or visit
10 Healthy Skin
of nurse leaders confirmed
that their organization will
be part of an accountable
care organization within
the next five years.
of nurse leaders
say that nursing
research is
being effectively
translated into
practice at the
Patient experience is #1
When ranking the most important
factors for providing high-quality
patient care, nurse leaders reported:
Nurse-to-patient staffing ratio
Nurse experience level
Nurse education/certification level
According to the newly
released HealthLeaders
Media Industry Survey
2011, nurse leaders are
most concerned about
1. Patient experience/
patient satisfaction
2. Quality/patient safety
3. Cost reduction
With the advent of the
HCAHPS (Hospital Consumers
Assessment of Healthcare
Providers and Systems)
survey and more government
requirements, nurses are
making the connection that
reimbursement will be tied
to patient satisfaction and
quality of care, and patient
safety beginning next year.
Nurse leaders rank priorities in national survey
Regarding hand
hygiene compliance,
of nurse leaders agreed that
the primary reason behind
failure to achieve hand-washing
compliance is lack of spine
to self-police and report
colleagues’ violations.
Source: HealthLeaders Media Industry Survey 2011: Nurse Leaders. Available at:
Speo|a| Feature
of nurse leaders said
their organization plans to
encourage more nurses
to pursue bachelor’s
degrees over the next
three years; 18 percent
plan to encourage
nurses to pursue
master’s degrees.
©2011 Medline Industries, Inc. NE1 is a trademark of Medline Industries, Inc.
Medline is a registered trademark of Medline Industries, Inc. Patent pending.
Wound measurement made easy
The NE1 Wound Assessment Tool is a proven way to
accurately measure and record wound characteristics,
featuring a unique right angle design to see length and
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and clinician’s name.
Key benefits
• Increase accuracy of wound assessment
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• Standardize wound documentation
• Drive appropriate reimbursement due
to more accurate wound assessment

Wound Assessment Tool
Accurate identification, consistent documentation
Interactive training and online competencies available
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Winner of
National HCA
1. Young DL, Esocado N, Landers MR, Black J. A pilot study providing
evidence for the validity of a new tool to improve assignment of NPUAP
stage to pressure ulcers. Advances in Skin & Wound Care. In press.
Camera not included.
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the Health Care
Delivery System
by Teresa Nguyen Clark, MPH, MBA
12 Healthy Skin
Speo|a| Feature

The Secretary shall establish a hospital value-based purchasing program under which
value-based incentive payments are made in a fiscal year to hospitals that meet the
performance standards...
H.R. 3590 Patient Protection and Affordable Care Act 2010
Title III, Subtitle A, Part I
What is hospital value-based purchasing?
Much talk exists in the media about value-based purchasing. Is
it legislation? Is it a change in payment? Is it a new focus? It is
all those things - legislation, payment, and focus. But what is it
to you?
The recently enacted health care reform law — H.R. 3590
Patient Protection and Affordable Care Act 2010 — established
a hospital value-based purchasing (VBP) program, which is a
new payment system that will be implemented for the Medicare
program by the Centers for Medicare & Medicaid Services
(CMS) starting in October 2012. Under the Medicare VBP pro-
gram, hospitals that do not surpass CMS-mandated perform-
ance targets will be subject to reimbursement penalties.
The Medicare VBP program initially focuses on five clinical con-
• Acute myocardial infarction (AMI)
• Heart failure (HF)
• Pneumonia (PN)
• Surgeries, as measured by the Surgical Care
Improvement Project (SCIP)
• Healthcare-associated infections (HAI)
In addition to these five clinical conditions, the Medicare VBP
program also focuses on Hospital Consumer Assessment of
Healthcare Providers and Systems (HCAHPS), which is the
patient’s perspective on quality.
How is any of this different than today?
Today, Medicare lets your hospital know ahead of time what
the performance target for payment will be. Knowing this ahead
of time, you can anticipate what your future reimbursements
may be, based upon your performance relative to the pre-
defined Medicare target. Then if you meet the performance
targets, you share in the savings with other hospitals.
Come 2012, in a hospital value-based purchasing environment,
you no longer know what the performance target will be ahead
of time. That is, Medicare will no longer pre-define the target
before the performance period. Instead, Medicare will set the
target after the performance period, with the performance tar-
get set at the national level.
This essentially means your hospital will now be in a national
competition for Medicare dollars, regardless of hospital char-
acteristics, such as size and teaching status. This also means
that going into a performance period, your hospital no longer
knows what the Medicare performance target will be.
How will this change what I do today?
Although October 2012 seems far away, Medicare will be start-
ing to look at your baseline performance this summer. This
leaves you little time to make changes that ready you for work-
ing in a value-based purchasing environment.
In addition to the timing of changes, value-based purchasing
will also affect your focus. Medicare has focused payment on
clinical conditions and it will continue to do so under VBP.
However, under VBP Medicare will now also focus on the
patient experience of care, as measured by the HCAHPS. The
HCAHPS will shift your focus from clinician and disease
process-centric to patient-centric.
Okay then - Where do I start?
With the upcoming changes, there are two places to start
1. How do you compare to the national market,
regardless of hospital characteristics?
2. From whose perspective is your patient experience
of care model based upon? Clinicians? Patients?
Title III focus on Medicare VBP dramatically alters the health
care landscape. If not prepared, your hospital, clinicians, and
leaders will be left in a precarious position when the Medicare
VBP payment effects begin October 2012.
Teresa Nguyen Clark, MPH, MBA, is vice president of clinical
business strategy and delivery for VHA, Inc., where she is respon-
sible for developing business and implementation strategies for
VHA’s clinical performance team to enhance the company’s efforts
to drive sustainable quality improvement with its members. Before
joining VHA in 2007, Teresa was the special assistant to the Cen-
ters for Medicare and Medicaid Services (CMS) chief medical offi-
cer and the director of the Office of Clinical Standards and Quality.
Improving Quality of Care Based on CMS Guidelines 13
©2010 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.
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Improving Quality of Care Based on CMS Guidelines 15
An ACO is a network of doctors and hospitals that comes together
voluntarily to share responsibility for providing care to patients. The
concept is part of U.S. healthcare reform under the Affordable Care
Act and primarily focuses on Medicare patients.
Accountable Care Organizations
Answering Your Questions About
What is an accountable care
organization (ACO)?
The plan is set to be established by January 1, 2012.
When will the ACO
program begin?
Speo|a| Feature
The goal of an ACO is to improve the safety and quality of patient care
and make health care more affordable. Today more than half of
Medicare patients have five or more chronic conditions and often
receive care from multiple physicians and multiple facilities. Failure to
coordinate care can often lead to patients not receiving proper care,
receiving duplicative care and being at an increased risk of suffering
the effects of medical errors.
What is the purpose
of an ACO?
Doctors and hospitals are the only providers allowed to form an ACO;
however, they will be responsible for incentivizing other healthcare
organizations, such as long-term care facilities and home health, to
work together on behalf of the patient. ACOs must agree to manage
all healthcare needs for a minimum of 5,000 Medicare beneficiaries
for at least five years.
Who is eligible to
form an ACO?
The benefit of forming an ACO lies in financial incentives from
Medicare for ACOs that demonstrate good quality care while keeping
costs down. The ACO concept was designed to make providers
jointly accountable for the health of their patients, giving them strong
incentives to cooperate with each other and save money. Financial
bonuses will be awarded when ACOs keep costs down, meet specific
quality benchmarks, and carefully manage patients with chronic
diseases. The goal is to avoid unnecessary tests, procedures and
Why would hospitals and doctors
want form an ACO?
• Nearly one in five Medicare patients discharged
from the hospital is readmitted within 30 days.
This could be avoided if patient care outside
the hospital was more aggressive and better
coordinated – through an ACO.
• ACOs could potentially save Medicare as much
as $960 million over three years.
How ACOs Can Help
1. Accountable Care Organizations: Improving Care Coordination for People with Medicare. U.S. Department of Health & Human Services website.
Available at Accessed March 31, 2011.
2. Gold J. Accountable care organizations, explained. Kaiser Health News. Available at
organizations-explained. Accessed March 23, 2011.
16 Healthy Skin
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The path
for quality
health care
By Lorri A. Downs BSN, MS, RN, CIC
18 Healthy Skin
Speo|a| Feature
Improving Quality of Care Based on CMS Guidelines 19
The U.S. healthcare delivery system is fragmented. Care is
delivered at many locations leading to waste and duplication of
services. To try to alleviate this problem, Congress has estab-
lished the Medicare Shared Savings Program for Accountable
Care Organizations (ACOs) under the Affordable Care Act. How
will this program change healthcare delivery? How will it affect
quality of care?
“Medicare Accountable Care Organizations (ACOs) are the first
step in reforming the American healthcare system. ACOs will be
the change in patient care delivery designed to accelerate
progress toward a three-part national goal:
➢ Better care for individuals
➢ Better health for populations
➢ Slow the growth of costs with improvements in care
ACOs will assume responsibility for a defined population of
Medicare beneficiaries. If the ACO succeeds in both delivering
high quality care and cost savings, the organization will share in
the Medicare savings it achieves.
On March 31, 2011 the Department of Health and Human
Services took the first step in forming accountable care
organizations (ACOs) by issuing the proposed rule for these
The heart of this concept of care delivery is to
bring providers and suppliers of Medicare covered services
together to coordinate care for Medicare beneficiaries.
Initially skilled nursing facilities, nursing homes and long-term
care hospitals are not specifically designated as eligible to form
independent ACOs.
ACOs will be required to provide the Centers for Medicare and
Medicaid Services (CMS) with a plan documenting and
addressing the following key Quality Processes:
➢ Promote evidence-based medicine
➢ Patient engagement
➢ Report on quality and cost metrics
➢ Coordination of care
As ACOs begin to be defined, and the list of requirements
unfold, clearly quality will be at the core. The National Quality
Strategy is a broad road map that will require the ongoing
development of specific goals and agreed metrics for healthcare
quality improvement. Efforts will focus on avoiding duplication of
services, ensuring accountability, and streamlining quality
1. Under the Affordable Care Act, existing guaranteed
Medicare-covered benefits won’t be reduced or taken
away. Neither will the ability to choose your own doctor.
2. Nearly four million people with Medicare received cost
relief during the healthcare reform law's first year.
Medicare recipients with prescription drug coverage who
had to pay for drugs in the coverage gap known as the
"donut hole," received a one-time, tax-free $250 rebate
from Medicare to help pay for their prescriptions.
3. Medicare recipients with high prescription drug costs that
put them in the donut hole now get a 50% discount on
covered brand-name drugs. Between today and 2020,
Medicare recipients will get continuous coverage for
prescription drugs. The donut hole will be closed
completely by 2020.
4. Medicare covers certain preventive services without
charging the Part B coinsurance or deductible.
Recipients will also be offered a free annual wellness exam.
5. The life of the Medicare Trust fund will be extended to at
least 2029, a 12-year extension as a result of reducing
waste, fraud and abuse, and slowing cost growth in
Medicare, which will provide recipients with future cost
savings on premiums and coinsurance.
At the end of the day, we all must increased collaboration and
communication between facilities to help reduce waste in our
healthcare system. Partnering for Prevention has become criti-
cally important. Teaching and supporting healthcare providers
about sustainable solutions across the continuumof care will help
prevent costly readmissions and hopefully translate into a health-
ier population.
About the author
Lorri Downs, BSN, MS, RN, CIC is a board-
certified infection preventionist and vice presi-
dent of infection prevention for Medline
Industries, Inc. She has a diverse portfolio of
more than 25 years in the nursing professions.
Her expertise focuses on infection prevention
surveillance at large acute care organizations,
plus ambulatory and public health settings. Lorri has developed hos-
pital infection control programs and local emergency preparedness
plans, and she has lectured on various infection prevention topics.
Things to Know about Healthcare Reform
and Medicare Benefit
20 Healthy Skin
Eliminate preventable health
care-acquired conditions
Opportunities for success:
* Eliminate hospital-acquired infections
* Reduce the number of serious adverse
medication events
Illustrative measures:
* Standardized infection ratio for central
line-associated blood stream infection
as reported by CDC’s National
Healthcare Safety Network
* Incidence of serious adverse
medication events
Create a delivery system that is less
fragmented and more coordinated,
where handoffs are clear, and patients
and clinicians have the information they
need to optimize the patient-clinician
Opportunities for success:
* Reduce preventable hospital
admissions and readmissions
* Prevent and manage chronic illness
and disability
* Ensure secure information exchange
to facilitate efficient care delivery
Illustrative measures:
* All-cause readmissions within 30 days
of discharge
* Percentage of providers who provide a
summary record of care for transitions
and referrals
Initial Goals, Opportunities for Success,
and Illustrative Measures National Quality
Strategy Priorities
and Goals,
with Illustrative
Safer Care
Improving Quality of Care Based on CMS Guidelines 21
Build a system that has the capacity
to capture and act on patient-reported
information, including preferences,
desired outcomes, and experiences
with health care
Opportunities for success:
* Integrate patient feedback on
preferences, functional outcomes,
and experiences of care into all care
settings and care delivery
* Increase use of EHRs that capture the
voice of the patient by integrating
patient-generated data in EHRs
* Routinely measure patient engagement
and self-management, shared
decision-making, and patient-reported
Illustrative measures:
* Percentage of patients asked
for feedback
Prevent and reduce the harm
caused by cardiovascular disease
Opportunities for success:
* Increase blood pressure control
in adults
* Reduce high cholesterol levels
in adults
* Increase the use of aspirin to prevent
cardiovascular disease
* Decrease smoking among adults
and adolescents
Illustrative measures:
* Percentage of patients ages 18 years
and older with ischemic vascular
disease whose most recent blood
pressure during the measurement
year is <140/90 mm Hg
* Percentage of patients with ischemic
vascular disease whose most recent
low-density cholesterol is <100
* Percentage of patients with ischemic
vascular disease who have
documentation of use of aspirin or
other antithrombotic during the
12-month measurement period
* Percentage of patients who received
evidence-based smoking cessation
services (e.g., medications)
Support every U.S. community as it
pursues its local health priorities
Opportunities for success:
* Increase the provision of clinical
preventive services for children and
* Increase the adoption of
evidence-based interventions to
improve health
Illustrative measures:
* Percentage of children and adults
screened for depression and receiving
a documented follow-up plan
* Percentage of adults screened for risky
alcohol use and if positive, received
brief counseling
* Percentage of children and adults who
use the oral health care system each
* Proportion of U.S. population served
by community water systems with
optimally fluoridated water
Identify and apply measures that can
serve as effective indicators of progress
in reducing costs
Opportunities for success:
* Build cost and resource use
measurement into payment reforms
* Establish common measures to assess
the cost impacts of new programs and
payment systems
* Reduce amount of health care
that goes to administrative burden
* Make costs and quality more
transparent to consumers
Illustrative measures:
* To be developed
U.S. Department of Health and Human Services
March 2011
Initial Goals, Opportunities for Success,
and Illustrative Measures
Priority Initial Goals, Opportunities for Success,
and Illustrative Measures
and Treatment
of Leading
Causes of
Health in
Care More
and Family-

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Improving Quality of Care Based on CMS Guidelines 23
The top priorities for organizations in 2011 are very simply
stated, but not easily executed. Here are the most important
areas of focus:
• Staff engagement and loyalty (HCAHPS)
• Nursing and physician engagement and collaboration
• Excellence with delivering the patient experience
• Reliable care that is founded on best practice quality
and safety practices (Pay for Performance -
Value Based Purchasing - Core Measures / SCIP /
Hospital-Acquired Conditions)
• Nursing staff at the forefront of designing, developing
and implementing solid EMRs (“Meaningful Use”-
Patient Protection Accountability Care Act-PPACA)
• Excellent, system-focused leaders who care and
engage all staff on their excellence journey
• An environment that fosters and supports the
STEEEP aims of Lean/Six Sigma (Safe-Timely-
Effective-Equitable-Efficient-Patient-Centered Care)
Building strong partnerships internally and externally is a neces-
sity for a successful health system. Interdisciplinary teams that
include: nurses, materials managers, purchasing, CWOCNs,
infection control preventionists, physicians, chief medical officers
and chief nursing officers must come together to evaluate current
clinical and service excellence delivery. Innovation and change
management will be a necessary core competency of staff and
leaders in positions to influence excellence.
The ideal state for CNOs and clinical leaders is to have collabo-
ration and standards in practice, processes, and leadership
across our nation. Remember, if excellence was that easy, we
would have nailed this years ago. Our dear leader, Florence
Nightingale, instructed us, “First Do No Harm.” Let’s continue to
learn from one another and provide our staff, physicians and
patients with excellence, and of course, eliminate harm.
2011 Nursing Leadership Priorities:
The CNO’s Perspective
by Candace S. Smith, MPA, RN, NEA-BC
CNOs can truly drive excellence with good teamwork in supporting the efforts of hospital staff and leaders. Providing
the front line with the tools to do their jobs is paramount, and CNOs can certainly influence their efforts.

First Do No Harm.
Speo|a| Feature
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in Advanced Wound Care

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Medline’s Educational Packaging offers all the information you need, step by step,
short and sweet, to help the Medline dressing do its job of healing.
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Improving Quality of Care Based on CMS Guidelines 25
Effects of a Just-in-Time Educational Intervention
Placed on Wound Dressing Packages
A Multicenter Randomized Controlled Trial
by Dea J. Kent, MSN, RN, NP-C, CWOCN
Purpose: I compared the effects of a just-in-time educational
intervention (educational materials for dressing application at-
tached to the manufacturer’s dressing package) to traditional
wound care education on reported confidence and dressing
application in a simulated model.
Subjects and Settings: Nurses from a variety of backgrounds
were recruited for this study. The nurses possessed all levels
of education ranging from licensed practical nurse to master
of science in nursing. Both novice and seasoned nurses were
included, with no stipulations regarding years of nursing
experience. Exclusion criteria included nurses who spent less
than 50% of their time in direct patient care and nurses with
advanced wound care training and/or certification (CWOCN,
CWON). Study settings included community-based acute
care facilities, critical access hospitals, long-term care facili-
ties, long-term acute care facilities, and home care agencies.
No Level I trauma centers were included in the study for
geographical reasons.
Methods: Participants were randomly allocated to control or
intervention groups. Each participant completed the Kent
Dressing Confidence Assessment tool. Subjects were then
asked to apply the dressing to a wound model under the
observation of either the principal investigator or a trained
observer, who scored the accuracy of dressing application
according to established criteria.
Results: None of the 139 nurses who received traditional
dressing packaging were able to apply the dressing to a
wound model correctly. In contrast, 88% of the nurses who
received the package with the educational guide attached to
it were able to apply the dressing to a wound model correctly
= 107.22, df = 1, P = .0001). Nurses who received the
dressing package with the attached educational guide agreed
that this feature gave them confidence to correctly apply the
dressing (88%), while no nurse agreed that the traditional
package gave him or her the confidence to apply the dress-
ing correctly (x
= 147.47, df = 4, P < .0001).
Conclusions: A just-in-time education intervention improved
nurses’ confidence when applying an unfamiliar dressing and
accuracy of application when applying the dressing to a sim-
ulated model compared to traditional wound care education.
Appropriate wound care, which includes accurate selection
and application of a variety of wound care products, is a key
responsibility for the individual wound care clinician and health
care facility. Wound care is especially challenging when pro-
vided by multiple caregivers with varied educational and
experiential backgrounds. Educating multiple persons to
deliver competent wound care may appear especially over-
whelming for agencies that lack a wound care specialist
to ensure adequate education for all involved staff or lay care
Seaman and colleagues
suggest that innovative dressings
may help caregivers improve wound-healing outcomes. How-
ever, this is true only when dressings are selected and
applied appropriately. Ayello and colleagues
demonstrated a
need for increasing both the quality and quantity of educa-
tion related to wound care. Nevertheless, little research has
been completed that evaluates the efficacy of educational
strategies to promote appropriate selection and application
of wound care products.
Improving Quality of Care Based on CMS Guidelines 25
26 Healthy Skin
Clinical decision making is a complex process that involves
the intersection of a number of factors, including knowledge
of wound healing, local and systemic factors that influence
wound healing, specific wound care interventions, and past
Nurses must make multiple decisions when car-
ing for an individual patient and that influence patient out-
comes such as wound healing.
Rycroft-Malone and
found that protocol-based care increased nurses’
independence and autonomy. Verdu
found that decision
trees assist nurses to make complex clinical decisions,
including the selection of appropriate wound dressings.
Educational intervention. Advances in the application of
informatics in health care have led to a teaching technique
commonly labeled “just-in-time” education.
This model is
adapted from the business world and is based on the con-
cept that learning is facilitated when the education is provided
in a time-sensitive manner (i.e., education delivered at the
moment it is most needed). This approach to education
allows for customization of content
and provides the learner
with tools that enhance their ability to provide effective care.
Just-in-time education also allows the learner to be more self-
There are many examples of “just-in-time” educa-
tion in the everyday world, such as reading directions for an
over-the-counter medication at the time of purchase. Wound
care specialists have developed a variety of tools, including
decision trees for selection of appropriate pressure redistribution
surfaces and algorithms for selecting an appropriate dressing,
that have proved useful for assisting generalists manage
wounds. Just-in-time education may prove useful for wound
care if it can be made available when a dressing is applied.
One company that manufactures dressings (Medline Industries,
Inc, Mundelein, Illinois) has developed a packaging system
based on the concept of “just-in-time” education (Figure 1).
Instructions for appropriate dressing use are attached to each
package. This study was undertaken to assess the effects of
this educational resource. Specifically, I examined nurses’
reported confidence in their ability to provide appropriate care
using an unfamiliar dressing and an objective assessment of
nurses’ ability to apply the dressing correctly to a wound
This randomized controlled trial compared self-reported confi-
dence levels in providing wound care and applying a dressing
to a model in 2 groups of nurses. Study procedures were
reviewed and approved by my facility’s institutional review
board, and all participants gave informed consent. Nurses
were recruited through informal announcements made on
various units including medical/surgical units, emergency
departments, surgery, day surgery, and long term acute
rehabilitation unit, home health care agencies, and long term
care facilities. Nurses with wound care certification (CWOCN,
CWON, and CWCN) and advanced practice nurses were ex-
cluded from participation. In addition, nurses who spent less
than 50% of their time in direct patient care were excluded.
I excluded these nurses since direct patient care is not the
focus of their routine responsibilities and their participation
may have introduced confounding variables into the study.
FIGURE 1. Educational guide attachment on dressing package
Nurses were randomly allocated to a control group receiving
traditional wound education, or the intervention group receiv-
ing just-in-time education. Simple random allocation was
completed by allowing each nurse to choose a colored card.
Cards were 1 of 2 colors; selection of 1 color led to allocation
to the control group, and selection of the other color resulted
in allocation to the intervention group. Participants had no
knowledge of which dressing the colored cards represented.
No compensation was provided to participants, and the com-
pany who designed the innovation had no input into the de-
sign, concept, or implementation of the study. However, the
company did supply dressings, free of charge, needed to
conduct the study.
Study setting. The study was conducted at 8 facilities in
central Indiana, including community hospitals, critical access
hospitals, long-term acute care units, long-term care facili-
ties, and home health agencies. The long-term acute care
units and home health agencies were used in the pilot study
only, due to staff availability. Facilities were selected that were
geographically near the principal investigator. Each facility was
contacted and the appropriate administrator was approached
about allowing me to solicit involvement in the study. Once
management approval was given, site visits for the recruit-
ment of subjects were completed.
Instruments. Data were collected using 2 tools: (1) the Kent
Dressing Confidence Assessment, a rating scale/question-
naire to assess the nurses’ feeling of confidence in dressing
application; and (2) a structured criteria form to be used to
evaluate each nurse’s ability to accurately apply the dressing
to the wound model (Figures 2 and 3).
The Kent Dressing Confidence Assessment is a questionnaire
used to measure nurses’ confidence in wound dressing
application; I developed the tool prior to data collection. It was
evaluated by a panel of researchers, with expertise in wound
care and instrument development, and professional educa-
tors. The tool was then revised in order
to obtain consensus as to measure-
ment criteria, wording, and general
presentation. Following content valida-
tion by the panel, the tool was further
evaluated in a pilot study involving 34
nurses. Each nurse randomly selected
1 of the test dressings and completed
the questionnaire. Demographic infor-
mation was collected on the nurses
involved in the pilot study, and they were
interviewed to determine if they found
the questionnaire clear and under-
standable. They were also asked to pro-
vide suggestions for improving wording
of any items they found confusing. All
participants indicated they found instru-
ment items clear, concise, easy to read,
easy to complete, and easy to under-
stand. The Kent Dressing Confidence
Assessment contains 10 questions;
each item is answered via a 5-point
scale, “strongly agree,” “agree,” “neu-
tral,” “disagree,” or “strongly disagree.”
Each item is scored individually. I then
developed a form using information
from the educational packaging that
specified correct criteria for dressing
application. This form contained 4
application criteria; each of the criteria
had to be demonstrated by the nurse in
order for the dressing application to be scored as “correctly
applied” (Figure 3).
Study procedures. I selected a dressing that was not famil-
iar to study participants in order to enable a more accurate
assessment of the effect of the educational intervention on
application and self-reported confidence with application. The
control group received the unfamiliar dressing in a “standard”
package with instructions to actually apply the dressing to the
wound model. Scissors and gauze were made available for
use, and the participants were told they could use any item
they thought necessary to apply the dressing. The nurses
were not asked to secure any secondary dressing in place.
Rather, they were instructed to apply the secondary dressing
according to package instructions. Participants were allowed
to ask questions, but no information about how to apply the
dressing was given by the principal investigator (D.K.) or
Improving Quality of Care Based on CMS Guidelines 27
Figure 2. Kent Dressing Confidence Assessment.
The package Strongly Somewhat Neutral Somewhat Strongly
directions on the Agree Agree Disagree Disagree
wound dressing
1. Provides directions
about use of the
2. Defines one or more
uses of the dressing.
3. Indicates instructions for
application of the dressing.
4. Indicates the method for
removing the dressing.
5. Explains how to apply
the dressing correctly.
6. Defines the change
frequency of the dressing.
7. Allows me to apply
the dressing safely.
8. Educates me about
specific precautions in
relation to the dressing.
9. Gives me confidence
that I can correctly apply
the dressing.
10. Will change my nursing
practice in relation to
application of wound
Please place an “x” in the category that best represents your answer
28 Healthy Skin
trained observer. The intervention group was
managed in an identical fashion, but they re-
ceived the unfamiliar dressing in a package
with an attached instruction sheet (Figure 1).
Each participant completed the Kent Dressing
Confidence Assessment tool (Figure 2). Sub-
jects were then asked to apply the dressing to
a wound model under the observation of
either the principal investigator (D.K.) or a
trained observer, who scored the accuracy of
dressing application according to established
criteria (Figure 3). The trained observer was a
nurse trained in providing wound care and
dressing application. I taught the observer to
score the subject based on the 4 criteria for
correct dressing application and on how to
interact with subjects during data collection.
I evaluated training by direct observation of
the data collector prior to data collection. In
order to avoid education among participants,
I al lowed only 1 participant in the study room
at any time. Subjects were asked to not to
speak of any part of their experience in the
study room until all data were collected at that
facility. Was dressing applied correctly
Data analysis. Proportions and chi-square analysis were
used to determine whether the educational intervention
affected nurses’ reported confidence when applying a novel
dressing and their observed performance when applying the
dressing to a model. Chi-square findings were validated with
the Fisher exact test.
One hundred seventy-three nurses participated in the study.
Among the control and intervention groups, there were 43
licensed practical nurses and 130 RNs, including diploma (n
= 7), associate degree (n = 65), bachelor’s degree (n = 55),
and master’s degree (n = 3) RNs. The most common cate-
gory of work experience was category B (2-5 years) among
the nurses. Forty-one nurses worked in a long-term care
facility, 13 worked in home health care, 18 worked in long-
term acute care, and the remaining 101 nurses worked in the
acute care hospital (Table 1). No statistically significant differ-
ences were found when groups were compared based on
educational preparation, care setting worked, or years of
Confidence with dressing application. Dressing applica-
tion confidence was evaluated via 3 items from the Kent
Dressing Confidence Assessment: (1) item 5 that queried cor-
rect dressing application; (2) item 7 that queried safe appli-
cation of the dressing; and (3) item 9 that queried confidence
when correctly applying the dressing. Significantly, fewer con-
trol group subjects agreed that they could correctly apply the
dressing (item 5) (4% vs 100%, x
= 173.00, df = 4, P =
.0001). Significantly, fewer control group subjects agreed that
they could safely apply the dressing as compared to subjects
receiving just-in-time education (item 7) (4% vs 91%, x
Figure 3. Criteria for dressing application. Yes No
1. Must trim dressing with scissors to fit the wound
2. Must remove the blue protective packaging from the
dressing prior to placing it into the wound
3. Must pack the dressing loosely into the wound bed,
filling it only 2/3 full.
4. Must cover with a secondary dressing
Must score “yes” in all categories to correctly apply dressing to the wound model.
Was dressing applied correctly Yes No
Table 1. Demographic Information
Control Intervention Group Total
Group, N Group, N Comparison
Licensure x
= 0.1549 N = 173
LPN 21 22 df = 1
RN 59 71 P = .69
Education x
= 1.6162 N = 173
LPN 21 22 df = 1
Diploma RN 4 3 P = .20
ADN RN 33 32
BSN RN 21 34
MSN RN 1 2
Experience, y x
= 0.1274 N = 173
<1 12 8 df = 1
2-5 20 22 P = .72
6-10 13 17
11-15 9 23
16-20 19 19
21-25 4 3
≥26 3 1
Care setting x
= 2.8728 N = 173
Acute care 46 55 df = 3
ECF 4 22 P = .41
Home care 19 9
Long-term acute care 11 7
Abbreviations: ADN, advance degree nurse; ECF, extended care facility; LPN, licensed practical nurse
Improving Quality of Care Based on CMS Guidelines 29
160.07, df = 4, P < .0001). Fewer nurses in the control group
agreed that they felt confident with dressing application when
compared to nurses in the intervention group (item 9) (19% vs
88%, x
= 147.47, df = 4, P < .0001) (Table 2).
Dressing application. None of the 62 nurses in the control
group were able to apply the dressing to the wound model
correctly as compared to 68 of 77 nurses (88%) in the inter-
vention group who were able to apply the dressing correctly
= 100.694, df = 1, P < .0001) (Figures 4 and 5). The most
common dressing errors were as follows: (1) failure to trim the
dressing to fill the wound cavity two-thirds full (100%);
(2) failure to remove the blue cover (carrier sheet) on the
dressing (68%); and (3) overpacking the wound by scrunch-
ing the entire dressing up in the wound bed (100%). Reported
data does not include pilot study groups.
Findings from this study provide evidence that use of a just-
in-time educational intervention (placement of an instructional
guide for application in the individual dressing packages)
enhances application technique and reported confidence
when applying a previously unfamiliar dressing. More subjects
in the intervention group reported confidence that they could
safely and correctly apply the dressing than did control group
subjects, and this perception was validated when subjects
were asked to apply the dressing to a model.
I reviewed the literature and found no other studies demon-
strating the efficacy of the just-in-time educational technique
in wound care. Poskus
reported that a just-in-time inter-
vention improved accuracy of a swallowing protocol. Simi-
larly, Grasso and colleagues
found that personal digital as-
sistants (an electronic device designed to deliver just-in-time
education) that accessed a drug database significantly re-
duced the rate of medication errors in 1 facility. Al-Saleh and
Williamson12 also found that personal digital assistants pro-
vide the ability to find information quickly and promote safe
patient care, as well as confidence in undergraduate nursing
Although this study did not directly measure dressing appli-
cation in a clinical practice setting, more subjects receiving
the intervention were able to accurately apply an unfamiliar
dressing accurately to a model than were subjects given tra-
ditional education. In addition, 71% of nurses who received
the just-in-time educational intervention reported they would
change their practice based on the package insert. It is not
known why the remaining 29% responded that they did not
feel that the intervention would prompt them to change their
practice. Some participants stated that they frequently pro-
vide wound care based on physician orders, without really
thinking about the purpose of a particular dressing. Others
expressed that dressing application is relatively intuitive, and
they simply glanced through the educational guide instead of
reading it, as observed by the investigator. However, since
accurate application of this type of dressing falls within the
scope of nursing practice, this response presents a challenge
to wound care nurses when educating peers about wound care.
I attributed application failures in the control group to a lack
of knowledge about dressing application, since no information
was available on the
dressi ng package
i tself. Factors con-
tributing to dressing
application failures for
intervention group
subjects may include
an assumption that
they could apply the
dressing correctly
without consulting
directions, or a history
of topical dressing
packages without
just-in-time informa-
tion aiding accurate
The package directions on the wound dressing package:
1. Provides directions about use of the dressing. 0 100
2. Defines one or more uses of the dressing. 0 100
3. Indicates instructions for application of the dressing. 0 100
4. Indicates the method for removing the dressing. 0 100
5. Explains how to apply the dressing correctly. 0 100
6. Defines the change frequency of the dressing. 0 100
7. Allows me to apply the dressing safely. 0 90
8. Educates me about specific precautions in 0 96
relation to the dressing.
9. Gives me confidence that I can correctly apply 0 88
the dressing.
10. Will change my nursing practice in relation to 0 71
my application of wound dressings.
% Agree
Table 2. Questionaire Results
Kent Dressing Confidence Assessment
Plain Package Package With Instructions
(n=80) (n=93)
30 Healthy Skin
Study limitations include using a model for dressing applica-
tion rather than direct observation in clinical practice. In addi-
tion, although subjects were instructed not to discuss
dressing application with other study participants, it was not
possible to ensure that subjects did not discuss application
outside the research setting. I did not include pilot study
dressing application data in the overall results. The outcomes
were similar for this portion of the study, but the focus was on
validation of the Confidence Assessment Tool and the study
Just-in-time education, in the form of education on a dress-
ing package, improved both nurses’ confidence in applica-
tion of an unfamiliar dressing and their accuracy when
applying the dressing to a simulated model. Study findings
provide evidence that manufacturers of wound dressings
should apply just-in-time educational techniques by placing
an educational guide on all dressing packages in order to
enhance the accuracy and safety of appl i cati on and,
ul ti mately, its efficacy in wound healing.
✔Just-in-time education in the form of an educational
guide on wound dressing packages led to increased
nursing confidence in a broad sample of nurses with
varying educational backgrounds and numbers of
years of experience.
✔Just-in-time education in the form of an educational
guide on wound dressing packages led to increased
safety and accuracy when applying an unfamiliar
dressing in a simulated model.
✔ More than 70% of nurses reported that placement of
an educational guide on wound dressing packages
would change their practice when delivering wound care.
The author thanks Medline Industries for supply of dress-
ings/packaging for the study. The author also thanks St.
Joseph Hospital, Kokomo, Indiana, for supporting this study
as well as Mark Smith, St. Vincent Hospital, Indianapolis,
Indiana, for statistical analysis of the data.
Dea J. Kent, MSN, RN, NP-C, CWOCN, Manager, Wound
Ostomy Clinic, Riverview Hospital, Noblesville, Indiana.
Correspondence: Dea J. Kent, MSN, RN, NP-C, CWOCN,
PO Box 386, Sharpsville, IN 46068 (
1. Seaman S, Herbster S, Muglia J, Murray M, Rick C. Simplifying modern wound
management for nonprofessional caregivers. Ostomy Wound Manag. 2000;46:18-27.
2. Ayello E, Baranoski S, Salati D. Wound care survey report. Nursing. 2005;35:36-45.
3. Banning M. A review of clinical decision making: models and current research.
J Clin Nurs. 2007;17:187-195.
4. Twycoss A, Powls L. How do children’s nurses make clinic decisions? Two preliminary
studies. J Clin Nurs. 2006;15:1324¬1335.
5. Rycroft-Malone J, Fontenla M, Bick D, Seers K. Protocol-based care: impact on roles
and service delivery. J Eval Clin Pract. 2008;14:867-873.
6. Verdu J. Can a decision tree help nurses to grade and treat pressure ulcers? J Wound
Care. 2003;12:45-50.
7. Yensen J. Just-in-time resources on demand. http://www.langara. Accessed May 25, 2008.
8. Barr R, Tagg J. Just-in-time education: learning in the global information age. Published December 2002.
Accessed June 5, 2008.
9. Bongiorni B, Spicknall M, Horsmon A, Cohen P. On-demand education to meet marine
industry professional development needs. J Ship Prod. 1999;15:164-178.
10. Poskus K. Triumphs and challenges of implementing a nursing bedside swallow
screening tool: a stroke coordinator’s perspective. Perspect Swallowing Swallowing
Disord (Dysphagia). 2009;18: 129-133.
11. Grasso B, Genest R, Yung K, Arnold C. Reducing errors in discharge medication lists
by using personal digital assistants. Psychiatr Serv. 2002;53:1325-1326.
12. Al-Saleh M, Williamson K. EBP and patient safety: using PDAs in nursing education
classes. Paper presented at: Summer Institute on Evidence-Based Practice; 2009.
Accessed January 29, 2010.
Published with permission from the Journal of Wound, Ostomy and Continence Nursing.
November/December 2010; 37(6):609-614.
Control Group 0
Intervention Group 68
Control Group 62
Intervention Group 9
Figure 4. Successful
dressing application
results, n = 68.
Figure 5. Dressing
application failures,
n = 71.
Improving Quality of Care Based on CMS Guidelines 31
The Wound,
Ostomy and
Nurses Society
43rd WOCN
Annual Conference
June 4-8, 2011, New Orleans, LA
June 5, 2011
10:00-11:00 am
“The Healing Power of Humor”
Stuart Robertshaw, EdD, JD
11:30 am-12:30 pm
“Lawsuits, Technology and Wounds:
How Electronic Records Change your Practice”
Kevin W. Yankowsky, JD
2:15-3:45 pm
Oral Paper Presentations
including “Effects of Just-in-Time Education
Intervention Placed on Wound Dressing Packages”
Dea J. Kent, MSN, RN, NP-C, CWOCN
June 6, 2011
9:15-10:15 am
“Preparing for the Future: Professional Opportunities
for the WOC Nurse”
Janice Colwell, MS, RN, CWOCN, FAAN and
Laurie McNichol, MSN, RN, GNP, CWOCN
June 7, 2011
2:15-3:15 pm
“Palliative Care”
Jay Horton, ACHPN, FNP-BC, MPH
June 8, 2011
10:30 -11:30 am
“Touch, Tenderness, and Time: From Mother
Teresa’s Calcutta to the Modern Bedside”
Anne Ryder
All general sessions will be available
via live webcast Eastern Time.
To view, go to
By Dionie Bibat, BSN, RN, WOC Nurse
It was a Tuesday morning in late July, and retired WOCNs Dora and
Nancy were having breakfast at an outdoor café. They were wait-
ing for Sara to join them. The sun was warm, and the two women
sipped coffee and reminisced about the past. They first met years
ago at ET school.
Dora, the older of the two, said, “I remember the days when we
used Maalox
and heat lamps for wounds. The faster the wound
dried the better.”
Nancy, who was the entrepreneur of the group replied, “Yeah, I used
to add sugar to the Maalox, and then do the heat lamp, and the only
thing I was really concerned about was to make sure the patient
did not get burned by the heat lamp.”
Sara, the youngest of the group finally arrived and sat to join them.
Not missing a beat, she replied, “Gosh, how on earth did you get
any wounds to heal with that kind of treatment?” The rest of the
conversation progressed to the more modern concepts of wound
Research shows that as early as 3000 BC, healers implemented
the importance of nutrition in wound care
and years later, in 1962,
evidence of moist wound healing was documented.
Despite the
growing knowledge that healing occurs when proper conditions are
appropriate, such as nutrition, moisture and health of the patient, cli-
nicians in the last 26 years were still using treatments such as
Maalox and heat lamps for wounds. Fortunately, with more aware-
ness, this type of treatment is no longer popular.
Wound healing is multidisciplinary; it is a collaborative approach
between the patient, nutritionist, wound nurse, physician and other
clinicians. Treatment of wounds not only involves assessing the
wound; it must be a holistic approach.
Factors to consider
Howdid the wound develop? What is the etiology? An excellent
patient history will help the clinician determine the cause of the
wound. There are “typical” characteristics of the most common
types of wounds, such as pressure ulcers, vascular wounds,
(including venous insufficiency and arterial disease) and neuro-
pathic/diabetic wounds. In some cases, it may be difficult to deter-
mine the origin of the wound, and diagnostic tests are necessary.
Consider a biopsy in a wound that is uncharacteristic or has an un-
familiar presentation.
Systemic support. The old saying “focus on the whole of the
patient, not the hole in the patient” is so true today. Assess the
patient’s entire system, such as evaluating their nutritional status by
taking a dietary history. Blood work, such as protein levels, pre-
albumin and blood glucose levels, may divulge more needed infor-
The Art of Wound
Improving Quality of Care Based on CMS Guidelines 33
34 Healthy Skin
Evaluating the circulatory status and blood oxygenation
are important factors to address. What medications does the
patient currently take? Look at both prescribed and over-the-
counter medications, as well as herbal supplements. Are there other
chronic conditions that could affect the ability to heal? Look for
mobility issues or impairments that could contribute to mechanical
stressors such as friction, shear and pressure. Supporting the
patient also includes educating the patient and family on the pre-
vention, etiology and treatment involved in wound healing.
Topical treatment of the wound. ”The Five Principles of Wound
Healing” uses the acronym WOUND. The key is to understand
these principles of wound healing and to apply them when choos-
ing an appropriate topical product.
W- is the wound healing?
O- optimal moisture
U- understand the periwound skin
N- necrotic or viable tissue
D- depth or dead space
With hundreds of dressings to choose from, newclinicians like Sara
may have difficulty finding the appropriate one. To add to the con-
fusion, economic factors also play a role in making these decisions.
It is extremely important to stay current with the latest trends in
wound care. Valuable information is readily available via wound
journals, peer discussions, conferences and education fairs. Here
are a few valuable resources:
• Educare Hotline 888-701-SKIN (7546)
• Wound Ostomy and Continence Nurses Society
• National Pressure Ulcer Advisory Panel
• Joint Commission on Accreditation of Healthcare
Organizations (Joint Commission)
• Wound Healing Society (WHS)
About the author
Dionie Bibat BSN, RN, WOC Nurse, is Vice President of Clinical
Services at Medline Industries, Inc. Prior to joining Medline, Dionie
worked for a major wound company as a Clinical Resource Specialist
and has 14 years experience as a sales representative. As a CWOCN
at Evanston Hospital in Evanston, IL, she created and revised protocols
regarding wound and ostomy care. She also developed and headed
the wound team at Evanston and participated in the products
1. Patel GK. The role of nutrition in the management of lower extremity wounds. Int J Low
Extrem Wounds. 2005;4(1):12-22.
2. Mulder G. Section Editor's Message: Genomic, Cellular, and Recombinant Technologies
in Tissue Repair. Wounds. 2008. Available at: Accessed May 2, 2011.
3. Bryant RA, Nix DP. Acute & Chronic Wounds Current Management Concepts. 3rd ed.
St. Louis, MO: Mosby; 2007.
4. The Wound Care Handbook. 2nd ed. Mundelein, IL: Medline Industries, Inc., 2008.
Improving Quality of Care Based on CMS Guidelines 35
More than just a survey tool
aoaq|º |e|ped l||º qua||ly·dr|ver operalor cul del|c|erc|eº. 8ul |lº rea| oerel|l |º rore
prolourd: |arreºº|rç perlorrarce |rprovererl |r|l|al|veº l|al lue| e·erp|ary care
esident needs and prefer-
ences tend to be moving
targets. This challenge
makes it important for operators
to have tools that can monitor
care and resident satisfac-
tion, pinpoint areas that need
improvement and establish
best practices across their
Providers with these abili-
ties have a distinct advan-
tage during Quality Indicator
Surveys. They can also react
quickly when changes or other
improvements are warranted.
These competenci es al so
translate to higher occupancy,
greater customer satisfaction
and exempl ary caregi vi ng
A growing number of long-
term care operators have
found that a web-based QA
tool called abaqis fulflls each
of these key goals, and more.
UHS-Pruitt, with its approxi-
mately 80 skilled nursing facili-
ties in Florida, Georgia, and
North and South Carolina, is
one such operator. The firm
chose abaqi s as par t of a
broad-based, organization-
wide QA initiative, and began
rolling out the solution in Sep-
tember 2009. As a Southeast
regional leader in long-term
care for more than 40 years,
UHS-Pruitt credits its endur-
ing success to an unwavering
commitment to quality of care
and service excellence. After
exploring various QA tools,
the company discovered that
abaqis was aptly suited to the
frm`s core operational philoso-
phy of delivering the best care
possible to its residents.
"We have always been very
qualit y focused," sai d Neil
Pruitt, chairman and CEO of
UHS-Pruitt Corp. "We wanted
our centers to have a special-
ized QA tool, and abaqis was
the right choice for us."
Marketed and distributed
exclusively through Medline
Industries, Inc., abaqis is the
only quality assessment and
reporting system tied directly
to the Centers for Medicare &
Medicaid Services` QIS evalu-
ation system. abaqis uses the
same rates and threshol d
compari sons used by sur-
veyors, which helps take the
guesswork out of the survey
process and enables long-term
care providers to proactively,
promptly and continuously
monitor and address resident
and family concerns.
"Before comi ng to UHS-
Pruitt, I was a state survey
be overwhelming and lonely. But
there are heroes out there showing
howsuccesscanbeachieved. Each
shows how a colleague turned a
challenging situation into a victory.
For four decades, UHS-Pruitt Corporation has delivered peace of mind to its patients,
residents, clients and their families.
$U00E$$ $T0P|E$ |º ºpor·
ºored oy Ved||re lrduºlr|eº. lrc.
learr rore al||re.cor
Survey Read|ness
36 Healthy Skin
agency director. I was excited
about using QIS and I was
pleased to learn that I would
be responsible for rolling out
abaqis in [UHS-Pruitt com-
munities]," said David Dunbar,
UHS-Pruitt`s chief compliance
Even though UHS-Pruitt had
consistently logged a good sur-
vey record, it found that abaqis
helped reduce citations by
roughly two per facility.
Tracking trends
Apositive survey experience is
indeed valuable for any opera-
tor, but that`s just one of abaqis`
notable advantages. Beyond
that-and perhaps even more
importantly-it`s a data-driven
QA tool that allows operators
to tackle more far-reaching
performance improvement
initiatives that enhance quality
care. That`s an essential ingre-
dient for success with a quality-
focused operator of any size, let
alone one like UHS-Pruitt that
serves approximately 20,000
patients and clients.
"We have a pretty exten-
sive QA [process] and abaq-
is is one of the QA tools we
have in place. abaqis gives us
access to data that we can then
run through our performance
improvement procedures,"
explained Pruitt.
A strategic, methodical and
well-planned implementation
helped UHS-Pruitt chart its
course for success. Each facil-
ity received comprehensive
training on the abaqis system
and staff was given ample time
to familiarize themselves with
the tool, ask questions, rise
above any challenges, and,
fully explore abaqis` many QA-
focused capabilities.
"As we rolled it out to our dif-
ferent facilities, we had individu-
als who really embraced it and
championed it. That helped
make the implementation pro-
cess a success," said Dunbar.
But it`s UHS-Pruitt`s orga-
nization-wide decision to tap
all of abaqis` potential that has
garnered the most impressive
results. "We find that abaqis
is most effective when admin-
istrators really drive ongoing
use and rely on it 365 days a
year. That`s when you really get
to see the macro data and are
able to spot trends and areas
that may need improvement.
Performance improvement
needs to be an ongoing pro-
cess," said Pruitt.
It`s a point that certainly isn`t
lost on Deborah Harwell, UHS-
Pruitt`s area vice president for
North Carolina, and the facili-
ties she oversees. Currently,
abaqis is in full swing in nine of
the 11 UHS-Pruitt communities
in the state, and the remaining
two facilities are poised to be
up and running soon.
The facilities use abaqis daily
to monitor resident satisfaction
and changes. "abaqis isn`t just
for surveys - although it is
very effective [in that capac-
ity]. We fnd that it`s especially
helpful as a continuous qual-
ity improvement and customer
service tool," Harwell noted.
The data obtained fromabaqis
is shared during performance
improvement meetings, and
the results are also shared with
the facility`s medical director on
a quarterly basis.
To fur ther maxi mi ze QA
efforts, Harwell routinely selects
four or fve of a facility`s more
challenging residents and then
uses abaqis to capture any
grievancesor concernsthat may
impact their satisfaction.
‘Very helpful’
"This is very helpful because it
allows us to monitor any issues
or changes, and see if there are
any trends developing - such
as if the majority of problems
are occurring on a certain shift,
for example. The more data
you have, the more effective
it becomes because you`re
better you`re able to address
issues quickly and effectively,"
reasoned Harwell, adding that
she personally monitors data
going into abaqis each week.
At the end of each quarter,
the data is reviewed and com-
piled, and then shared amongst
all 11 of UHS-Pruitt`s North
Carolina facilities.
" We l ook at how many
reviews were done and the
challenges that were shared,
and even howthose challenges
were resolved. This informa-
tion sharing allows us to drive
best practices across all our
centers," she said.
As one of UHS-Pruitt`s train-
ers for the abaqis system for
North Carolina, Harwell saw
frsthand howuser-friendly and
fexible the tool was - and how
important it was for each facility
to fully maximize the solution`s
"It was really embraced by
us and has become an impor-
tant part of our overall quality
improvement process. Our
goal is to provide the very best
quality of care and quality of life
for our residents, and abaqis
helps us do that," she contin-
ued. "I`m a huge supporter of
abaqis, and I keep reiterating
to my administrators its value
and benefts. The results have
been phenomenal."
While abaqis helps reduce inspector citations, its ability to help operators improve
the care they deliver to residents is even more notable, users claim.
¨we Wanted our centers to have a
spec|a||zed 0A too|, and abaq|s Was
the r|ght cho|ce for us."
|e|| º|v||| C|±||¤±¤ ±¤1 CF0 ||S·º|v||| C¤|¤
The abaqis Quality Assurance System is the only QA tool that exactly replicates the
methods and procedures of the Quality Indicator Survey (QIS). abaqis uses the same
calculations, thresholds and analysis as the QIS to quickly highlight residents at risk
and provides the tools to address their needs.
The three- step abaqis process improves
resident satisfaction and survey results
Using abaqis for your quality assurance
will improve quality of care and life for
your nursing home residents, which in
turn will also improve resident satisfaction
and survey results.
Quality Assurance System
Placing your residents
at the center of care
Step 1 Communicate
– Open a dialog with your residents
Step 2 Investigate
– Find root causes for problems
and develop solutions
Step 3 Take action
– Empower your staff, enhance
care and sustain excellence
©2011 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.
Download a QR Code Reader app
Launch the QR app
Scan this QR Code or visit
of Fungating
38 Healthy Skin
By Kelli J. Bergstrom,
Improving Quality of Care Based on CMS Guidelines 39
A fungating wound is a malignant lesion that infiltrates the skin
and its supporting blood and lymph vessels. They tend to
develop in the last few months of a patient's life, and often
impair psychosocial well-being. Fungating wounds present
unique challenges for WOC nursing management, including
prevention or management of bleeding and control of exudate
and odor. Our knowledge of the epidemiology, etiology,
assessment, and management of these lesions is limited. This
article provides an overview of the epidemiology of fungating
wounds, their assessment and options for management,
focusing on local wound management, control of associated
symptoms, and psychosocial support for patient and family.
A cancer diagnosis can be devastating for any patient, espe-
cially when complicated by a fungating wound. A fungating
wound can be present for years, but they usually develop in the
last few months of a patient's life. Although fungating wounds
pose a challenge for patients and caregivers, Clark
reports that
only 90 research articles have been published on the topic in
the past 30 years. Approximately 5% of patients with cancer
and 10% of those with metastatic disease will develop a
fungating wound.
Although they can arise from any type of
underlying malignant tumor, the majority of metastatic cuta-
neous lesions arise from primary tumor sites involving the
breast, lungs, skin, and gastrointestinal tract.
wounds require additional research focusing on their etiology
and presentation, physical and social impact, and management,
especially as patients approach end of life,
and WOC nurses
should both initiate and participate in interdisciplinary studies
addressing these challenging wounds.
Etiology and Presentation
A fungating wound, also known as a malignant lesion, is
defined as the infiltration and proliferation of malignant cells in
to the skin and its supporting blood and lymph vessels.
It may
evolve from the site of the primary cancerous lesion or from a
secondary lesion.
Fungating malignant wounds may be locally
advanced, metastatic, or recurrent.
Metastatic spread tends to
occur along pathways of minimal resistance, such as tissue
planes, blood or lymph vessels of the skin, or through implan-
tation of tumor cells through a surgical incision.
They frequently
occur in patients between the ages of 60 and 70 years and
often develop during the last 6 months of life.
Diagnosis is
based on histological assessment and cultures from the
surface of the wound to confirm the presence of anaerobic
organisms that flourish on the necrotic tissue. If these organ-
isms are not accurately identified, inappropriate treatments can
lead to the production of by-products that can interact with
wound drainage resulting in periwound maceration.
Fungating wounds have a tendency to expand rapidly, and they
show a propensity to become locally invasive, or form shallow
Initially, they present as multiple nontender nodules that
are skin-toned, pink, violet-blue, or black-brown in color, but
they go on to develop in to papillary lesions (resembling a cau-
liflower stalk) that may be complicated by an ulcer, sinus tract,
or fistula.
The most common location for a fungating malignant
tumor is the breast; these lesions represent 62% of fungating
wounds. Head and neck lesions account for 24%, the groin,
genitals and back account for approximately 3%, and all other
regions account for 8% of all fungating wounds.
As these
lesions expand, they tend to disrupt the local blood supply,
resulting in necrosis of the malignant tumor and underlying
wounds present
unique challenges,
including prevention or
management of bleeding
and control of exudate
and odor.
tissue. Anaerobic organisms readily grow and proliferate in this
warm, moist, and oxygen-poor environment. It is the prolifera-
tion of these anaerobic organisms that create their characteristic
exudate and malodor. Tumor infiltration of the local lymphatic
vessels can also affect interstitial tissue drainage resulting in
lymphedema of the affected region.
Assessment is an ongoing process due to the progressive
nature of the wound, and the evolving condition of the
It is necessary for the WOC nurse to take a holistic
approach in assessing the interrelationship between patient and
the wound.
In addition to assessing local wound factors, the
WOC nurse should consider the cause and stage of the under-
lying cancer, previous and current treatment, the patient’s
understanding of the diagnosis, nutritional status, impact of the
malignancy and wound on the patient's and caregivers’ psy-
chosocial status and quality of life. Assessment should also
evaluate availability of resources and social support networks.
Local wound assessment includes evaluation of its location,
dimensions, depth, percentage of devitalized tissue, degree of
tissue adherence of the wound surface, volume and character-
istics of exudate, odor, history of bleeding, quality and intensity
of pain, signs of fistula or sinus formation, and condition of the
periwound skin.
Assessment data are then used to develop a
management plan, taking care to ensure that the planned
interventions are consistent with the patient's goals and priori-
ties and do not adversely interact with other components of the
management plan.
The management goals of a fungating tumor vary, depending on
the stage of the underlying cancer, the patient's prognosis, and
the individual's own goals and wishes. In some cases, the goal
is to arrest tumor growth. In these cases, a multidisciplinary
approach is required that may include radiotherapy, chemother-
apy, surgery, hormone manipulation, neutron therapy, and low
intensity laser therapy.
In other situations fungating tumors
occur at the end of life, and treatment is completed in a pallia-
tive care setting that focuses on comfort and maintenance of
the best possible quality of life for the patient and family.
either case, it is important to remember that the symptoms pro-
duced by a fungating wound are often as distressing as the
wound itself. Therefore, management focuses on alleviation of
bothersome symptoms including pain, cutaneous irritation,
exudate, bleeding, odor, and psychosocial support, regardless
of whether treatment is delivered in a palliative or aggressive
care context.
Pain is a subjective symptom impacted by the underlying con-
dition, the wound itself, and dressing changes.
includes location, nature, duration, onset, frequency, intensity,
impact on activities of daily living, aggravating and alleviating
factors, current analgesia use, and effects of treatment. Stan-
dardized pain scales are used to assess intensity. Evaluation
should also differentiate nociceptive pain (caused by stimula-
tion of nerve endings when provoked by inflammatory media-
tors) from neuropathic pain (caused by nerve damage and
dysfunction) because treatment differs depending on the type of
pain. Analgesics, including opioids and nonopioid agents, are
used for nociceptive pain, while adjuvant agents, such as
amitriptyline and carbamazepine, are more effective for neuro-
pathic pain. Analgesics and adjuvant agents may be prescribed
separately or concurrently to achieve a combined effect.
According to recent case studies, topical opioids applied to the
wound surface can provide immediate local analgesia and work
indirectly to diminish the inflammatory process.
When man-
aging pain associated with dressing changes, several interven-
tions may be implemented, such as a “booster” dose of
analgesia prior to dressing changes, use of nonadherent soft
silicone dressings, gentle care techniques, and reduced
frequency of dressing changes.
40 Healthy Skin
Continued on page 42
Assessment is an ongoing process due to
the progressive nature of the wound, and
the evolving condition of the patient.
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42 Healthy Skin
Periwound Skin Irritation
Patients with fungating wounds often experience a creeping,
intense itching sensation attributed to the activity of the tumor.
Because of its invasiveness, the tumor causes severe damage
to the patient's peripheral nerve supply, which is responsible for
transmitting pruritic sensations. Typical inflammatory mediators
are not involved; therefore, intense itching is normally not
responsive to traditional antihistamines. Alternative options for
treatment include cancer specific hormone therapy, chemother-
apy, tricyclic antidepressants, or Transcutaneous Electrical
Nerve Stimulation.
Fungating wounds may produce large amounts of exudate
resulting in discomfort and embarrassment for the patient.
Exudate also may lead to periwound maceration, increasing the
risk of infection.
Several types of dressings may be used to
manage high-volume exudate, and WOC nurses are a valuable
resource when selecting an appropriate dressing. The optimal
dressing should be nonadherent to the tumor to reduce pain
and trauma associated with dressing changes. It should effec-
tively absorb exudate and toxins while maintaining a moist sur-
face that supports autolytic debridement of necrotic tissue. If
the wound is friable and bleeds easily, a dressing with hemo-
static properties is beneficial. Control of odor and restoration of
body symmetry and cosmetic acceptability with the use of less
bulky dressings are also important principles to consider for the
patient's self-image.
The categories of dressings normally rec-
ommended include activated charcoal dressings for odor con-
trol, alginates for bleeding wounds, foam/hydropolymer
dressings for exuding wounds, hydrocolloid sheets for lightly
exuding wounds or protection of surrounding skin, hydrofiber
dressings for heavily exuding wounds, and semipermeable film
membranes for protection of intact skin. If the volume of wound
exudate is too high even for highly absorbent dressings and
requires more than 2 to 3 dressing changes per day, a wound
manager pouch may be necessary to collect drainage and protect
surrounding skin.
Ointment based skin protectants or liquid
polymer acrylate barrier films should be considered for patients
with exudate that compromises intact skin.
Not only is the selection of the most effective dressing a chal-
lenge; determining the best way to secure the dressing is often
difficult. Some dressings are self-adhesive, but most require a
separate product. Depending on the location and size of the
wound, traditional adhesives, such as a tape, may not be
appropriate. In addition, the patient may be more vulnerable to
skin tears and breakdown due to the underlying malignancy and
its impact on nutritional status. In some cases, standard adhe-
sive products may potentiate problems and a cling dressing
wrap or a tubular net bandage may be used to secure dressings
without resorting to an adhesive secondary cover.
Because blood vessels can be disrupted by the infiltration of
tumor cells, bleeding at the wound site is common in patients
with fungating wounds.
There are several treatment options
to control spontaneous bleeding, including oral antifibrinolytics,
such as tranexamic acid, and radiotherapy.
In situations where
the bleeding is associated with dressing changes, interventions
to prevent bleeding include gentle technique for application and
removal of dressings, maintaining a moist wound and dressing
interface, gentle cleansing techniques, and use of nonfibrous,
nonadherent dressing materials. Certain dressings, such as cal-
cium alginates, have hemostatic properties that exchange
sodium ions for calcium ions, promoting the clotting cascade
within the wound bed.
It is important for the WOC nurse to
monitor the patient's hemoglobin levels because if the patient
becomes anemic, a blood transfusion or iron tablets may be
The presence and severity of odor is subjective and influenced
by multiple factors such as the patient's ability to perceive odor,
along with the perceptions of caregivers and family members.
This symptom can be one of the most devastating aspects of
a fungating wound.
As noted previously, wound odor is
associated with necrotic tissue that supports the growth of
anaerobic bacteria, and the presence of volatile fatty acids in
the wound. Stagnant exudate, infection, and fistula formation
are also contributing factors.
Treatment for odor encompasses multiple aspects of wound
care. Systemic antibiotics may be appropriate if there is evi-
dence of clinical infection. However, excessive use of antimi-
crobial agents should be avoided because it can lead to
overgrowth of resistant organisms such as methicillin-resistant
Staphylococcus aureus and vancomycin-resistant enterococcus,
and some antibiotics increase the risk of nausea and vomiting.
Metronidazole has been evaluated for use as a topical agent for
reducing wound odor.
It is a synthetic antimicrobial drug,
which works against anaerobic bacteria and protozoa; however,
it can take up to 2 to 3 days before odor is reduced.
Improving Quality of Care Based on CMS Guidelines 43
wound should be cleansed with normal saline and the metron-
idazole applied liberally and covered with a secondary dress-
ing. For heavily exudative wounds, consider the use of crushed
metronidazole tablets sprinkled over the wound surface and
covered with a petroleum-jelly-coated dressing. For dry
wounds, the gel form of metronidazole is more appropriate.
Metronidazole should not be used in conjunction with any other
topical creams, gels, or ointments because its effectiveness and
antimicrobial activity could be potentially diluted.
Although it
has been shown to be effective in many odorous wounds, it is
ineffective in wounds that are too moist or dry.
Charcoal dressings also may be used to alleviate odor. Because
the molecules that are responsible for the malodor are attracted
to the carbon surface, the activated charcoal dressing acts as
a filter to absorb these molecules, preventing them from being
released into the air.
In order to be effective, a charcoal dress-
ing must be fitted as a sealed unit directly on to the wound.
There are limitations for application on charcoal dressings in fun-
gating wounds because the dressing is effective only in wounds
that produce minimal exudate.
Silver dressings may also
reduce wound odor because of its antimicrobial effect against
a wide range of organisms including methicillin-resistant Staphy-
lococcus aureus and vancomycin-resistant enterococcus, thus
inhibiting bacterial growth and preventing colonization; however,
they tend to be expensive especially when frequent dressing
changes are needed.
Alternative topical agents sometimes used to control odor
include sugar paste, medical honey, and yogurt.
There are
several controlled trials and case studies supporting the bene-
fits of sugar paste and honey in wound care,
but the evidence
for yogurt is limited to anecdotal reports. Because sugar paste
is not commercially available in the United States, a specific
combination of caster sugar, icing sugar, polyethylene glycol,
and hydrogen peroxide is recommended in the literature. This
paste is prepared in both thick and thin consistencies in the
hospital pharmacy and stored in a screw-top plastic container
for up to 6 months. The table shows the formula for sugar
Sugar paste has the ability to absorb fluid due to its
high osmolality, thereby starving bacteria of fluid and inhibiting
their growth. On contact with the wound, sugar paste liquefies,
and prevents dehydration of normal cells. It also enables
sloughing of necrotic cells and promotes granulation tissue for-
Some studies have shown it to be effective against
Staphylococcus aureus, Streptococcus faecalis, Escherichia
coli, and Candida albicans.
Although it can be useful for
patients with fungating wounds, the effect wears off over time
so it is necessary to apply a thick layer to the surface of the
wound and secure with a petroleum-jelly-coated dressing twice
or more a day.
Honey has been used as a dressing since ancient times, but
due to the emergence of antibiotic-resistant strains of microor-
ganisms, there is an increased interest in its wound healing
properties. Medical grade honey derived from the Leptosper-
mum species found in the manuka flower of Australia and New
Zealand, inhibits bacterial growth in several ways, including its
acidic pH, which prevents biofilm formation, the slow release of
hydrogen peroxide, which is toxic to microbes, and high
osmolality, which inhibits bacterial growth.
Honey also acts as
a debriding agent with several mechanisms of action. It
encourages autolytic debridement due to its strong osmotic
action of pulling fluid from the wound and washing the base to
remove debris and slough.
The production of hydrogen per-
oxide contributes to debridement by activating proteases to
breakdown unwanted tissue.
Odor control is attributed to
inhibition of bacterial growth and removal of necrotic tissue from
the wound base.
However, topical honey may be difficult to
apply and requires the use of an absorbant secondary dressing.
Therefore, it may not be an option for wounds that are too
moist. Advances in technology have provided several forms of
honey-impregnated dressings, including alginates and hydro-
colloids that may be more effective in the management of fun-
gating wounds. These dressings received US Federal Drug
Administration approval in 2007 and are manufactured through
Medihoney, Derma Sciences, Canada.
Because blood vessels
can be disrupted by the
infiltration of tumor cells,
bleeding at the wound site
is common in patients with
fungating wounds
44 Healthy Skin
other studies could be found to support its use. Maggots are
highly effective in debriding necrotic tissue and removing bac-
teria through ingestion; however, there is a great potential for
bleeding and patient acceptance may be difficult.
Psychosocial Support
Fungating wounds are an ongoing reminder of the underlying
disease that frequently provoke a wide range of negative emo-
tions such as guilt, shame, confusion, frustration, loss of power,
and denial.25 Fungating wounds are often disfiguring and mal-
odorous, which can profoundly impair a patient's self-image.
Because the location, appearance, and odor of a wound may
be a source of embarrassment and distress for both the patient
and family, all are at risk for social isolation, depression, dimin-
ished sexual expression, and difficulty maintaining relationships
with family and friends.27 The WOC nurse should evaluate the
individual's coping mechanisms and social support networks
to determine the impact of the wound on psychosocial status
and social support networks.28 Patients and families affected
by fungating wounds may require additional support and coun-
seling from psychologists, social workers, bereavement coun-
selors, as well as hospice and other professionals. Patients and
family members should play an active role in determining wound
care, and treatments should be chosen to minimize the
wound's impact on the patient and family, provide adequate
control of symptoms, and allow for the potential of intimacy. The
treatment pl an shoul d al so provi de comfort as wel l as
i ndependence.
Fungating wounds are a devastating complication of malignan-
cies. WOC nurses should take an active role in assessment and
management of the fungating malignant wound, focusing on
management of distressing symptoms such as pain, excessive
exudate, odor, and bleeding. The WOC nurse is ideally suited to
make recommendations for care, assure that appropriate inter-
ventions are being carried out, provide education to the patient
and caregivers, and offer solutions to existing and future prob-
lems. The WOC nurse should also act as an advocate for
patients with fungating wounds by providing support and
encouragement, and helping assist the patient to maintain dignity
and maximize comfort during the end of life. WOC nurses
should generate and participate in further research about
fungating wounds, including the search for the most effective
methods for controlling odor and exudate.
Yogurt has also been used to control odor in fungating wounds.
Evidence is insufficient to confirm or refute its efficacy, but clin-
ical experience and anecdotal reports in the literature suggest
it is effective in some cases.
Most manufactured yogurts con-
tain the active culture, lactobacillus, which produces lactic acid
lowering the pH in the wound bed and inhibiting growth of odor-
producing organisms.
At least 1 newer yogurt preparation also
contains Bifidobacterium culture; it is described as helping reg-
ulate the digestive tract, and its effect on malodorous fungating
wounds is not known. Room temperature plain yogurt should
be applied to the wound surface and covered with a petro-
leum-jelly-coated dressing.
Treatment should be repeated 4
times a day for 2 to 3 days until odor is resolved.
Aromatherapy is another option for odor management. Essen-
tial oils of lavender, lemon, citrus, or tea can be used on the
bandage or secondary dressing, but not directly on the wound
bed itself. Scented candles and burning oils, as well as kitty lit-
ter and coffee grounds placed throughout the patient's home
may help to mask the odor.
Frequent dressing changes and
proper disposal of waste products is also recommended since
saturated dressings can harbor odor.
Debridement is useful in fungating wounds with large amounts
of necrotic tissue. Sharp wound debridement is contraindicated
because of the risk for potential bleeding and malignant cell
seeding. Autolytic debridement is preferred because it avoids
the risk for bleeding and it can be promoted with any dressing
regimen that maintains a moist wound surface. Autolytic de-
bridement may occur naturally where devitalized tissue eventu-
ally separates on its own.
Larval therapy has been suggested
for use in fungating wounds by Thomas and colleagues
but no
Aromatherapy is another option
for odor management.
Improving Quality of Care Based on CMS Guidelines 45
Key Points
• As a WOC nurse, it is necessary to understand the etiology
and presentation of fungating wounds so that they can
be accurately assessed and managed.
• Management of fungating wounds focuses on controlling
pain, cutaneous irritation, exudate, bleeding, odor, and
psychosocial issues.
• There is a need for further research by WOC nurses so that
patients can be managed more effectively.
Correspondence: Kelli J. Bergstrom, BSN, RN, ET, CWOCN,
The James Cancer Hospital and Solove Research Institute,
300 W 10th St, Starling Loving Hall Rm M200, Columbus,
OH 43210 (
1. Clark J. Metronidazole gel in managing malodorous fungating wounds.
Br J Nurs. 2002; 11(6):54–60.
2. Lookingbill DP, Spangler N, Helm KF. Cutaneous metastases in patients with
metastatic carcinoma: a retrospective study of 4020 patients. J Am Acad
Dermatol. 1993; 29:228–236.
3. Lookingbill DP, Spangler N, Sexton FM. Skin involvement as the presenting sign
of internal carcinoma. J Am Acad Dermatol. 1990; 22:19–26.
4. Seaman S. Management of fungating wounds in advanced cancer. Semin Oncol
Nurs. 2006; 22(3):185–193.
5. Hampton S. Managing symptoms of fungating wounds. J Community Nurs.
2004; 18(10):20–28.
6. Grocott P. Palliative management of fungating wounds. J Wound Care. 1995;
7. Collier M. Management of patients with fungating wounds. Nurs Stand. 2000;
8. Grocott P. Care of patients with fungating malignant wounds. Nurs Stand. 2007;
21(24):57–58, 60, 62.
9. Wilson V. Assessment and management of fungating wounds: a review. Br J
Community Nurs. 2005; 10(3):S28–S34.
10. Dowsett C. Malignant fungating wounds: assessment and management.
Br J Community Nurs. 2002; 7(8):394–400.
11. Burns J, Stephens M. Palliative wound management: the use of a glycerine
hydrogel. Br J Nurs. 2003; 12(6):S14–S18.
12. Krajnik M, Zbigniew Z, Finlay I, Luczak J, Van Sorge AA. Potential uses of topical
opioids in palliative care- report of 6 cases. Int Assoc Stud Pain. 1999; 80(1-2):
13. Grocott P. The Palliative Management of Fungating Malignant Wounds. Paper
presented at the meeting hosted by SAWMA and ASTN at the Queen Elizabeth
Hospital; 2003.
14. Draper C. The management of malodor and exudate in fungating wounds.
Br J Nurs. 2005; 14(11):S4–S12.
15. Nazarko L. Malignant fungating wounds. Nurs Res Care. 2006; 8(9):402–406.
16. Adderley UJ, Smith R. Topical agents and dressings for fungating wounds.
Cochrane Database Syst Rev. 2007;(2):CD003948. DOI:
17. Bauer C, Geriach MA, Doughty D. Care of metastatic skin lesions. J Wound,
Ostomy, Continence Nurs. 2000; 27(4):247–251.
18. Tanner AG, Owen ERTC, Seal DV. Successful treatment of chronically infected
wounds with sugar paste. Eur J Clin Microbiol Infect Dis. 1988; 7:524–525.
19. Newton H. Using sugar paste to heal postoperative wounds. Nurs Times. 2000;
20. Pieper B. Honey-based dressings and wound care: an option for care in the United
States. J Wound, Ostomy, Continence Nurs. 2009; 36(1):60–68.
21. Blair SE, Coccetin NN, Harry EJ, Carter DA. The unusual antibacterial activity of
medical-grade leptospermum honey: antibacterial spectrum, resistance and
transcriptome analysis. Eur J Clin Microbiol Infect Dis. 2009; 28(10):1199–1208.
22. Gribbons CA, Aliapoulios MA. Treatment for advanced breast carcinoma. Am J Nurs.
1972; 72(4):678–682.
23. Welch LB. Simple new remedy for the odor of open lesions. RN. 1981; 44(2):42–43.
24. Jones M, Andrews A, Thomas S. A case history describing the use of sterile larvae
(maggots) in a malignant wound. World Wide Wounds [serial online]. February 14,
1998; Available from: CINAHL Plus with Full Text.
25. Lund-Nielsen B, Muller K, Adamsen L. Malignant wounds in women with breast cancer:
feminine and sexual perspectives. J Clin Nurs. 2005; 14:56–64.
26. Lo SF, Hu WY, Hayter M, Chang SC, Hsu MY, Wu LY. Experiences of living with a
malignant fungating wound: a qualitative study. J Clin Nurs. 2008; 17(20):2699–2708.
27. McDonald A, Lesage P. Palliative management of pressure ulcers and malignant wounds
in patients with advanced illness. J Palliat Med. 2006; 9(2):285–295.
28. Laverty D. Fungating wounds: informing practice through knowledge/theory. Br J Nurs.
2003; 12(15):S29–S40.
29. Kirsner R. Malignant wounds. Wound healing perspectives: a clinical pathway to
success. 2007;4(1):1–8.
Printed with permission from the Journal of Wound, Ostomy & Continence Nursing.
January/February 2011; 38(1):31–37.
Medline’s Pressure Ulcer Prevention Program now has a
component designed specifically for the perioperative services.
The easy-to-use interactive CD addresses the following:
• Hospital-acquired conditions
• CMS reimbursement changes
• Best practices for pressure ulcer prevention
• Perioperative assessment tools
• Critical patient and equipment risk factors
Pressure Ulcer
©2011 Medline Industries, Inc.
Medline is a registered trademark of Medline Industries, Inc.
Download a QR Code Reader app
Launch the QR app
Scan this QR Code or visit
Now on
Medline University
A new online education course:
“Proper Perioperative Positioning
to Prevent Patient Injuries”
PLUS an interactive virtual
simulation competency!
Register at
to get started.
They’re lurking in ...
Remember the old riddle, “Where do most pressure ulcers
occur?” The answer is — in the ambulance!
Well, the truth is pressure ulcers do occur in the ambulance — and lots of other places you
might not even think about, including the operating room (OR). In fact, the pressure ulcer
incidence rate as a result of surgery may be as high as 66 percent
and 42 percent of all
hospital-acquired pressure ulcers are occurring in surgical patients.
Here are some more daunting facts:
• 37 percent of patients undergoing head or neck surgery develop sacral ulcers
• Cardiac, general vascular and open heart surgeries have a high incidence of occiput
and heel ulcers
• 72 percent of perioperative pressure ulcers occur on heels
The following types of surgical patients are at greater risk
for pressure ulcers:
• Neonates
• Elderly
• Malnourished
• Morbidly obese
• Patients with chronic diseases
• Patients with existing pressure ulcers
by Cynthia A. Fleck, RN, BSN, MBA,
The Operating Room
and Beyond!
Improving Quality of Care Based on CMS Guidelines 47
48 Healthy Skin
Perioperative risk factors for
pressure ulcer development
Certain conditions specific to the surgical experience can
also contribute to the risk of pressure ulcers. Some of
these conditions include blood volume loss, temperature,
time and moisture.
Blood volume loss. Blood volume loss and shunting can
increase the hazard of pressure ulcers and lack of blood
flow to the lower extremities.
Temperature. Another consideration is the cold OR envi-
ronment. The body will likely shunt blood away from the
skin into the trunk of the body to protect the vital organs,
which can be dangerous to the skin. The use of warming
blankets tends to occur in lengthy procedures. These can
be helpful to prevent cooling of the body, which can con-
tribute to pressure ulcers, however, the blanket should be
covered with a sheet.
Time. Increased time in the OR is associated with
increased pressure ulcer development as well.
lasting between three and four hours had pressure ulcer
incidence rates of 5.8 percent; seven or more hours had
incident rates of 13.3 percent,
and there is a significant
increase in pressure ulcer incidence for operations lasting
longer than eight hours.
Moisture. We all know moisture can wreak havoc on the
skin and predispose individuals to pressure ulcers, so it is
recommended that pooling of any fluid or blood be moni-
tored intraoperatively. It is suggested that the OR surface
have minimal linens or layering. There are also novel OR
products available (modern-day “chux” that are super
absorbent) that can actually absorb large volumes of fluid
and remain dry to the touch, thus protecting the patient’s skin.
Evaluating surgical surfaces
Always remember that no matter where a patient’s body
resides, pressure ulcers can develop rapidly. OR surfaces
should be evaluated before each case, and the Association
of periOperative Registered Nurses (AORN) guidelines
recommend using pressure redistribution surfaces for
surgeries lasting longer than two-and-a-half hours.
In fact, I recently had foot surgery, and my surgeon origi-
nally thought it would last only a couple of hours. Lo and
behold, it lasted three hours and 45 minutes, and although
I am a fairly young, well-nourished and healthy individual,
I succumbed to a Stage II perioperative pressure ulcer. The
Perioperative tips for avoiding pressure ulcers
• Assure that the OR table or surface is of
sufficient size to support the patient –
especially important for obese patients whose
bodies may be larger than the average size
OR surface
• Lift – do not drag – the patient from surface
to surface.
• Monitor pressure points when possible during
“time outs”
Post-operative considerations for avoiding
pressure ulcers
• Be aware of a possible delay in visualization
due to bandages and other monitoring
• Prolonged immobility or confinement to a bed
or chair increases pressure ulcer risk
Improving Quality of Care Based on CMS Guidelines 49
lesson to be learned: because there is no guarantee how
long a surgery will take, a pressure redistribution surface
should be available in every operating room.
There are high-quality surfaces that self-adjust (Figure 1),
provide a stable environment for the surgeon and OR staff
to work and conform to the patient’s body. Some of these
surfaces contain the same type of visco or viscoelastic
memory foam many of us sleep on in our own bedrooms.
When evaluating various surfaces, ask the vendor about
the warranty, weight limits, cleaning instructions and com-
parative data such as pressure mapping. This will help you
make an educated decision regarding your purchase.
Important steps to take after surgery
At the hand-off to the post-anesthesia care unit (PACU) it
is advisable to:
• Clean and dry the patient’s skin
• Conduct a post-op skin assessment, noting:
- Skin irritation
- Discoloration
- Bruising
- Swelling
• Provide a thorough report including:
- Results of pre-surgery risk factors and potential
new risks that developed during surgery
- Results and skin assessment performed before,
during and after surgery
- How long the surgery lasted
Pressure ulcer risk in ancillary services
There is also high risk for pressure ulcers in ancillary
• Radiology
• Renal dialysis
• Cardiac and vascular procedure laboratories
The problem is that until awareness is increased, we will
continue doing what we always did, and patients will con-
tinue to develop pressure ulcers.
Patients undergoing lengthy radiology procedures have a
53.8 percent incidence of pressure ulcers. Emergency
departments are another area of risk, with 40 percent of
patients admitted through the emergency department at
risk for pressure ulcer development.
The average emergency department patient waits six to
eight hours lying on a stretcher that usually consists of two
to three inches of open-celled foam and an uncomfortable
non-conformable cover that can contribute to the devel-
opment of pressure ulcers.
This is especially important now that acute care facilities
are financially responsible for acquired pressure ulcers –
which can be quite costly. Many hospitals have instituted
a comprehensive program to prevent pressure ulcers
across the continuum, including the OR, ED and ancillary
areas. Introducing a tool kit on average can reduce a facility’s
Figure 1
AORN guidelines recommend using
pressure redistribution surfaces for
surgeries lasting longer than 2
/2 hours.
50 Healthy Skin
pressure ulcers by 70 percent while substantially increas-
ing the knowledge of licensed staff and nurse assistants.
Take your knowledge and pass it on
Consider sharing this article with the emergency depart-
ment, ancillary areas such as the cath lab, dialysis and
other high-risk area personnel, and of course with the
ambulance companies where your patients could be at
risk. If you are on a skin care committee, get the other
members involved, as these care areas present jeopardy that
can be easily mitigated.
When we ask ourselves the age-old question of where
all the pressure ulcers are occurring, now we have more
ammunition to fight the battle. And yes, the ambulance,
with its tiny vinyl-covered two-inch, foam mattress may
be part of the problem. The good news is that we have
answers and products that can make positive change
About the author
Cynthia Ann Fleck, RN, BSN, MBA,
CWS, DNC, CFCNis a certified wound spe-
cialist, dermatology advanced practice
nurse, certified foot and nail care nurse,
writer, speaker, a past president and chair-
man of the board for the American Acad-
emy of Wound Management (AAWM), past
director for the Association for the Ad-
vancement of Wound Care (AAWC), and Vice President, Clinical
Marketing for Medline Industries, Inc. Cynthia can be reached at
1. Recommended practices for positioning the patient in the perioperative
practice setting. In: Perioperative Standards and Recommended Practices.
Denver, CO: AORN, Inc; 2010.
2. Beckrich K, Aronovitch SA. Hospital-acquired pressure ulcers: a comparison
of costs in medical vs. surgical patients. Nursing Economics. 1999;
3. Recommended practices for positioning the patient in the perioperative
practice setting. In: Perioperative Standards and Recommended Practices.
Denver, CO: AORN, Inc; 2010.
4. Recommended practices for positioning the patient in the perioperative
practice setting. In: Perioperative Standards and Recommended Practices.
Denver, CO: AORN, Inc; 2010.
5. Keller C. The obese patient as a surgical risk. Seminars in Perioperative
Nursing. 1999; 8(3):109-117.
6. McEwen DR. Intraoperative positioning of surgical patients. AORN Journal.
1996; 63(6):1058-1063, 1066-1075, 1077-1082.
7. Papantonio C, Wallop J, Koldner K. Sacral ulcers following cardiac surgery:
incidence and risks. Adv in Wound Care. 1994;7(2):24-36.
8. Aronovitch S. Intraoperatively acquired pressure ulcer prevalence: a national
study. J Wound Ostomy Continence Nursing. 1999;26(3):130-136.
9. Ratliff C, Rodeheaver G. Prospective study of the incidence of OR-induced
pressure ulcers in elderly patients undergoing lengthy surgical procedures.
Adv Skin Wound Care. 1998;11(suppl 3):10.
10. Allman RM, Goode PS, Burst N, Bartolluci AA, Thomas DR. Pressure ulcer
hospital complications and disease severity: impact on hospital costs and
length of stay. Advances in Skin & Wound Care, 1999;12(1):22-30.
11. Tarpey A, Gould D, Fox C, Davies P, Cocking M. Evaluating support surfaces
for patients in transit through the accident and emergency department.
J Clin Nurs. 2000;9(2):189-198.
12. Armstrong DG, Ayello EA, Capitulo KL, Fowler E, Krasner DL, Levine JM, et
al. New opportunities to improve pressure ulcer prevention and treatment:
implications of the CMS inpatient hospital care present on admission (POA)
indicators/hospital-acquired conditions policy. J Wound Ostomy Continence
Nurs. 2008. 35(5):485-492.
Improving Quality of Care Based on CMS Guidelines 51
Download a QR Code Reader app
Launch the QR app
Scan this QR Code or visit
52 Healthy Skin
Download a QR Code Reader app
Launch the QR app
Scan this QR Code or visit
Urinary tract infections (UTIs) are the most common HAIs;
80 percent of these i nfecti ons are attri butabl e to an
i ndwelling urethral catheter.
catheter management system helps providers reduce the
risk of infection by combining evidence-based principles and
training with an innovative one-layer tray design.
Arkansas Methodist Medical Center
Clinicians at Arkansas Methodist Medical Center (AMMC), one
of the first hospitals to implement the ERASE CAUTI system,
are using the program to change the way they assess and
perform urinary catheter insertions. Since implementing the
program a year ago, the Paragould, Ark., hospital has seen a
21 percent reduction in catheterizations and CAUTIs.
Medline’s ERASE CAUTI Foley catheter management system, featuring a revolutionary
one-layer tray design, is helping hospitals “Get to Zero” – reducing hospital-acquired infections
(HAIs) through improved education about evidence-based practices. Launched just 18 months
ago, the ERASE CAUTI program is used by more than 250 hospitals across the country,
helping to significantly reduce the risk of catheter-associated urinary tract infections (CAUTIs)
and cut Foley catheter use and related costs by an average of 20 percent.
ERASE CAUTI Program Helps
Hospitals Reduce Catheter
Use by 20 Percent
Revolutionary Foley Catheter Tray
Education Helps Improve Patient Safety
"The one-layer tray design is labeled in a specific sequence
that helps guide our nurses during the catheterization
process to adhere to current CDC recommendations,
including aseptic technique," said Lisa Bridges, RN, infec-
tion preventionist for AMMC. "To help us reduce catheteri-
zations, we are requiring our entire nursing staff to take the
program education on the alternatives to catheterization.
Plus, the new tray has a checklist to help the nurse make a
decision on whether catheterization is appropriate for the
patient and to assure the education transfers into everyday
clinical practice."
As measured by the number of catheterizations performed in
March and April 2009 versus the same time in period in
Improving Quality of Care Based on CMS Guidelines 53
54 Healthy Skin
2010, AMMC reduced the number of catheterizations from
192 to 151, a 21 percent drop (based on adjusted patient
day). This decrease contributed to the hospital achieving
zero CAUTIs in April 2010, compared to three in April 2009,
according to Bridges.
Another leading factor causing CAUTI is leaving a catheter in
place for more than two days after surgery.
The Surgical
Care Improvement Project (SCIP) recommends removal of
catheters within 24-48 hours post-operatively. In the first
quarter of 2009, only 20 percent of the catheters AMMC
placed in the O.R. were being removed within two days. With
the implementation of the ERASE CAUTI program, the
removal rate increased to 50 percent in the first quarter
of 2010.
"With the Foley InserTag and checklist sticker placed on the
patient's chart, nurses and physicians knew exactly when
the catheters had been placed," said Bridges, "and were
abl e to remove them i n the necessary 24-48 hours
after surgery."
Also, included in the tray is a patient education care card that
looks like an actual get well card. According to Bridges, the
card is a more effective way to educate patients about the
procedure, including the risks and complications associated
with closed system Foley catheters.
"Before, we had to print our education from the computer,
and it was not something the patient or the clinician normally
took time to review," said Bridges. "The patient care card
has significantly improved our ability to provide patients and
families with a tool to help them better understand the proper
care and maintenance of the catheter, signs and symptoms
of CAUTI and how they can help reduce the chances of
developing CAUTI."
Floyd Medical Center
To help reduce its CAUTI rates, Georgia-based Floyd Med-
ical Center is utilizing the innovative tray, along with facility-
wide physician and nurse education on the appropriate use
of catheters and the importance of avoiding catheters when
not medically necessary. The initiative has led to an 83 per-
cent reduction in CAUTIs and a 23 percent decline in the
number of catheterizations performed at the hospital. In
recognition of its accomplishments, the 304-bed non-profit
teaching hospital in Athens, GA., earned first place in VHA
Georgia’s 2010 Clinical Excellence award category.
“We forged a hospital-wide initiative focused on reducing
catheter use and related urinary tract infections,” said Darrell
Dean, D.O., M.P.H., medical director for clinical and operational
performance improvement at Floyd Medical Center. “The
Medline tray has many design elements and product
enhancements that were integral in our program to reduce
variation in practice and achieve our goal of reducing
Dr. Dean cited the kit’s larger sterile barrier drape and one-layer
tray design (versus the industry standard two-layer tray) as
important factors to helping the nursing staff maintain aseptic
technique. He also pointed to the tray’s checklists as vital
tools to CAUTI prevention – one that helps document a valid
clinical reason for inserting a catheter and another that
reviews the proper steps to catheter insertion. Upon
completion, the checklists are then added to the patient’s
chart for proper documentation of insertion.
Unity Hospital
Unity Hospital, a 340-bed nonprofit facility in Rochester, New
York, is experiencing similar results with the ERASE CAUTI
program. According to data from the hospital, the facility
reduced its urine nosocomial infection markers (NIMs) 32

To help us reduce
catheterizations, we
are requiring our entire
nursing staff to take
the program education
on the alternatives
to catheterization.
Improving Quality of Care Based on CMS Guidelines 55

We forged a hospital-
wide initiative focused
on reducing catheter
use and related urinary
tract infections...
percent in August 2010 compared to the same time period
in 2009. The associated cost for each urine NIM marker is
$3,637, which demonstrates a significant cost-avoidance
following the introduction of the ERASE CAUTI program,
according to Unity Hospital. Urine NIMs are an electronic
marker that uses sophisticated algorithms to analyze existing
microbiology laboratory and patient census data to identify
hospital-acquired infections.
Although we had a low CAUTI rate in 2009, after imple-
menting the ERASE CAUTI program, rates continue to trend
downward,” said Erica Perez, Unity’s clinical educator. “The
program ties in education, nursing power and a new indus-
try product that promotes best processes by reinforcing the
CDC guidelines to decrease the opportunity for a CAUTI to
According to Perez, the hospital began using the ERASE
CAUTI program because it identified gaps in standardization
and knowledge regarding the proper insertion technique and
clinical indications for using a Foley catheter.
“The Medline program offered the tools to reduce the incon-
sistencies we observed in the technique nurses used to
insert catheters due to differing protocols at previous facili-
ties where nurses have practiced, variance in how nurses
were initially taught the procedure and different types of Foley
trays nurses have used in the past," Perez said.
Perez emphasized that Medline’s one-layer tray presents the
procedure components in an intuitive manner, guiding the
nurse through the procedure from left to right. The innovative
tray also makes it easier to maintain aseptic technique since
all the components are in one tray versus the traditional
two layers.
The hospital staff also took advantage of the program’s
online education, which reinforced aseptic technique through
learning modules and an interactive competency tool the
clinicians used to demonstrate knowledge of proper Foley
insertion technique. To date, more than 500 nurses at Unity
have completed the education classes via Medline’s e-learn-
ing site Medline University –
These online modules have been added to the hospital’s
clinical orientation as a mandatory core competency for new
nursing staff.
Following a successful trial period last summer, the program
was rolled out facility-wide to all acute care units in August
“The implementation of the ERASE CAUTI program has
helped us improve the standard of care for patients receiv-
ing a Foley catheter and has reduced the risk of CAUTI,” said
Perez. “The reduction in urine NIMs indicates fewer patients
may be at risk for developing a CAUTI.”
1 Lo E, Nicolle L, Classen D, Arias A, Podgorny K, Anderson DJ, et al. SHEA/IDSA
practice recommendation: strategies to prevent catheter-associated urinary tract
infections in acute care hospitals. Infect Control Hosp Epidemiol. 2008;29:S41–S50.
2 Wald HL, Ma A, Bratzler DW, Kramer AM. Indwelling urinary catheter use in the
postoperative period: analysis of the national surgical infection prevent project data.
Arch Surg. 2008; 143:551-557.
What did we do after
designing a revolutionary
new catheter tray system?
We found THREE more ways
to make it even better.
We’re obsessed with engineering new and better
technology for healthcare workers. So after we
revolutionized the outdated Foley catheter tray with
a unique, one-layer system design, we immediately
turned our attention to addressing how we could
make it even easier to use. We studied how the
tray was being used in the field. The result was
three more great improvements.
Combined with the previous innovative tray redesign
and comprehensive ERASE CAUTI education, these
three new features help to improve patient safety and
quality, while reducing avoidable costs associated with
waste and urinary tract infections.
©2011 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.
Download a QR Code Reader app
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A checklist that fits better
in the medical record
The reformatted checklist is smaller, making
it easier to place in the paper chart or
attach to the electronic medical record.
Education you’ll want to present
to your patient
There’s nothing like the new Patient
Education Care Card. Designed to look
and feel like a “Get Well Soon” card, it
tells patients about catheterization so
they know you are providing them the
best care possible.
Real photography on the outside –
so you know exactly what’s inside
A photo on the package helps identify the
contents of the kit, serves as an educational
tool for the clinician and can be used to
discuss the procedure with the patient.
Also, the label opens up to a booklet with
step-by-step instructions and helpful tips
for the clinician.
Sometimes, you just need a buddy. Buddy
the Brave lion cub is here to help your youngest
catheter patients. Along with some serious patient
(and parent) education resources, you’ll find some
upbeat fun and even a bravery award sticker in
every tray.
But it’s more than just fun. There’s published evidence
that distraction helps children tolerate unpleasant
procedures better than adult reassurance does.
You trust Medline for clinical innovations, such as our
industry-leading catheter tray design. Now, we can be
your patient’s buddy, too.
Introducing Medline’s new
Pediatric Catheter Tray. The
latest addition to the innovative
ERASE CAUTI product line.


Bravery Sticker
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©2011 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.
Download a QR Code Reader app
Launch the QR app
Scan this QR Code or visit

Visit for
24 nursing home administrator courses.
Topics include:
• Diabetes
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• Pressure Ulcer Prevention
• Spend Management
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trademarks of Medline Industries, Inc.
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A Guide to
MDS 3.0 Section H
by Amin Setoodeh, BSN, RN
• List the changes in section H from MDS 2.0 to 3.0
• State the intent of section H
• Describe how to conduct the assessment for urinary
• Describe how to conduct the assessment for bowel
Now that facilities across the U.S. have put the first six months
of the transition from MDS 2.0 to MDS 3.0 behind them, it may
be time to evaluate systems for what is working or what might
need improvement. Although we may use the word “coding”
when we talk about the MDS, it is important to remember that
what we are actually doing is an assessment. The MDS is not
meant to be a comprehensive assessment, but to identify
potential problems that lead to further investigation, assessment,
care planning and treatment. In addition, MDS 3.0 lies at the
center of regulatory reporting and RUG reimbursement. All of this
makes accurate completion critical. Regular education of everyone
on the interdisciplinary team can help with accuracy, speed, and
regulatory compliance in addition to the benefits of better care.
This article covers MDS 3.0 Section H, Bladder & Bowel, and
can be used for ongoing training as well as ideas for i mprove-
ment of this important aspect of care.
As with other sections of the MDS, the change from 2.0 to 3.0
for Bladder & Bowel (Section H) reflects the focus on individual-
ized resident care and clinical relevance. Management of incon-
tinence in long-term care facilities has a major impact on the
emotional and physical well-being of the resident; and few will
argue that it is not challenging for staff. With new questions
surrounding toileting plans, CMS, through the new MDS,
supports a focus on promoting continence, rather than
simply managing the incontinence. In order to improve the
continence of your residents, you must proactively increase
awareness of causes and treatments of incontinence with staff,
residents and families. Team members with longevity in long-
term care may need encouragement to embrace new
approaches to continence management that reflect a change
in the culture of long-term care as well as clinical evidence
and research.
Note: Your main source of information for completing the resi-
dent assessment instrument is the Long-Term Care Facility Res-
ident Assessment Instrument* User’s Manual for MDS 3.0. You
should have a copy of the manual handy and read the instruc-
tions for Section H before attempting to complete the section.
Furthermore, you may download the RAI user’s manual at the
CMS MDS 3.0 training website. Please keep in mind, it is your
responsibility to check CMS website for any updates or revisions
to the RAI User’s Manual.
Improving Quality of Care Based on CMS Guidelines 61
Continued on page 63
Survey Read|ness
This webinar gives a QIS overview and demonstration on how the abaqis
system can
help prepare for both the traditional and QIS survey processes. This demonstration also
highlights how abaqis
• Rich reporting capabilities to identify which care areas to target for
quality improvement
• Root cause analysis on a facility-wide or individual-resident basis, enabling
prioritization and focusing of interventions for maximum impact
• Emphasis on information reported by residents and families to help identify
the needs of residents, aiding your efforts to improve consumer satisfaction
Now with the new Stage 2 module featuring:
• A dashboard view of triggered care areas based on data collected
using abaqis
Stage 1 Suite
• Investigative tools to determine deficiencies in triggered care areas
Quality Assurance
System Webinar
Download a QR Code Reader app
Launch the QR app
Scan this QR Code or visit
Improving Quality of Care Based on CMS Guidelines 63
Changes from 2.0 to 3.0 – A review
There are several significant changes in the MDS Section H:
• MDS 3.0 calls for a 7-day look-back period for the actual
coding of continence versus MDS 2.0’s 14-day
look-back period
• Now includes trial toileting programs for individuals who
are identified to be incontinent or at risk to become
incontinent. This may be a major change and challenge
for your facility if you do not have a well-defined system for
implementing a toileting program
• Urinary incontinence and fecal incontinence toileting programs
are addressed separately
• A resident’s response to the toileting program is captured,
allowing CMS to collect and perhaps report data on the
success of toileting plans across the nation’s nursing facilities
• Questions concerning urinary toileting programs (H0200)
should use a look-back period to the most recent
admission/readmission assessment, the most recent prior
assessment, or to when incontinence was first noted
• MDS 3.0 clears up the confusion about the wording
of continence items such as coding residents with an
catheter indwelling as “continent”
• Fecal impaction was dropped as a specific item from Section
H and constipation is addressed with a yes or no response
There are two main goals for MDS 3.0 Section H
• The first goal is to gather the specifics of a resident’s
continence status: including use of bowel and bladder
appliances, degree of urinary and fecal continence, use of
and response to urinary toileting programs and bowel patterns
• The second goal is that each resident who is incontinent or
at risk of developing incontinence is identified, assessed,
and provided with an individualized treatment plan. These
interventions may include medication, behavioral treatments,
containment devices and services to achieve or maintain
as normal elimination function as possible
Facilities across the nation have delved deeply into their systems,
processes, procedures and protocols to prepare for 3.0. This
analysis is a great opportunity to embrace a different approach
for the management of incontinence. The goal should be to identify
the specific root of the issue in order to develop an individualized
nursing intervention with focus on promoting normal bladder and
bowel function.
Is this occurring in your facility? Look at your current incontinence
management program and establish:
• Do you have a clear protocol to collect the required
information necessary for completion of section H?
• Do you have a continence management team?
• Do you have a specific toileting protocol with a focus on
promoting normal bowel and bladder function?
• Are you able to conduct a complete bowel and bladder
assessment to identify the specific type of incontinence?
• Are you considering the resident’s elimination patterns to
develop an individualized nursing intervention for toileting?
• Does the staff understand the differences between the
different types of urinary incontinence?
If the answer to any of the above questions is no or maybe, there
is an opportunity to modify your current incontinence manage-
ment program to promote compliance with the intent of CMS
F315 and the MDS 3.0.
Completion of MDS 3.0 Section H
Section H0100 Appliances
It is important to know what appliances are in use and the history
and rationale for such use. Item H0100 records the appliances
that were in use during the standard 7-day look-back period by
asking you to check all that apply.
64 Healthy Skin
To determine the urinary or bowel appliances used in the look-
back period, examine the resident to note the presence of any
urinary or bowel appliances. Furthermore, review the medical
record for current or past use of urinary or bowel appliances.
Some areas of potential confusion are spelled out in the RAI
• Suprapubic catheters and nephrostomy tubes are indwelling
catheters and should not be coded mistakenly as an ostomy.
• Even if used occasionally (e.g. daytime only), condom
catheters (men) and external urinary pouches (women) should
be coded properly as external catheters.
• Ostomies used for feeding, such as gastrostomy, should not
be coded in section H which is strictly for elimination ostomies.
The MDS is designed to collect information to assist your clinical
team to develop resident-centered care plans. When developing
care plans for urinary and bowel appliances, consider interven-
tions that are consistent with the resident’s goals and minimize
complications associated with the use of the appliances. Every
effort should be taken to assure the appliances fit well, are com-
fortable and promote the resident’s dignity.
External catheter – Make sure the catheter fits well and it is
comfortable; look for leakage and implement your facility guide-
lines to promote and maintain skin integrity. This is particularly
important when the product involves adhesive. As always, be
sure you are promoting resident dignity by explaining the ration-
ale for use of the appliance and making sure the device is con-
cealed properly.
Indwelling catheter – Verify there is a valid medical justification
for use of the indwelling catheter and consider the risk and ben-
efits of use as well as the duration of use. Furthermore, consider
the potential complications resulting from the use of an indwelling
catheter such as:
• Increased risk of urinary tract infection
• Blockage of the catheter with associated bypassing of urine
• Pain / discomfort
• Damage to the urethra
Mitigate the potential complications by including interventions in
the resident’s care plan such as the CDC’s recommended guide-
lines for securement of the catheter to the skin and maintaining
unobstructed urine flow.
Ostomy – Inspect the peristomal skin for redness, tenderness,
denudation and skin breakdown and monitor the site routinely.
If possible, ask the resident to report any discomfort.
Section H200 Urinary Toileting Program
The questions in H0200, Urinary Toileting Program, capture three
aspects of a resident’s toileting program:
A. Whether a toileting program has been attempted for this
resident since urinary incontinence was noted in this facility
B. The resident’s response to the trial program (improvement
or otherwise)
C. Whether a toileting program is currently being used to
manage a resident’s urinary incontinence
Why the focus on toileting programs? According to the CMS, an
individualized, resident-centered toileting program may decrease
or prevent urinary incontinence, minimizing or avoiding the neg-
ative consequences of incontinence. In fact, research has
shown that anywhere from one quarter to one third of residents
participating in an active individualized toileting program will
regain normal bladder function or will experience a reduction
Appliances and Definitions from the RAI Manual
• Indwelling Catheter - A catheter that is maintained within
the bladder for the purpose of continuous drainage of urine.
• External Catheter – A device attached to the shaft of
the penis like a condom for males or a receptacle pouch
that fits around the labia majora for females. It connects to
a drainage bag
• Intermittent Catheterization - Insertion and removal
of a catheter through the urethra for bladder drainage. (Note:
Please keep in mind that a one-time catheterization to obtain
a urine specimen during the look-back period does not
qualify as intermittent catheterization).
• Suprapubic Catheter - An indwelling catheter that is placed
by a urologist directly into the bladder through the abdomen
• Nephrostomy Tube - A catheter inserted through the skin into
the kidney in individuals with an abnormality of the ureter or
the bladder
• Ostomy - Any type of surgically created opening of the
gastrointestinal or genitourinary tract for discharge of
body waste
• Urostomy - A stoma for the urinary system used in cases
where long-term drainage of urine through the bladder and
urethra is not possible
• Ileostomy - A stoma that has been constructed by bringing
the end or loop of small intestine out onto the surface of
the skin
• Colostomy - A stoma that has been constructed by
connecting a part of the colon onto the anterior abdominal wall
Improving Quality of Care Based on CMS Guidelines 65
in the episodes of incontinence, which may improve quality of
life, lower cost and reduce the required time of care.
Despite myths to the contrary, many incontinent residents will
respond positively to a toileting program as long as the program
is developed based on the individual’s specific type of inconti-
nence, voiding pattern and cognitive ability. Although staff may
expect toileting programs to be more successful with residents
who do not have cognitive impairment, cognitive status has not
been shown to be a predictor of success with a prompted void-
ing program. [What is a predictor of success? A positive re-
sponse to a short (usually 3-day) trial of prompted voiding!
Those residents who successfully urinate in the toilet for 66 per-
cent or more of the prompts by nursing staff will often continue
to be continent during an active prompted voiding program.]
Also note that a toileting program should not be dismissed
because it is only effective during the day. Daytime continence is
certainly a “win,” and the program should continue even though
there are barriers to continence during the night.
CMS Definitions
The following toileting interventions may be used to promote
as much normal elimination possible or reduce the episodes
of incontinence:
• Habit Training/Scheduled Voiding - A behavior technique
that calls for scheduled toileting at regular intervals on
a planned basis to match the resident’s voiding habits
or needs.
• Bladder Rehabilitation/Bladder Retraining - A behavioral
technique that requires the resident to resist or inhibit the
sensation of urgency (“the strong desire to urinate”), to
postpone or delay voiding, and to urinate according to
a timetable rather than to the urge to void.
• Prompted voiding - Regular monitoring with encouragement
to report continence status using a schedule and promoting
the resident to toilet. Provide positive feedback when the
resident is continent and attempts to toilet.
In order to develop effective toileting programs for your residents,
establish an assessment process in your facility that includes a
focus on determining the specific type of urinary incontinence.
This information not only is required as per F-Tag 315 regulatory
guidelines, but it is also necessary to help the staff provide an
individualized program. For example, bladder retraining might be
the first program considered for urge incontinence; similarly,
scheduled voiding may be the intervention of choice for over-
flow incontinence. Although “type of incontinence” is not asked
for on the MDS instrument, it plays a critical role in development
of the toileting program and overall continence management.
What qualifies as a toileting program?
RAI 3.0 Manual refers to a toileting program as
• Organized, planned, documented, monitored, and evaluated
• Consistent with the nursing home’s policies and procedures
and current standards of practice
As such, the toileting program needs to be documented in the
medical record and must be based on each resident’s specific
assessment and voiding pattern. The nursing interventions must
be resident-specific and communicated to the staff for imple-
mentation. The response to the treatment must be documented.
CMS makes it clear that the following are not toileting programs:
• Simply tracking continence status with a voiding record
• Changing pads or wet garments
• Assistance with toileting or hygiene without a resident-specific,
documented and communicated plan
Coding H200A for Urinary Toileting Program Trial
When assessing for a toileting program trial (H200A), review the
medical record for evidence of a trial of an individualized, resi-
dent-centered toileting program such as bladder retraining,
prompted voiding, habit training/scheduled voiding (see box for
those behavioral programs defined in the RAI manual). A proper
toileting trial should include observations of at least three days of
toileting patterns with prompting to toilet and documentation of
the results in a bladder record or voiding diary. In MDS 2.0, pres-
ence of a toileting program was often checked without evidence
of a real program. MDS 2.0 also failed to account for and report
on those residents who had an unsuccessful trial. MDS 3.0 was
written to correct these issues as well as separate toileting pro-
grams from appliances.
Code 0 (No) if the resident did not undergo a toileting trial. This
includes residents who are continent of urine on their own as well
as those who are continent with assistance. You will also code 0
(No) for residents who use a permanent catheter or ostomy as
well as residents who prefer not to participate in a trial.
66 Healthy Skin
Code 1 (Yes) for those residents who did partake in a toileting
program trial at least once since admission, readmission, prior
assessment or when urinary incontinence was first noted in your
Code 9 (Unable to determine) if records cannot be obtained to
determine if a trial toileting program has been attempted. If 9 is
coded here, you’ll skip H0200B and go to H0200C, where you
will be asked about whether a current toileting program or trial is
in process.
Section H0200B Response to Toileting Program
You found information in the resident’s record regarding a toilet-
ing program trial – so, what was the outcome of that trial?
H0200B asks for the resident’s response – whether there was
improvement in continence. To assess the outcome of the toi-
leting trial, review the resident’s responses as recorded during
the trial. Note any changes in the number of incontinence
episodes and degree of wetness the resident experiences. Your
look-back period for H0200B should be based on the most
recent admission/readmission assessment, the most recent prior
assessment or when incontinence was first noted. While there is
no clear definition of what is considered improvement, the RAI
Manual suggests that one less incontinent episode per day could
be considered a success.
Tracking Elimination Patterns
If your facility does not have a comprehensive continence man-
agement program that includes successful toileting program
interventions, one of the most important improvements to pro-
mote toileting should start with tracking and recording voiding
patterns. Voiding patterns are important in assessment, devel-
opment of individualized care plans and ongoing monitoring of
toileting programs. Without one it would be difficult for the staff
filling out the MDS H0200B regarding the response to a resi-
dent’s toileting trial. Voiding records may help detect urinary pat-
terns or intervals between incontinence episodes while allowing
the clinical team to help the resident avoid or reduce the fre-
quency of episodes. If regular and consistent documentation of
elimination is a standard aspect of care in your facility rather than
a rare occurrence; complete and accurate voiding diaries will
become the norm.
When implementing a new voiding record system, meet with all
the staff involved in the process. Clearly highlight the expecta-
tion and how the staff should document and communicate with
each other. Voiding records will be used for several reasons – so
consider a process that makes it easy for assessment, care plan-
ning, and MDS completion. Because the records are instrumen-
tal in developing individualized care, educate the clinical team on
how to use the information gathered. Start with a few residents
at time and designate a staff member to document and report all
findings by end of the shift. To encourage proper documenta-
tion, use a new copy of the form for each shift.
When Coding Section H0200B
Code 0 (No improvement) if the frequency of the resident’s uri-
nary incontinence did not decrease during the toileting trial.
Code 1 (Decreased wetness) if the resident’s urinary inconti-
nence frequency decreased, but the resident remained inconti-
nent. Keep in mind there is no quantitative definition of
improvement. However the improvement should be clinically
meaningful, such as reduction of at least one less incontinent
void per day than before the toileting program was implemented.
Code 2 (Completely dry) if the resident becomes completely
continent of urine, with no episodes of urinary incontinence dur-
ing the toileting trial. For residents who have undergone more
than one toileting program trial during their stay, use the most
recent trial to complete this item.
Code 9 (Unable to determine or trial in progress) if the
response to the toileting trial cannot be determined because
information cannot be found or because the trial is still in progress
Section H200C – Current Toileting Program
This final question in the toileting program section asks for cur-
rent toileting program information about the resident. Here, the
look-back period is seven days and specifically uses four days as
the determinant for whether the coding is Yes or No. If an indi-
vidualized toilet plan was used more than four days out of the
last seven, then you would code yes.
C. Current toileting programor trial - Is a toileting program (e.g., scheduled toileting, prompted voiding, or bladder training) currently
being used to manage the resident's urinary continence?
0. No...
1. Yes.
Enter Code
Improving Quality of Care Based on CMS Guidelines 67
Make sure to review the medical record for evidence of a resi-
dent-specific toileting program being used to manage inconti-
nence during the 7-day look-back period. Note the number of
days that the toileting program was carried out during the look-
back period. Remember that a successful individualized toilet-
ing program could be a daytime toileting plan with a resident
preference to treat nighttime incontinence with incontinence
products or pads.
A final note on Toileting Programs – consider reevaluating a res-
ident whenever there is a change in cognition, physical ability or
urinary tract function.
Section H0300 Urinary Continence
This segment of MDS 3.0 documents a resident’s urinary incon-
tinence status. Although the majority of residents admitted to
long-term care facilities may experience urinary incontinence,
caregivers need to remember how much incontinence can im-
pact the quality of life for an individual. That is why, in 1995, the
original MDS 2.0 included information regarding the resident’s
continence status to trigger one of 16 Resident Assessment Pro-
tocols (RAPs) the goal of which was to develop a complete and
individualized care plan for incontinence management. Unfortu-
nately, 15 years later, far too many residents in the United States
have a canned continence care plan of “check and change.”
CMS recognizes the following negative effects of incontinence:
• Increased risk of long-term institutionalization
• Increased risk of repeated urinary tract infections
• Interference with participation in activities
• Social embarrassment
• Increased feelings of dependency and depression
• Increased risk of falls and injuries resulting from attempts
to reach a toilet unassisted
Part of the education of your staff should be what constitutes
incontinence versus continence. Caregivers should understand
that any voluntary void into a toilet, commode, urinal or bedpan
is considered a continent episode. This is true even if assisted by
nursing staff or as the result of a toileting program. The key here
is voluntary. Urinary incontinence, on the other hand, is any
involuntary loss of urine.
To code section H0300, begin with reviewing the medical record
such as physician history, physical examination, nursing assess-
ments, progress notes, bladder records or flow sheets for doc-
umentation of incontinence during the 7 day look-back period.
Consult with the responsible nursing staff regarding the resident’s
incontinent incidents. Interview the resident, if able, regarding
his/her continence or with family members if the resident is
unable to share this history.
MDS coding makes a distinction between occasionally inconti-
nent, frequently incontinent and always incontinent. The new
MDS 3.0 definitions of these three for coding purposes have
changed from 2.0’s definitions as well as dropping a fourth 2.0
“usually continent” category altogether. Confusion about whether
to code an individual with an indwelling catheter as continent has
been eliminated. Instructions for coding intermittent catheteriza-
tion are included in the RAI manual: you will want to code conti-
nence level based on continence between those intermittent
Code 0 (Always continent) if throughout the 7 day look-back
period the resident has been continent of urine without any
episodes of incontinence
Code 1 (Occasionally incontinent) if during the 7-day look-
back period the resident was incontinent less than 7 episodes
Code 2 (Frequently incontinent) if during the 7-day look-back
period the resident was incontinent of urine 7 or more episodes,
but had at least one continent void. This includes incontinence of
any amount of urine – daytime or nighttime
Code 3 (Always incontinent) if during the 7 day look-back
period, the resident had no continent voids
Code 9 (Not rated) if during the 7-day look-back period the res-
ident had an indwelling bladder catheter, condom catheter,
ostomy, or no urine output. This includes residents on chronic
dialysis with no urine output for the entire 7 days.
H0400 Bowel Continence
Fecal incontinence also has a major impact on quality of life, very
similar to urinary incontinence. Bowel incontinence may inter-
fere with participation in activities; it may be embarrassing and
can lead to increased feelings of dependency and defeatism.
Furthermore, bowel incontinence may increase the risk of long-
term institutionalization and skin breakdown.
68 Healthy Skin
To conduct a complete bowel assessment, start by reviewing the
medical record, including physician notes, physical examination,
nursing assessments, progress notes and bowel records/incon-
tinence flow sheets. Interview residents if they are capable of dis-
cussing their bowel habits. Speak to the family members if the
resident is unable to report on continence. The nursing assis-
tants who care routinely for that resident are another source of in-
formation. For coding purposes, even a temporary bowel
incontinence precipitated by loose stools or diarrhea from any
cause including a stomach ailment, laxatives or other medica-
tions would count as incontinence. This is another point to stress
to those charged with completing bowel and bladder records.
To complete the coding of H0400:
Code 0 (Always continent) If throughout the 7-day look-back
period the resident has been continent of bowel on all occasions
of bowel movements, without any episodes of incontinence
Code 1 (Occasionally incontinent) If during the 7-day look-
back period the resident was incontinent of stool once. This
includes bowel incontinence of any amount during the day or night
Code 2 (Frequently incontinent) If during the 7-day look-back
period the resident was incontinent of bowel more than once but
had at least once continent bowel movement. This includes
incontinence of any amount of stool day or night
Code 3 (Always incontinent) If during the 7-day look-back
period the resident was incontinent of bowel for all bowel move-
ments and had no continent bowel movements
Code 9 (Not rated) If during the 7-day look-back period the res-
ident had an ostomy or did not have a bowel movement for the
entire 7 days
H0500 Bowel Toileting Program
Item H0500 documents whether a toileting program is being
used to manage a resident’s fecal incontinence. There has been
significantly more research on the impact of toileting programs on
urinary incontinence than for fecal incontinence. What few stud-
ies have been done suggest some of the following items to con-
sider when creating your continence program:
• Many residents take medications that cause constipation
• Many treatments for constipation cause or contribute to
fecal incontinence
• The severe straining resulting from constipation may cause
sphincter dysfunctions contributing to fecal incontinence
• The task of toileting residents with constipation averaged over
seven minutes, which may explain why direct care staff may
not prompt or assist in toileting
• Nursing home staff under-detects and thus under-reports
symptoms of constipation
• Prompted toileting programs, along with dietary changes, may
increase the number of bowel movements and the number of
bowel movements in the toilet, but seem to have little effect
on number of fecal incontinence episodes
Despite these factors, a systematically implemented bowel toi-
leting program may decrease or prevent bowel incontinence and
minimize or avoid the negative consequences of fecal inconti-
nence. Many incontinent residents respond to a bowel toileting
program that is modeled after their voiding pattern.
Coding for H0500
Similar to the urinary incontinence program, you should review
the medical record for evidence of a bowel toileting program to
complete item H0500. Look for implementation of an individual-
ized, resident- specific toileting program based on an assess-
ment of the resident’s unique bowel pattern.
You should find evidence that the individualized program was
communicated orally to staff and the resident. The resident’s
response to the toileting program and subsequent evaluations
should also be documented in the medical record.
Code 0 (No) If the resident is not currently on a toileting program
targeted specifically at managing bowel continence
Code 1 (Yes) If the resident is currently on a toileting program
targeted specifically at managing bowel continence
Improving Quality of Care Based on CMS Guidelines 69
H0600 Bowel Patterns
Item H0600 documents whether a resident has experienced any
problems with constipation during the 7- day look-back period.
Whether a resident suffers from constipation is now a yes/no
question in order to highlight this very common problem for res-
idents in long-term care facilities. As noted above, constipation
is a side effect of many medications as well as a consequence of
immobility. The focus of constipation, through the MDS, can help
facilities to detect possible dehydration as well as decrease the
risk of fecal impaction.
Fecal impaction, as a separate question, was eliminated from the
new MDS. The MDS 3.0 validation panel did not consider the
MDS 2.0 question of fecal impaction as reflecting the real inci-
dence of fecal impaction.* Since there was no evidence that this
2.0 question improved reporting or prevention; the MDS turns
its focus on constipation which prompts detection and manage-
ment of constipation, thereby reducing potential of impaction.
Besides leading to fecal impaction, severe constipation may
• Abdominal pain
• Anorexia
• Vomiting
• Bowel incontinence
• Delirium
• Urinary incontinence
Sometimes fecal impaction manifests as fecal incontinence with
watery stool from higher in the bowel (or irritation from the
impaction) moving around the impacted mass, causing soiling.
Education of your staff should include this detail, as it is coun-
terintuitive to look for impaction if there is some, albeit liquid,
The RAI Manual Definitions:
Fecal Impaction: A large mass of dry, hard stool that can
develop in the rectum due to chronic constipation. This mass
may be so hard that the resident is unable to move it from the
Constipation: If the resident has two or fewer bowel movements
during the 7 day look-back period or if most bowel movements
consist of hard stool that is difficult to pass.
To begin the assessment for bowel patterns, review the medical
record including physician history, physical assessment, nursing
notes and bowel records for evidence of constipation. Interview
the resident if possible or speak to the family members. Ask the
direct care staff about problems with constipation.
Code H0600 as follows:
Code 0 (No) If the resident shows no signs of constipation dur-
ing the 7-day look-back period
Code 1 (Yes) If the resident shows signs of constipation during
the 7-day look-back period code (such as two or less bowel
movements or difficult to pass hard stools)
This completes Section H of the MDS. As you have learned, it
gives a snapshot of the resident’s continence status. Because it
is so comprehensive, section H of the MDS truly requires your
facility to develop systems that facilitate the collection and doc-
umentation of bladder and bowel assessment and interventions.
Your interdisciplinary MDS team should analyze the current
process flow and systems to optimize capturing this information
and reduce duplication of efforts and documentation.
An overall goal of the update to the MDS is to increase the rele-
vance of the clinical items, and section H certainly reflects this.
CMS makes it clear that it is important for U.S. nursing home
residents to obtain the highest level of bowel and bladder func-
tion possible. Section H will help you capture those efforts.
* Also, fecal impaction is an incident/event; the MDS attempts to capture
the general condition of the resident.
1. A major change from MDS 2.0 to 3.0 is:
a. 3.0 has a 14-day look-back period for section H
b. 3.0 requires completion of a voiding diary within 30 days
c. 3.0 calls for 7-day look-back period for section H
d. 3.0 has a look-back period of 3 days for voiding diaries
2. Which of the following is not considered a
toileting program?
a. Elimination Recording
b. Habit training
c. Bladder retraining
d. Prompted voiding
3. Residents with catheters should be coded
as continent
a. T
b. F
4. Which of the following should not be coded as an
appliance in Section H?
a. Urostomy
b. Colostomy
c. Ileostomy
d. Gastrostomy
5. Residents should be reevaluated for individualized
continence care plan when there is
a. Change of cognition
b. Change to urinary tract function
c. Change of physical ability
d. All of the above
6. Which of the following is considered an example of
a toileting program by RAI Manual?
a. Toileting according to the residents voiding pattern
b. Changing incontinence product and performing perineal
care when requested by resident
c. Observation and tracking of resident’s bowel and
bladder activity
d. Changing pad or garment every two hours
7. Voiding records can
a. Give the date of first urinary incontinence episode
b. Help detect urinary or fecal voiding patterns
c. Determine Urge Incontinence
d. Report urinary tract infections
8. Residents with dementia are not candidates for a
toileting program
a. T
b. F
9. If a resident has watery stool or some fecal
incontinence, it is impossible for them to have
fecal impaction.
a. T
b. F
10. The following are all risks of incontinence except:
a. Increased risk of long-term institutionalization
b. Increased risk of repeated urinary tract infections
c. Reduction of participation in activities
d. Congestive heart failure
e. Increased feelings of dependency and depression
70 Healthy Skin
A Guide to MDS 3.0 Section H
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Since its inception in 1979, The Skin Cancer Foundation
has always recommended using a sunscreen with a sun
protection factor (SPF) of 15 or higher as one important
part of a complete sun protection regimen. Recent
attacks on sunscreens by the Environmental Working
Group (EWG) and by the media point to imperfections
and potential risks but miss the point that sunscreen con-
tinues to be one of the safest and most effective sun pro-
tection methods available.
We are concerned that the criticisms will raise unneces-
sary fears and cause people to stop using sunscreen,
doing their skin serious harm.
In general, the criticisms have not been based on hard
science. In fact, The Skin Cancer Foundation’s Photobi-
ology Committee, an independent volunteer panel of top
experts on sun damage and sun protection, reviewed the
same studies reviewed by the EWG and found that their
determination of what made a sunscreen bad or good
was based on “junk science.”
Continued on page 76
Chairman Warwick L. Morison, MB, BS, MD, FRCP, Professor of
Dermatology, Johns Hopkins Medical School at Green Spring, MD.
John H. Epstein, MD, Clinical Professor of Dermatology, University of
California at San Francisco.
Heidi Jacobe, MD, Assistant Professor, Dermatology, University of
Texas Southwestern Medical Center at Dallas.
Henry W. Lim, MD, Chairman, Department of Dermatology, Henry Ford
Medical Group, Detroit.
Steven Q. Wang, MD, Director of Dermatologic Surgery and Dermatol-
ogy, Memorial Sloan-Kettering Cancer Center at Basking Ridge, NJ.
Skin Cancer Foundation Sunscreen Statement
74 Healthy Skin
Oar|ng for Yourse|f
Independent outcomes research
was conducted in an
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by using Medline Remedy products exclusively, as part of
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1. Shannon RJ, Coombs M, et al. Reducing hospital-acquired pressure ulcers with a silicone-based dermal nourishing
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©2011 Medline Industries, Inc. Medline and Medline Remedy are registered trademarks of Medline Industries, Inc.
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76 Healthy Skin
Here, the Photobiology Committee responds to the criticisms
and explains why sunscreen remains an essential part of any-
one’s daily sun safety program.
As sunscreen use has gone up in the past 30 years, so has
melanoma incidence. Systematic review of all studies from 1966
to 2003 shows no evidence to support the relationship between
sunscreen use and increased risk of melanoma, the deadliest
formof skin cancer. Actually, some important epidemiological re-
search has indicated that population groups using sunscreen
have reduced their melanoma incidence.
The use of excessive SPFs and terms such as “broad-spectrum
protection” or “multispectrum protection” on sunscreen labels
mislead us into a false sense of security, when sunscreens
really do not protect adequately against UVA radiation.
Because both ultraviolet A (UVA) and ultraviolet B (UVB) are
harmful, you need protection from both kinds of rays. “Broad-
spectrum protection” and “multispectrum protection” mean
only that a sunscreen offers protection against parts of both
the UVA and the UVB spectrum. It does not mean complete
protection. Because there is no consensus on how much pro-
tection the terms indicate, they may not be entirely meaningful.
SPF refers specifically to how much protection is offered
against UVB rays, but to date in the United States, we have no
equivalent measurement to represent the degree of UVA pro-
tection in a sunscreen. Nonetheless, UVA protection in sun-
screen has greatly improved in recent years. To make sure you
are getting effective UVA as well as UVB coverage, look for a
sunscreen with an SPF of 15 or higher, plus some combination
of the following UVA-screening ingredients: stabilized avoben-
zone, ecamsule (also known as Mexoryl), oxybenzone, titanium
dioxide, and/or zinc oxide.
For everyday use, an SPF of 15 or higher is generally adequate,
while SPFs of 30 or higher are appropriate for active, extended
outdoor activity. [BOLD]
An SPF 15 sunscreen screens out 93% of the sun's UVB rays,
whereas SPF 30 protects against 97% and SPF 50 against 98%.
The Skin Cancer Foundation agrees that in most cases, SPFs
beyond 50 are unnecessary.
Sunscreen blocks vitamin D.
Although solar UVB is one source of vitamin D, the benefits of
exposure to UVB cannot be separated from the harmful effects
of sun exposure: skin cancer, cataracts, immune system sup-
pression, and premature aging. In addition, excessive exposure
to the sun actually depletes our body's supply of vitamin D. The
safest way to obtain vitamin D is through a combination of diet
and vitamin D supplements. The Skin Cancer Foundation rec-
ommends increasing your intake of vitamin D to 1,000 mg daily.
The sunscreen ingredient oxybenzone may be a carcinogen.
Old research on rodents suggested that oxybenzone, a syn-
thetic estrogen, can penetrate the skin, may cause allergic re-
actions, and may disrupt the body’s hormones, producing
harmful free radicals that may contribute to melanoma. How-
ever, there has never been any evidence that oxybenzone,
which has been available for 20 years, has any adverse health
effect in humans. The ingredient is approved by the Food and
Drug Administration (FDA) for human use on the basis of ex-
haustive review. The Photobiology Committee reviewed the
studies on oxybenzone and found no basis for concern.
Retinyl palmitate, a form of vitamin A and an ingredient in 41%
of sunscreens, speeds up growth of tumors and other lesions
when exposed to the sun.
The EWG cites an FDA study for these data and faults the FDA
for not releasing the study. However, the FDA is yet to release the
study precisely because it has not gone through proper peer re-
view. Thus, the EWG based its criticisms on an unapproved 10-
year-old study of mice that has never been published in any
Improving Quality of Care Based on CMS Guidelines 77
journal. To date, there is no scientific evidence that vitamin A is
a carcinogen in humans. What's more, only trace amounts of
retinyl palmitate appear in sunscreens, and some evidence sug-
gests that it is actually protective against cancer.
Nanoparticles in micronized zinc oxide and titanium dioxide
may be more harmful than larger forms of these chemicals,
crossing the placenta and affecting the developing fetus, or
causing DNA damage linked to cancer.
Micronized versions of zinc oxide and titanium dioxide were de-
signed to improve them cosmetically so that they no longer left
a tell-tale splotch of white on the skin. This improvement greatly
increased the use of sunscreens containing these ingredients,
which is a good thing because they are the two most effective
ingredients to date in sunscreens against the entire UV spec-
trum. Multiple studies have demonstrated that the nanoparti-
cles in these ingredients do not penetrate the skin, and there is
furthermore no strong evidence of their toxicity. The general sci-
entific consensus (which even the EWG now admits) is that they
pose no risk to human health.
Criticisms have also been leveled against the Skin Cancer
Foundation’s Seal of Recommendation program, saying that
sunscreen companies simply pay for use of the Seal.
In actuality, manufacturers must provide scientific data on their
sun protection product showing that it sufficiently and safely aids
in the prevention of sun-induced damage to the skin. The data
are reviewed by an independent volunteer team of photobiolo-
gists-experts in the study of the interaction between ultraviolet
radiation and the skin. Every sunscreen product awarded the
Seal is monitored annually to ensure that it continues to meet
the criteria. The Seal of Recommendation requirements include:
• an SPF of 15 or greater,
• validation of the SPF number by testing on 20 people,
• substantiated data that the product does not cause pho-
totoxic reactions or contact irritation, and
• substantiation for any claims that a sunscreen is water
sweat resistant.
The Skin Cancer Foundation also awards the Seal to other sun
protection products, such as clothing, window film, awnings,
hats, and sunglasses.
Consumers should rest assured that sunscreen products are
safe and effective when used as directed and should be con-
sidered a vital part of a comprehensive sun protection program
that includes the following sun safety strategies:
• Seek the shade, especially between 10:00 a.m.
and 4:00 p.m.
• Do not burn. Wear a sunscreen with an SPF of 15 or
higher every day.
• Apply 1 oz (2 tbsp) of sunscreen to your entire body 30
minutes before going outside. Reapply every 2 hours or
after swimming or excessive sweating.
• Cover up with clothing, including a broad-brimmed hat
and UV-blocking sunglasses.
• Keep newborns out of the sun. Sunscreens should be
used on babies over the age of 6 months.
• Examine your skin from head to toe once every month.
• See your doctor every year for a professional skin
• Avoid tanning and UV tanning salons.
Printed with permission from the Journal of the Dermatology Nurses’ Association. Sep-
tember/October 2010; 2(5):228-229.
78 Healthy Skin
Diagnosis and staging of pressure ulcers is an important aspect
of clinical practice in healthcare settings, having an enormous
impact on patient health, caregiver utilization effectiveness,
reduction of pain and suffering, and health economic issues.
Major benefits to the patient and the healthcare system can
result if the skin condition is accurately diagnosed and appropriate
actions taken commensurate with the nature of the diagnosis.
The NPUAP Pressure Ulcer Classification System lists four dif-
ferent stages of pressure ulcers and two additional descriptions.
In addition, because the breach of skin to Stage I is preceded by
certain signals, it is of enormous and disproportionate benefit for
active and urgent intervention as soon as these signals are rec-
ognized. Those signals could include a reddened discoloration
on a Caucasian that is blanchable.
Training of nursing and other clinical staff is critical so that these
signals do not go unnoticed. Even if they are noticed, the words
that describe these conditions matter. The use of the right words
to describe these imminently dangerous conditions of skin can
call the nursing staff into action because some well chosen
words, by themselves, can potentially convey a sense of urgency
and provide a call for urgent action.
A Stage I pressure ulcer has been described as “non-blanchable
erythema”. Pressure ulcer development actually occurs before a
pressure ulcer is actually noted; the physiologic changes are
often non-visible to the naked eye and include temperature
changes and itching. (3) Pressure and shear that are causing this
tissue damage must be recognized and considered an alarm to
institute or upgrade prevention measures. (8) Several terms have
been used in clinical literature to describe the condition of skin
immediately before it before it becomes a Stage I (NPUAP) pres-
sure ulcer. The terms “blanchable erythema” (6) or “reactive
hyperemia” (7) have been used to describe this condition. How-
ever, a less frequently used term “Pre-Stage I” has been used
previously and it is the authors’ view that this concept is more
descriptive of the skin condition, and perhaps, a call to urgent
action if such a diagnosis is indeed reached.
This study describes a survey of clinicians whose opinions were
sought about which of a set of three descriptions would be
deemed the most effective call to action steps to prevent further
The objective of this study is the identification of the right
terms to be used for the description of the skin health that
exists just prior to the creation of a Stage I pressure ulcer.
Such a well chosen and “call to action” term to describe a
common condition in clinical settings is appropriate for inclu-
sion, for example, in a skin/wound assessment tool that has
been developed to assist non-expert clinicians in staging and
19 nurses and 11 CNAs in a 30 bed hospital rehabilitation
unit, none of whom would be deemed an expert in wound
assessment and staging, were asked which of the following
terms were more likely to result in immediate preventive
action. Immediate interventions are described as off-loading
heels, turning, and communicating the problem to others.
QUESTION: Which termgives you the best understanding of
a problem that required an immediate active intervention?
Term choices: Blanchable Erythema, Pre-Stage I, Reactive
90%of those subjects surveyed felt that the term“Pre-Stage
I” wound result in preventative action.
Following this survey, the lead author who is a practicing
clinician observed that when “reactive hyperemia” or “blanch-
able erythema” were diagnosed by her in patient documen-
tation, there was less proactive action taken by the subjects
of the survey. Diagnosis described as “Pre-Stage I” resulted
in a far higher frequency of proactive steps such as offload-
ing and patient turning. Quantitative data to support this
observation was not gathered.
The choice of the right term to describe an emergent condi-
tion on the skin is important, because this can be a “call to
action” by its very nature. It appears fromliterature that many
terms have been used to describe the reddening of skin that
is known to precede the formation of the Stage I Pressure
Ulcer. It is felt that all possible steps are worth considering in
preventing this crucial first stage of damage to skin.
PRE-STAGE I: An obvious, more descriptive, and clinically
impactful term than “Reactive Hyperemia” or “Blanchable
Erythema” in describing the state before Stage I
Improving Quality of Care Based on CMS Guidelines 79
From this survey based research, it appears that the respon-
dents strongly felt that the use of the term “Pre-Stage I” is
appropriate for the typical reddening of the skin that precedes
a Stage I pressure ulcer. Other terms used clinically to de-
scribe the same condition did not seem to have the same
call-to-action urgency that the use of the term “Pre-Stage I”
had in the opinion of the respondents.
Though quantitative data on the observation was not col-
lected, actual diagnosis as Pre-Stage I skin conditions led to
a higher level of proactive steps being taken to prevent further
deterioration, compared to the diagnosis as either “blanch-
able erythema” or “reactive hyperemia.”
Based on the findings of this study, the authors recommend
that the term “Pre-Stage I” is most appropriate in clinical sit-
uations and for inclusion in any staging tool that is created to
augment the current state of the art in wound assessment
and staging.
1 National Pressure Ulcer Advisory Panel and European Pressure Ulcer
Advisory Panel. Prevention and treatment of pressure ulcers: clinical practice guideline.
Washington DC: National Pressure Ulcer Advisory Panel; 2009.
2 Bhattacharya SB. Pressure Ulcers –Kansas Reynolds Program in Aging. Kansas
University School of Medicine.
3 Sharp CA and McLaws M-L, A discourse on pressure ulcer physiology: the implications
of repositioning and staging. World Wide Wounds 2005.
4 Porter A, Cooter R. Surgical management of pressure ulcers. Primary Intention
5 Kosiak M. Etiology and pathology of ischemic ulcers. Arch Phys Med Rehabil 1959;
40(2): 62-9.
6 Edlich RF, Winters KL, Woodard CR, Buschbacher RM, Long WB, Gebhart JH, and Ma
EK. Pressure Ulcer Prevention. Journal of Long Term Effects of Medical Implants.
7 Sanders W, Allen RD. Pressure Management in the Operating Room: Problems and
Solutions. Managing Infection Control 2006;6(9):63-72.
8 Defloor T, Schoonhoven L, Fletcher J, Furtado K, Heyman H, Lubbers M, Lyder C and
Witherow A. Pressure Ulcer Classification Differentiation Between Pressure Ulcers and
Moisture Lesions. EPUAP Statement. accessed 2-10-2011.
Nancy Estocado, PT, CWS
Margaret Falconio West BSN, RN, APN/CNS, CWOCN
Debashish Chakravarthy, PhD
Sunrise Hospital, Las Vegas, NV
Medline Industries, Inc. Mundelein, IL
Patient A1 – small
area of discoloration
(redness) noted on
the heel
Patient A2 – using a
clear disk to assess
the area, note the
blanching or lightening
of the red area
Patient B1 –
reddened area on
the heel
Patient B2 – using
the clinician’s finger,
note the blanching of
the area
80 Healthy Skin
Improving Quality of Care Based on CMS Guidelines 81
Time flies. In just 21 months, the federal government will start
penalizing hospitals with higher than expected readmission rates.
And even though much about the regulations-to come remains
unclear, clinicians along the care continuum are scrambling to
get ready.
Or they should be. It’s not just important for a hospital’s bottom
line. It’s important for the patient.
We’ve been talking with some of the nation’s experts on the sub-
ject, including Stephen F. Jencks, M.D., whose April 2009 article
in the New England Journal of Medicine set the tone for today’s
readmission prevention energy. His review of nearly 12 million
beneficiaries discharged fromhospitals between 2003 and 2004
found that nearly 21 percent, or one in five, were re-hospitalized
within 30 days and 34 percent were readmitted within 90 days.
We also spoke with Amy Boutwell, MD, an internist at Newton-
Wellesley Hospital in Newton, MA and Director of Health Policy
Strategy for the Institute for Healthcare Improvement; Timothy
Ferris, MD, medical director of the Massachusetts General Physi-
cians Organization, and Estee Neuhirth, director of field studies
at Kaiser Permanente in California.
Some of these strategies aren’t yet proven to work in all settings,
of course. And many are still in the demonstrations phase. But
with national readmission rates as high one in five, and higher for
certain diseases, many providers are trying anything that sounds
Here are some of the prevention strategies that these and other
experts think might be worth a shot. Many involve—to a greater
or lesser degree —following the patient out of the hospital,
Ways to
Reduce Hospital
By Cheryl Clark
for HealthLeaders Media
December 27, 2010
Continued on page 83
©2011 Medline Industries, Inc.
Medline is a registered trademark
of Medline Industries, Inc.
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Improving Quality of Care Based on CMS Guidelines 83
either in-person, electronically, or by phone, but others involve
upside-down introspection and re-evaluation by providers along
the care continuum.
1. Discharge Summaries
Dictate discharge summaries within 24 hours of discharge.
Boutwell says that standard practice and policy at most hospi-
tals is that discharge summaries are completed within 30 days
of the discharge. “I was trained that the summary is a retro-
spective report of what happened in hospitalization. But what we
need today is anticipatory guidance. Patients get discharged and
go home. They can’t fill their meds, insurance doesn’t cover the
med or they have questions. They’re nervous and worried. They
call their primary care provider, who didn’t even know they were
Boutwell says that 30-day-discharge summary policies “might
have sufficed in a time gone by. But that doesn’t work anymore.
Information needs to be available at the time of discharge.
There’s a growing recognition of this need, but staff bylaws
haven’t changed.”
2. Lengthen the Handoff Process
At every juncture in patient care process, especially discharge,
have teams talk to each other about the patient. And by the way,
don’t call them discharges. Call them “transitions.” Standardize
them for a variety of providers, from hospital to rehabilitation
facility to skilled nursing facility to home and back.
Boutwell says that “taking this person-centered approach shifts
the concept from discharge, which is a moment in time and
you’re done with it, to a transition—a shared accountability. We
need to make sure the receiving providers understand who this
patient is, with a 360-degree view.
Jencks adds that “senders and receivers, for example hospital
discharge planners and skilled nursing facility staff and home
health” meet often enough so they can learn about the realities
of the transitions they initiate and receive.
3. Provide Medication on Discharge
Send the patient home with a 30-day medication supply,
wrapped in packaging that clearly explains timing, dosage,
frequency, etc. Some health centers with Medicaid patients may
be trying this strategy, which is difficult for hospitals to do with
Medicare patients because of distinctions between Part A and
Part B payment. Still, for some high-risk populations, such as
patients with congestive heart failure and those who have been
readmitted before, it might be worth it for the hospital to absorb
the cost.
4. Make a Follow-up Plan Before Discharge
Have hospital staff make follow-up appointments with patient’s
physician and don’t discharge patient until this schedule is set
up. A key is to make sure the patient has transportation to the
physician’s office, understands the importance of meeting that
time frame, and following up with a phone call to the physician
to assure that the visit was completed.
5. Telehealth
We couldn’t find anyone using video monitors to communicate
on a daily basis with the use of such software as Skype, for
example, but some readmission experts say it’s an interesting
approach to keep up visual as well as verbal communication with
patients, especially those that are high risk for readmission.
On a more practical scale, Home Healthcare Partners in Dallas
uses health coaches, intensive care clinicians, and wireless tech-
nology to record vital signs on a daily basis for about 2,100
discharged Medicare fee-for-service beneficiaries for between
84 Healthy Skin
60 to 120 days. So far, they have done this for about 7,000
unduplicated patients in the last two years, for several hundred
hospitals in Dallas and Louisiana, says HHP’s CEO, Wayne Bazzle.
The target population for intense monitoring includes those with
four or five co-morbidities and who have a primary diagnosis of
congestive heart failure, chronic obstructive pulmonary disease,
diabetes, Alzheimer’s and hypertension.
Bazzle says that the effort involves phone calls of between five
and 15 minutes, and is frequent enough with the same team“so
we have their trust. We can help them stay out of the hospital if
they'’re more truthful with us about what’s going on, and if we
see some deterioration, we can help them cope. Normally it’s a
medication management issue, or they’ve become a little too
relaxed with their diet.”
6. Identify Frequent Flyers
Customize your hospita’s admission and re-admission rates for
demographic and disease characteristics to identify those at
highest risk, and expend extra resources on their care needs.
This may involve special programs for homeless patients, such
as the one effort by a cohort of Los Angeles hospitals who grap-
pled with how to safely discharge homeless patients without
violating city laws.
The Los Angeles project nowdischarges homeless patients who
meet certain criteria to a half-way type of house in nearby Bell,
and saved $3 million for hospitals in its first few months. Expan-
sions in other parts of Southern California are underway.
7. Understand What's Happening After Discharge
Kaiser Permanente is using video cameras to chronicle home
settings and the entire care process to determine what’s
happening to the patient after discharge that provoked a
The team is also using video of the care team, from the phar-
macist, home care providers, nurses, and physicians about their
care of that patient, to highlight wrinkles and cracks in the
system that brought the patient back to the hospital.
So far, Kaiser officials say that the video project has contributed
to a reduction in readmission rates at some hospitals where it
has been tried, such as from 15.7 percent to 9 percent at
Kaiser’s South Bay Medical Center near Los Angeles, because
it gave the team information to streamline care, says Kaiser’s
8. Provide Home Care on Wheels
Just like Meals-on-Wheels can be scheduled in advance, so can
case management, housekeeping services, transportation to the
pharmacy and physician’s office. At Piedmont Hospital in Atlanta,
in collaboration with the Area Agency on Aging, patients having
elective knee surgery get coupons and prescheduling, “so that
by the time you get out of the hospital, it’s waiting there for you,”
Boutwell says. She adds that this kind of a pre-arrangement for
post-transition care is “spreading like wildfire” among a number
of hospitals, but so far it’s mainly being tried with elective
Many strategies involve—to a greater or lesser
degree —following the patient out of the hospital,
either in-person, electronically, or by phone.
Improving Quality of Care Based on CMS Guidelines 85
9. Consider Physician Medication Reconciliation
A recent paper in the New England Journal of Medicine by Yut-
ing Zhang of the University of Pittsburgh noted the wide geo-
graphic variation among physicians’ prescribing practices with
medications that should be avoided in patients over age 65. She
also noted variation in prescribing practices for drugs that have
a high risk for negative drug-disease interaction.
Jencks says that Zhang and colleagues “are pointing us to a
rather important gap in the most common thinking about transi-
tions—that we are to make sure that patients are able to get and
take medications, get recommended follow-up, and generally do
as they are told. But we know that medication plans can be in
life-threatening error, that physicians often recommend a time-to-
follow-up that is too long, that discharge plans are often written
in ignorance of the patient’s pre-admission history and experi-
ence. In general, we need to be much more critical of the plans
patients get.”
10. Make Sure Patients Understand
Patients may nod, and say they understand what they’re sup-
posed to do after they leave the hospital. But “teach back,” in
which they and their caregivers repeat back those instructions,
even to more than one hospital caregiver, needs to be constantly
reinforced, readmission experts say. Jencks says that caregivers
need to understand that their patients are often heavily med-
icated, stressed, groggy and confused. And that their disease
state may impair their ability to understand what they are being
told, much less remember it two days later.
11. Focus on Highest-risk Patients
Examine the readmission patterns at your hospital and see which
patients, with which conditions, diseases or procedures, have
the most readmissions. If resources are limited as they are at
most hospitals, push them toward a select group of patients in
a more intense way to see if increased effort makes a difference.
For example, in his New England Journal of Medicine paper,
Jencks showed that for certain diseases or conditions, and in
certain parts of the country, readmission rates are even higher
than the national average of one in five. For example, for med-
ical patients, the readmission rate for heart failure patients was
27 percent; for those with psychoses, 24.6 percent; chronic
obstructive pulmonary disease, 22.6 percent. Patients with
pneumonia and gastrointestinal problems were re-hospitalized
at rates of 21 percent and 19.2 percent respectively.
For surgical patients, those with vascular surgery had the high-
est readmission rate, 23.9 percent, followed by those with hip or
femur surgery, 17.9 percent. Perhaps these are the places where
readmissions can be most quickly reduced.
States with the Highest Hospital Readmission Rates
Washington, D.C. 23.2%
Maryland 22%
Louisiana 21.9%
New Jersey 21.9%
Illinois 21.7%
West Virginia 21.3%
Kentucky 21.2%
Mississippi 21.1%
Missouri 20.8%
New York 20.7%
Massachusetts 20.2%
Oklahoma 20.1%
12. Listen to the Patient
Involve the emergency room, hospice or home health providers
to make sure patients don’t come to the emergency room for
non-emergent end-of-life care issues. Providing patients and
their family members with informed choices, opportunities for
advance directives, and counseling in the emergency roomsetting
may avert painful, unnecessary admissions. Look for this to be
a major expansion of palliative care professionals inside the ED.
“There really needs to be a care plan that reflects the patient’s
wishes,” Jencks says. “This is quite different from either a med-
ical power of attorney or what is often called a living will because
it lays out the goals of treatment.
“Cure? Palliation? Functional independence? Playing dominoes
with friends? Hospice? This kind of plan has little relevance to
persons without substantial chronic conditions, but it is totally
relevant to a patient with one or more chronic conditions that
have required hospitalization. With such a plan, one can often
avoid readmissions that really do not serve the patient’s needs or
values. What is, after all, worse than a readmission? Readmission
of a patient who does not want to be readmitted,” Jencks says.
Reprinted with permission from HCPro, Inc. (February 2011) Copyright
HCPro, Marblehead, MA. For more information, call 800/639-7477 or visit
Improving Quality of Care Based on CMS Guidelines 85
©2011 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.
Introducing Medline’s New
A wide variety of tools to help you provide
individualized continence care
Incontinence is one of the most costly and labor intensive
issues in nursing homes and long-term care facilities.
Despite years of research and clinical efforts to improve
it, the prevalence of incontinence remains high.
Medline has created this Continence Management
Program to help long-term care facilities develop
individualized continence programs for residents and
comply with Medicare regulations.
The program includes:
• RN/LPN workbook with 4 CE credits
• CNA workbook
• Reproducible care plans, assessment
guidelines and other quality assurance tools
Download a QR Code Reader app
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Replaces Compass
Box F315
Improving Quality of Care Based on CMS Guidelines 87
By Joyce Norman, BSN, RN, CWOCN, DAPWCA
How should I assess a lower extremity wound?
Where do I start?
We suggest breaking your assessment down into
three simple steps.
STEP 1. Inspect the lower extremity,
and note your findings. (See also chart.)
Venous leg ulcers tend to be weepy, swollen (edema),
exhibit “normal” hair growth, cause severe pain or heav-
iness, appear in the gaiter area. They can be irregularly
shaped and have heavy drainage.
Arterial wounds have an absence of hair growth, occur
along with muscle wasting, change color with position
changes, show temperature changes, often appear on
the tips of toes or on the ankles, lateral aspect of foot
and the shin, they have a round wound bed appearance
and light to no drainage. They usually develop from a
mi nor trauma, such as bumpi ng the extremi ty on
a device.
Pressure ulcers exhibit “normal” hair growth, appear
usually over a bony prominence, have a round wound
bed and can have light to no drainage or heavy drainage.
Diabetic foot ulcers go along with muscle wasting, can
appear on the tips of the toes (usually because of ill-fit-
ting shoes), cause severe pain or no pain, show temper-
ature changes, occur on the ankles, have a round wound
bed (especially if a callous is also present) and exhibit
light to no drainage.
Regu|ar Feature
Assessing Lower Extremity Wounds
Characteristic Your Wound Venous Leg Pressure Arterial Diabetic Foot
Ulcer (VLU) Ulcer (PU) Ulcer (DFU)
Weepy lower extremity X
Edema lower extremity X
Normal hair growth X X
Lack of hair growth X X
Muscle wasting X X
Wounds on tips of toes X X (ill-fitting
Severe pain X X
Lack of pain X
Color changes with X X X
position changes
Temperature changes X X
Gaiter area X
Ankle X X X
Round wound bed X X X (typically
with callous)
Irregularly shaped wound X
Heavy drainage X X
Light to no drainage X X X
Over a bony prominence X
STEP 2. Touch the extremity, especially
bony prominences.
This is something that can easily be done as care is pro-
vided not just during bathing. Feel the heels when reposi-
tioning or turning. Note the temperature of the extremity
as compared to the other leg. Is the skin dry? Does it feel
and look good? Or is the skin overly moist?
STEP 3. Use the information you have gathered
to help determine the type of wound.
Wounds on the foot are frequently related to neuropathy
and diabetes. Although neuropathy can develop from
other causes, many times it is related to diabetes. These
foot wounds are commonly called diabetic foot ulcers
(DFU). “Diabetic” wounds can also appear on the ankle.
For diabetics, it is just as bad to wear ill-fitting or worn out
shoes as it is to wear no shoes at all. If your patient/resi-
dent has decreased sensation in the feet, he or she may
not realize footwear that is rubbing on the skin and form-
ing a blister or that a foreign object such as a tack or peb-
ble could be causing a problem. These wounds are
typically small in nature and present with a callous ring
around them. They will not always have a reliable Ankle
Brachial Index (ABI) study, as the small vessels could be
calcified, resulting in a non-reliable measurement. Also,
due to the neuropathy, the pain will vary from absent to
very severe.
Circulation problems
When caring for patients with factors that can affect their
circulation, we want to understand that not only can this
cause problems like stroke (CVA), or heart issues, (MI,
atrial fib, hypertension, hyperlipidemia), it can also have
an impact on their lower extremities. Some signs and
symptoms to be aware of include:
• Atrophy of the calf muscle, with a straight
or stove pipe appearance to leg
• Lack of hair
• Diminished or absence of pulses
• Color changes with position
• Temperature changes (feet cooler)
These can be indications that the patient has lost blood
flow to the lower extremity, and minor injuries, such as
simply bumping their shin on a chair or bed, might result
in a wound that will not heal. This is where the diminished
blood flow has affected the lower leg, and the end result
is a wound.
88 Healthy Skin
Are you facing a skin or wound care
dilemma with a patient or resident?
Call Medline’s Educare Hotline at 888-701-SKIN (7546)
to discuss a wound care issue with one of our
experienced wound care nurses. The hotline is available
Monday through Friday, 8 am to 5 pm, Central Time.
Skin changes
Changes in the skin and edema are additional problems
that can be assessed easily. Skin changes might include:
• Edema below the knee, which resolves
with elevation
• Red or ruddy colored skin, especially around
the ankle area
• Wounds or scars that start at the ankle
These are classic signs and symptoms of venous hyper-
tension, and can be resolved with elevation, education
about proper ambulation and compression.
There can be other problems with the lower extremities as
well, which may require a specialist, such as a surgeon,
lymphedema therapist, dermatologist or others.
Always remember that wounds are abnormal. The patient
may have a wound that can be easily resolved with the
correct treatment. In cases where a wound or skin prob-
lem is not resolving despite comprehensive care, some-
thing else may be wrong, and the patient will require
further assessment.
©2011 Medline Industries, Inc. Medline and Marathon are registered
trademarks of Medline Industries, Inc.
Problem: Peristomal Irritation
Solution: Marathon
Cyanoacrylate Liquid
Skin Protectant
Peristomal irritation can lead to decreased wear time, pain
and embarrassment about leakage. So it only makes
sense to do everything you can to protect the peristomal
area. Marathon Liquid Skin Protectant helps protect
against irritation and maceration by creating a barrier
against moisture and chemical assault.
Marathon, a cyanoacrylate, bonds to the skin surface,
integrating with the epidermis on a molecular level to
seal in moisture. While other skin protectants may flake
off, Marathon stays in place, offering robust protection
and increased wafer wear time.
Stoma site before
treatment with Marathon.
Same stoma site after
treatment with Marathon.
\ Cy∙an∙o∙a∙cry∙late \
A fast-acting adhesive that bonds with the skin
to create a barrier against moisture and friction.
1. Data on file
Download a QR Code Reader app
Launch the QR app
Scan this QR Code or visit
Ventilator-Associated Pneumonia
can be deadly.
VAPrevent can be easy.
follows IHI
Ventilator Bundle
guidelines. With
this checklist,
you can too.
Sequential dispensing
system and thumb grip for
easy, one-at-a-time access
— in the right order
The three parts of the VAPrevent program you’ll want to know:
Only Medline gives you these three options for oral care: IHI-recommended
chlorhexidine gluconate (CHG), the alcohol-free moisturizing of Biotene
or the proven antisepsis of hydrogen peroxide. Procedure kits feature
innovative components, like graduated suction catheters and toothbrushes
with integrated gum and tongue scrubbers. Breakthrough package design
communicates and educates, all while leaving less waste behind. And the
intuitive stack-pack design with its one-at-a-time dispenser makes it easy
for caregivers to stay on track with care protocols.
When your staff knows how to use a product appropriately, its effectiveness
increases greatly. That’s why Medline developed the Medline VAP program,
which helps build knowledge and clinical skills with educational modules
for both novice and experienced clinicians, as well as an online interactive
competency for oral care. A program manager helps you implement your
program and stays active as you progress, providing 90-day reports to
help you track your incidence of VAP.
If you expected a VAP program this innovative would come at a price
premium, you’re in for a pleasant surprise. VAPrevent from Medline
comes to you for five to ten percent lower than competitors. In a tough,
pay-for-performance environment, VAPrevent represents a major value.
1 Bingham M, Ashley J, De Jong M, Swift C. Implementing a unit-level intervention to reduce the probability
of ventilator-associated pneumonia. Nursing Research. 2010; 59(1): S40-S47.
2 Trouillet J, Chastre J, Vuagnat A, Joly-Guillou M, Combaux D, Dombret M, et al. Ventilator-associated
pneumonia cased by potentially drug-resistant bacteria. Am J Respir Crit Care Med. 1998. 157(2):531-539.
©2011 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.
Clear visuals let
you identify the
right kit quickly
for your patient’s
VAPrevent is a comprehensive system to give your staff the tools to deliver excellent oral
care. And for ventilator patients, excellent oral care may be part of the difference between
ventilator-associated pneumonia and staying healthy.
Evidence-based innovation in oral care for ventilator patients
Download a QR Code Reader app
Launch the QR app
Scan this QR Code or visit
92 Healthy Skin
Make Your Facility a Greener Place to Work
Did You Know?
• The National Institute for Occupational Safety and
Health (NIOSH) estimates that eight to 12 percent of
all healthcare workers have become allergic to latex.
The likelihood of nurses developing asthma during
their career is 2.17 times greater if they used powdered
latex gloves. Latex-free gloves offer a safe alternative
and, with new technology, many feel just like latex.
• Disinfecting and sterilizing agents and housekeeping
chemicals can build up on surfaces and in the air each
time cleaning or disinfecting occurs, and may lead to
asthma, allergies, and other, more serious health
problems. Besides using alternative products, facilities
can increase education and awareness for staff on
proper use and handling of chemicals. When mercury-
containing equipment breaks, mercury vapors are
spread through the air of a room where nurses work
and breathe. Eliminate mercury-containing equipment
wherever possible at your facility.
• 90 percent of nurses report workplace exposure to
the most commonplace healthcare hazards, which
include hand and skin disinfection products. Products
nurses use to clean or moisturize a patient’s skin or hair
can contain ingredients that may be hazardous. Several
safe alternatives exist that are not only safer for patients
and staff, but have less impact on the environment.
Improving Quality of Care Based on CMS Guidelines 93
Environmental health is a concern for every nurse. Latex, chemical cleaners and disinfectants,
deodorizers, and skincare products all have been linked with allergies, skin or eye irritation and/or
asthma. Talk to your materials manager about implementing policies that support a healthier
work environment.
For more information on Medline’s Sustainability Program, contact
Francesca Olivier at 847-643-3821 or
1 Environmental Working Group website. Nurses’ workplace exposures. Available at Accessed April 26, 2011.
Learn More and Take Action
Join the EnviRN Knowledge Network, the online learning
resource for nurses concerned about environmental health.
It is made possible by the Alliance of Nurses for Environ-
mental Health (ANHE), a national organization of nurses and
nursing organizations working to promote healthy people
and healthy environments by educating and leading the
nursing profession, advancing research, incorporating
evidence-based research and influencing policy. Here are
just a few things you can do at
• Take the Nurses Pledge: By making simple changes
in your everyday life, you can live and work in healthier
environments. EnviRN is asking nurses to make three
personal changes and three changes where you work.
• Click on “Essentials” for an introduction to the intersection
of environmental health nursing practice.
• At “Hazards A – Z” you will find a library on
environmental hazards and the health concerns they
trigger, along with news articles and educational
Speo|a| Feature
94 Healthy Skin
3,100 Miles. 57 days. $208,613
The Wound, Ostomy and Continence Nurses Society
(WOCN), partnering with one of its founding members Dr.
Katherine Jeter, age 72, embarked on one of its most
comprehensive fundraising initiatives to date: Raising
$208,613 in scholarship funds to support the continued
education of WOC nurses.
Katherine began her journey with intensive training begin-
ning in 2010, and then she traveled 3,100 miles by bicycle
from San Diego, CA to St. Augustine, FL from March 4,
through April 29, 2011.
Dr. Jeter and WOCN!
San Diego, CA
Experience Katherine’s journey day by day
Speo|a| Feature
Improving Quality of Care Based on CMS Guidelines 95
With Age Comes Satisfaction
“Although I’ve given up a lot of things this past year, I’m
completely satisfied with what I’ve gained. Many ask me,
“Has it been worth it?” In other words, have I sacrificed
things that I wish I had not? I won’t lie, I have missed some
things this past year, including entertaining friends at our
mountain home and some of the ski season, but it was all
worth it.
“I’ve grown as a person. I’m working on maintaining a
healthy physique to prevent the recurrence of breast cancer.
I have met a whole group of new friends. And I hope I'm
encouraging young and old alike to be active.
I may be retired, but that doesn’t mean I should sit around
and do nothing. It feels good to work toward growing as
an individual, while giving back.”
Opposite page: Evonne Fowler, MSN, RN, CNS, CWOCN, sends
Katherine off with a smile at the start of the trip in California.
Above: Medline Clinical Education Specialist Kim Kehoe, BSN,
RN, CWOCN, DAPWCA congratulates Katherine at the finish line
in Florida.
St. Augustine, FL
How to
96 Healthy Skin
Improving Quality of Care Based on CMS Guidelines 97
by Wolf J. Rinke, PhD, RD, CSP
98 Healthy Skin
Let’s face it—health care is a team “sport.” No matter what your
current role, sooner or later you’ll end up being a team leader.
And when that happens, your success depends on your team
members’ willingness to go the extra mile. (Hint: if you are not
yet a team leader, read this anyway because the time to
practice is now.) Here are six strategies to keep your team
members “juiced.”
1. Treat all team members as if they are volunteers.
I refer to this as the most important leadership principle of all
time. I discovered it while I was a Board member of one of my
professional associations and the Chair for the Council on
Education. In that role the Board looked to me to implement
new Standards of Education, which had been in limbo for
countless years. A team of 12 professionals was on my com-
mittee. All highly educated, all volunteers, all having their own
agenda. I quickly became aware that all the “crutches” that I
relied on during my “day job” did not work. For example, one of
my committee members, let’s call her Julie, was really gung-ho.
Any time there was a project to be done she was the first one
to volunteer. There was only one problem—Julie seldom deliv-
ered. Forget delivering on time, she just did not deliver. At work,
when any of my team members did that, I could counsel them
and if that did not work I could use the ultimate “crutch”—
I could fire them. Trying that with Julie, however, produced just
the opposite results. Her response: “Hey I don’t need this; I’m
outta here—more time with the family.”
After banging my head against the proverbial brick wall several
times I finally figured out that my autocratic strategies simply
did not work with volunteers. I had to develop an entirely different
skill set to motivate these people. And after I had mastered
them, I transferred these new strategies to my “day job.” For
me this was a defining moment that enabled me to transform
myself from an autocratic manager to a highly effective leader.
What was that concept? Are you ready for it? This is BIG! Drum
roll please! Treat all employees as if they are volunteers.
Now, stop and think, what would you say to your team mem-
bers if indeed they were volunteers? How about: "Please."
"Thank you!" "Can I count on you?" "I need your help." "I really
appreciate what you’ve done." "Thanks for being on my team!"
"Thanks for showing up." And now the one that blows the
autocratic managers away: "Could you do me a favor?" That
one just doesn’t sit well with lots of managers. Here are some
of the things they’ve said to me: "What are you talking about?
You’re paying them; they owe you a good job." Or "You’ve got
to be nuts. They are not doing you any favor, it’s their job," and
so on. All really good arguments, and all really, really incorrect.
(If you agree with any of these, it’s time to wake up and smell the
coffee. Because the only thing pay will do is get team members
to show up, and stay with you. (Not bad, but certainly not peak
performance.) And the fastest way to achieve peak perform-
ance is to treat all employees as if they are volunteers.
2. Catch team members doing things almost right!
Most of us were taught to supervise team members by catch-
ing them making mistakes. Someone even gave it a name:
management by exception. Unfortunately most team members
will live up or in this case down, to your expectation. To reverse
this, you will need to learn to catch team members doing things
right. No wait, let me modify that, catch team members doing
things almost right! The problem is that if you are a perfection-
ist some of your team members just have a tough time getting
it right, especially if right is defined as the way you would have
done it. Then you must compliment or recognize that positive
performance in some way. In other words, you must learn to
...the fastest way to achieve peak
performance is to treat all employees
as if they were volunteers
Continued on page 100
©2011 Medline Industries, Inc. Medline is a registered trademark
of Medline Industries, Inc
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100 Healthy Skin
practice management by appreciation (MBA). Although difficult
to master, this is a more powerful strategy than you will ever
learn in any university MBA program. Catching team members
doing things almost right means you use your abundant men-
tal energy to look for your team members moving in the right di-
rection, instead of using the same amount of energy to catch
them messing up. If you look hard enough, you will find that
most team members do several things each day that they feel
really great about. Find it, and then be sure to make a big deal
about it, ideally in public. If you still find yourself slipping back
into old habits use the 10 penny system. Put 10 pennies in your
left pocket or in case you don’t have pockets, the left side of
your desk. Every time you catch one of your team members
doing something almost right and let them know about it, trans-
fer one penny from your left pocket to your right pocket. On the
other hand if you provide negative reinforcement to one of your
team members, reverse the process; but this time move three
pennies back to the left pocket. Your goal is to have all pennies
in your right pocket at the end of each day.
3. Make work fun.
I learned a long time ago that if it’s fun, it gets done. So ask
yourself, are your team members having fun? Better yet ask
them. It’s very hard to be motivated and energized if work is a
big pain. In fact Sigmund Freud got this right when he identified
the Pleasure Principle, which basically says that all human
beings move themselves in the direction of pleasure and move
themselves away from pain. So if you have a high turnover rate,
have team members who abuse sick leave or have trouble get-
ting team members to show up for work on time, you can be
sure that working for you is painful. What to do? Ask five of your
team members to serve on a “Celebration or Fun Team.” Give
them a budget. If you don’t have one, suggest that they con-
tact local merchants who’d love to achieve greater visibility in
your organization. Suggest that they ask those merchants to
make donations to your Celebration Team. Example: movie tick-
ets, a weekend for two at a local resort, etc., etc. Just be sure
to give those who donate lots of visibility. Now ask the Cele-
bration Team to get together to identify specific things they are
planning to do each month that make work fun. Tell them any-
thing goes, provided that they stay within their allocated budget
and it does not violate any laws, rules or regulations.
4. Be positive and energetic
Attitudes, just like colds are
catching. Positive attitudes are
caught just as easily as negative
attitudes. The only problem is
that negative attitudes suck the
energy out of your team mem-
bers like a giant sponge—some-
thing your peak performers are
just not going to put up with. On
the other hand, positive attitudes
are like the little Energizer bunny.
They will keep your team mem-
I learned a long
time ago that if it’s
fun, it gets done.
Continued on page 102
HEELMEDIX™ Heel Protector
Pressure relief and skin protection all in one
The heels are the most common site for facility-acquired pressure
ulcers in long-term care, and the second most common site over-
According to clinical experts, the most effective aspect of
pressure ulcer prevention for heels is pressure relief, also known
as offloading.
Offloading is achieved with the use of pillows or
heel protection devices that relieve pressure by elevating the heel.
The HEELMEDIX Heel Protector is designed to help eliminate
pressure, friction and shear on the skin by elevating the heel.
Made of soft, suede-like material on the inside and easy-to-clean
nylon on the outside. Adjustable straps are soft against vulnerable
skin. Includes a mesh laundry bag with patient ID label to simplify
washing and sorting.
Relieve Pressure on Vulnerable Heels
©2011 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.
Fowler E, Scott-Williams S, McGuire JB. Practice recommendations for preventing heel pressure
ulcers. Ostomy Wound Management. 2008;54(10):42:48.
Langemo D, Thompson P, Hunter S, Hanson D, Anderson J. Heel pressure ulcers: stand guard.
Advances in Skin & Wound Care. 2008;21(6):282-292.
Straight-back strapping
provides extra room,
ventilation and protection
against foot drop
than the leading
Criss-cross strapping
isolates the foot and
floats the hell
Download a QR Code Reader app
Launch the QR app
Scan this QR Code or visit
102 Healthy Skin
bers going, and going, and going (well, you get it.) To build a
positive attitude, become aware of your conversations including
the ones that you have inside of your head. Recognize that pos-
itive language energizes you, and negative, cynical, “stinking
thinking” conversations de-energize you and your team mem-
bers. Make it a practice to say positive things, especially about
other people, or say nothing at all. Also recognize that your
mind can hold only one thought at a time. It can either be pos-
itive or negative, it is your choice! So when you catch yourself
thinking positive thoughts, congratulate yourself. On the other
hand when you are thinking negative thoughts, catch yourself,
change those thoughts, then give yourself credit. Remember
because of “mirror neurons” your team members take their cue
from you! You must be the role model for the kind of behaviors
you want them to exhibit. (For in-depth strategies of how to
make this happen read Make It a Winning Life--Success
Strategies for Life, Love and Business available at http://wol-
5. Build on team members' strengths.
Statistics tell us that 25% of the US population hates what they
do, another 56% could take it or leave it, and only 19% love
what they do. Typically team members who love what they do
are in jobs that let them build on their strengths. So find out
what your team members love to do and do everything in your
power to assign them to those projects or place them in those
positions. What if you end up losing them? Think about it: would
you rather have team members who love what they do and
hence are peak performers, or those who stick with you
because they can’t get a job anywhere? Even your most dedi-
cated team members are going to get burnt out really fast if
they are not building on their strengths. So you would be much
better served to get team members in positions or projects that
enable them to build on their strengths even if you lose them.
Just remember that whoever inherits one of your team mem-
bers will be much more likely to reciprocate in the future. Plus
the team member who has left you will become an "ambas-
sador of goodwill" for you. And in today's competitive health
care industry, good will is a very valuable commodity when you
need to fill your next vacancy.
6. Get team members to listen to motivational
audio programs.
Mary Kay sales associates, or for that matter all highly suc-
cessful sales professionals, have this figured out. You must pro-
vide team members with external motivation if you want them
to consistently perform at peak performance. So start building
an audio-program library. Suggest to your team members that
they listen to a program every day on their way to work. Meet
in brief weekly meetings and have team members share one
powerful principle they learned from each program. That way
everyone can learn from everyone else, and energize each other
at the same time. Supplement these activities by showing a mo-
tivational program during your next in-service. (Aren’t your team
members getting tired of the same mandatory training?) Or bet-
ter yet hire a motivational speaker to energize your next "all
hands" team meeting. Your team members will be positively
surprised, feel honored and energized. And when they are
energized everyone’s job will be much more enjoyable, and to
top it all off, your patients will be less grumpy and may even get
better faster.
© 2011 Wolf J. Rinke
Dr. Wolf J. Rinke, RD, CSP is a keynote
speaker, seminar leader, management con-
sultant, executive coach and editor of the free
electronic newsletter Read and Grow Rich,
available at In ad-
dition he has authored numerous CDs, DVDs
and books including Make It a Winning Life:
Success Strategies for Life, Love and Busi-
ness, Winning Management: 6 Fail-Safe Strategies for Building
High-Performance Organizations and Don’t Oil the Squeaky Wheel
and 19 Other Contrarian Ways to Improve Your Leadership Effec-
tiveness; available at His company also pro-
duces a wide variety of quality pre-approved continuing
professional education (CPE) self-study courses, available at Reach him at
Recognize that positive
language energizes you.
Yes, They’re Genuine.
Only Medline’s Pink Pearl™ gloves combine
aloe, nitrile and breast cancer awareness.
©2011 Medline Industries, Inc.
Medline is a registered trademark
and Pink Pearl is a trademark of
Medline Industries, Inc.
Download a QR Code Reader app
Launch the QR app
Scan this QR Code or visit
- Schedule ma mmogra m
- Start worki ng on pi nk glove dance
video for pi nkglovedance. com
Order pi nk gloves for Breast
Cancer Awareness Month
- Partici pate i n breast cancer walk
- Visit the National Breast Cancer
Foundation website
- Re me mber to do monthly self
breast exa ms.
- Not too l ate to order pi nk gloves!
104 Healthy Skin
2011 Things to do
Countdown to Breast Cancer
Awareness Month!
Speo|a| Feature
Improving Quality of Care Based on CMS Guidelines 105
Medline celebrates
six years of breast
cancer awareness
Since 2006, Medline has been hosting “Together We Can Save
Lives Through Early Detection” breast cancer awareness break-
fast forums at the Association of periOperative Registered
Nurses (AORN) Annual Congress to raise breast cancer aware-
ness and share the importance of early detection.
Every year, Medline invites a celebrity breast cancer survivor to
share her survival story and her own inspirational message of
hope. At the 2011 breakfast forum, held March 21 in Philadel-
phia, Pa., more than 1,100 operating room nurses gathered to
hear actors Jill Eikenberry and Michael Tucker, stars of the T.V.
hit L.A. Law, talk about Eikenberry’s battle with breast cancer.
A big surprise occurred at the end of their talk when Eikenberry
was greeted by the nurse that cared for her during her initial bout
with breast cancer almost 25 years ago and again during her
recurrence two years ago.
"I took care of her both times and gave her extra care," said
Rubita Conception, a perioperative registered nurse at The
Mount Sinai Medical Center in New York City. "I am a regular at
Medline's annual breast cancer awareness breakfast, but when
I saw that Jill and Michael were speaking, I had to make sure I
came today."
At the event, Medline Chief Marketing Officer Sue MacInnes pre-
sented National Breast Cancer Foundation (NBCF) President
Janelle Hail with a check for $242,606 to help fund mammo-
grams for underserved women. Over the past five years, Medline
has donated more than three quarters of a million dollars to the
NBCF as part of its campaign to promote early detection and
awareness of breast cancer. Mammography is among the best
forms of screening for breast cancer. Early detection can
increase the five-year survival rate by 93 percent.
1. Survival rates for breast cancer. American Cancer Society website. Available at:
survival-rates <
cancer-overview-survival-rates>. Accessed April 28, 2011.
Speo|a| Feature
106 Healthy Skin
Healthy Eating
1 cup finely shredded cheddar cheese
½ cup sour cream
8 oz. cream cheese, softened
1 pkg. taco seasoning
12 green olives or green chiles/pimentos
3 large tortillas
Mix ingredients together, and spread onto the tortillas. Roll up
tortillas. Place into a zip lock bag and chill. When ready to serve,
slice and serve with salsa.
Hint: Healthier alternative ~ low fat cheese and low fat sour
cream and whole wheat tortillas may be used.
Judy DeSalvo, Marketing Business Manager – Mundelein
Judy DeSalvo has been working at Medline for nine years. She
basically “does it all” to keep the Marketing Department running
efficiently. Judy sees print projects through to completion, mak-
ing sure vendor estimates are correct on
invoices, all the way down to ensuring
marketing materials arrive on time and in
the right location at trade shows and
meetings. She’s often been sighted mov-
ing boxes of brochures and Medline dolls,
and she’s even been known to wield a
screwdriver to repair a piece of office
equipment in a pinch so coworkers can
get their jobs done.
This recipe is Judy’s favorite appetizer, which she inherited from
her Aunt Judy a year ago. It’s a highly requested dish at the
many events Judy attends.
Judy was also involved in creating Medline’s first and second
edition cookbooks, which feature recipes fromMedline employ-
ees. The latest edition is available for purchase, and the pro-
ceeds go to Medline’s Spirit of Giving fund, which helps support
Medline employees in times of need.
Aunt Judy’s
Tortilla Roll-Ups
Servings: 9
Calories: 166
Fat: 15.6 g
Sodium: 159 mg
Fiber: 0.1 g

The Medline employee cookbook
is $10. To purchase your own
copy, please e-mail Judy at
Improving Quality of Care Based on CMS Guidelines 107
The following pages contain
practical tools for implementing
patient-focused care practices
at your facility.
Wound Care
What Type of Wound Is It?……………………………….108
Patient Safety
One Needle, One Syringe, Only One Time………..…. .110
Spinal Injection Procedures Performed without
a Facemask Pose Risk for Bacterial Meningitis……….117
National Diabetes Fact Sheet, 2011................................ 111
Improving Quality of Care Based on CMS Guidelines 107
The following pages contain
practical tools for implementing
patient-focused care practices
at your facility.
Wound Care
What Type of Wound Is It?……………………………….108
Patient Safety
One Needle, One Syringe, Only One Time………..…. .110
Spinal Injection Procedures Performed without
a Facemask Pose Risk for Bacterial Meningitis………. .99
National Diabetes Fact Sheet, 2011................................ 111
108 Healthy Skin
Damage to the skin or underlying struc-
tures as a result of tissue compression and
inadequate perfusion
Usually over a bony prominence
Usually circular
Can have viable or necrotic tissue
Can be very large or very small
Can vary from none to heavy
Can be localized, usually not seen
Usually not present
Usually, but often undertreated
• Remove necrotic tissue
• Maintain optimal moisture
• Protect periwound skin
• Control bioburden
• Remove pressure
Failure of venous valve function in return-
ing blood from the lower extremities to the
heart causing venous congestion, leading
to venous hypertension
Gaiter area (ankle to mid calf), often
meedial malleolus, may be circumferential
Irregular shaped
Usually shallow, can have viable or
necrotic tissue
Usually large
Can vary from none to heavy to general-
ized weeping
Generalized edema to lower extremity
Usually seen
> 0.8
Usually normal, or undetectable due
to edema
Often in dependent position, with edema
• Compression
• Remove necrotic tissue
• Maintain optimal moisture
• Protect periwound skin
• Control bioburden
• Ensure lower extremity moisturization
Wound Margin
Wound Bed
Wound Size
Limb Staining
Ankle Brachial Index
Pedal Pulses
Best Practice
What type of wound is it?
Improving Quality of Care Based on CMS Guidelines 109
Wounds caused by ischemia, related to
the presence of arterial occlusive disease
Distal aspect of arterial circulation, can be
anywhere on the leg (i.e. toes and feet)
“Punched out,” well defined borders
Pale wound bed, little or no granulation,
necrotic tissue is common
Can be small, often increases due to lack
of arterial perfusion
Minimal to no exudate
If present, localized
Usually not present
< 0.8
< 0.5 - indicates inability to heal
Usually reduced or absent
Occurs at rest, nocturnal, or when
extremity is elevated
• If perfusion not adequate, consider
vascular consult
• If perfusion is adequate, follow protocol
based on wound assessment and
• If dry, stable eschar leave intact
Neuropathy is often associated with dia-
betes. Wounds result from damage to the
autonomic, sensory or motor nerves and
have an arterial perfusion deficit
Can be anywhere on the lower extremity,
often on the foot
Similar to arterial, usually with a
callous edge
Similar to arterial
Often small
Similar to arterial
Similar to arterial
Similar to arterial
Not reliable, sometimes > 1.0 falsely eval-
uated due to calcification
Not reliable
Due to neuropathy, pain may be absent
or severe
• Maintain optimal moisture
• Control diabetes, if appropriate
• Repetitive removal of callous
• Bioburden control and prevention
of systemic infection
• Remove pressure with appropriate
offloading shoe or other appliance
For more information, please visit:
The One & Only Campaign is a public health
campaign aimed at raising awareness among
the general public and healthcare providers
about safe injection practices.
1 needle
1 syringe
1 time
Patients and healthcare providers must
both insist on nothing less than One Needle,
One Syringe, Only One Time for each and
every injection.
Forms & Tools One & Only Campaign
National Center for Chronic Disease Prevention and Health Promotion
Division of Diabetes Translation
National Diabetes Fact Sheet, 2011
Among U.S. residents aged 65 years and older, 10.9 million, or 26.9%,
had diabetes in 2010.
About 215,000 people younger than 20 years had diabetes (type 1 or
type 2) in the United States in 2010.
About 1.9 million people aged 20 years or older were newly
diagnosed with diabetes in 2010 in the United States.
In 2005–2008, based on fasting glucose or hemoglobin A1c levels,
35% of U.S. adults aged 20 years or older had prediabetes (50% of
adults aged 65 years or older). Applying this percentage to the entire
U.S. population in 2010 yields an estimated 79 million American
adults aged 20 years or older with prediabetes.
Diabetes is the leading cause of kidney failure, nontraumatic lower-
limb amputations, and new cases of blindness among adults in the
United States.
Diabetes is a major cause of heart disease and stroke.
Diabetes is the seventh leading cause of death in the United States.
Diabetes afects 25.8 million people
8.3%of the U.S. population
18.8 million people
7.0 million people
All ages, 2010
Centers for Disease Control and
Prevention. National diabetes fact
sheet: national estimates and general
information on diabetes and prediabetes
in the United States, 2011. Atlanta, GA:
U.S. Department of Health and Human
Services, Centers for Disease Control and
Prevention, 2011.
Improving Quality of Care Based on CMS Guidelines 111
CDC Diabetes Facts Forms & Tools
112 Healthy Skin
Heart disease and stroke
In 2004, heart disease was noted on 68% of diabetes-related death certifcates among people aged 65 years or older.
In 2004, stroke was noted on 16% of diabetes-related death certifcates among people aged 65 years or older.
Adults with diabetes have heart disease death rates about 2 to 4 times higher than adults without diabetes.
The risk for stroke is 2 to 4 times higher among people with diabetes.
In 2005–2008, of adults aged 20 years or older with self-reported diabetes, 67% had blood pressure greater than or equal to
140/90 millimeters of mercury (mmHg) or used prescription medications for hypertension.
Blindness and eye problems
Diabetes is the leading cause of new cases of blindness among adults aged 20–74 years.
In 2005–2008, 4.2 million (28.5%) people with diabetes aged 40 years or older had diabetic retinopathy, and of these, 655,000
(4.4% of those with diabetes) had advanced diabetic retinopathy that could lead to severe vision loss.
Kidney disease
Diabetes is the leading cause of kidney failure, accounting for 44% of all new cases of kidney failure in 2008.
In 2008, 48,374 people with diabetes began treatment for end-stage kidney disease.
In 2008, a total of 202,290 people with end-stage kidney disease due to diabetes were living on chronic dialysis or with a kidney
Nervous systemdisease
About 60% to 70% of people with diabetes have mild to severe forms of nervous system damage. The results of such damage
include impaired sensation or pain in the feet or hands, slowed digestion of food in the stomach, carpal tunnel syndrome,
erectile dysfunction, or other nerve problems.
Almost 30% of people with diabetes aged 40 years or older have impaired sensation in the feet (i.e., at least one area that lacks
Severe forms of diabetic nerve disease are a major contributing cause of lower-extremity amputations.
More than 60% of nontraumatic lower-limb amputations occur in people with diabetes.
In 2006, about 65,700 nontraumatic lower-limb amputations were performed in people with diabetes.
Complications of diabetes in the United States
Forms & Tools CDC Diabetes Facts
Improving Quality of Care Based on CMS Guidelines 113
Dental disease

Complications of pregnancy

Other complications

Working together, people
with diabetes, their
support network, and
their health care providers
can reduce the occurrence
of diabetes complications.
Complications of diabetes in the United States (continued) a
tal (gum) disease is mor iodon er P
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ears or older ar es aged 60 y eople with diabet
. es e diabet v than people who do not ha
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en ha t , they of e these illnesses quir
t can es tha o biochemical imbalanc
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o ha e as likely t wic e t es ar eople with diabet
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y par t man ec es can af fe , diabet e v
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e likely e 2–3 times mor ears or older ar
ession, which can e depr v o ha
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, or do , climb stairs er of a mile
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es in a timely manner tic ac e pr e car tiv en ev eiving other pr
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o e pr , and their health car k or w
ogether ing t k or W . tions -limb amputa
tions such as blindness omplica ious c
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y , and b , and blood lipids
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CDC Diabetes Facts Forms & Tools

- 500
Bladder Scanner
Safely Measures
Bladder Volume
Minimize unnecessary catheterization
Research has shown that 80 percent of urinary tract
infections acquired at healthcare facilities are associated
with an indwelling urethral catheter.
This type of infection
is known as CAUTI, or catheter-associated urinary
tract infection.
Avoiding unnecessary catheter use
is a primary strategy for preventing
CAUTI, and clinical guidelines
recommend the consideration of
alternatives to catheterization.
Bladder scanners accurately
assess bladder volumes,
and many urinary catheterizations
can be avoided.
1. Lo E, Nicolle L, Classen D, Arias A, Podgorny K, Anderson DJ, et al.
SHEA/IDSA practice recommendation: strategies to prevent catheter-associated
urinary tract infections in acute care hospitals. Infect Control Hosp Epidemiol.
2. Stokowski, LA. Preventing catheter-associated urinary tract infections. Medscape
Nursing Perspectives. February 3, 2009.
3. Stevens E. Bladder ultrasound: avoiding unnecessary catheterizations. Med/Surg
Nursing. 2005; 14(4):249-253.
©2011 Medline Industries, Inc.
Medline is a registered trademark of Medline Industries, Inc.
Download a QR Code Reader app
Launch the QR app
Scan this QR Code or visit
Preventing diabetes complications
Glucose control

Blood pressure control

Control of blood lipids

Preventive care practices for eyes, feet, and kidneys

Detecting and treating
diabetic eye disease with
laser therapy can reduce
the development of severe
vision loss by an estimated
50%to 60%.
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tudies in the Unit S
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Improving Quality of Care Based on CMS Guidelines 115
CDC Diabetes Facts Forms & Tools
1 Shannon R, |aJo|e J. Eoonom|o |mpaot of Ü|trasorbs® AP Absorbent Pads |n
prevent|on of hosp|ta|-aoqu|red pressure u|oers. G|oba| Hea|th Eoonom|o Projeots, ||O
and New York Method|st Hosp|ta|, Brook|yn, NY. Maroh 2009.
*Manufaotured under Ü.S. patent number 6,675,702. **Ü|tra-Fresh |s an EPA Reg|stered
Ant|m|orob|a|. Th|s produot does not proteot users or others aga|nst d|sease-oaus|ng
baoter|a. ©2011 Med||ne lndustr|es, lno. Med||ne and Ü|trasorbs are reg|stered trademarks
of Med||ne lndustr|es, lno. Ü|tra-Fresh |s a trademark of Med||ne lndustr|es, lno. SuperOore
|s a reg|stered trademark of MoA|r|a|d's v||esstoffe GmbH & Oo.
Drier Patients. Fresher Air.
Ultrasorbs UF provides the same patented* SuperCore
Ultrasorbs AP. The core draws in moisture, locks it away from
the skin and feels dry to the touch in just minutes. In addition,
Ultrasorbs UF contains antimicrobial Ultra-Fresh protection to
inhibit the growth of bacteria and yeasts that can cause odors.
• Locks odor-causing moisture away in the absorbent core
• Makes for a fresher room
• Clinically shown to help maintain skin integrity as part
of an overall pressure ulcer prevention program.
Dryness & Odor Control In One Ultra-Fresh

Our latest Ultrasorbs innovation.
The advanced features of Ultrasorbs AP
plus antimicrobial Ultra-Fresh to inhibit
bacteria and yeast that cause odor**
To request a free bag of
Ultrasorbs UF, send an e-mail
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Spinal Injection Procedures Performed
without a Facemask Pose Risk for
Bacterial Meningitis
The Centers for Disease Control and Prevention (CDC) is concerned
about the occurrence of bacterial meningitis among patients
undergoing spinal injection procedures that require injection of
material or insertion of a catheter into epidural or subdural spaces
(e.g., myelogram, administration of spinal or epidural anesthesia, or
intrathecal chemotherapy). Outbreaks of bacterial meningitis
following these spinal injection procedures continue to be
identified among patients whose procedures were performed by a
healthcare provider who did not wear a facemask (e.g., may be
labeled as surgical, medical procedure, or isolation mask),
with the
most recent occurrence in October 2010 (CDC unpublished data).
This notice serves as a reminder that facemasks should always be
worn by healthcare providers when performing these spinal
injection procedures.
CDC has investigated multiple outbreaks of bacterial meningitis
among patients undergoing spinal injection procedures. Recent
outbreaks have occurred among patients in acute care hospitals
who received spinal anesthesia or epidural anesthesia, and also
among patients at an outpatient imaging facility who underwent
In each of these outbreak investigations, nearly all spinal injection
procedures that resulted in infection were performed by a common
healthcare provider who did not wear a facemask. The strain of
bacteria isolated from the cerebrospinal fluid of these patients was
identical to the strain recovered from the oral flora of the healthcare
provider who performed the spinal injection procedure. These
findings illustrate the risk of bacterial meningitis associated with
droplet transmission of the oral flora from healthcare providers to
patients during spinal injection procedures.
National Center for Emerging and Zoonotic Infectious Diseases
Division of Healthcare Quality Promotion
Improving Quality of Care Based on CMS Guidelines 117
CDC Clinical Reminder Forms & Tools
118 Healthy Skin
Since facemasks have been shown to limit spread of droplets arising from the oral flora,
the CDC has
recommended their use by healthcare providers when performing spinal injection procedures.
In addition to wearing a facemask, healthcare providers should ensure adherence to all CDC
recommended safe injection practices including using a single-dose vial of medication for only one
Anyone performing a spinal injection procedure should review the following CDC recommendations to
ensure that they are not placing their patients at risk for infections such as bacterial meningitis.
Facemasks should always be used when injecting material or inserting a catheter into the epidural
or subdural space.
Aseptic technique and other safe injection practices (e.g., using a single-dose vial of medication or
contrast solution for only one patient) should always be followed for all spinal injection
These recommendations apply not only in acute care settings such as hospitals, but in any setting where
spinal injection procedures are performed, such as outpatient imaging facilities, ambulatory surgery
centers, and pain management clinics.
Additional information is available at:
1. Centers for Disease Control and Prevention. Bacterial meningitis after intrapartum spinal
anesthesia - New York and Ohio, 2008-2009. MMWR Morb Mortal Wkly Rep. 2010;59(3):65-9.
2. Centers for Disease Control and Prevention. 2007 Guideline for isolation precautions: preventing
transmission of infectious agents in healthcare settings. Available at: Accessed January 25, 2011.
3. Philips BJ, Fergusson S, Armstrong P, Anderson FM, Wildsmith JA. Surgical face masks are effective
in reducing bacterial contamination caused by dispersal from the upper airway. Br J Anaesth.
For more information please contact Centers for Disease Control and Prevention
1600 Clifton Road NE, Atlanta, GA 30333
Telephone: 1-800-CDC-INFO (232-4636)/TTY: 1-888-232-63548
Email: Web:
Forms & Tools CDC Clinical Reminder
How 4 square inches of Puracol
changed chronic wound care.
This is Puracol Plus Micro-
Scaffold as seen through an
electron microscope. Its open,
cellular structure allows easy
fibroblast migration.
The high
strength of the MicroScaffold
also assists in establishing a
fresh wound bed.
Each Puracol package is
a 2-Minute Course

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


, made entirely of pure native collagen.
Chronic wounds tend not to heal when unbalanced levels
of elastase and MMPs (inflammatory enzymes) destroy the
body’s own collagen and growth factors.
But apply Puracol Plus and help restore nature’s balance.
In vitro studies show that Puracol Plus has the ability
to reduce the levels of elastase and MMPs from
surrounding fluid.
1. Schultz GS, Mast BA. Molecular analysis
of the environment of healing and chronic
wounds: Cytokines, proteases, and growth
factors. Wounds. 1998;10 (6 Suppl): 1F-9F.
2. Data on file.
©2011 Medline Industries, Inc.
Puracol is a registered trademark of Medline Industries, Inc.
Medline is a registered trademark of Medline Industries, Inc.
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©2011 Medline Industries, Inc. Medline and Remedy
are registered trademark of Medline Industries, Inc.
MKT211157/LIT847/3 M/RPN5
Introducing ...
Now you and your family can enjoy professional
quality Remedy skin care products at home.
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