Healthy Skin Magazine - Volume 9 Issue 2

Improving Quality of Care Based on CMS Guidelines
Volume 9, Issue 2
Free CE Inside!
Get Set for

Breast Cancer
Awareness Month
Wound Care Pioneer
Dr. Katherine Jeter
Bikes 3,100 Miles!
Page 94
What is an
ACO?
Energize
Your Team
Nurses Leaders
Rate Patient
Experience #
1
Join the team!
HEALTHY SKIN
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 for writers and contributors. Whether youʼd like to try your
happens in the healthcare industry – and we want to hear hand at writing or offer suggestions for future articles, we
from you! Have you ever wished you could write an want to hear what you have to say! You never know – the
article that would be published in a large-circulation next time you open an issue of Healthy Skin, it might be
magazine? Nowʼs your chance. Healthy Skin is looking to read your own article!
Contact us at healthyskin@medline.com 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.
HEALTHY SKIN
Improving Quality of Care Based on CMS Guidelines
Survey Readiness
35 More than Just a Survey Tool
Editor
Sue MacInnes, RD, LD
61 A Guide to MDS 3.0 Section H
Clinical Editor Prevention

Margaret Falconio-West, BSN, RN, APN/CNS, 47 They’re Lurking in the Operating Room and Beyond!
CWOCN, DAPWCA 53 ERASE CAUTI Program Helps Hospitals Reduce Catheter Use by
20 Percent
Senior Writer Page 12
78 PRE-STAGE I: An Obvious, More Descriptive, and Clinically
Carla Esser Lake
Impactful Term than “Reactive Hyperemia” or “Blanchable Erythema”
Creative Director in Describing the State Before Stage I
Michael A. Gotti 80 12 Ways to Reduce Hospital Admissions
Clinical Team Treatment

Clay Collins, BSN, RN, CWOCN, CFCN, 25 Effects of a Just-in-Time Educational Intervention Placed on Wound
CWS, DAPWCA Dressing Packages
Lorri Downs, BSN, RN, MS, CIC 32 The Art of Wound Management
Cynthia Fleck, BSN,MBA, RN, CWS, DNC, 38 Assessment and Management of Fungating Wounds Page 32
CFCN, DAPWCA, FCCWS
Joyce Norman, BSN, RN, CWOCN, Special Features
DAPWCA 5 Medline’s Grant Program
Kim Kehoe, BSN, RN, CWOCN, DAPWCA 10 Patient Experience is #1
Elizabeth O’Connell-Gifford, BSN, MBA, RN, 12 Transforming the Health Care Delivery System
CWOCN, DAPWCA 15 Answering Your Questions About Accountable Care Organizations
Jackie Todd, RN, CWCN, DAPWCA 18 The Path Forward for Quality Health Care
23 2011 Nursing Leadership Priorities: The CNO’s Perspective
Wound Care Advisory Board 92 Make Your Facility a Greener Place to Work Page 92
Christine Baker, MSN, RN, CWOCN, APN 94 Congratulations Dr. Jeter and WOCN!
Katherine A. Beam, DNP, RN, ACNS-BC 104 Countdown to Breast Cancer Awareness Month
Patricia Rae Brooks, MSN, RN, ANP, CWOCN 105 Medline Celebrates Six Years of Breast Cancer Awareness
Amparo Cano, MSN, CWON
Jill Cox, CWOCN Regular Features
Sue Creehan, RN, CWOCN 6 Two Important National Initiatives for Improving Quality of Care
Donna Crossland, MSN, RN, CWOCN 8 Breaking News
Barbara Delmore, PHD, RN, CWCN, AAPWCA
72 Product Spotlight: Optilock
87 Hotline Hot Topic: Assessing Lower Extremity Wounds
Karen Keaney Gluckman, MSN, FNP-BC, APN, Page 94
CWOCN
Caring for Yourself
Anita Prinz, RN, MSN, CWOCN, CFNC, COS-C
74 If Recent Attacks on Sunscreen Concern You
Mary Ransbury, RN, BSN, PHN, CWON
96 How to Energize Your Team
Denise Robinson, MPH, RN, CHWOCN
106 Recipe: Aunt Judy’s Tortilla Roll-Ups
Diane Whitworth, RN, CWOCN
Forms & Tools

108 What Type of Wound Is It?
110 One Needle, One Syringe, Only One Time
111 National Diabetes Fact Sheet, 2011 Page 105
117 Spinal Injection Procedures Performed without a Facemask Pose Risk
for Bacterial Meningitis
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.
©2011 Medline Industries, Inc. Healthy Skin is published by Medline Industries, Inc. One Medline Place, Mundelein, IL 60060. 1-800-MEDLINE.
Improving Quality of Care Based on CMS Guidelines 3

Healthy Skin
Letter from the Editor
A 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!
One of these people is my daughter, Molly, a sophomore From start to finish it took several years. But the result
at the University of Colorado. Last month, I watched her was a multi-centered randomized controlled study, which
swim, bike and run alongside her teammates to win the was accepted and published in the November/December
2011 USA Triathlon Collegiate National Champi- 2010 issue of the Journal of WOCN. The results were so
onship…over 120 colleges and 1,600 athletes participated. compelling that she is also presenting the study at the
School colors lined the transition area, teammates upcoming WOCN conference in June in New Orleans.
cheered and family and friends took pictures as these Dea had a vision and a goal…and she never let herself
incredibly talented athletes sped by. The spirit, teamwork waiver regardless of the obstacles she faced along
and leadership were unbelievably motivating. I was so the way.
proud of her and inspired by her effort and determination.
All of this leads me to Dr. Jeter’s story. Now this is a truly
Another person who inspires me is Dea Kent, CWOCN. inspiring story. At the age of 72, Dr. Jeter biked clear
She conducted and wrote the study you’ll find on page across the country – 3,100 miles! Oh, and did I mention
25, titled the “Effects of Just-in-Time Educational Inter- that she’s a breast cancer survivor? She achieved this
vention Placed on Wound Packages.” A few years ago, incredible feat, in partnership with the Wound, Ostomy
Dea was at a special launch presentation for Medline’s and Continence Nurses Society (WOCN) to raise money
newly designed wound care packaging. The packaging to support the continuing education of WOC nurses.
was unique because the design provided “just in time (See the full story on page 94.) How can you not be
education,” allowing the bedside nurse to correctly apply inspired by Dr. Jeter, her goal and her achievements?
various wound dressing products. After the presenta- I’m in awe of her dedication and determination. But it
tion, Dea kept thinking that she would really like to test makes me want to set new goals for myself and achieve
the packaging to see if it made a difference in helping them. I hope it affects you the same way.
the non- wound care specialist in their confidence level
and technique in applying wound dressings. Dea had al- Best regards,
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 Sue MacInnes, RD, LD
not a PhD, but I know I can do this.” Editor
4 Healthy Skin
Special Feature
MEDLINE’S GRANT PROGRAM

Supporting the Adoption of Solutions
into Everyday Practice
2011 Submission Dates May 1- June 30, 2011
Medline is committing up to $1 million over several years to stim- 2. In addition, the applicant should submit the following with
ulate the gathering of solid evidence that supports the adoption the letter (not included in the 3-page limit):
of solutions into clinical practice. Review panel members that a. Brief biography about the individuals involved (limited
represent a breadth of research and practice knowledge will to one page each), which includes any experience about
select grant recipients to be awarded up to $25,000 each for the area of study focus.
pilot grants and up to $100,000 each for an empirical study. b. Budget estimate (limited to one page), including the major
expenditure categories.
Objectives
• To stimulate research that will lead to the development of 3. Only one application from a healthcare provider will be
new targeted interventions aimed at improving patient safety considered. Institutions cannot submit more than one
and decreasing healthcare-acquired conditions application.
• To test the costs and effectiveness of interventions and
programs designed to improve the quality of care and 4. The review committee will review all LOIs received after the
increase patient safety. June 30, 2011 deadline. Accepted letters will be assigned to
• To disseminate practical, evidence-based solutions within the most appropriate research mentor, who will contact the
and across healthcare facilities, leading to improved applicant and work with him or her to develop the letter into
patient safety. a full proposal of 5-7 pages in length, including a complete
budget. Proposal and budget guidelines will be sent after
These awards are designed to assist healthcare providers in the approval of the letter of intent.
developing and testing creative solutions or interventions for
reducing or preventing healthcare-acquired harms. Recipients of Most of the projects that are chosen for full proposal
grant award will be paired with a research mentor/consultant submission will be funded; however, this process may
through the grant program to develop methods and guide the involve a subsequent resubmission a revised proposal
conduct of the study, ensuring that a rigorous research process so that the funded research plan is clear.
is followed. These studies can be small pilot studies aimed at
developing and testing the feasibility of new solutions or larger 5. Pilot grants will generally be up to six months in duration with
evaluation studies to more fully test the cots, effectiveness or dis- a budget of no more than $25,000. Empirical studies can be
semination of evidence-based solutions. Please note that at this up to $100,000 and last up to a year in duration. Pilot study
time, the program is only accepting submissions from healthcare grantees can go on to submit an empirical study grant at the
providers based in the United States, Canada or Mexico. successful conclusion of the pilot project, or applicants can
apply for a full empirical study grants based on their initial
Award Process letter of intent if they have an existing practice with some
1. In response to our request for applications (RFA), providers evidence base that they wish to evaluate.
will submit a letter (limited to 3 pages) of intent providing the
following information: 6. The final report for a pilot grant study should be a brief
• The patient safety event that the study will address paper written for a Medline publication (Healthy Skin, The
• Whether the applicant is proposing a pilot study OR Connection or Infection Prevention Now) whether or not
($25,000 limit) or empiric study ($100,000 limit) the study is successful. The final report for an empirical study
• The proposed patient safety solution is a paper to be submitted for publication in a peer-reviewed
• The objective of the study journal.
• The proposed approach to the study (enough detail to
understand how the patient safety solution will be E-mail your request for application to:
implemented and how the investigator plans to measure grantprogram@medline.com
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

Two Important National Initiatives
for Improving Quality of Care
Achieving better outcomes starts with an understanding of current quality
of care initiatives. Hereʼs what you need to know about national projects and
policies that are driving changes in nursing home and home health care.
QIO Utilization and Quality Control Peer Review Organization

1 9th Round Statement of Work
Origin: The QIO Statement of Work is based upon Part B of the Title XI of the Social Security Act. The Medicare-funded
“Ninth Scope of Work” plan became effective August 1, 2008 and will remain in effect through July , 2011.
Purpose: To carry out statutorily mandated review activities, such as:
Stay tuned for
• Reviewing the quality of care provided to beneficiaries; details on 10th Round
• Reviewing beneficiary appeals of certain provider notices; Statement of Work
• Reviewing potential anti-dumping cases; and COMING SOON
• Implementing quality improvement activities as a result of case review activities.
Goal: In the 9th SOW, the QIO Program has been redesigned with a framework for accountability and also in content. The
content now consists of four themes with the goal to help providers, both in long-term care and acute-care facilities,
prevent illness, decrease harm to patients and reduce waste in health care.
Of note: QIOs will be required to help Medicare promote three overarching themes: adopt value-driven healthcare,
support the adoption and use of health information technology and reduce health disparities in their communities.
Under the direction of the Centers for Medicare & Medicaid Services (CMS), the QIO Program consists of a national
network of 53 QIOs located in each of the 50 U.S. states, the District of Columbia, Puerto Rico and the Virgin Islands.
Quality Improvement Organization Program’s 9th Scope of Work Theme

The official Executive Summaries for the 9th SOW Theme are available at:
http://providers.ipro.org/index/9SOW_summaries
2 Advancing Excellence in America’s Nursing Homes
Origin: A coalition-based, two-year campaign initiated on September 26, 2006 to improve quality of life for nursing home
residents and staff. The coalition has continued the campaign beyond its first-round end of August 25, 2008 for an
additional 2 years (until September 26, 2010).
Purpose: A coalition consisting of the Centers for Medicare & Medicaid Services (CMS), organizations representing providers,
consumers and government that developed a grassroots campaign to build on and complement the work of existing
quality initiatives including Nursing Home Quality Initiative (NHQI), Quality First and the culture change movement.
Goal: To ensure that continuous quality improvement is comprehensive, sustainable and consumer-focused, the coalition
has adopted goals that seek to improve clinical care, incorporate nursing home resident and family satisfaction
surveys into continuing quality improvements and increase staff retention to allow for better, more consistent
care for nursing home residents.
Participating providers will commit to focusing on at least three of the eight measurable goals, including at least one clinical goal and
one operational process goal. Current participants may choose to continue with the same goals, add additional goals or change goals
for the next two-year campaign.
6 Healthy Skin
The 9th Scope of Work Content Themes
Theme #1: Beneficiary Protection Activities will focus on Theme #4: Prevention Activities will focus on nine Tasks:
nine Tasks: 1. Recruiting participating practices
1. Case reviews 2. Identifying the pool of non-participating practices
2. Quality improvement activities (QIAs) 3. Promoting care management processes for preventive services
3. Alternative dispute resolution (ADR) using EHRs
4. Sanction activities 4. Completing assessments of care processes
5. Physician acknowledgement monitoring 5. Assisting with data submissions
6. Collaboration with other CMS contractors 6. Monitoring statewide rates (mammograms, CRC screens, influenza
7. Promoting transparency through reporting and pneumococcal immunizations)
8. Quality data reporting 7. Administering an assessment of care practices
9. Communication (education and information) 8. Producing an annual report of statewide trends, showing baseline
and rates
Theme #2: Patient Pathways/Care Transitions Activities 9. Submitting plans to optimize performance at 18 months
will focus on three Tasks:
1. Community and provider selection and recruitment There will be two periods of evaluation under the 9th SOW. The first
2. Interventions evaluation will focus on the QIO's work in three Theme areas (Care
3. Monitoring Transitions, Patient Safety and Prevention) and will occur at the end
of 18 months. The second evaluation will examine the QIO's perform-
Theme #3: Patient Safety Activities will focus on six ance on Tasks within all Theme areas (Beneficiary Protection, Care
primary Topics: Transitions, Patient Safety and Prevention). The second evaluation will
1. Reducing rates of health care-associated methicillin-resistant take place at the end of the 28th month of the contract term and will be
Staphylococcus aureus (MRSA) infections based on the most recent data available to CMS. The performance
2. Reducing rates of pressure ulcers in nursing homes and hospitals results of the evaluation at both time periods will be used to determine
3. Reducing rates of physical restraints in nursing homes the performance on the overall contract.
4. Improving inpatient surgical safety and heart failure treatment
in hospitals Focus for the 9th Scope of Work
5. Improving drug safety – Move away from projects that are “siloed” in specific care settings
6. Providing quality improvement technical assistance to nursing – Focused activities for providers most in need
homes in need – New emphasis on senior leadership (CEOs, BODs) involvement
in facility quality improvement programs
Clinical and Operational/Process Goals
Clinical Goals: Goal Actual Operational/Process Goals: Goal Actual

Goal 1: Reducing high-risk pressure ulcers < 10% 11% Goal 5: Establishing individual targets for > 90% 36.5%
Goal 2: Reducing the use of daily < 5% 3% improving quality
physical restraints Goal 6: Assessing resident and family 22.5%
Goal 3: Improving pain management for < 4% 3% satisfaction with quality of care
longer-term nursing home residents Goal 7: Increasing staff retention 13.9%
Goal 4: Improving pain management for < 15% 19% Goal 8: Improving consistent assignment 26.6%
short-stay, post-acute nursing of nursing home staff so that
home residents residents receive care from the
same caregivers
Trends in Goal Selection

Each nursing home participating in Advancing Excellence selects a minimum of three goals (outlined above).
The goals – and the percentage of participating nursing homes that have selected them – are listed below.
Participating nursing homes: 7,481

Goal 1: 70.9% Goal 5: 32.1%
Percentage of participating nursing homes:* 47.6%
Goal 2: 45.3% Goal 6: 62.8% Participating consumers: 2,233
Goal 3: 54.2% Goal 7: 41.2%
Goal 4: 39.6% Goal 8: 31.3% Average number of goals per
nursing home: 3.8
Visit this Web site to view progress by state!
www.nhqualitycampaign.org/star_index.aspx?controls=states_map
*Based on the latest available count of Medicare/Medicaid nursing homes

BREAKING NEWS
HHS announces new patient AHRQ issues findings from
safety partnership hospital culture of safety survey
The Department of Health and Human Services (HHS) The Agency for Healthcare Research and Quality (AHRQ) just
recently introduced Partnership for Patients, a collaboration released the latest findings from its Hospital Survey on
with hospitals and others to reduce hospital-acquired condi- Patient Safety Culture, a tool to help hospitals evaluate their
tions (HACs) and preventable hospital readmissions. The efforts to create a culture of safety. The voluntary survey looks
initiative will use $1 billion in Patient Protection and Affordable at 12 areas, including communication openness; handoffs
Care Act funding to test models of safer care delivery, pro- and transitions; management support for patient safety;
mote best practices and help Medicare patients at high risk organizational learning/continuous improvement; staffing;
for readmission safely transition from the hospital to other care supervisor/manager expectations and teamwork. The results
settings. By 2014, participants hope to reduce HACs by 40 were based on data from 1,032 U.S. hospitals.
percent and preventable readmissions by 20 percent to save
up to $35 billion across the health care system. Areas of strength:
• teamwork within units
• supervisor/manager expectations
Medicare patients spending less
time in the hospital at end of life Areas for potential improvement:
Medicare beneficiaries with severe chronic illness spent fewer • non-punitive response to mistakes
days in the hospital at the end of life in 2007 than they did in • handoffs/transitions
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.
Source: American Hospital Association
8 Healthy Skin
800 facilities have joined the program.
Are you one of them?
Get results with
Medline’s Pressure Ulcer Prevention Program
• Average reduction in facility-acquired If you are interested in:
pressure ulcers: 70.5% Implementing a program that allows you
• Average annual savings: $306,000 to achieve these results and sustain them
over time
How does it work? Reducing the incidence of pressure ulcers
With a compelling combination of products at your facility
and education: Learning more about Medline’s Pressure
1. Medline’s strategic product bundle, including Ulcer Prevention Program
skin care and incontinence products
2. Medline’s free educational program for
nurses and nursing assistants, including VIEW A PRESSURE ULCER PREVENTION
4 CE credits for nurses plus online, PROGRAM SUCCESS STORY
interactive competencies 1 Download a QR Code Reader app
2 Launch the QR app
3 Scan this QR Code or visit
1. Medline Industries, Inc. Data on file.
http://www.medline.com/
qr-code/jennie-edmundson/
©2011 Medline Industries, Inc. Medline is a registered
trademark of Medline Industries, Inc.
Special Feature
Patient experience is #1
Nurse leaders rank priorities in national survey
According to the newly

released HealthLeaders
Media Industry Survey 73%
of nurse leaders said
2011, nurse leaders are
their organization plans to
most concerned about encourage more nurses
1. Patient experience/ to pursue bachelor’s
patient satisfaction degrees over the next
three years; 18 percent
2. Quality/patient safety plan to encourage
3. Cost reduction nurses to pursue
master’s degrees.
of nurse leaders
39%
With the advent of the
HCAHPS (Hospital Consumers say that nursing
Assessment of Healthcare research is
Providers and Systems) being effectively
survey and more government translated into
pay-for-performance practice at the
requirements, nurses are bedside.
making the connection that
reimbursement will be tied
to patient satisfaction and When ranking the most important
quality of care, and patient factors for providing high-quality
safety beginning next year. patient care, nurse leaders reported:
#
Regarding hand 1 MOST IMPORTANT
hygiene compliance, Nurse-to-patient staffing ratio
48%
of nurse leaders agreed that
53%
of nurse leaders confirmed
#
#
2 MOST IMPORTANT
Nurse experience level
that their organization will

3 MOST IMPORTANT
the primary reason behind
be part of an accountable Nurse education/certification level
failure to achieve hand-washing
compliance is lack of spine care organization within
to self-police and report the next five years.
colleagues’ violations.
Source: HealthLeaders Media Industry Survey 2011: Nurse Leaders. Available at: www.healthleadersmedia.com/intelligence
10 Healthy Skin
Camera not included.
NE1™ Wound Assessment Tool

Accurate identification, consistent documentation
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 Winner of
width measurements at the same time. It also contains National HCA
areas to record the type of wound, plus the date, time Innovators
Award
and clinician’s name.
Key benefits
• Increase accuracy of wound assessment
by more than 100 percent1
• Standardize wound documentation Interactive training and online competencies available
• Drive appropriate reimbursement due on-demand at www.medlineuniversity.com
to more accurate wound assessment
LEARN MORE ABOUT THE NE1 WOUND ASSESSMENT
Reference
1 Download a QR Code Reader app
1. Young DL, Esocado N, Landers MR, Black J. A pilot study providing 2 Launch the QR app
evidence for the validity of a new tool to improve assignment of NPUAP
stage to pressure ulcers. Advances in Skin & Wound Care. In press. 3 Scan this QR Code or visit
©2011 Medline Industries, Inc. NE1 is a trademark of Medline Industries, Inc.
http://www.medlineNE1.com
Medline is a registered trademark of Medline Industries, Inc. Patent pending.
Special Feature
Transforming
the Health Care
Delivery System
by Teresa Nguyen Clark, MPH, MBA
12 Healthy Skin

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...
What is hospital value-based purchasing?

H.R. 3590 Patient Protection and Affordable Care Act 2010
Title III, Subtitle A, Part I
This essentially means your hospital will now be in a national

competition for Medicare dollars, regardless of hospital char-
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 acteristics, such as size and teaching status. This also means
all those things - legislation, payment, and focus. But what is it that going into a performance period, your hospital no longer
to you? knows what the Medicare performance target will be.
The recently enacted health care reform law — H.R. 3590 How will this change what I do today?
Patient Protection and Affordable Care Act 2010 — established Although October 2012 seems far away, Medicare will be start-
a hospital value-based purchasing (VBP) program, which is a ing to look at your baseline performance this summer. This
new payment system that will be implemented for the Medicare leaves you little time to make changes that ready you for work-
program by the Centers for Medicare & Medicaid Services ing in a value-based purchasing environment.
(CMS) starting in October 2012. Under the Medicare VBP pro-
gram, hospitals that do not surpass CMS-mandated perform- In addition to the timing of changes, value-based purchasing
ance targets will be subject to reimbursement penalties. will also affect your focus. Medicare has focused payment on
clinical conditions and it will continue to do so under VBP.
The Medicare VBP program initially focuses on five clinical con- However, under VBP Medicare will now also focus on the
ditions: patient experience of care, as measured by the HCAHPS. The
• Acute myocardial infarction (AMI) HCAHPS will shift your focus from clinician and disease
• Heart failure (HF) process-centric to patient-centric.
• Pneumonia (PN)
• Surgeries, as measured by the Surgical Care Okay then - Where do I start?
Improvement Project (SCIP) With the upcoming changes, there are two places to start
• Healthcare-associated infections (HAI) looking:
1. How do you compare to the national market,
In addition to these five clinical conditions, the Medicare VBP regardless of hospital characteristics?
program also focuses on Hospital Consumer Assessment of 2. From whose perspective is your patient experience
Healthcare Providers and Systems (HCAHPS), which is the of care model based upon? Clinicians? Patients?
patient’s perspective on quality.
Title III focus on Medicare VBP dramatically alters the health
How is any of this different than today? care landscape. If not prepared, your hospital, clinicians, and
Today, Medicare lets your hospital know ahead of time what leaders will be left in a precarious position when the Medicare
the performance target for payment will be. Knowing this ahead VBP payment effects begin October 2012.
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 Teresa Nguyen Clark, MPH, MBA, is vice president of clinical
targets, you share in the savings with other hospitals. business strategy and delivery for VHA, Inc., where she is respon-
sible for developing business and implementation strategies for
Come 2012, in a hospital value-based purchasing environment, VHA’s clinical performance team to enhance the company’s efforts
you no longer know what the performance target will be ahead to drive sustainable quality improvement with its members. Before
of time. That is, Medicare will no longer pre-define the target joining VHA in 2007, Teresa was the special assistant to the Cen-
before the performance period. Instead, Medicare will set the ters for Medicare and Medicaid Services (CMS) chief medical offi-
target after the performance period, with the performance tar- cer and the director of the Office of Clinical Standards and Quality.
get set at the national level.

TenderWet ACTIVE GENTLY REMOVES
NECROTIC TISSUE & PATHOGENS
TenderWet Active
TenderWet Active polyacrylate wound dressings
rinse and debride necrotic wounds for up to 24 hours!
Plus, they won’t stick to the wound bed, reducing
patient discomfort at dressing removal.
TenderWet Active dressings have a “rinsing” effect as

large-molecule proteins found in dead tissue and bacteria
are attracted to TenderWet Active's core.
We’re confident you’ll find TenderWet Active more effective

LEARN MORE ABOUT TENDERWET ACTIVE
than wet gauze therapy because TenderWet Active can
be left in place for up to 24 hours without drying out while
2 Launch the QR app
simultaneously removing harmful microorganisms and
stubborn necrotic tissue.
http://www.medline.com/wound-
skin-care/tenderwet-active/
By debriding necrotic tissue, absorbing and retaining
pathogens and keeping the wound moist, TenderWet
Active helps create an ideal healing environment.
©2010 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.
Special Feature
Answering Your Questions About

Accountable Care Organizations
What is an accountable care An ACO is a network of doctors and hospitals that comes together
voluntarily to share responsibility for providing care to patients. The
organization (ACO)? concept is part of U.S. healthcare reform under the Affordable Care
Act and primarily focuses on Medicare patients.1
When will the ACO

The plan is set to be established by January 1, 2012.
program begin?

The goal of an ACO is to improve the safety and quality of patient care
What is the purpose
and make health care more affordable. Today more than half of
of an ACO? 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.1
Who is eligible to Doctors and hospitals are the only providers allowed to form an ACO;
however, they will be responsible for incentivizing other healthcare
form an ACO?
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.2
Why would hospitals and doctors The benefit of forming an ACO lies in financial incentives from
Medicare for ACOs that demonstrate good quality care while keeping
want form an ACO?
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
hospitalizations.1
How ACOs Can Help

• 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.1
• ACOs could potentially save Medicare as much

as $960 million over three years.1
References
1. Accountable Care Organizations: Improving Care Coordination for People with Medicare. U.S. Department of Health & Human Services website.
Available at http://healthcare.gov/news/factsheets/accountablecare03322011a.html. Accessed March 31, 2011.
2. Gold J. Accountable care organizations, explained. Kaiser Health News. Available at http://www.npr.org/2011/01/18/132937232/accountable-care-
organizations-explained. Accessed March 23, 2011.
16 Healthy Skin
Patient safety is in your hands
Epi-clenz™ Gel Instant Hand Sanitizers contain tain

70% v/v ethyl alcohol to disinfect hands of mostt
common disease-causing germs. They also contain ntain
aloe vera and vitamin E to care for and soothe the
skin. The Breesia formula is a desirable option
if a mild, pleasant fragrance is preferred.
LEARN MORE ABOUT EPI-CLENZ
Also available in a 1 Download a QR Code Reader app

foaming formulation. 2 Launch the QR app
hand-hygiene/instant-hand-
sanitizers/default.asp
©2011 Medline Industries, Inc. Medline and Epi-clenz are registered trademarks of Medline Industries, Inc.
Special Feature
The path
forward
for quality
health care
By Lorri A. Downs BSN, MS, RN, CIC
18 Healthy Skin
The U.S. healthcare delivery system is fragmented. Care is
delivered at many locations leading to waste and duplication of
TOP 5
Things to Know about Healthcare Reform
services. To try to alleviate this problem, Congress has estab-
and Medicare Benefit4
lished the Medicare Shared Savings Program for Accountable
Care Organizations (ACOs) under the Affordable Care Act. How 1. Under the Affordable Care Act, existing guaranteed
will this program change healthcare delivery? How will it affect Medicare-covered benefits won’t be reduced or taken
quality of care? away. Neither will the ability to choose your own doctor.
2. Nearly four million people with Medicare received cost
“Medicare Accountable Care Organizations (ACOs) are the first relief during the healthcare reform law's first year.
step in reforming the American healthcare system. ACOs will be Medicare recipients with prescription drug coverage who
the change in patient care delivery designed to accelerate had to pay for drugs in the coverage gap known as the
progress toward a three-part national goal:1 "donut hole," received a one-time, tax-free $250 rebate
➢ Better care for individuals from Medicare to help pay for their prescriptions.
➢ Better health for populations 3. Medicare recipients with high prescription drug costs that
➢ Slow the growth of costs with improvements in care put them in the donut hole now get a 50% discount on
covered brand-name drugs. Between today and 2020,
ACOs will assume responsibility for a defined population of Medicare recipients will get continuous coverage for
Medicare beneficiaries. If the ACO succeeds in both delivering prescription drugs. The donut hole will be closed
high quality care and cost savings, the organization will share in completely by 2020.
the Medicare savings it achieves.2 4. Medicare covers certain preventive services without
charging the Part B coinsurance or deductible.
On March 31, 2011 the Department of Health and Human Recipients will also be offered a free annual wellness exam.
Services took the first step in forming accountable care 5. The life of the Medicare Trust fund will be extended to at
organizations (ACOs) by issuing the proposed rule for these least 2029, a 12-year extension as a result of reducing
organizations.1 The heart of this concept of care delivery is to waste, fraud and abuse, and slowing cost growth in
bring providers and suppliers of Medicare covered services Medicare, which will provide recipients with future cost
together to coordinate care for Medicare beneficiaries. savings on premiums and coinsurance.
Initially skilled nursing facilities, nursing homes and long-term

care hospitals are not specifically designated as eligible to form At the end of the day, we all must increased collaboration and
independent ACOs. communication between facilities to help reduce waste in our
healthcare system. Partnering for Prevention has become criti-
ACOs will be required to provide the Centers for Medicare and cally important. Teaching and supporting healthcare providers
Medicaid Services (CMS) with a plan documenting and about sustainable solutions across the continuum of care will help
addressing the following key Quality Processes: prevent costly readmissions and hopefully translate into a health-
➢ Promote evidence-based medicine ier population.
➢ Patient engagement
➢ Report on quality and cost metrics About the author
➢ Coordination of care Lorri Downs, BSN, MS, RN, CIC is a board-
certified infection preventionist and vice presi-
As ACOs begin to be defined, and the list of requirements dent of infection prevention for Medline
unfold, clearly quality will be at the core. The National Quality Industries, Inc. She has a diverse portfolio of
Strategy is a broad road map that will require the ongoing more than 25 years in the nursing professions.
development of specific goals and agreed metrics for healthcare Her expertise focuses on infection prevention
quality improvement. Efforts will focus on avoiding duplication of surveillance at large acute care organizations,
services, ensuring accountability, and streamlining quality plus ambulatory and public health settings. Lorri has developed hos-
reporting. pital infection control programs and local emergency preparedness
plans, and she has lectured on various infection prevention topics.

National Quality Priority Initial Goals, Opportunities for Success,
and Illustrative Measures
Strategy Priorities #1 Goal:
and Goals, Safer Care

Eliminate preventable health
care-acquired conditions
with Illustrative Opportunities for success:

* Eliminate hospital-acquired infections
Measures3 * 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
Goal:
#2 Create a delivery system that is less
Effective fragmented and more coordinated,
where handoffs are clear, and patients
Care and clinicians have the information they
Coordination need to optimize the patient-clinician
partnership
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
20 Healthy Skin
Priority Initial Goals, Opportunities for Success, Priority Initial Goals, Opportunities for Success,
and Illustrative Measures and Illustrative Measures
#3 Goal: #5 Goal:
Support every U.S. community as it
Build a system that has the capacity
Person- to capture and act on patient-reported Supporting pursues its local health priorities
information, including preferences,
and Family- desired outcomes, and experiences
Better Opportunities for success:
Centered with health care Health in * Increase the provision of clinical
preventive services for children and
Care Opportunities for success:
Communities adults
* Integrate patient feedback on * Increase the adoption of
preferences, functional outcomes, evidence-based interventions to
and experiences of care into all care improve health
settings and care delivery
* Increase use of EHRs that capture the Illustrative measures:
voice of the patient by integrating * Percentage of children and adults
patient-generated data in EHRs screened for depression and receiving
* Routinely measure patient engagement a documented follow-up plan
and self-management, shared * Percentage of adults screened for risky
decision-making, and patient-reported alcohol use and if positive, received
outcomes brief counseling
* Percentage of children and adults who
Illustrative measures: use the oral health care system each
* Percentage of patients asked year
for feedback * Proportion of U.S. population served
by community water systems with
optimally fluoridated water
#4 Goal:
Prevent and reduce the harm
Prevention caused by cardiovascular disease #6 Goal:
Identify and apply measures that can
and Treatment Opportunities for success: Making serve as effective indicators of progress
of Leading * Increase blood pressure control
Care More in reducing costs
in adults
Causes of * Reduce high cholesterol levels Affordable Opportunities for success:
Mortality in adults * Build cost and resource use
* Increase the use of aspirin to prevent measurement into payment reforms
cardiovascular disease * Establish common measures to assess
* Decrease smoking among adults the cost impacts of new programs and
and adolescents payment systems
* Reduce amount of health care
Illustrative measures: spending
* Percentage of patients ages 18 years that goes to administrative burden
and older with ischemic vascular * Make costs and quality more
disease whose most recent blood transparent to consumers
pressure during the measurement
year is <140/90 mm Hg Illustrative measures:
* Percentage of patients with ischemic * To be developed
vascular disease whose most recent
low-density cholesterol is <100
* Percentage of patients with ischemic U.S. Department of Health and Human Services
March 2011
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)

OPTILOCK™
Super Absorbent Wound Dressing
Gentle on wounds,
tough on exudate
OPTILOCK’s superabsorbent polymer
core absorbs moderate to heavy exudate,
locks in fluid—even under compression—
and protects periwound skin from maceration.
Non-adherent contact layer prevents the dressing
from sticking to the wound. Gentle removal and fewer
dressing changes mean greater patient comfort.
LEARN MORE ABOUT OPTILOCK

2 Launch the QR app
wound-skin-care/optilock/
Special Feature
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.
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
(HCAHPS)
“ First Do No Harm.
Building strong partnerships internally and externally is a neces-
sity for a successful health system. Interdisciplinary teams that
• Excellence with delivering the patient experience include: nurses, materials managers, purchasing, CWOCNs,
(HCAHPS) infection control preventionists, physicians, chief medical officers
• Reliable care that is founded on best practice quality and chief nursing officers must come together to evaluate current
and safety practices (Pay for Performance - clinical and service excellence delivery. Innovation and change
Value Based Purchasing - Core Measures / SCIP / management will be a necessary core competency of staff and
Hospital-Acquired Conditions) leaders in positions to influence excellence.
• Nursing staff at the forefront of designing, developing
The ideal state for CNOs and clinical leaders is to have collabo-
and implementing solid EMRs (“Meaningful Use”-
ration and standards in practice, processes, and leadership
Patient Protection Accountability Care Act-PPACA)
across our nation. Remember, if excellence was that easy, we
• Excellent, system-focused leaders who care and
would have nailed this years ago. Our dear leader, Florence
engage all staff on their excellence journey
Nightingale, instructed us, “First Do No Harm.” Let’s continue to
• An environment that fosters and supports the learn from one another and provide our staff, physicians and
STEEEP aims of Lean/Six Sigma (Safe-Timely- patients with excellence, and of course, eliminate harm.
Effective-Equitable-Efficient-Patient-Centered Care)

MEDLINE’S REVOLUTIONARY SHOW-AND-TELL PACKAGING
Each package is a 2-Minute Course

in Advanced Wound Care ™
Medline’s Educational Packaging offers all the information you need, step by step,
short and sweet, to help the Medline dressing do its job of healing.
LEARN MORE ABOUT ADVANCED WOUND

CARE EDUCATIONAL PACKAGING

2 Launch the QR app

http://www.medline.com/ep
Treatment
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 (x2 = 107.22, df = 1, P = .0001). Nurses who received the
intervention (educational materials for dressing application at- dressing package with the attached educational guide agreed
tached to the manufacturer’s dressing package) to traditional that this feature gave them confidence to correctly apply the
wound care education on reported confidence and dressing dressing (88%), while no nurse agreed that the traditional
application in a simulated model. package gave him or her the confidence to apply the dress-
ing correctly (x2 = 147.47, df = 4, P < .0001).
Subjects and Settings: Nurses from a variety of backgrounds
were recruited for this study. The nurses possessed all levels Conclusions: A just-in-time education intervention improved
of education ranging from licensed practical nurse to master nurses’ confidence when applying an unfamiliar dressing and
of science in nursing. Both novice and seasoned nurses were accuracy of application when applying the dressing to a sim-
included, with no stipulations regarding years of nursing ulated model compared to traditional wound care education.
experience. Exclusion criteria included nurses who spent less
than 50% of their time in direct patient care and nurses with Introduction
advanced wound care training and/or certification (CWOCN, Appropriate wound care, which includes accurate selection
CWON). Study settings included community-based acute and application of a variety of wound care products, is a key
care facilities, critical access hospitals, long-term care facili- responsibility for the individual wound care clinician and health
ties, long-term acute care facilities, and home care agencies. care facility. Wound care is especially challenging when pro-
No Level I trauma centers were included in the study for vided by multiple caregivers with varied educational and
geographical reasons. experiential backgrounds. Educating multiple persons to
deliver competent wound care may appear especially over-
Methods: Participants were randomly allocated to control or whelming for agencies that lack a wound care specialist
intervention groups. Each participant completed the Kent to ensure adequate education for all involved staff or lay care
Dressing Confidence Assessment tool. Subjects were then providers.
asked to apply the dressing to a wound model under the
observation of either the principal investigator or a trained Seaman and colleagues1 suggest that innovative dressings
observer, who scored the accuracy of dressing application may help caregivers improve wound-healing outcomes. How-
according to established criteria. ever, this is true only when dressings are selected and
applied appropriately. Ayello and colleagues2 demonstrated a
Results: None of the 139 nurses who received traditional need for increasing both the quality and quantity of educa-
dressing packaging were able to apply the dressing to a tion related to wound care. Nevertheless, little research has
wound model correctly. In contrast, 88% of the nurses who been completed that evaluates the efficacy of educational
received the package with the educational guide attached to strategies to promote appropriate selection and application
it were able to apply the dressing to a wound model correctly of wound care products.

Clinical decision making is a complex process that involves board, and all participants gave informed consent. Nurses
the intersection of a number of factors, including knowledge were recruited through informal announcements made on
of wound healing, local and systemic factors that influence various units including medical/surgical units, emergency
wound healing, specific wound care interventions, and past departments, surgery, day surgery, and long term acute
experience.3 Nurses must make multiple decisions when car- rehabilitation unit, home health care agencies, and long term
ing for an individual patient and that influence patient out- care facilities. Nurses with wound care certification (CWOCN,
comes such as wound healing.4 Rycroft-Malone and CWON, and CWCN) and advanced practice nurses were ex-
associates5 found that protocol-based care increased nurses’ cluded from participation. In addition, nurses who spent less
independence and autonomy. Verdu6 found that decision than 50% of their time in direct patient care were excluded.
trees assist nurses to make complex clinical decisions, I excluded these nurses since direct patient care is not the
including the selection of appropriate wound dressings. focus of their routine responsibilities and their participation
may have introduced confounding variables into the study.
Educational intervention. Advances in the application of
informatics in health care have led to a teaching technique
commonly labeled “just-in-time” education.7 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 content8 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-
directed.9 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 FIGURE 1. Educational guide attachment on dressing package
decision trees for selection of appropriate pressure redistribution
surfaces and algorithms for selecting an appropriate dressing, Nurses were randomly allocated to a control group receiving
that have proved useful for assisting generalists manage traditional wound education, or the intervention group receiv-
wounds. Just-in-time education may prove useful for wound ing just-in-time education. Simple random allocation was
care if it can be made available when a dressing is applied. completed by allowing each nurse to choose a colored card.
Cards were 1 of 2 colors; selection of 1 color led to allocation
One company that manufactures dressings (Medline Industries, to the control group, and selection of the other color resulted
Inc, Mundelein, Illinois) has developed a packaging system in allocation to the intervention group. Participants had no
based on the concept of “just-in-time” education (Figure 1). knowledge of which dressing the colored cards represented.
Instructions for appropriate dressing use are attached to each No compensation was provided to participants, and the com-
package. This study was undertaken to assess the effects of pany who designed the innovation had no input into the de-
this educational resource. Specifically, I examined nurses’ sign, concept, or implementation of the study. However, the
reported confidence in their ability to provide appropriate care company did supply dressings, free of charge, needed to
using an unfamiliar dressing and an objective assessment of conduct the study.
nurses’ ability to apply the dressing correctly to a wound
model. Study setting. The study was conducted at 8 facilities in
central Indiana, including community hospitals, critical access
Methods hospitals, long-term acute care units, long-term care facili-
This randomized controlled trial compared self-reported confi- ties, and home health agencies. The long-term acute care
dence levels in providing wound care and applying a dressing units and home health agencies were used in the pilot study
to a model in 2 groups of nurses. Study procedures were only, due to staff availability. Facilities were selected that were
reviewed and approved by my facility’s institutional review geographically near the principal investigator. Each facility was
26 Healthy Skin
tors. The tool was then revised in order
Figure 2. Kent Dressing Confidence Assessment.
Please place an “x” in the category that best represents your answer
to obtain consensus as to measure-
ment criteria, wording, and general
The package Strongly Somewhat Neutral Somewhat Strongly
directions on the Agree Agree Disagree Disagree
presentation. Following content valida-
wound dressing tion by the panel, the tool was further
package:
evaluated in a pilot study involving 34
1. Provides directions nurses. Each nurse randomly selected
about use of the
dressing. 1 of the test dressings and completed
the questionnaire. Demographic infor-
2. Defines one or more
uses of the dressing.
mation was collected on the nurses
involved in the pilot study, and they were
3. Indicates instructions for
application of the dressing.
interviewed to determine if they found
the questionnaire clear and under-
4. Indicates the method for standable. They were also asked to pro-
removing the dressing.
vide suggestions for improving wording
5. Explains how to apply of any items they found confusing. All
the dressing correctly.
participants indicated they found instru-
6. Defines the change ment items clear, concise, easy to read,
frequency of the dressing.
easy to complete, and easy to under-
7. Allows me to apply stand. The Kent Dressing Confidence
the dressing safely.
Assessment contains 10 questions;
8. Educates me about each item is answered via a 5-point
specific precautions in scale, “strongly agree,” “agree,” “neu-
relation to the dressing.
tral,” “disagree,” or “strongly disagree.”
9. Gives me confidence Each item is scored individually. I then
that I can correctly apply
the dressing. developed a form using information
from the educational packaging that
10. Will change my nursing
practice in relation to
specified correct criteria for dressing
application of wound application. This form contained 4
dressings.
application criteria; each of the criteria
had to be demonstrated by the nurse in
contacted and the appropriate administrator was approached order for the dressing application to be scored as “correctly
about allowing me to solicit involvement in the study. Once applied” (Figure 3).
management approval was given, site visits for the recruit-
ment of subjects were completed. Study procedures. I selected a dressing that was not famil-
iar to study participants in order to enable a more accurate
Instruments. Data were collected using 2 tools: (1) the Kent assessment of the effect of the educational intervention on
Dressing Confidence Assessment, a rating scale/question- application and self-reported confidence with application. The
naire to assess the nurses’ feeling of confidence in dressing control group received the unfamiliar dressing in a “standard”
application; and (2) a structured criteria form to be used to package with instructions to actually apply the dressing to the
evaluate each nurse’s ability to accurately apply the dressing wound model. Scissors and gauze were made available for
to the wound model (Figures 2 and 3). use, and the participants were told they could use any item
they thought necessary to apply the dressing. The nurses
The Kent Dressing Confidence Assessment is a questionnaire were not asked to secure any secondary dressing in place.
used to measure nurses’ confidence in wound dressing Rather, they were instructed to apply the secondary dressing
application; I developed the tool prior to data collection. It was according to package instructions. Participants were allowed
evaluated by a panel of researchers, with expertise in wound to ask questions, but no information about how to apply the
care and instrument development, and professional educa- dressing was given by the principal investigator (D.K.) or

trained observer. The intervention group was
managed in an identical fashion, but they re- Table 1. Demographic Information
ceived the unfamiliar dressing in a package Control Intervention Group Total

with an attached instruction sheet (Figure 1). Group, N Group, N Comparison
Licensure x2 = 0.1549 N = 173

Each participant completed the Kent Dressing LPN 21 22 df = 1
RN 59 71 P = .69
Confidence Assessment tool (Figure 2). Sub-
jects were then asked to apply the dressing to Education x2 = 1.6162 N = 173
a wound model under the observation of LPN 21 22 df = 1
Diploma RN 4 3 P = .20
either the principal investigator (D.K.) or a ADN RN 33 32
trained observer, who scored the accuracy of BSN RN 21 34
dressing application according to established MSN RN 1 2
criteria (Figure 3). The trained observer was a Experience, y x2 = 0.1274 N = 173
nurse trained in providing wound care and <1 12 8 df = 1
2-5 20 22 P = .72
dressing application. I taught the observer to
6-10 13 17
score the subject based on the 4 criteria for 11-15 9 23
correct dressing application and on how to 16-20 19 19
21-25 4 3
interact with subjects during data collection.
≥26 3 1
I evaluated training by direct observation of
the data collector prior to data collection. In Care setting x2 = 2.8728 N = 173
Acute care 46 55 df = 3
order to avoid education among participants, ECF 4 22 P = .41
I allowed only 1 participant in the study room Home care 19 9
at any time. Subjects were asked to not to Long-term acute care 11 7
speak of any part of their experience in the

Abbreviations: ADN, advance degree nurse; ECF, extended care facility; LPN, licensed practical nurse
study room until all data were collected at that
facility. Was dressing applied correctly 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-
Figure 3. Criteria for dressing application. Yes No
gory of work experience was category B (2-5 years) among
1. Must trim dressing with scissors to fit the wound the nurses. Forty-one nurses worked in a long-term care
2. Must remove the blue protective packaging from the facility, 13 worked in home health care, 18 worked in long-
dressing prior to placing it into the wound
3. Must pack the dressing loosely into the wound bed,
term acute care, and the remaining 101 nurses worked in the
filling it only 2/3 full. acute care hospital (Table 1). No statistically significant differ-
4. Must cover with a secondary dressing ences were found when groups were compared based on
Must score “yes” in all categories to correctly apply dressing to the wound model. educational preparation, care setting worked, or years of
Was dressing applied correctly Yes No
experience.
Confidence with dressing application. Dressing applica-

Data analysis. Proportions and chi-square analysis were tion confidence was evaluated via 3 items from the Kent
used to determine whether the educational intervention Dressing Confidence Assessment: (1) item 5 that queried cor-
affected nurses’ reported confidence when applying a novel rect dressing application; (2) item 7 that queried safe appli-
dressing and their observed performance when applying the cation of the dressing; and (3) item 9 that queried confidence
dressing to a model. Chi-square findings were validated with when correctly applying the dressing. Significantly, fewer con-
the Fisher exact test. trol group subjects agreed that they could correctly apply the
dressing (item 5) (4% vs 100%, x2 = 173.00, df = 4, P =
Results .0001). Significantly, fewer control group subjects agreed that
One hundred seventy-three nurses participated in the study. they could safely apply the dressing as compared to subjects
Among the control and intervention groups, there were 43 receiving just-in-time education (item 7) (4% vs 91%, x2 =
28 Healthy Skin
160.07, df = 4, P < .0001). Fewer nurses in the control group vention improved accuracy of a swallowing protocol. Simi-
agreed that they felt confident with dressing application when larly, Grasso and colleagues11 found that personal digital as-
compared to nurses in the intervention group (item 9) (19% vs sistants (an electronic device designed to deliver just-in-time
88%, x2 = 147.47, df = 4, P < .0001) (Table 2). education) that accessed a drug database significantly re-
duced the rate of medication errors in 1 facility. Al-Saleh and
Dressing application. None of the 62 nurses in the control Williamson12 also found that personal digital assistants pro-
group were able to apply the dressing to the wound model vide the ability to find information quickly and promote safe
correctly as compared to 68 of 77 nurses (88%) in the inter- patient care, as well as confidence in undergraduate nursing
vention group who were able to apply the dressing correctly student.
(x2 = 100.694, df = 1, P < .0001) (Figures 4 and 5). The most
common dressing errors were as follows: (1) failure to trim the Although this study did not directly measure dressing appli-
dressing to fill the wound cavity two-thirds full (100%); cation in a clinical practice setting, more subjects receiving
(2) failure to remove the blue cover (carrier sheet) on the the intervention were able to accurately apply an unfamiliar
dressing (68%); and (3) overpacking the wound by scrunch- dressing accurately to a model than were subjects given tra-
ing the entire dressing up in the wound bed (100%). Reported ditional education. In addition, 71% of nurses who received
data does not include pilot study groups. the just-in-time educational intervention reported they would
change their practice based on the package insert. It is not
Discussion known why the remaining 29% responded that they did not
Findings from this study provide evidence that use of a just- feel that the intervention would prompt them to change their
in-time educational intervention (placement of an instructional practice. Some participants stated that they frequently pro-
guide for application in the individual dressing packages) vide wound care based on physician orders, without really
enhances application technique and reported confidence thinking about the purpose of a particular dressing. Others
when applying a previously unfamiliar dressing. More subjects expressed that dressing application is relatively intuitive, and
in the intervention group reported confidence that they could they simply glanced through the educational guide instead of
safely and correctly apply the dressing than did control group reading it, as observed by the investigator. However, since
subjects, and this perception was validated when subjects accurate application of this type of dressing falls within the
were asked to apply the dressing to a model. scope of nursing practice, this response presents a challenge
to wound care nurses when educating peers about wound care.
I reviewed the literature and found no other studies demon-
strating the efficacy of the just-in-time educational technique I attributed application failures in the control group to a lack
in wound care. Poskus10 reported that a just-in-time inter- of knowledge about dressing application, since no information
was available on the
dressing package
Table 2. Questionaire Results itself. Factors con-
tributing to dressing
% Agree
application failures for
Kent Dressing Confidence Assessment Plain Package Package With Instructions
(n=80) (n=93) intervention group
The package directions on the wound dressing package:
subjects may include
1. Provides directions about use of the dressing. 0 100
2. Defines one or more uses of the dressing. 0 100
an assumption that
3. Indicates instructions for application of the dressing. 0 100 they could apply the
4. Indicates the method for removing the dressing. 0 100 dressing correctly
5. Explains how to apply the dressing correctly. 0 100
without consulting
6. Defines the change frequency of the dressing. 0 100
7. Allows me to apply the dressing safely. 0 90
directions, or a history
8. Educates me about specific precautions in 0 96 of topical dressing
relation to the dressing. packages without
9. Gives me confidence that I can correctly apply 0 88
the dressing. just-in-time informa-
10. Will change my nursing practice in relation to 0 71 tion aiding accurate
my application of wound dressings.
application.

Limitations KEY POINTS
Study limitations include using a model for dressing applica- ✔ Just-in-time education in the form of an educational
tion rather than direct observation in clinical practice. In addi- guide on wound dressing packages led to increased
tion, although subjects were instructed not to discuss nursing confidence in a broad sample of nurses with
dressing application with other study participants, it was not varying educational backgrounds and numbers of
possible to ensure that subjects did not discuss application years of experience.
outside the research setting. I did not include pilot study ✔ Just-in-time education in the form of an educational
dressing application data in the overall results. The outcomes guide on wound dressing packages led to increased
were similar for this portion of the study, but the focus was on safety and accuracy when applying an unfamiliar
validation of the Confidence Assessment Tool and the study dressing in a simulated model.
procedures. ✔ More than 70% of nurses reported that placement of
an educational guide on wound dressing packages
Figure 4. Successful would change their practice when delivering wound care.
70 dressing application
results, n = 68.
60
50 Acknowledgments
40
The author thanks Medline Industries for supply of dress-
30
20
ings/packaging for the study. The author also thanks St.
10 Joseph Hospital, Kokomo, Indiana, for supporting this study
0 as well as Mark Smith, St. Vincent Hospital, Indianapolis,
Indiana, for statistical analysis of the data.
Control Group 0
Intervention Group 68
Dea J. Kent, MSN, RN, NP-C, CWOCN, Manager, Wound

Ostomy Clinic, Riverview Hospital, Noblesville, Indiana.
Figure 5. Dressing Correspondence: Dea J. Kent, MSN, RN, NP-C, CWOCN,
70 application failures,
n = 71. PO Box 386, Sharpsville, IN 46068 (deajkent@aol.com).
60
50
40
References
30 1. Seaman S, Herbster S, Muglia J, Murray M, Rick C. Simplifying modern wound
20 management for nonprofessional caregivers. Ostomy Wound Manag. 2000;46:18-27.
10 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.
0
J Clin Nurs. 2007;17:187-195.
4. Twycoss A, Powls L. How do children’s nurses make clinic decisions? Two preliminary
Control Group 62 studies. J Clin Nurs. 2006;15:1324¬1335.
Intervention Group 9 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.
bc.ca/vnc/ksu/ksu.htm#_TOC11. Accessed May 25, 2008.
Conclusions 8. Barr R, Tagg J. Just-in-time education: learning in the global information age.
Just-in-time education, in the form of education on a dress- http://knowledge.wharton.upenn.edu/. Published December 2002.
ing package, improved both nurses’ confidence in applica- Accessed June 5, 2008.
9. Bongiorni B, Spicknall M, Horsmon A, Cohen P. On-demand education to meet marine
tion of an unfamiliar dressing and their accuracy when industry professional development needs. J Ship Prod. 1999;15:164-178.
applying the dressing to a simulated model. Study findings 10. Poskus K. Triumphs and challenges of implementing a nursing bedside swallow
screening tool: a stroke coordinator’s perspective. Perspect Swallowing Swallowing
provide evidence that manufacturers of wound dressings Disord (Dysphagia). 2009;18: 129-133.
should apply just-in-time educational techniques by placing 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.
an educational guide on all dressing packages in order to 12. Al-Saleh M, Williamson K. EBP and patient safety: using PDAs in nursing education
enhance the accuracy and safety of application and, classes. Paper presented at: Summer Institute on Evidence-Based Practice; 2009.
http://www. acestar.uthscsa.edu/institute/su09/documents/Al-Saleh_000.pdf.
ultimately, its efficacy in wound healing. Accessed January 29, 2010.
Published with permission from the Journal of Wound, Ostomy and Continence Nursing.
November/December 2010; 37(6):609-614.
30 Healthy Skin
GENERAL SESSIONS
June 5, 2011
10:00-11:00 am
“The Healing Power of Humor”
The Wound, Stuart Robertshaw, EdD, JD
11:30 am-12:30 pm
Ostomy and “Lawsuits, Technology and Wounds:

How Electronic Records Change your Practice”
Kevin W. Yankowsky, JD
Continence 2:15-3:45 pm
Oral Paper Presentations
Nurses Society including “Effects of Just-in-Time Education

Intervention Placed on Wound Dressing Packages”
Dea J. Kent, MSN, RN, NP-C, CWOCN
43rd WOCN June 6, 2011

Annual Conference 9:15-10:15 am
“Preparing for the Future: Professional Opportunities
for the WOC Nurse”
June 4-8, 2011, New Orleans, LA 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 http://www.prolibraries.com/-
wocns/?select=sessionlist&conferenceID=6

Treatment
The Art of Wound

Management
By Dionie Bibat, BSN, RN, WOC Nurse appropriate, such as nutrition, moisture and health of the patient, cli-
It was a Tuesday morning in late July, and retired WOCNs Dora and nicians in the last 26 years were still using treatments such as
Nancy were having breakfast at an outdoor café. They were wait- Maalox and heat lamps for wounds. Fortunately, with more aware-
ing for Sara to join them. The sun was warm, and the two women ness, this type of treatment is no longer popular.
sipped coffee and reminisced about the past. They first met years
ago at ET school. Wound healing is multidisciplinary; it is a collaborative approach
between the patient, nutritionist, wound nurse, physician and other
Dora, the older of the two, said, “I remember the days when we clinicians. Treatment of wounds not only involves assessing the
used Maalox® and heat lamps for wounds. The faster the wound wound; it must be a holistic approach.
dried the better.”
Factors to consider
Nancy, who was the entrepreneur of the group replied, “Yeah, I used How did the wound develop? What is the etiology? An excellent
to add sugar to the Maalox, and then do the heat lamp, and the only patient history will help the clinician determine the cause of the
thing I was really concerned about was to make sure the patient wound. There are “typical” characteristics of the most common
did not get burned by the heat lamp.” types of wounds, such as pressure ulcers, vascular wounds,
(including venous insufficiency and arterial disease) and neuro-
Sara, the youngest of the group finally arrived and sat to join them. pathic/diabetic wounds. In some cases, it may be difficult to deter-
Not missing a beat, she replied, “Gosh, how on earth did you get mine the origin of the wound, and diagnostic tests are necessary.
any wounds to heal with that kind of treatment?” The rest of the Consider a biopsy in a wound that is uncharacteristic or has an un-
conversation progressed to the more modern concepts of wound familiar presentation.
management.
Systemic support. The old saying “focus on the whole of the
Research shows that as early as 3000 BC, healers implemented patient, not the hole in the patient” is so true today. Assess the
the importance of nutrition in wound care1 and years later, in 1962, patient’s entire system, such as evaluating their nutritional status by
evidence of moist wound healing was documented.2 Despite the taking a dietary history. Blood work, such as protein levels, pre-
growing knowledge that healing occurs when proper conditions are albumin and blood glucose levels, may divulge more needed infor-

mation.3 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.3 About the author
Dionie Bibat BSN, RN, WOC Nurse, is Vice President of Clinical
Topical treatment of the wound. ”The Five Principles of Wound Services at Medline Industries, Inc. Prior to joining Medline, Dionie
worked for a major wound company as a Clinical Resource Specialist
Healing” uses the acronym WOUND. The key is to understand
and has 14 years experience as a sales representative. As a CWOCN
these principles of wound healing and to apply them when choos-
at Evanston Hospital in Evanston, IL, she created and revised protocols
ing an appropriate topical product.4
regarding wound and ostomy care. She also developed and headed
the wound team at Evanston and participated in the products
W- is the wound healing? committee.
O - optimal moisture
U - understand the periwound skin References
1. Patel GK. The role of nutrition in the management of lower extremity wounds. Int J Low
Extrem Wounds. 2005;4(1):12-22.
N - necrotic or viable tissue 2. Mulder G. Section Editor's Message: Genomic, Cellular, and Recombinant Technologies
in Tissue Repair. Wounds. 2008. Available at: www.woundsresearch.com/article/2268
D - depth or dead space http://www.woundsresearch.com/article/2268. Accessed May 2, 2011.
3. Bryant RA, Nix DP. Acute & Chronic Wounds Current Management Concepts. 3rd ed.
St. Louis, MO: Mosby; 2007.
With hundreds of dressings to choose from, new clinicians like Sara 4. The Wound Care Handbook. 2nd ed. Mundelein, IL: Medline Industries, Inc., 2008.
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
www.wocn.org
• National Pressure Ulcer Advisory Panel
(NPUAP), www.npuap.org
• Joint Commission on Accreditation of Healthcare
Organizations (Joint Commission) www.jointcommission.org
• Wound Healing Society (WHS) www.woundheal.org
34 Healthy Skin
Survey Readiness
SUCCESS STORIES
More than just a survey tool

%&#

!-
ABOUT THIS SERIES '(
-
9 #

)
*

8 +
,

4

SUCCESS STORIES
#
#

"

-

-((. "

#

/(

%&#

-

! "
!

"

$
0

-

12

3 +

,45
%&#
,
12

-
"

3
6

!
6

For four decades, UHS-Pruitt Corporation has delivered peace of mind to its patients,
residents, clients and their families.

,

6
7

-

6
0 -
R

-

-

!

#

"

#

- # "

- $ 18
%&#


SUCCESS STORIES

!
&

$ 0

:%&#
#

;3 < <

%&#
0
$
‘Very helpful’
4 %&#
1

#

>

=

Tracking trends
!

"
!

# 0

0 = 0
0

8 3
>

&

>0 #

"

#
"

While abaqis helps reduce inspector citations, its ability to help operators improve
#
the care they deliver to residents is even more notable, users claim.

0
# BB %&#
0 +

# ,

1 2
%&#

! -(((( !

12
!#
" # $%

#
" :
; #

"

3
3 <
" %&#
0
#

8 0 %&#
0
# BB %&#

3 #
+
,
&

!
0
$

#

"

C! >
#
12

%&#

#

! 0

4 #

1 0 =

?@A

> 1

0

: #
#

; 2 $ 0

#

5

3 &

!
0 "#
#

3

3 #
1"

# 0
0
10

# <
&
%&#

0

0

+
,
#

$

#
,

! " 3
36 Healthy Skin
Quality Assurance System
Placing your residents

at the center of care
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
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
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 LEARN MORE ABOUT ABAQIS
and survey results.
2 Launch the QR app
programs/abaqis/
Assessment
and
Management
of Fungating
Wounds
By Kelli J. Bergstrom,
BSN, RN, ET, CWOCN
38 Healthy Skin
Treatment
Fungating
wounds present
unique challenges,
including prevention or
management of bleeding
and control of exudate
and odor.
Abstract Etiology and Presentation

A fungating wound is a malignant lesion that infiltrates the skin A fungating wound, also known as a malignant lesion, is
and its supporting blood and lymph vessels. They tend to defined as the infiltration and proliferation of malignant cells in
develop in the last few months of a patient's life, and often to the skin and its supporting blood and lymph vessels.6 It may
impair psychosocial well-being. Fungating wounds present evolve from the site of the primary cancerous lesion or from a
unique challenges for WOC nursing management, including secondary lesion.7 Fungating malignant wounds may be locally
prevention or management of bleeding and control of exudate advanced, metastatic, or recurrent.8 Metastatic spread tends to
and odor. Our knowledge of the epidemiology, etiology, occur along pathways of minimal resistance, such as tissue
assessment, and management of these lesions is limited. This planes, blood or lymph vessels of the skin, or through implan-
article provides an overview of the epidemiology of fungating tation of tumor cells through a surgical incision.9 They frequently
wounds, their assessment and options for management, occur in patients between the ages of 60 and 70 years and
focusing on local wound management, control of associated often develop during the last 6 months of life.10 Diagnosis is
symptoms, and psychosocial support for patient and family. based on histological assessment and cultures from the
surface of the wound to confirm the presence of anaerobic
Introduction organisms that flourish on the necrotic tissue. If these organ-
A cancer diagnosis can be devastating for any patient, espe- isms are not accurately identified, inappropriate treatments can
cially when complicated by a fungating wound. A fungating lead to the production of by-products that can interact with
wound can be present for years, but they usually develop in the wound drainage resulting in periwound maceration.7
last few months of a patient's life. Although fungating wounds
pose a challenge for patients and caregivers, Clark1 reports that Fungating wounds have a tendency to expand rapidly, and they
only 90 research articles have been published on the topic in show a propensity to become locally invasive, or form shallow
the past 30 years. Approximately 5% of patients with cancer craters.7 Initially, they present as multiple nontender nodules that
and 10% of those with metastatic disease will develop a are skin-toned, pink, violet-blue, or black-brown in color, but
fungating wound.2,3 Although they can arise from any type of they go on to develop in to papillary lesions (resembling a cau-
underlying malignant tumor, the majority of metastatic cuta- liflower stalk) that may be complicated by an ulcer, sinus tract,
neous lesions arise from primary tumor sites involving the or fistula.8 The most common location for a fungating malignant
breast, lungs, skin, and gastrointestinal tract.4 Fungating tumor is the breast; these lesions represent 62% of fungating
wounds require additional research focusing on their etiology wounds. Head and neck lesions account for 24%, the groin,
and presentation, physical and social impact, and management, genitals and back account for approximately 3%, and all other
especially as patients approach end of life,5 and WOC nurses regions account for 8% of all fungating wounds.10 As these
should both initiate and participate in interdisciplinary studies lesions expand, they tend to disrupt the local blood supply,
addressing these challenging wounds. resulting in necrosis of the malignant tumor and underlying

Treatment
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
Assessment is an ongoing process due to intensity laser therapy.10 In other situations fungating tumors
occur at the end of life, and treatment is completed in a pallia-
the progressive nature of the wound, and
tive care setting that focuses on comfort and maintenance of
the evolving condition of the patient.10 the best possible quality of life for the patient and family.11 In
either case, it is important to remember that the symptoms pro-
duced by a fungating wound are often as distressing as the
tissue. Anaerobic organisms readily grow and proliferate in this wound itself. Therefore, management focuses on alleviation of
warm, moist, and oxygen-poor environment. It is the prolifera- bothersome symptoms including pain, cutaneous irritation,
tion of these anaerobic organisms that create their characteristic exudate, bleeding, odor, and psychosocial support, regardless
exudate and malodor. Tumor infiltration of the local lymphatic of whether treatment is delivered in a palliative or aggressive
vessels can also affect interstitial tissue drainage resulting in care context.
lymphedema of the affected region.7
Pain
Assessment Pain is a subjective symptom impacted by the underlying con-
Assessment is an ongoing process due to the progressive dition, the wound itself, and dressing changes.10 Assessment
nature of the wound, and the evolving condition of the includes location, nature, duration, onset, frequency, intensity,
patient.10 It is necessary for the WOC nurse to take a holistic impact on activities of daily living, aggravating and alleviating
approach in assessing the interrelationship between patient and factors, current analgesia use, and effects of treatment. Stan-
the wound.7 In addition to assessing local wound factors, the dardized pain scales are used to assess intensity. Evaluation
WOC nurse should consider the cause and stage of the under- should also differentiate nociceptive pain (caused by stimula-
lying cancer, previous and current treatment, the patient’s tion of nerve endings when provoked by inflammatory media-
understanding of the diagnosis, nutritional status, impact of the tors) from neuropathic pain (caused by nerve damage and
malignancy and wound on the patient's and caregivers’ psy- dysfunction) because treatment differs depending on the type of
chosocial status and quality of life. Assessment should also pain. Analgesics, including opioids and nonopioid agents, are
evaluate availability of resources and social support networks.9 used for nociceptive pain, while adjuvant agents, such as
amitriptyline and carbamazepine, are more effective for neuro-
Local wound assessment includes evaluation of its location, pathic pain. Analgesics and adjuvant agents may be prescribed
dimensions, depth, percentage of devitalized tissue, degree of separately or concurrently to achieve a combined effect.
tissue adherence of the wound surface, volume and character- According to recent case studies, topical opioids applied to the
istics of exudate, odor, history of bleeding, quality and intensity wound surface can provide immediate local analgesia and work
of pain, signs of fistula or sinus formation, and condition of the indirectly to diminish the inflammatory process.10,12 When man-
periwound skin.9 Assessment data are then used to develop a aging pain associated with dressing changes, several interven-
management plan, taking care to ensure that the planned tions may be implemented, such as a “booster” dose of
interventions are consistent with the patient's goals and priori- analgesia prior to dressing changes, use of nonadherent soft
ties and do not adversely interact with other components of the silicone dressings, gentle care techniques, and reduced
management plan.7 frequency of dressing changes.
Continued on page 42
40 Healthy Skin
Join 140,000 other nurses
for free CE courses at
Medline University
200 courses
20 curriculum tracks
Interactive competencies
Flexible access: PC, iPhone, iPad
Free registration
REGISTER WITH MEDLINE UNIVERSITY TODAY

2 Launch the QR app
http://www.medlineuniversity.com ©2011 Medline Industries, Inc. Medline and Medline University
are registered trademarks of Medline Industries, Inc.
Periwound Skin Irritation skin tears and breakdown due to the underlying malignancy and
Patients with fungating wounds often experience a creeping, its impact on nutritional status. In some cases, standard adhe-
intense itching sensation attributed to the activity of the tumor. sive products may potentiate problems and a cling dressing
Because of its invasiveness, the tumor causes severe damage wrap or a tubular net bandage may be used to secure dressings
to the patient's peripheral nerve supply, which is responsible for without resorting to an adhesive secondary cover.
transmitting pruritic sensations. Typical inflammatory mediators
are not involved; therefore, intense itching is normally not Bleeding
responsive to traditional antihistamines. Alternative options for Because blood vessels can be disrupted by the infiltration of
treatment include cancer specific hormone therapy, chemother- tumor cells, bleeding at the wound site is common in patients
apy, tricyclic antidepressants, or Transcutaneous Electrical with fungating wounds.10 There are several treatment options
Nerve Stimulation.13 to control spontaneous bleeding, including oral antifibrinolytics,
such as tranexamic acid, and radiotherapy.8 In situations where
Exudate the bleeding is associated with dressing changes, interventions
Fungating wounds may produce large amounts of exudate to prevent bleeding include gentle technique for application and
resulting in discomfort and embarrassment for the patient. removal of dressings, maintaining a moist wound and dressing
Exudate also may lead to periwound maceration, increasing the interface, gentle cleansing techniques, and use of nonfibrous,
risk of infection.10 Several types of dressings may be used to nonadherent dressing materials. Certain dressings, such as cal-
manage high-volume exudate, and WOC nurses are a valuable cium alginates, have hemostatic properties that exchange
resource when selecting an appropriate dressing. The optimal sodium ions for calcium ions, promoting the clotting cascade
dressing should be nonadherent to the tumor to reduce pain within the wound bed.5 It is important for the WOC nurse to
and trauma associated with dressing changes. It should effec- monitor the patient's hemoglobin levels because if the patient
tively absorb exudate and toxins while maintaining a moist sur- becomes anemic, a blood transfusion or iron tablets may be
face that supports autolytic debridement of necrotic tissue. If required.10
the wound is friable and bleeds easily, a dressing with hemo-
static properties is beneficial. Control of odor and restoration of Odor
body symmetry and cosmetic acceptability with the use of less The presence and severity of odor is subjective and influenced
bulky dressings are also important principles to consider for the by multiple factors such as the patient's ability to perceive odor,
patient's self-image.7 The categories of dressings normally rec- along with the perceptions of caregivers and family members.14
ommended include activated charcoal dressings for odor con- This symptom can be one of the most devastating aspects of
trol, alginates for bleeding wounds, foam/hydropolymer a fungating wound. 15 As noted previously, wound odor is
dressings for exuding wounds, hydrocolloid sheets for lightly associated with necrotic tissue that supports the growth of
exuding wounds or protection of surrounding skin, hydrofiber anaerobic bacteria, and the presence of volatile fatty acids in
dressings for heavily exuding wounds, and semipermeable film the wound. Stagnant exudate, infection, and fistula formation
membranes for protection of intact skin. If the volume of wound are also contributing factors.1
exudate is too high even for highly absorbent dressings and
requires more than 2 to 3 dressing changes per day, a wound Treatment for odor encompasses multiple aspects of wound
manager pouch may be necessary to collect drainage and protect care. Systemic antibiotics may be appropriate if there is evi-
surrounding skin.9 Ointment based skin protectants or liquid dence of clinical infection. However, excessive use of antimi-
polymer acrylate barrier films should be considered for patients crobial agents should be avoided because it can lead to
with exudate that compromises intact skin.10 overgrowth of resistant organisms such as methicillin-resistant
Staphylococcus aureus and vancomycin-resistant enterococcus,
Not only is the selection of the most effective dressing a chal- and some antibiotics increase the risk of nausea and vomiting.10
lenge; determining the best way to secure the dressing is often
difficult. Some dressings are self-adhesive, but most require a Metronidazole has been evaluated for use as a topical agent for
separate product. Depending on the location and size of the reducing wound odor.16 It is a synthetic antimicrobial drug,
wound, traditional adhesives, such as a tape, may not be which works against anaerobic bacteria and protozoa; however,
appropriate. In addition, the patient may be more vulnerable to it can take up to 2 to 3 days before odor is reduced.15 The
42 Healthy Skin
several controlled trials and case studies supporting the bene-
fits of sugar paste and honey in wound care,16 but the evidence
for yogurt is limited to anecdotal reports. Because sugar paste
Because blood vessels is not commercially available in the United States, a specific
combination of caster sugar, icing sugar, polyethylene glycol,
can be disrupted by the and hydrogen peroxide is recommended in the literature. This
paste is prepared in both thick and thin consistencies in the
infiltration of tumor cells, hospital pharmacy and stored in a screw-top plastic container
for up to 6 months. The table shows the formula for sugar
bleeding at the wound site paste.18 Sugar paste has the ability to absorb fluid due to its
high osmolality, thereby starving bacteria of fluid and inhibiting
is common in patients with their growth. On contact with the wound, sugar paste liquefies,
and prevents dehydration of normal cells. It also enables
fungating wounds sloughing of necrotic cells and promotes granulation tissue for-
mation.19 Some studies have shown it to be effective against
Staphylococcus aureus, Streptococcus faecalis, Escherichia
coli, and Candida albicans.18 Although it can be useful for
wound should be cleansed with normal saline and the metron- patients with fungating wounds, the effect wears off over time
idazole applied liberally and covered with a secondary dress- so it is necessary to apply a thick layer to the surface of the
ing. For heavily exudative wounds, consider the use of crushed wound and secure with a petroleum-jelly-coated dressing twice
metronidazole tablets sprinkled over the wound surface and or more a day.15,19
covered with a petroleum-jelly-coated dressing. For dry
wounds, the gel form of metronidazole is more appropriate.17 Honey has been used as a dressing since ancient times, but
Metronidazole should not be used in conjunction with any other due to the emergence of antibiotic-resistant strains of microor-
topical creams, gels, or ointments because its effectiveness and ganisms, there is an increased interest in its wound healing
antimicrobial activity could be potentially diluted.7 Although it properties. Medical grade honey derived from the Leptosper-
has been shown to be effective in many odorous wounds, it is mum species found in the manuka flower of Australia and New
ineffective in wounds that are too moist or dry.15 Zealand, inhibits bacterial growth in several ways, including its
acidic pH, which prevents biofilm formation, the slow release of
Charcoal dressings also may be used to alleviate odor. Because hydrogen peroxide, which is toxic to microbes, and high
the molecules that are responsible for the malodor are attracted osmolality, which inhibits bacterial growth.20 Honey also acts as
to the carbon surface, the activated charcoal dressing acts as a debriding agent with several mechanisms of action. It
a filter to absorb these molecules, preventing them from being encourages autolytic debridement due to its strong osmotic
released into the air.14 In order to be effective, a charcoal dress- action of pulling fluid from the wound and washing the base to
ing must be fitted as a sealed unit directly on to the wound.10 remove debris and slough.21 The production of hydrogen per-
There are limitations for application on charcoal dressings in fun- oxide contributes to debridement by activating proteases to
gating wounds because the dressing is effective only in wounds breakdown unwanted tissue.20 Odor control is attributed to
that produce minimal exudate.15 Silver dressings may also inhibition of bacterial growth and removal of necrotic tissue from
reduce wound odor because of its antimicrobial effect against the wound base.21 However, topical honey may be difficult to
a wide range of organisms including methicillin-resistant Staphy- apply and requires the use of an absorbant secondary dressing.
lococcus aureus and vancomycin-resistant enterococcus, thus Therefore, it may not be an option for wounds that are too
inhibiting bacterial growth and preventing colonization; however, moist. Advances in technology have provided several forms of
they tend to be expensive especially when frequent dressing honey-impregnated dressings, including alginates and hydro-
changes are needed.14 colloids that may be more effective in the management of fun-
gating wounds. These dressings received US Federal Drug
Alternative topical agents sometimes used to control odor Administration approval in 2007 and are manufactured through
include sugar paste, medical honey, and yogurt.15 There are Medihoney, Derma Sciences, Canada.20

Aromatherapy is another option
for odor management.
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.5
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.26
Because the location, appearance, and odor of a wound may
be a source of embarrassment and distress for both the patient
Yogurt has also been used to control odor in fungating wounds. and family, all are at risk for social isolation, depression, dimin-
Evidence is insufficient to confirm or refute its efficacy, but clin- ished sexual expression, and difficulty maintaining relationships
ical experience and anecdotal reports in the literature suggest with family and friends.27 The WOC nurse should evaluate the
it is effective in some cases.9 Most manufactured yogurts con- individual's coping mechanisms and social support networks
tain the active culture, lactobacillus, which produces lactic acid to determine the impact of the wound on psychosocial status
lowering the pH in the wound bed and inhibiting growth of odor- and social support networks.28 Patients and families affected
producing organisms.22 At least 1 newer yogurt preparation also by fungating wounds may require additional support and coun-
contains Bifidobacterium culture; it is described as helping reg- seling from psychologists, social workers, bereavement coun-
ulate the digestive tract, and its effect on malodorous fungating selors, as well as hospice and other professionals. Patients and
wounds is not known. Room temperature plain yogurt should family members should play an active role in determining wound
be applied to the wound surface and covered with a petro- care, and treatments should be chosen to minimize the
leum-jelly-coated dressing.23 Treatment should be repeated 4 wound's impact on the patient and family, provide adequate
times a day for 2 to 3 days until odor is resolved. control of symptoms, and allow for the potential of intimacy. The
treatment plan should also provide comfort as well as
Aromatherapy is another option for odor management. Essen- independence.29
tial oils of lavender, lemon, citrus, or tea can be used on the
bandage or secondary dressing, but not directly on the wound Conclusion
bed itself. Scented candles and burning oils, as well as kitty lit- Fungating wounds are a devastating complication of malignan-
ter and coffee grounds placed throughout the patient's home cies. WOC nurses should take an active role in assessment and
may help to mask the odor.15 Frequent dressing changes and management of the fungating malignant wound, focusing on
proper disposal of waste products is also recommended since management of distressing symptoms such as pain, excessive
saturated dressings can harbor odor.5 exudate, odor, and bleeding. The WOC nurse is ideally suited to
make recommendations for care, assure that appropriate inter-
Debridement is useful in fungating wounds with large amounts ventions are being carried out, provide education to the patient
of necrotic tissue. Sharp wound debridement is contraindicated and caregivers, and offer solutions to existing and future prob-
because of the risk for potential bleeding and malignant cell lems. The WOC nurse should also act as an advocate for
seeding. Autolytic debridement is preferred because it avoids patients with fungating wounds by providing support and
the risk for bleeding and it can be promoted with any dressing encouragement, and helping assist the patient to maintain dignity
regimen that maintains a moist wound surface. Autolytic de- and maximize comfort during the end of life. WOC nurses
bridement may occur naturally where devitalized tissue eventu- should generate and participate in further research about
ally separates on its own.14 Larval therapy has been suggested fungating wounds, including the search for the most effective
for use in fungating wounds by Thomas and colleagues24 but no methods for controlling odor and exudate.
44 Healthy Skin
Key Points 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.
• As a WOC nurse, it is necessary to understand the etiology 21. Blair SE, Coccetin NN, Harry EJ, Carter DA. The unusual antibacterial activity of
medical-grade leptospermum honey: antibacterial spectrum, resistance and
and presentation of fungating wounds so that they can transcriptome analysis. Eur J Clin Microbiol Infect Dis. 2009; 28(10):1199–1208.
be accurately assessed and managed. 22. Gribbons CA, Aliapoulios MA. Treatment for advanced breast carcinoma. Am J Nurs.
1972; 72(4):678–682.
• Management of fungating wounds focuses on controlling 23. Welch LB. Simple new remedy for the odor of open lesions. RN. 1981; 44(2):42–43.
pain, cutaneous irritation, exudate, bleeding, odor, and 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,
psychosocial issues. 1998; Available from: CINAHL Plus with Full Text.
• There is a need for further research by WOC nurses so that 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.
patients can be managed more effectively. 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.
Correspondence: Kelli J. Bergstrom, BSN, RN, ET, CWOCN, 28. Laverty D. Fungating wounds: informing practice through knowledge/theory. Br J Nurs.
2003; 12(15):S29–S40.
The James Cancer Hospital and Solove Research Institute, 29. Kirsner R. Malignant wounds. Wound healing perspectives: a clinical pathway to
300 W 10th St, Starling Loving Hall Rm M200, Columbus, success. 2007;4(1):1–8.
OH 43210 (kelli.bergstrom@osumc.edu). Printed with permission from the Journal of Wound, Ostomy & Continence Nursing.
January/February 2011; 38(1):31–37.
References
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;
4(5):240–242.
7. Collier M. Management of patients with fungating wounds. Nurs Stand. 2000;
15(11):46–52.
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):
121–125.
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:
10.1002(14651858.CD003948.pub2.
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;
96(36):15–16.

Perioperative
Pressure Ulcer
Education
MORE IMPORTANT THAN EVER BEFORE
VIEW A PRESSURE ULCER PREVENTION

Medline’s Pressure Ulcer Prevention Program now has a PROGRAM SUCCESS STORY
component designed specifically for the perioperative services.
The easy-to-use interactive CD addresses the following:
2 Launch the QR app
• Hospital-acquired conditions
• CMS reimbursement changes http://www.medline.com/
• Best practices for pressure ulcer prevention qr-code/jennie-edmundson/
• Perioperative assessment tools
• Critical patient and equipment risk factors
©2011 Medline Industries, Inc.
Medline is a registered trademark of Medline Industries, Inc.
Now on
Medline University
A new online education course:
“Proper Perioperative Positioning
to Prevent Patient Injuries”
PLUS an interactive virtual

simulation competency!
Register at
www.medlineuniversity.com
to get started.
Prevention
They’re lurking in ...
The Operating Room

and Beyond!
by Cynthia A. Fleck, RN, BSN, MBA,
ET/WOCN, CWS, DWC, CFCN
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 percent1 and 42 percent of all
hospital-acquired pressure ulcers are occurring in surgical patients.2
Here are some more daunting facts:

• 37 percent of patients undergoing head or neck surgery develop sacral ulcers3
• Cardiac, general vascular and open heart surgeries have a high incidence of occiput
and heel ulcers
• 72 percent of perioperative pressure ulcers occur on heels4
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

Perioperative risk factors for
pressure ulcer development Perioperative tips for avoiding pressure ulcers
Certain conditions specific to the surgical experience can • Assure that the OR table or surface is of
also contribute to the risk of pressure ulcers. Some of sufficient size to support the patient –
these conditions include blood volume loss, temperature, especially important for obese patients whose
time and moisture. bodies may be larger than the average size
OR surface
Blood volume loss. Blood volume loss and shunting can • Lift – do not drag – the patient from surface
increase the hazard of pressure ulcers and lack of blood to surface.
flow to the lower extremities.5,6 • Monitor pressure points when possible during
“time outs”
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, Post-operative considerations for avoiding
which can be dangerous to the skin. The use of warming pressure ulcers
blankets tends to occur in lengthy procedures. These can • Be aware of a possible delay in visualization
be helpful to prevent cooling of the body, which can con- due to bandages and other monitoring
tribute to pressure ulcers, however, the blanket should be equipment
covered with a sheet. • Prolonged immobility or confinement to a bed
or chair increases pressure ulcer risk10
Time. Increased time in the OR is associated with
increased pressure ulcer development as well.7 Surgeries
lasting between three and four hours had pressure ulcer
incidence rates of 5.8 percent; seven or more hours had Evaluating surgical surfaces
incident rates of 13.3 percent,8 and there is a significant Always remember that no matter where a patient’s body
increase in pressure ulcer incidence for operations lasting resides, pressure ulcers can develop rapidly. OR surfaces
longer than eight hours.9 should be evaluated before each case, and the Association
of periOperative Registered Nurses (AORN) guidelines
Moisture. We all know moisture can wreak havoc on the recommend using pressure redistribution surfaces for
skin and predispose individuals to pressure ulcers, so it is surgeries lasting longer than two-and-a-half hours.
recommended that pooling of any fluid or blood be moni-
tored intraoperatively. It is suggested that the OR surface In fact, I recently had foot surgery, and my surgeon origi-
have minimal linens or layering. There are also novel OR nally thought it would last only a couple of hours. Lo and
products available (modern-day “chux” that are super behold, it lasted three hours and 45 minutes, and although
absorbent) that can actually absorb large volumes of fluid I am a fairly young, well-nourished and healthy individual,
and remain dry to the touch, thus protecting the patient’s skin. I succumbed to a Stage II perioperative pressure ulcer. The
48 Healthy Skin
AORN guidelines recommend using
pressure redistribution surfaces for
surgeries lasting longer than 2 1/2 hours.
Figure 1
lesson to be learned: because there is no guarantee how Pressure ulcer risk in ancillary services
long a surgery will take, a pressure redistribution surface There is also high risk for pressure ulcers in ancillary
should be available in every operating room. services:
• Radiology
There are high-quality surfaces that self-adjust (Figure 1), • Renal dialysis
provide a stable environment for the surgeon and OR staff • Cardiac and vascular procedure laboratories
to work and conform to the patient’s body. Some of these
surfaces contain the same type of visco or viscoelastic The problem is that until awareness is increased, we will
memory foam many of us sleep on in our own bedrooms. continue doing what we always did, and patients will con-
When evaluating various surfaces, ask the vendor about tinue to develop pressure ulcers.
the warranty, weight limits, cleaning instructions and com-
parative data such as pressure mapping. This will help you Patients undergoing lengthy radiology procedures have a
make an educated decision regarding your purchase. 53.8 percent incidence of pressure ulcers. Emergency
departments are another area of risk, with 40 percent of
Important steps to take after surgery patients admitted through the emergency department at
At the hand-off to the post-anesthesia care unit (PACU) it risk for pressure ulcer development.11
is advisable to:
• Clean and dry the patient’s skin The average emergency department patient waits six to
• Conduct a post-op skin assessment, noting: eight hours lying on a stretcher that usually consists of two
- Skin irritation to three inches of open-celled foam and an uncomfortable
- Discoloration non-conformable cover that can contribute to the devel-
- Bruising opment of pressure ulcers.
- Swelling
• Provide a thorough report including: This is especially important now that acute care facilities
- Results of pre-surgery risk factors and potential are financially responsible for acquired pressure ulcers –
new risks that developed during surgery which can be quite costly. Many hospitals have instituted
- Results and skin assessment performed before, a comprehensive program to prevent pressure ulcers
during and after surgery across the continuum, including the OR, ED and ancillary
- How long the surgery lasted areas. Introducing a tool kit on average can reduce a facility’s

pressure ulcers by 70 percent while substantially increas- References
1. Recommended practices for positioning the patient in the perioperative
ing the knowledge of licensed staff and nurse assistants.12 practice setting. In: Perioperative Standards and Recommended Practices.
Denver, CO: AORN, Inc; 2010.
Take your knowledge and pass it on 2. Beckrich K, Aronovitch SA. Hospital-acquired pressure ulcers: a comparison
of costs in medical vs. surgical patients. Nursing Economics. 1999;
Consider sharing this article with the emergency depart-
17(5):263-271
ment, ancillary areas such as the cath lab, dialysis and 3. Recommended practices for positioning the patient in the perioperative
other high-risk area personnel, and of course with the practice setting. In: Perioperative Standards and Recommended Practices.
ambulance companies where your patients could be at Denver, CO: AORN, Inc; 2010.
4. Recommended practices for positioning the patient in the perioperative
risk. If you are on a skin care committee, get the other practice setting. In: Perioperative Standards and Recommended Practices.
members involved, as these care areas present jeopardy that Denver, CO: AORN, Inc; 2010.
can be easily mitigated. 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.
When we ask ourselves the age-old question of where 1996; 63(6):1058-1063, 1066-1075, 1077-1082.
all the pressure ulcers are occurring, now we have more 7. Papantonio C, Wallop J, Koldner K. Sacral ulcers following cardiac surgery:
incidence and risks. Adv in Wound Care. 1994;7(2):24-36.
ammunition to fight the battle. And yes, the ambulance,
8. Aronovitch S. Intraoperatively acquired pressure ulcer prevalence: a national
with its tiny vinyl-covered two-inch, foam mattress may study. J Wound Ostomy Continence Nursing. 1999;26(3):130-136.
be part of the problem. The good news is that we have 9. Ratliff C, Rodeheaver G. Prospective study of the incidence of OR-induced
answers and products that can make positive change pressure ulcers in elderly patients undergoing lengthy surgical procedures.
Adv Skin Wound Care. 1998;11(suppl 3):10.
happen. 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.
About the author 12. Armstrong DG, Ayello EA, Capitulo KL, Fowler E, Krasner DL, Levine JM, et
Cynthia Ann Fleck, RN, BSN, MBA, al. New opportunities to improve pressure ulcer prevention and treatment:
implications of the CMS inpatient hospital care present on admission (POA)
CWS, DNC, CFCN is a certified wound spe-
indicators/hospital-acquired conditions policy. J Wound Ostomy Continence
cialist, dermatology advanced practice Nurs. 2008. 35(5):485-492.
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
cfleck@medline.com.
50 Healthy Skin
SIMPLIFIED
TO SAVE YOU TIME
ERASE CAUTI
®
LEARN MORE ABOUT THE ERASE CAUTI SYSTEM

2 Launch the QR app

http://www.erasecauti.com/

NO CA
CATHETER
CAT
ATHETER
THETER
IS THE BEST CATH
CATHETER
CA
ATHETER
THETER
ERASE CAUTI
®

2 Launch the QR app

52 Healthy Skin
Prevention
ERASE CAUTI Program Helps

Hospitals Reduce Catheter
Use by 20 Percent
Revolutionary Foley Catheter Tray
Education Helps Improve Patient Safety
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.
Urinary tract infections (UTIs) are the most common HAIs; "The one-layer tray design is labeled in a specific sequence
80 percent of these infections are attributable to an that helps guide our nurses during the catheterization
indwelling urethral catheter.1 The ERASE CAUTI Foley process to adhere to current CDC recommendations,
catheter management system helps providers reduce the including aseptic technique," said Lisa Bridges, RN, infec-
risk of infection by combining evidence-based principles and tion preventionist for AMMC. "To help us reduce catheteri-
training with an innovative one-layer tray design. zations, we are requiring our entire nursing staff to take the
program education on the alternatives to catheterization.
Arkansas Methodist Medical Center Plus, the new tray has a checklist to help the nurse make a
Clinicians at Arkansas Methodist Medical Center (AMMC), one decision on whether catheterization is appropriate for the
of the first hospitals to implement the ERASE CAUTI system, patient and to assure the education transfers into everyday
are using the program to change the way they assess and clinical practice."
perform urinary catheter insertions. Since implementing the
program a year ago, the Paragould, Ark., hospital has seen a As measured by the number of catheterizations performed in
21 percent reduction in catheterizations and CAUTIs. March and April 2009 versus the same time in period in

2010, AMMC reduced the number of catheterizations from took time to review," said Bridges. "The patient care card
192 to 151, a 21 percent drop (based on adjusted patient has significantly improved our ability to provide patients and
day). This decrease contributed to the hospital achieving families with a tool to help them better understand the proper
zero CAUTIs in April 2010, compared to three in April 2009, care and maintenance of the catheter, signs and symptoms
according to Bridges. of CAUTI and how they can help reduce the chances of
developing CAUTI."
Another leading factor causing CAUTI is leaving a catheter in
place for more than two days after surgery.2 The Surgical Floyd Medical Center
Care Improvement Project (SCIP) recommends removal of To help reduce its CAUTI rates, Georgia-based Floyd Med-
catheters within 24-48 hours post-operatively. In the first ical Center is utilizing the innovative tray, along with facility-
quarter of 2009, only 20 percent of the catheters AMMC wide physician and nurse education on the appropriate use
placed in the O.R. were being removed within two days. With of catheters and the importance of avoiding catheters when
the implementation of the ERASE CAUTI program, the not medically necessary. The initiative has led to an 83 per-
removal rate increased to 50 percent in the first quarter cent reduction in CAUTIs and a 23 percent decline in the
of 2010. number of catheterizations performed at the hospital. In
recognition of its accomplishments, the 304-bed non-profit
"With the Foley InserTag and checklist sticker placed on the teaching hospital in Athens, GA., earned first place in VHA
patient's chart, nurses and physicians knew exactly when Georgia’s 2010 Clinical Excellence award category.
the catheters had been placed," said Bridges, "and were
able to remove them in the necessary 24-48 hours “We forged a hospital-wide initiative focused on reducing
after surgery." catheter use and related urinary tract infections,” said Darrell
Dean, D.O., M.P.H., medical director for clinical and operational
Also, included in the tray is a patient education care card that performance improvement at Floyd Medical Center. “The
looks like an actual get well card. According to Bridges, the Medline tray has many design elements and product
card is a more effective way to educate patients about the enhancements that were integral in our program to reduce
procedure, including the risks and complications associated variation in practice and achieve our goal of reducing
with closed system Foley catheters. CAUTI.”
"Before, we had to print our education from the computer, Dr. Dean cited the kit’s larger sterile barrier drape and one-layer
and it was not something the patient or the clinician normally 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
To help us reduce clinical reason for inserting a catheter and another that
catheterizations, we reviews the proper steps to catheter insertion. Upon
completion, the checklists are then added to the patient’s
are requiring our entire
chart for proper documentation of insertion.
nursing staff to take
the program education Unity Hospital
Unity Hospital, a 340-bed nonprofit facility in Rochester, New
on the alternatives
York, is experiencing similar results with the ERASE CAUTI
to catheterization. program. According to data from the hospital, the facility
reduced its urine nosocomial infection markers (NIMs) 32
54 Healthy Skin
“ 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 The hospital staff also took advantage of the program’s
in 2009. The associated cost for each urine NIM marker is online education, which reinforced aseptic technique through
$3,637, which demonstrates a significant cost-avoidance learning modules and an interactive competency tool the
following the introduction of the ERASE CAUTI program, clinicians used to demonstrate knowledge of proper Foley
according to Unity Hospital. Urine NIMs are an electronic insertion technique. To date, more than 500 nurses at Unity
marker that uses sophisticated algorithms to analyze existing have completed the education classes via Medline’s e-learn-
microbiology laboratory and patient census data to identify ing site Medline University – www.medlineuniversity.com.
hospital-acquired infections. These online modules have been added to the hospital’s
clinical orientation as a mandatory core competency for new
Although we had a low CAUTI rate in 2009, after imple- nursing staff.
menting the ERASE CAUTI program, rates continue to trend
downward,” said Erica Perez, Unity’s clinical educator. “The Following a successful trial period last summer, the program
program ties in education, nursing power and a new indus- was rolled out facility-wide to all acute care units in August
try product that promotes best processes by reinforcing the 2010.
CDC guidelines to decrease the opportunity for a CAUTI to
develop.” “The implementation of the ERASE CAUTI program has
helped us improve the standard of care for patients receiv-
According to Perez, the hospital began using the ERASE ing a Foley catheter and has reduced the risk of CAUTI,” said
CAUTI program because it identified gaps in standardization Perez. “The reduction in urine NIMs indicates fewer patients
and knowledge regarding the proper insertion technique and may be at risk for developing a CAUTI.”
clinical indications for using a Foley catheter.
References
“The Medline program offered the tools to reduce the incon- 1 Lo E, Nicolle L, Classen D, Arias A, Podgorny K, Anderson DJ, et al. SHEA/IDSA
sistencies we observed in the technique nurses used to practice recommendation: strategies to prevent catheter-associated urinary tract
infections in acute care hospitals. Infect Control Hosp Epidemiol. 2008;29:S41–S50.
insert catheters due to differing protocols at previous facili-
2 Wald HL, Ma A, Bratzler DW, Kramer AM. Indwelling urinary catheter use in the
ties where nurses have practiced, variance in how nurses postoperative period: analysis of the national surgical infection prevent project data.
were initially taught the procedure and different types of Foley Arch Surg. 2008; 143:551-557.
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.

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 Combined with the previous innovative tray redesign
technology for healthcare workers. So after we and comprehensive ERASE CAUTI education, these
revolutionized the outdated Foley catheter tray with three new features help to improve patient safety and
a unique, one-layer system design, we immediately quality, while reducing avoidable costs associated with
turned our attention to addressing how we could waste and urinary tract infections.
make it even easier to use. We studied how the
tray was being used in the field. The result was
three more great improvements. LEARN MORE ABOUT THE ERASE CAUTI SYSTEM
2 Launch the QR app

1 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.
2 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.
3 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.
SAFER CATHETERIZATION
FOR KIDS
Pediatric
Catheter
Tray
Children’s
Introducing Medline’s new Activities
Pediatric Catheter Tray. The
latest addition to the innovative
ERASE CAUTI product line.
Sometimes, you just need a buddy. Buddy

ra
st
the Brave lion cub is here to help your youngest
mB v
e
catheter patients. Along with some serious patient

I’
(and parent) education resources, you’ll find some

upbeat fun and even a bravery award sticker in
dy
every tray.
Li
ke
But it’s more than just fun. There’s published evidence Bud
that distraction helps children tolerate unpleasant
Bravery Sticker
procedures better than adult reassurance does.
You trust Medline for clinical innovations, such as our

industry-leading catheter tray design. Now, we can be
LEARN MORE ABOUT MEDLINE’S ERASE CAUTI
your patient’s buddy, too.
PROGRAM AND ALTERNATIVES TO CATHETERIZATION
2 Launch the QR app
buddy-the-brave
GIVE YOUR
PATIENTS
PATIENTS
TIE
T
EXTRA CARE
ERASE CAUTI
®

2 Launch the QR app

“
“Excellent.
50 FREE NAB-approved
credits now available at
Medline University.
Visit www.medlineuniversity.com for
24 nursing home administrator courses.
Topics include:
• QIS
• Diabetes
• Infection Control
• Pressure Ulcer Prevention
• Spend Management
• Wound and Skin Care
Access courses
on your computer,
iPhone or iPad.

2 Launch the QR app
http://www.medlineuniversity.com
Follow us
Be the first to know when we
add new courses and content.

Medline and Medline University are registered
trademarks of Medline Industries, Inc.
Survey Readiness
CE ARTICLE
A Guide to
MDS 3.0 Section H
by Amin Setoodeh, BSN, RN
As with other sections of the MDS, the change from 2.0 to 3.0
Objectives: for Bladder & Bowel (Section H) reflects the focus on individual-
• List the changes in section H from MDS 2.0 to 3.0 ized resident care and clinical relevance. Management of incon-
• State the intent of section H tinence in long-term care facilities has a major impact on the
• Describe how to conduct the assessment for urinary emotional and physical well-being of the resident; and few will
incontinence argue that it is not challenging for staff. With new questions
• Describe how to conduct the assessment for bowel surrounding toileting plans, CMS, through the new MDS,
incontinence 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
Now that facilities across the U.S. have put the first six months awareness of causes and treatments of incontinence with staff,
of the transition from MDS 2.0 to MDS 3.0 behind them, it may residents and families. Team members with longevity in long-
be time to evaluate systems for what is working or what might term care may need encouragement to embrace new
need improvement. Although we may use the word “coding” approaches to continence management that reflect a change
when we talk about the MDS, it is important to remember that in the culture of long-term care as well as clinical evidence
what we are actually doing is an assessment. The MDS is not and research.
meant to be a comprehensive assessment, but to identify
potential problems that lead to further investigation, assessment, Note: Your main source of information for completing the resi-
care planning and treatment. In addition, MDS 3.0 lies at the dent assessment instrument is the Long-Term Care Facility Res-
center of regulatory reporting and RUG reimbursement. All of this ident Assessment Instrument* User’s Manual for MDS 3.0. You
makes accurate completion critical. Regular education of everyone should have a copy of the manual handy and read the instruc-
on the interdisciplinary team can help with accuracy, speed, and tions for Section H before attempting to complete the section.
regulatory compliance in addition to the benefits of better care. Furthermore, you may download the RAI user’s manual at the
This article covers MDS 3.0 Section H, Bladder & Bowel, and CMS MDS 3.0 training website. Please keep in mind, it is your
can be used for ongoing training as well as ideas for improve- responsibility to check CMS website for any updates or revisions
ment of this important aspect of care. to the RAI User’s Manual.

LEARN MORE ABOUT THE ONLY INTEGRATED SOLUTION
FOR SURVEY READINESS IN NURSING HOMES
Quality Assurance
System Webinar
This webinar gives a QIS overview and demonstration on how the abaqis® system can
help prepare for both the traditional and QIS survey processes. This demonstration also
highlights how abaqis® provides:
• Rich reporting capabilities to identify which care areas to target for
quality improvement
• Root cause analysis on a facility-wide or individual-resident basis, enabling
prioritization and focusing of interventions for maximum impact
• Emphasis on information reported by residents and families to help identify
the needs of residents, aiding your efforts to improve consumer satisfaction
Now with the new Stage 2 module featuring:

• A dashboard view of triggered care areas based on data collected
using abaqis® Stage 1 Suite
• Investigative tools to determine deficiencies in triggered care areas
EXPERIENCE THE ABAQIS DEMO

2 Launch the QR app
abaqisdemo/
Changes from 2.0 to 3.0 – A review Facilities across the nation have delved deeply into their systems,
processes, procedures and protocols to prepare for 3.0. This
There are several significant changes in the MDS Section H: analysis is a great opportunity to embrace a different approach
• MDS 3.0 calls for a 7-day look-back period for the actual for the management of incontinence. The goal should be to identify
coding of continence versus MDS 2.0’s 14-day the specific root of the issue in order to develop an individualized
look-back period nursing intervention with focus on promoting normal bladder and
• Now includes trial toileting programs for individuals who bowel function.
are identified to be incontinent or at risk to become
incontinent. This may be a major change and challenge Is this occurring in your facility? Look at your current incontinence
for your facility if you do not have a well-defined system for management program and establish:
implementing a toileting program
• Urinary incontinence and fecal incontinence toileting programs • Do you have a clear protocol to collect the required
are addressed separately information necessary for completion of section H?
• A resident’s response to the toileting program is captured, • Do you have a continence management team?
allowing CMS to collect and perhaps report data on the • Do you have a specific toileting protocol with a focus on
success of toileting plans across the nation’s nursing facilities promoting normal bowel and bladder function?
• Questions concerning urinary toileting programs (H0200) • Are you able to conduct a complete bowel and bladder
should use a look-back period to the most recent assessment to identify the specific type of incontinence?
admission/readmission assessment, the most recent prior • Are you considering the resident’s elimination patterns to
assessment, or to when incontinence was first noted develop an individualized nursing intervention for toileting?
• MDS 3.0 clears up the confusion about the wording • Does the staff understand the differences between the
of continence items such as coding residents with an different types of urinary incontinence?
catheter indwelling as “continent”
• Fecal impaction was dropped as a specific item from Section If the answer to any of the above questions is no or maybe, there
H and constipation is addressed with a yes or no response is an opportunity to modify your current incontinence manage-
ment program to promote compliance with the intent of CMS
There are two main goals for MDS 3.0 Section H F315 and the MDS 3.0.
• The first goal is to gather the specifics of a resident’s Completion of MDS 3.0 Section H
continence status: including use of bowel and bladder
appliances, degree of urinary and fecal continence, use of Section H0100 Appliances
and response to urinary toileting programs and bowel patterns
• The second goal is that each resident who is incontinent or It is important to know what appliances are in use and the history
at risk of developing incontinence is identified, assessed, and rationale for such use. Item H0100 records the appliances
and provided with an individualized treatment plan. These that were in use during the standard 7-day look-back period by
interventions may include medication, behavioral treatments, asking you to check all that apply.
containment devices and services to achieve or maintain
as normal elimination function as possible1

Appliances and Definitions from the RAI Manual complications associated with the use of the appliances. Every
effort should be taken to assure the appliances fit well, are com-
• Indwelling Catheter - A catheter that is maintained within fortable and promote the resident’s dignity.
the bladder for the purpose of continuous drainage of urine.
• External Catheter – A device attached to the shaft of External catheter – Make sure the catheter fits well and it is
the penis like a condom for males or a receptacle pouch comfortable; look for leakage and implement your facility guide-
that fits around the labia majora for females. It connects to lines to promote and maintain skin integrity. This is particularly
a drainage bag important when the product involves adhesive. As always, be
• Intermittent Catheterization - Insertion and removal sure you are promoting resident dignity by explaining the ration-
of a catheter through the urethra for bladder drainage. (Note: ale for use of the appliance and making sure the device is con-
Please keep in mind that a one-time catheterization to obtain cealed properly.
a urine specimen during the look-back period does not
qualify as intermittent catheterization). Indwelling catheter – Verify there is a valid medical justification
• Suprapubic Catheter - An indwelling catheter that is placed for use of the indwelling catheter and consider the risk and ben-
by a urologist directly into the bladder through the abdomen efits of use as well as the duration of use. Furthermore, consider
• Nephrostomy Tube - A catheter inserted through the skin into the potential complications resulting from the use of an indwelling
the kidney in individuals with an abnormality of the ureter or catheter such as:
the bladder • Increased risk of urinary tract infection
• Ostomy - Any type of surgically created opening of the • Blockage of the catheter with associated bypassing of urine
gastrointestinal or genitourinary tract for discharge of • Pain / discomfort
body waste • Damage to the urethra
• Urostomy - A stoma for the urinary system used in cases
where long-term drainage of urine through the bladder and Mitigate the potential complications by including interventions in
urethra is not possible the resident’s care plan such as the CDC’s recommended guide-
• Ileostomy - A stoma that has been constructed by bringing lines for securement of the catheter to the skin and maintaining
the end or loop of small intestine out onto the surface of unobstructed urine flow.
the skin
• Colostomy - A stoma that has been constructed by Ostomy – Inspect the peristomal skin for redness, tenderness,
connecting a part of the colon onto the anterior abdominal wall denudation and skin breakdown and monitor the site routinely.
If possible, ask the resident to report any discomfort.
To determine the urinary or bowel appliances used in the look-

back period, examine the resident to note the presence of any Section H200 Urinary Toileting Program
urinary or bowel appliances. Furthermore, review the medical
record for current or past use of urinary or bowel appliances. The questions in H0200, Urinary Toileting Program, capture three
aspects of a resident’s toileting program:
Some areas of potential confusion are spelled out in the RAI A. Whether a toileting program has been attempted for this
manual: resident since urinary incontinence was noted in this facility
• Suprapubic catheters and nephrostomy tubes are indwelling B. The resident’s response to the trial program (improvement
catheters and should not be coded mistakenly as an ostomy. or otherwise)
• Even if used occasionally (e.g. daytime only), condom C. Whether a toileting program is currently being used to
catheters (men) and external urinary pouches (women) should manage a resident’s urinary incontinence
be coded properly as external catheters.
• Ostomies used for feeding, such as gastrostomy, should not Why the focus on toileting programs? According to the CMS, an
be coded in section H which is strictly for elimination ostomies. individualized, resident-centered toileting program may decrease
or prevent urinary incontinence, minimizing or avoiding the neg-
The MDS is designed to collect information to assist your clinical ative consequences of incontinence. In fact, research has
team to develop resident-centered care plans. When developing shown that anywhere from one quarter to one third of residents
care plans for urinary and bowel appliances, consider interven- participating in an active individualized toileting program will
tions that are consistent with the resident’s goals and minimize regain normal bladder function or will experience a reduction
64 Healthy Skin
in the episodes of incontinence, which may improve quality of the first program considered for urge incontinence; similarly,
life, lower cost and reduce the required time of care. scheduled voiding may be the intervention of choice for over-
flow incontinence. Although “type of incontinence” is not asked
Despite myths to the contrary, many incontinent residents will for on the MDS instrument, it plays a critical role in development
respond positively to a toileting program as long as the program of the toileting program and overall continence management.
is developed based on the individual’s specific type of inconti-
nence, voiding pattern and cognitive ability. Although staff may What qualifies as a toileting program?
expect toileting programs to be more successful with residents RAI 3.0 Manual refers to a toileting program as
who do not have cognitive impairment, cognitive status has not • Organized, planned, documented, monitored, and evaluated
been shown to be a predictor of success with a prompted void- • Consistent with the nursing home’s policies and procedures
ing program. [What is a predictor of success? A positive re- and current standards of practice
sponse to a short (usually 3-day) trial of prompted voiding!
Those residents who successfully urinate in the toilet for 66 per- As such, the toileting program needs to be documented in the
cent or more of the prompts by nursing staff will often continue medical record and must be based on each resident’s specific
to be continent during an active prompted voiding program.] assessment and voiding pattern. The nursing interventions must
be resident-specific and communicated to the staff for imple-
Also note that a toileting program should not be dismissed mentation. The response to the treatment must be documented.
because it is only effective during the day. Daytime continence is
certainly a “win,” and the program should continue even though CMS makes it clear that the following are not toileting programs:
there are barriers to continence during the night. • Simply tracking continence status with a voiding record
• Changing pads or wet garments
CMS Definitions • Assistance with toileting or hygiene without a resident-specific,
The following toileting interventions may be used to promote documented and communicated plan
as much normal elimination possible or reduce the episodes
of incontinence: Coding H200A for Urinary Toileting Program Trial
• Habit Training/Scheduled Voiding - A behavior technique
that calls for scheduled toileting at regular intervals on When assessing for a toileting program trial (H200A), review the
a planned basis to match the resident’s voiding habits medical record for evidence of a trial of an individualized, resi-
or needs. dent-centered toileting program such as bladder retraining,
• Bladder Rehabilitation/Bladder Retraining - A behavioral prompted voiding, habit training/scheduled voiding (see box for
technique that requires the resident to resist or inhibit the those behavioral programs defined in the RAI manual). A proper
sensation of urgency (“the strong desire to urinate”), to toileting trial should include observations of at least three days of
postpone or delay voiding, and to urinate according to toileting patterns with prompting to toilet and documentation of
a timetable rather than to the urge to void. the results in a bladder record or voiding diary. In MDS 2.0, pres-
• Prompted voiding - Regular monitoring with encouragement ence of a toileting program was often checked without evidence
to report continence status using a schedule and promoting of a real program. MDS 2.0 also failed to account for and report
the resident to toilet. Provide positive feedback when the on those residents who had an unsuccessful trial. MDS 3.0 was
resident is continent and attempts to toilet. written to correct these issues as well as separate toileting pro-
grams from appliances.
In order to develop effective toileting programs for your residents,
establish an assessment process in your facility that includes a Code 0 (No) if the resident did not undergo a toileting trial. This
focus on determining the specific type of urinary incontinence. includes residents who are continent of urine on their own as well
This information not only is required as per F-Tag 315 regulatory as those who are continent with assistance. You will also code 0
guidelines, but it is also necessary to help the staff provide an (No) for residents who use a permanent catheter or ostomy as
individualized program. For example, bladder retraining might be well as residents who prefer not to participate in a trial.

Code 1 (Yes) for those residents who did partake in a toileting When implementing a new voiding record system, meet with all
program trial at least once since admission, readmission, prior the staff involved in the process. Clearly highlight the expecta-
assessment or when urinary incontinence was first noted in your tion and how the staff should document and communicate with
facility. each other. Voiding records will be used for several reasons – so
consider a process that makes it easy for assessment, care plan-
Code 9 (Unable to determine) if records cannot be obtained to ning, and MDS completion. Because the records are instrumen-
determine if a trial toileting program has been attempted. If 9 is tal in developing individualized care, educate the clinical team on
coded here, you’ll skip H0200B and go to H0200C, where you how to use the information gathered. Start with a few residents
will be asked about whether a current toileting program or trial is at time and designate a staff member to document and report all
in process. findings by end of the shift. To encourage proper documenta-
tion, use a new copy of the form for each shift.
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 When Coding Section H0200B
the trial. Note any changes in the number of incontinence Code 0 (No improvement) if the frequency of the resident’s uri-
episodes and degree of wetness the resident experiences. Your nary incontinence did not decrease during the toileting trial.
look-back period for H0200B should be based on the most
recent admission/readmission assessment, the most recent prior Code 1 (Decreased wetness) if the resident’s urinary inconti-
assessment or when incontinence was first noted. While there is nence frequency decreased, but the resident remained inconti-
no clear definition of what is considered improvement, the RAI nent. Keep in mind there is no quantitative definition of
Manual suggests that one less incontinent episode per day could improvement. However the improvement should be clinically
be considered a success. meaningful, such as reduction of at least one less incontinent
void per day than before the toileting program was implemented.
Tracking Elimination Patterns
Code 2 (Completely dry) if the resident becomes completely
If your facility does not have a comprehensive continence man- continent of urine, with no episodes of urinary incontinence dur-
agement program that includes successful toileting program ing the toileting trial. For residents who have undergone more
interventions, one of the most important improvements to pro- than one toileting program trial during their stay, use the most
mote toileting should start with tracking and recording voiding recent trial to complete this item.
patterns. Voiding patterns are important in assessment, devel-
opment of individualized care plans and ongoing monitoring of Code 9 (Unable to determine or trial in progress) if the
toileting programs. Without one it would be difficult for the staff response to the toileting trial cannot be determined because
filling out the MDS H0200B regarding the response to a resi- information cannot be found or because the trial is still in progress
dent’s toileting trial. Voiding records may help detect urinary pat-
terns or intervals between incontinence episodes while allowing Section H200C – Current Toileting Program
the clinical team to help the resident avoid or reduce the fre-
quency of episodes. If regular and consistent documentation of This final question in the toileting program section asks for cur-
elimination is a standard aspect of care in your facility rather than rent toileting program information about the resident. Here, the
a rare occurrence; complete and accurate voiding diaries will look-back period is seven days and specifically uses four days as
become the norm. 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.
Enter Code C. Current toileting program or 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.
66 Healthy Skin
Make sure to review the medical record for evidence of a resi- ments, progress notes, bladder records or flow sheets for doc-
dent-specific toileting program being used to manage inconti- umentation of incontinence during the 7 day look-back period.
nence during the 7-day look-back period. Note the number of Consult with the responsible nursing staff regarding the resident’s
days that the toileting program was carried out during the look- incontinent incidents. Interview the resident, if able, regarding
back period. Remember that a successful individualized toilet- his/her continence or with family members if the resident is
ing program could be a daytime toileting plan with a resident unable to share this history.
preference to treat nighttime incontinence with incontinence
products or pads. MDS coding makes a distinction between occasionally inconti-
nent, frequently incontinent and always incontinent. The new
A final note on Toileting Programs – consider reevaluating a res- MDS 3.0 definitions of these three for coding purposes have
ident whenever there is a change in cognition, physical ability or changed from 2.0’s definitions as well as dropping a fourth 2.0
urinary tract function. “usually continent” category altogether. Confusion about whether
to code an individual with an indwelling catheter as continent has
Section H0300 Urinary Continence been eliminated. Instructions for coding intermittent catheteriza-
tion are included in the RAI manual: you will want to code conti-
This segment of MDS 3.0 documents a resident’s urinary incon- nence level based on continence between those intermittent
tinence status. Although the majority of residents admitted to catheterizations.
long-term care facilities may experience urinary incontinence,
caregivers need to remember how much incontinence can im- Code 0 (Always continent) if throughout the 7 day look-back
pact the quality of life for an individual. That is why, in 1995, the period the resident has been continent of urine without any
original MDS 2.0 included information regarding the resident’s episodes of incontinence
continence status to trigger one of 16 Resident Assessment Pro-
tocols (RAPs) the goal of which was to develop a complete and Code 1 (Occasionally incontinent) if during the 7-day look-
individualized care plan for incontinence management. Unfortu- back period the resident was incontinent less than 7 episodes
nately, 15 years later, far too many residents in the United States
have a canned continence care plan of “check and change.” Code 2 (Frequently incontinent) if during the 7-day look-back
period the resident was incontinent of urine 7 or more episodes,
CMS recognizes the following negative effects of incontinence: but had at least one continent void. This includes incontinence of
• Increased risk of long-term institutionalization any amount of urine – daytime or nighttime
• Increased risk of repeated urinary tract infections
• Interference with participation in activities Code 3 (Always incontinent) if during the 7 day look-back
• Social embarrassment period, the resident had no continent voids
• Increased feelings of dependency and depression
• Increased risk of falls and injuries resulting from attempts Code 9 (Not rated) if during the 7-day look-back period the res-
to reach a toilet unassisted ident had an indwelling bladder catheter, condom catheter,
ostomy, or no urine output. This includes residents on chronic
Part of the education of your staff should be what constitutes dialysis with no urine output for the entire 7 days.
incontinence versus continence. Caregivers should understand
that any voluntary void into a toilet, commode, urinal or bedpan H0400 Bowel Continence
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 Fecal incontinence also has a major impact on quality of life, very
is voluntary. Urinary incontinence, on the other hand, is any similar to urinary incontinence. Bowel incontinence may inter-
involuntary loss of urine. fere with participation in activities; it may be embarrassing and
can lead to increased feelings of dependency and defeatism.
To code section H0300, begin with reviewing the medical record Furthermore, bowel incontinence may increase the risk of long-
such as physician history, physical examination, nursing assess- term institutionalization and skin breakdown.

To conduct a complete bowel assessment, start by reviewing the ies have been done suggest some of the following items to con-
medical record, including physician notes, physical examination, sider when creating your continence program:
nursing assessments, progress notes and bowel records/incon- • Many residents take medications that cause constipation
tinence flow sheets. Interview residents if they are capable of dis- • Many treatments for constipation cause or contribute to
cussing their bowel habits. Speak to the family members if the fecal incontinence
resident is unable to report on continence. The nursing assis- • The severe straining resulting from constipation may cause
tants who care routinely for that resident are another source of in- sphincter dysfunctions contributing to fecal incontinence
formation. For coding purposes, even a temporary bowel • The task of toileting residents with constipation averaged over
incontinence precipitated by loose stools or diarrhea from any seven minutes, which may explain why direct care staff may
cause including a stomach ailment, laxatives or other medica- not prompt or assist in toileting6
tions would count as incontinence. This is another point to stress • Nursing home staff under-detects and thus under-reports
to those charged with completing bowel and bladder records. symptoms of constipation
• Prompted toileting programs, along with dietary changes, may
To complete the coding of H0400: increase the number of bowel movements and the number of
Code 0 (Always continent) If throughout the 7-day look-back bowel movements in the toilet, but seem to have little effect
period the resident has been continent of bowel on all occasions on number of fecal incontinence episodes
of bowel movements, without any episodes of incontinence
Despite these factors, a systematically implemented bowel toi-
Code 1 (Occasionally incontinent) If during the 7-day look- leting program may decrease or prevent bowel incontinence and
back period the resident was incontinent of stool once. This minimize or avoid the negative consequences of fecal inconti-
includes bowel incontinence of any amount during the day or night nence. Many incontinent residents respond to a bowel toileting
program that is modeled after their voiding pattern.
Code 2 (Frequently incontinent) If during the 7-day look-back
period the resident was incontinent of bowel more than once but Coding for H0500
had at least once continent bowel movement. This includes Similar to the urinary incontinence program, you should review
incontinence of any amount of stool day or night the medical record for evidence of a bowel toileting program to
complete item H0500. Look for implementation of an individual-
Code 3 (Always incontinent) If during the 7-day look-back ized, resident- specific toileting program based on an assess-
period the resident was incontinent of bowel for all bowel movement of the resident’s unique bowel pattern.
ments and had no continent bowel movements
You should find evidence that the individualized program was
Code 9 (Not rated) If during the 7-day look-back period the res- communicated orally to staff and the resident. The resident’s
ident had an ostomy or did not have a bowel movement for the response to the toileting program and subsequent evaluations
entire 7 days should also be documented in the medical record.
H0500 Bowel Toileting Program Code 0 (No) If the resident is not currently on a toileting program
targeted specifically at managing bowel continence
Item H0500 documents whether a toileting program is being
used to manage a resident’s fecal incontinence. There has been Code 1 (Yes) If the resident is currently on a toileting program
significantly more research on the impact of toileting programs on targeted specifically at managing bowel continence
urinary incontinence than for fecal incontinence. What few stud-
68 Healthy Skin
H0600 Bowel Patterns The RAI Manual Definitions:
Fecal Impaction: A large mass of dry, hard stool that can
Item H0600 documents whether a resident has experienced any develop in the rectum due to chronic constipation. This mass
problems with constipation during the 7- day look-back period. may be so hard that the resident is unable to move it from the
Whether a resident suffers from constipation is now a yes/no rectum.
question in order to highlight this very common problem for res-
idents in long-term care facilities. As noted above, constipation Constipation: If the resident has two or fewer bowel movements
is a side effect of many medications as well as a consequence of during the 7 day look-back period or if most bowel movements
immobility. The focus of constipation, through the MDS, can help consist of hard stool that is difficult to pass.
facilities to detect possible dehydration as well as decrease the
risk of fecal impaction. To begin the assessment for bowel patterns, review the medical
record including physician history, physical assessment, nursing
Fecal impaction, as a separate question, was eliminated from the notes and bowel records for evidence of constipation. Interview
new MDS. The MDS 3.0 validation panel did not consider the the resident if possible or speak to the family members. Ask the
MDS 2.0 question of fecal impaction as reflecting the real inci- direct care staff about problems with constipation.
dence of fecal impaction.* Since there was no evidence that this
2.0 question improved reporting or prevention; the MDS turns Code H0600 as follows:
its focus on constipation which prompts detection and manage- Code 0 (No) If the resident shows no signs of constipation dur-
ment of constipation, thereby reducing potential of impaction. ing the 7-day look-back period
Besides leading to fecal impaction, severe constipation may Code 1 (Yes) If the resident shows signs of constipation during
cause: the 7-day look-back period code (such as two or less bowel
• Abdominal pain movements or difficult to pass hard stools)
• Anorexia
• Vomiting Conclusion
• Bowel incontinence This completes Section H of the MDS. As you have learned, it
• Delirium gives a snapshot of the resident’s continence status. Because it
• Urinary incontinence is so comprehensive, section H of the MDS truly requires your
facility to develop systems that facilitate the collection and doc-
Sometimes fecal impaction manifests as fecal incontinence with umentation of bladder and bowel assessment and interventions.
watery stool from higher in the bowel (or irritation from the Your interdisciplinary MDS team should analyze the current
impaction) moving around the impacted mass, causing soiling. process flow and systems to optimize capturing this information
Education of your staff should include this detail, as it is coun- and reduce duplication of efforts and documentation.
terintuitive to look for impaction if there is some, albeit liquid,
incontinence. 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
* Also, fecal impaction is an incident/event; the MDS attempts to capture residents to obtain the highest level of bowel and bladder func-
the general condition of the resident. tion possible. Section H will help you capture those efforts.

CE TEST
A Guide to MDS 3.0 Section H

1. A major change from MDS 2.0 to 3.0 is: 6. Which of the following is considered an example of
a. 3.0 has a 14-day look-back period for section H a toileting program by RAI Manual?
b. 3.0 requires completion of a voiding diary within 30 days a. Toileting according to the residents voiding pattern
c. 3.0 calls for 7-day look-back period for section H b. Changing incontinence product and performing perineal
d. 3.0 has a look-back period of 3 days for voiding diaries care when requested by resident
c. Observation and tracking of resident’s bowel and
2. Which of the following is not considered a bladder activity
toileting program? d. Changing pad or garment every two hours
a. Elimination Recording
b. Habit training 7. Voiding records can
c. Bladder retraining a. Give the date of first urinary incontinence episode
d. Prompted voiding b. Help detect urinary or fecal voiding patterns
c. Determine Urge Incontinence
3. Residents with catheters should be coded d. Report urinary tract infections
as continent
a. T 8. Residents with dementia are not candidates for a
b. F toileting program
a. T
4. Which of the following should not be coded as an b. F
appliance in Section H?
a. Urostomy 9. If a resident has watery stool or some fecal
b. Colostomy incontinence, it is impossible for them to have
c. Ileostomy fecal impaction.
d. Gastrostomy a. T
b. F
5. Residents should be reevaluated for individualized
continence care plan when there is 10. The following are all risks of incontinence except:
a. Change of cognition a. Increased risk of long-term institutionalization
b. Change to urinary tract function b. Increased risk of repeated urinary tract infections
c. Change of physical ability c. Reduction of participation in activities
d. All of the above d. Congestive heart failure
e. Increased feelings of dependency and depression
Visit www.medlineuniversity.com and login or create an account.

Choose your course to take the test and receive 1 FREE CE CREDIT.
70 Healthy Skin
“ Oh “
Yeah!
Learning opportunities for
CNAs at Medline University
Online CNA courses available at

www.medlineuniversity.com.
Visit today to learn more about:

• Hand hygiene
• Incontinence
• Skin care
• Long-term care
• Pressure ulcers
Access courses
on your computer,
iPhone or iPad.

2 Launch the QR app
http://www.medlineuniversity.com
Follow us
Be the first to know when we
add new courses and content.
©2011 Medline Industries,

Inc. Medline and Medline
University are registered
trademarks of Medline
Industries, Inc.
product spotlight
OPTILOCK NON-ADHESIVE, SUPER ABSORBENT WOUND DRESSING
A new Absorbs
The super absorbent polymer core efficiently absorbs high volumes of exudate.
standard Gently absorbs exudate, even for the most heavily draining wounds.
for gentle Locks

wound care The unique reverse funnel design of the non-adherent contact layer helps direct
fluid into the core. Inside the core, exudate is converted into a gel that’s kept
firmly away from the wound, even under compression. Gently protects against
maceration, including the periwound skin.
Adjusts
Continually adapts the level of absorption to the amount of wound drainage.
Gently provides an optimal moist wound healing environment.
Protects
Non-adherent wound contact layer prevents the dressing from sticking to the
wound or periwound skin. Gently releases from the wound during dressing
changes.
72 Healthy Skin
Dispersion Layer
Evenly distributes and quickly
quick transfers
exudate into the superabsorbent
superabso core.
Super Absorbent Core

Absorbs large amounts of exudate,
e
which is converted to a gel and locked
away from the wound.
Blue Protective Backin

Backing
Helps protect clothing and sheets.
Optilock absorbs and retains
more fluid
In manufacturer’s laboratory testing, Medline’s OptiLock
dressings outperformed a leading silicone-faced foam
dressing. OptiLock’s remarkable absorption and fluid
retention capabilities raise the bar for gentle wound care.
Absorption Capacity Under Compression1 Fluid Loss Under Compression1
20 1.0
18
16 0.8
Absorbency (g/100cm2)
14
Fluid Loss (g)
12 0.6
10
8 0.4
6
4 0.2
2
0 0.0
OptiLock Leading OptiLock Leading
Silicone-Faced Silicone-Faced
Foam Dressing Foam Dressing
Educational Packaging Recommended Uses

OptiLock features Medline’s Educational Packaging (EP). OptiLock is a primary dressing for use on partial thick-
The package focuses on patient safety and correct prod- ness and full thickness wounds or a secondary dressing
uct application. Each package serves as a 2-Minute on full-thickness wounds, including:
Course on Wound Care.™ • Ulcers (pressure, venous, neuropathic/diabetic)
• Postoperative wounds
• First- and second-degree burns
Reference The dressing can remain in place up to seven days,

1. Data on file.
depending on the amount of exudate.

Caring for Yourself
Skin Cancer Foundation Sunscreen Statement

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.”
Authors:
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.
74 Healthy Skin
®
Medline Remedy
Serious care.
Serious results.
Nosocomial pressure Nosocomial pressure Estimated cost

ulcers reduced by ulcers reduced to zero savings of $6,677.11
50% after 3 months1 after 8 months1 per patient1
Independent outcomes research1 was conducted in an LEARN MORE ABOUT REMEMDY

acute care facility where, after implementation of a
prevention program, the only additional change during 2 Launch the QR app
the reduction period was the focus of improving skin care 3 Scan this QR Code or visit
by using Medline Remedy products exclusively, as part of http://www.medline.com/
wound-skin-care/remedy/
a formal skincare regimen. The results were amazing!
1. Shannon RJ, Coombs M, et al. Reducing hospital-acquired pressure ulcers with a silicone-based dermal nourishing
emollient-associated skincare regimen. Adv Skin Wound Care, 2009;22:461-7.
©2011 Medline Industries, Inc. Medline and Medline Remedy are registered trademarks of Medline Industries, Inc.
Here, the Photobiology Committee responds to the criticisms An SPF 15 sunscreen screens out 93% of the sun's UVB rays,
and explains why sunscreen remains an essential part of any- whereas SPF 30 protects against 97% and SPF 50 against 98%.
one’s daily sun safety program. The Skin Cancer Foundation agrees that in most cases, SPFs
beyond 50 are unnecessary.
As sunscreen use has gone up in the past 30 years, so has
melanoma incidence. Systematic review of all studies from 1966 Sunscreen blocks vitamin D.
to 2003 shows no evidence to support the relationship between
sunscreen use and increased risk of melanoma, the deadliest Although solar UVB is one source of vitamin D, the benefits of
form of skin cancer. Actually, some important epidemiological re- exposure to UVB cannot be separated from the harmful effects
search has indicated that population groups using sunscreen of sun exposure: skin cancer, cataracts, immune system sup-
have reduced their melanoma incidence. pression, and premature aging. In addition, excessive exposure
to the sun actually depletes our body's supply of vitamin D. The
The use of excessive SPFs and terms such as “broad-spectrum safest way to obtain vitamin D is through a combination of diet
protection” or “multispectrum protection” on sunscreen labels and vitamin D supplements. The Skin Cancer Foundation rec-
mislead us into a false sense of security, when sunscreens ommends increasing your intake of vitamin D to 1,000 mg daily.
really do not protect adequately against UVA radiation.
The sunscreen ingredient oxybenzone may be a carcinogen.
Because both ultraviolet A (UVA) and ultraviolet B (UVB) are
harmful, you need protection from both kinds of rays. “Broad- Old research on rodents suggested that oxybenzone, a syn-
spectrum protection” and “multispectrum protection” mean thetic estrogen, can penetrate the skin, may cause allergic re-
only that a sunscreen offers protection against parts of both actions, and may disrupt the body’s hormones, producing
the UVA and the UVB spectrum. It does not mean complete harmful free radicals that may contribute to melanoma. How-
protection. Because there is no consensus on how much pro- ever, there has never been any evidence that oxybenzone,
tection the terms indicate, they may not be entirely meaningful. which has been available for 20 years, has any adverse health
SPF refers specifically to how much protection is offered effect in humans. The ingredient is approved by the Food and
against UVB rays, but to date in the United States, we have no Drug Administration (FDA) for human use on the basis of ex-
equivalent measurement to represent the degree of UVA pro- haustive review. The Photobiology Committee reviewed the
tection in a sunscreen. Nonetheless, UVA protection in sun- studies on oxybenzone and found no basis for concern.
screen has greatly improved in recent years. To make sure you
are getting effective UVA as well as UVB coverage, look for a Retinyl palmitate, a form of vitamin A and an ingredient in 41%
sunscreen with an SPF of 15 or higher, plus some combination of sunscreens, speeds up growth of tumors and other lesions
of the following UVA-screening ingredients: stabilized avoben- when exposed to the sun.
zone, ecamsule (also known as Mexoryl), oxybenzone, titanium
dioxide, and/or zinc oxide. 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
For everyday use, an SPF of 15 or higher is generally adequate, study precisely because it has not gone through proper peer re-
while SPFs of 30 or higher are appropriate for active, extended view. Thus, the EWG based its criticisms on an unapproved 10-
outdoor activity. [BOLD] year-old study of mice that has never been published in any
76 Healthy Skin
journal. To date, there is no scientific evidence that vitamin A is Consumers should rest assured that sunscreen products are
a carcinogen in humans. What's more, only trace amounts of safe and effective when used as directed and should be con-
retinyl palmitate appear in sunscreens, and some evidence sug- sidered a vital part of a comprehensive sun protection program
gests that it is actually protective against cancer. that includes the following sun safety strategies:
• Seek the shade, especially between 10:00 a.m.
Nanoparticles in micronized zinc oxide and titanium dioxide and 4:00 p.m.
may be more harmful than larger forms of these chemicals, • Do not burn. Wear a sunscreen with an SPF of 15 or
crossing the placenta and affecting the developing fetus, or higher every day.
causing DNA damage linked to cancer. • Apply 1 oz (2 tbsp) of sunscreen to your entire body 30
minutes before going outside. Reapply every 2 hours or
Micronized versions of zinc oxide and titanium dioxide were de- after swimming or excessive sweating.
signed to improve them cosmetically so that they no longer left • Cover up with clothing, including a broad-brimmed hat
a tell-tale splotch of white on the skin. This improvement greatly and UV-blocking sunglasses.
increased the use of sunscreens containing these ingredients,
• Keep newborns out of the sun. Sunscreens should be
which is a good thing because they are the two most effective
used on babies over the age of 6 months.
ingredients to date in sunscreens against the entire UV spec-
• Examine your skin from head to toe once every month.
trum. Multiple studies have demonstrated that the nanoparti-
cles in these ingredients do not penetrate the skin, and there is • See your doctor every year for a professional skin
furthermore no strong evidence of their toxicity. The general sci- examination.
entific consensus (which even the EWG now admits) is that they • Avoid tanning and UV tanning salons.
pose no risk to human health.
Printed with permission from the Journal of the Dermatology Nurses’ Association. Sep-
tember/October 2010; 2(5):228-229.
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.

CASE STUDY
PRE-STAGE I: An obvious, more descriptive, and clinically

impactful term than “Reactive Hyperemia” or “Blanchable
Erythema” in describing the state before Stage I
INTRODUCTION OBJECTIVE
Diagnosis and staging of pressure ulcers is an important aspect The objective of this study is the identification of the right
of clinical practice in healthcare settings, having an enormous terms to be used for the description of the skin health that
impact on patient health, caregiver utilization effectiveness, exists just prior to the creation of a Stage I pressure ulcer.
reduction of pain and suffering, and health economic issues. Such a well chosen and “call to action” term to describe a
Major benefits to the patient and the healthcare system can common condition in clinical settings is appropriate for inclu-
result if the skin condition is accurately diagnosed and appropriate sion, for example, in a skin/wound assessment tool that has
actions taken commensurate with the nature of the diagnosis. been developed to assist non-expert clinicians in staging and
assessment.
The NPUAP Pressure Ulcer Classification System lists four dif-
ferent stages of pressure ulcers and two additional descriptions. METHODS
In addition, because the breach of skin to Stage I is preceded by 19 nurses and 11 CNAs in a 30 bed hospital rehabilitation
certain signals, it is of enormous and disproportionate benefit for unit, none of whom would be deemed an expert in wound
active and urgent intervention as soon as these signals are rec- assessment and staging, were asked which of the following
ognized. Those signals could include a reddened discoloration terms were more likely to result in immediate preventive
on a Caucasian that is blanchable. action. Immediate interventions are described as off-loading
heels, turning, and communicating the problem to others.
Training of nursing and other clinical staff is critical so that these
signals do not go unnoticed. Even if they are noticed, the words QUESTION: Which term gives you the best understanding of
that describe these conditions matter. The use of the right words a problem that required an immediate active intervention?
to describe these imminently dangerous conditions of skin can
call the nursing staff into action because some well chosen Term choices: Blanchable Erythema, Pre-Stage I, Reactive
words, by themselves, can potentially convey a sense of urgency Hyperemia.
and provide a call for urgent action.
RESULTS
RATIONALE 90% of those subjects surveyed felt that the term “Pre-Stage
A Stage I pressure ulcer has been described as “non-blanchable I” wound result in preventative action.
erythema”. Pressure ulcer development actually occurs before a
pressure ulcer is actually noted; the physiologic changes are Following this survey, the lead author who is a practicing
often non-visible to the naked eye and include temperature clinician observed that when “reactive hyperemia” or “blanch-
changes and itching. (3) Pressure and shear that are causing this able erythema” were diagnosed by her in patient documen-
tissue damage must be recognized and considered an alarm to tation, there was less proactive action taken by the subjects
institute or upgrade prevention measures. (8) Several terms have of the survey. Diagnosis described as “Pre-Stage I” resulted
been used in clinical literature to describe the condition of skin in a far higher frequency of proactive steps such as offload-
immediately before it before it becomes a Stage I (NPUAP) pres- ing and patient turning. Quantitative data to support this
sure ulcer. The terms “blanchable erythema” (6) or “reactive observation was not gathered.
hyperemia” (7) have been used to describe this condition. How-
ever, a less frequently used term “Pre-Stage I” has been used DISCUSSION AND CONCLUSION
previously and it is the authors’ view that this concept is more The choice of the right term to describe an emergent condi-
descriptive of the skin condition, and perhaps, a call to urgent tion on the skin is important, because this can be a “call to
action if such a diagnosis is indeed reached. action” by its very nature. It appears from literature that many
terms have been used to describe the reddening of skin that
This study describes a survey of clinicians whose opinions were is known to precede the formation of the Stage I Pressure
sought about which of a set of three descriptions would be Ulcer. It is felt that all possible steps are worth considering in
deemed the most effective call to action steps to prevent further preventing this crucial first stage of damage to skin.
damage.
78 Healthy Skin
Prevention
Nancy Estocado, PT, CWS1

Margaret Falconio West BSN, RN, APN/CNS, CWOCN2
Debashish Chakravarthy, PhD2
1
Sunrise Hospital, Las Vegas, NV
2
Medline Industries, Inc. Mundelein, IL
Patient A1 – small
area of discoloration
From this survey based research, it appears that the respon- (redness) noted on
dents strongly felt that the use of the term “Pre-Stage I” is the heel
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 Patient A2 – using a
deterioration, compared to the diagnosis as either “blanch- clear disk to assess
able erythema” or “reactive hyperemia.” the area, note the
blanching or lightening
Based on the findings of this study, the authors recommend of the red area
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.
References
1 www.npuap.org 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. Patient B1 –
2 Bhattacharya SB. Pressure Ulcers –Kansas Reynolds Program in Aging. Kansas
University School of Medicine. www2.kumc.edu/coa/education/FacDevPowerPoint. reddened area on
3 Sharp CA and McLaws M-L, A discourse on pressure ulcer physiology: the implications the heel
of repositioning and staging. World Wide Wounds 2005. www.worldwidewounds.com.
4 Porter A, Cooter R. Surgical management of pressure ulcers. Primary Intention
1999;7(4):151-155.
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.
2004;12(4):285-304.
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. NPUAP.org accessed 2-10-2011.
Patient B2 – using
the clinician’s finger,
note the blanching of
the area

80 Healthy Skin
Prevention
12
Ways to
Reduce Hospital
Readmissions
By Cheryl Clark
for HealthLeaders Media
December 27, 2010
Time flies. In just 21 months, the federal government will start We also spoke with Amy Boutwell, MD, an internist at Newton-
penalizing hospitals with higher than expected readmission rates. Wellesley Hospital in Newton, MA and Director of Health Policy
And even though much about the regulations-to come remains Strategy for the Institute for Healthcare Improvement; Timothy
unclear, clinicians along the care continuum are scrambling to Ferris, MD, medical director of the Massachusetts General Physi-
get ready. cians Organization, and Estee Neuhirth, director of field studies
at Kaiser Permanente in California.
Or they should be. It’s not just important for a hospital’s bottom
line. It’s important for the patient. Some of these strategies aren’t yet proven to work in all settings,
of course. And many are still in the demonstrations phase. But
We’ve been talking with some of the nation’s experts on the sub- with national readmission rates as high one in five, and higher for
ject, including Stephen F. Jencks, M.D., whose April 2009 article certain diseases, many providers are trying anything that sounds
in the New England Journal of Medicine set the tone for today’s plausible.
readmission prevention energy. His review of nearly 12 million
beneficiaries discharged from hospitals between 2003 and 2004 Here are some of the prevention strategies that these and other
found that nearly 21 percent, or one in five, were re-hospitalized experts think might be worth a shot. Many involve—to a greater
within 30 days and 34 percent were readmitted within 90 days. or lesser degree —following the patient out of the hospital,

LEARN MORE ABOUT COMPASS PROGRAM:
WOUND CARE PREVENTION & TREATMENT

2 Launch the QR app

programs/compass/

Medline is a registered trademark
of Medline Industries, Inc.
either in-person, electronically, or by phone, but others involve Jencks adds that “senders and receivers, for example hospital
upside-down introspection and re-evaluation by providers along discharge planners and skilled nursing facility staff and home
the care continuum. health” meet often enough so they can learn about the realities
of the transitions they initiate and receive.
1. Discharge Summaries
Dictate discharge summaries within 24 hours of discharge. 3. Provide Medication on Discharge
Boutwell says that standard practice and policy at most hospi- Send the patient home with a 30-day medication supply,
tals is that discharge summaries are completed within 30 days wrapped in packaging that clearly explains timing, dosage,
of the discharge. “I was trained that the summary is a retro- frequency, etc. Some health centers with Medicaid patients may
spective report of what happened in hospitalization. But what we be trying this strategy, which is difficult for hospitals to do with
need today is anticipatory guidance. Patients get discharged and Medicare patients because of distinctions between Part A and
go home. They can’t fill their meds, insurance doesn’t cover the Part B payment. Still, for some high-risk populations, such as
med or they have questions. They’re nervous and worried. They patients with congestive heart failure and those who have been
call their primary care provider, who didn’t even know they were readmitted before, it might be worth it for the hospital to absorb
admitted. the cost.
Boutwell says that 30-day-discharge summary policies “might 4. Make a Follow-up Plan Before Discharge
have sufficed in a time gone by. But that doesn’t work anymore. Have hospital staff make follow-up appointments with patient’s
Information needs to be available at the time of discharge. physician and don’t discharge patient until this schedule is set
There’s a growing recognition of this need, but staff bylaws up. A key is to make sure the patient has transportation to the
haven’t changed.” physician’s office, understands the importance of meeting that
time frame, and following up with a phone call to the physician
2. Lengthen the Handoff Process to assure that the visit was completed.
At every juncture in patient care process, especially discharge,
have teams talk to each other about the patient. And by the way, 5. Telehealth
don’t call them discharges. Call them “transitions.” Standardize We couldn’t find anyone using video monitors to communicate
them for a variety of providers, from hospital to rehabilitation on a daily basis with the use of such software as Skype, for
facility to skilled nursing facility to home and back. example, but some readmission experts say it’s an interesting
approach to keep up visual as well as verbal communication with
Boutwell says that “taking this person-centered approach shifts patients, especially those that are high risk for readmission.
the concept from discharge, which is a moment in time and
you’re done with it, to a transition—a shared accountability. We On a more practical scale, Home Healthcare Partners in Dallas
need to make sure the receiving providers understand who this uses health coaches, intensive care clinicians, and wireless tech-
patient is, with a 360-degree view. nology to record vital signs on a daily basis for about 2,100
discharged Medicare fee-for-service beneficiaries for between

60 to 120 days. So far, they have done this for about 7,000 7. Understand What's Happening After Discharge
unduplicated patients in the last two years, for several hundred Kaiser Permanente is using video cameras to chronicle home
hospitals in Dallas and Louisiana, says HHP’s CEO, Wayne Bazzle. settings and the entire care process to determine what’s
happening to the patient after discharge that provoked a
The target population for intense monitoring includes those with readmission.
four or five co-morbidities and who have a primary diagnosis of
congestive heart failure, chronic obstructive pulmonary disease, The team is also using video of the care team, from the phar-
diabetes, Alzheimer’s and hypertension. macist, home care providers, nurses, and physicians about their
care of that patient, to highlight wrinkles and cracks in the
Bazzle says that the effort involves phone calls of between five system that brought the patient back to the hospital.
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 So far, Kaiser officials say that the video project has contributed
they'’re more truthful with us about what’s going on, and if we to a reduction in readmission rates at some hospitals where it
see some deterioration, we can help them cope. Normally it’s a has been tried, such as from 15.7 percent to 9 percent at
medication management issue, or they’ve become a little too Kaiser’s South Bay Medical Center near Los Angeles, because
relaxed with their diet.” it gave the team information to streamline care, says Kaiser’s
Neuwirth.
6. Identify Frequent Flyers
Customize your hospita’s admission and re-admission rates for 8. Provide Home Care on Wheels
demographic and disease characteristics to identify those at Just like Meals-on-Wheels can be scheduled in advance, so can
highest risk, and expend extra resources on their care needs. case management, housekeeping services, transportation to the
This may involve special programs for homeless patients, such pharmacy and physician’s office. At Piedmont Hospital in Atlanta,
as the one effort by a cohort of Los Angeles hospitals who grap- in collaboration with the Area Agency on Aging, patients having
pled with how to safely discharge homeless patients without elective knee surgery get coupons and prescheduling, “so that
violating city laws. 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
The Los Angeles project now discharges homeless patients who post-transition care is “spreading like wildfire” among a number
meet certain criteria to a half-way type of house in nearby Bell, of hospitals, but so far it’s mainly being tried with elective
and saved $3 million for hospitals in its first few months. Expan- patients.
sions in other parts of Southern California are underway.
Many strategies involve—to a greater or lesser

degree —following the patient out of the hospital,
either in-person, electronically, or by phone.
84 Healthy Skin
9. Consider Physician Medication Reconciliation For surgical patients, those with vascular surgery had the high-
A recent paper in the New England Journal of Medicine by Yut- est readmission rate, 23.9 percent, followed by those with hip or
ing Zhang of the University of Pittsburgh noted the wide geo- femur surgery, 17.9 percent. Perhaps these are the places where
graphic variation among physicians’ prescribing practices with readmissions can be most quickly reduced.
medications that should be avoided in patients over age 65. She
also noted variation in prescribing practices for drugs that have States with the Highest Hospital Readmission Rates
a high risk for negative drug-disease interaction. Washington, D.C. 23.2%
Maryland 22%
Jencks says that Zhang and colleagues “are pointing us to a Louisiana 21.9%
rather important gap in the most common thinking about transi-
New Jersey 21.9%
tions—that we are to make sure that patients are able to get and
Illinois 21.7%
take medications, get recommended follow-up, and generally do
West Virginia 21.3%
as they are told. But we know that medication plans can be in
Kentucky 21.2%
life-threatening error, that physicians often recommend a time-to-
Mississippi 21.1%
follow-up that is too long, that discharge plans are often written
in ignorance of the patient’s pre-admission history and experi- Missouri 20.8%
ence. In general, we need to be much more critical of the plans New York 20.7%
patients get.” Massachusetts 20.2%
Oklahoma 20.1%
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 12. Listen to the Patient
which they and their caregivers repeat back those instructions, Involve the emergency room, hospice or home health providers
even to more than one hospital caregiver, needs to be constantly to make sure patients don’t come to the emergency room for
reinforced, readmission experts say. Jencks says that caregivers non-emergent end-of-life care issues. Providing patients and
need to understand that their patients are often heavily med- their family members with informed choices, opportunities for
icated, stressed, groggy and confused. And that their disease advance directives, and counseling in the emergency room setting
state may impair their ability to understand what they are being may avert painful, unnecessary admissions. Look for this to be
told, much less remember it two days later. a major expansion of palliative care professionals inside the ED.
11. Focus on Highest-risk Patients “There really needs to be a care plan that reflects the patient’s
Examine the readmission patterns at your hospital and see which wishes,” Jencks says. “This is quite different from either a med-
patients, with which conditions, diseases or procedures, have ical power of attorney or what is often called a living will because
the most readmissions. If resources are limited as they are at it lays out the goals of treatment.
most hospitals, push them toward a select group of patients in
a more intense way to see if increased effort makes a difference. “Cure? Palliation? Functional independence? Playing dominoes
with friends? Hospice? This kind of plan has little relevance to
For example, in his New England Journal of Medicine paper, persons without substantial chronic conditions, but it is totally
Jencks showed that for certain diseases or conditions, and in relevant to a patient with one or more chronic conditions that
certain parts of the country, readmission rates are even higher have required hospitalization. With such a plan, one can often
than the national average of one in five. For example, for med- avoid readmissions that really do not serve the patient’s needs or
ical patients, the readmission rate for heart failure patients was values. What is, after all, worse than a readmission? Readmission
27 percent; for those with psychoses, 24.6 percent; chronic of a patient who does not want to be readmitted,” Jencks says.
obstructive pulmonary disease, 22.6 percent. Patients with
pneumonia and gastrointestinal problems were re-hospitalized Reprinted with permission from HCPro, Inc. (February 2011) Copyright
at rates of 21 percent and 19.2 percent respectively. HCPro, Marblehead, MA. For more information, call 800/639-7477 or visit
www.HealthLeadersMedia.com.

Introducing Medline’s New
CONTINENCE MANAGEMENT PROGRAM
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 Replaces Compass
comply with Medicare regulations. Box F315
The program includes: LEARN MORE ABOUT CONTINENCE

• RN/LPN workbook with 4 CE credits MANAGEMENT PROGRAMS AND PRODUCTS
• CNA workbook 1 Download a QR Code Reader app
• Reproducible care plans, assessment 2 Launch the QR app
guidelines and other quality assurance tools 3 Scan this QR Code or visit
programs/continence-
management-program/
Regular Feature
t l i n e H o t To p ic
H o
Assessing Lower Extremity Wounds
By Joyce Norman, BSN, RN, CWOCN, DAPWCA
Question: changes, show temperature changes, often appear on

How should I assess a lower extremity wound? the tips of toes or on the ankles, lateral aspect of foot
Where do I start? and the shin, they have a round wound bed appearance
and light to no drainage. They usually develop from a
Answer: minor trauma, such as bumping the extremity on
We suggest breaking your assessment down into a device.
three simple steps.
Pressure ulcers exhibit “normal” hair growth, appear
STEP 1. Inspect the lower extremity, usually over a bony prominence, have a round wound
and note your findings. (See also chart.) bed and can have light to no drainage or heavy drainage.
Venous leg ulcers tend to be weepy, swollen (edema),
exhibit “normal” hair growth, cause severe pain or heav- Diabetic foot ulcers go along with muscle wasting, can
iness, appear in the gaiter area. They can be irregularly appear on the tips of the toes (usually because of ill-fit-
shaped and have heavy drainage. ting shoes), cause severe pain or no pain, show temper-
ature changes, occur on the ankles, have a round wound
Arterial wounds have an absence of hair growth, occur bed (especially if a callous is also present) and exhibit
along with muscle wasting, change color with position light to no drainage.

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
shoes)
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 calcified, resulting in a non-reliable measurement. Also,
bony prominences. due to the neuropathy, the pain will vary from absent to
This is something that can easily be done as care is pro- very severe.
vided not just during bathing. Feel the heels when reposi-
tioning or turning. Note the temperature of the extremity Circulation problems
as compared to the other leg. Is the skin dry? Does it feel When caring for patients with factors that can affect their
and look good? Or is the skin overly moist? circulation, we want to understand that not only can this
cause problems like stroke (CVA), or heart issues, (MI,
STEP 3. Use the information you have gathered atrial fib, hypertension, hyperlipidemia), it can also have
to help determine the type of wound. an impact on their lower extremities. Some signs and
Wounds on the foot are frequently related to neuropathy symptoms to be aware of include:
and diabetes. Although neuropathy can develop from • Atrophy of the calf muscle, with a straight
other causes, many times it is related to diabetes. These or stove pipe appearance to leg
foot wounds are commonly called diabetic foot ulcers • Lack of hair
(DFU). “Diabetic” wounds can also appear on the ankle. • Diminished or absence of pulses
For diabetics, it is just as bad to wear ill-fitting or worn out • Color changes with position
shoes as it is to wear no shoes at all. If your patient/resi- • Temperature changes (feet cooler)
dent has decreased sensation in the feet, he or she may These can be indications that the patient has lost blood
not realize footwear that is rubbing on the skin and form- flow to the lower extremity, and minor injuries, such as
ing a blister or that a foreign object such as a tack or peb- simply bumping their shin on a chair or bed, might result
ble could be causing a problem. These wounds are in a wound that will not heal. This is where the diminished
typically small in nature and present with a callous ring blood flow has affected the lower leg, and the end result
around them. They will not always have a reliable Ankle is a wound.
Brachial Index (ABI) study, as the small vessels could be
88 Healthy Skin
\ Cy∙an∙o∙a∙cry∙late \
A fast-acting adhesive that bonds with the skin
to create a barrier against moisture and friction.
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.
Problem: Peristomal Irritation
Solution: Marathon® Cyanoacrylate Liquid
Skin Protectant
Skin changes Peristomal irritation can lead to decreased wear time, pain
Changes in the skin and edema are additional problems and embarrassment about leakage. So it only makes
that can be assessed easily. Skin changes might include: sense to do everything you can to protect the peristomal
• Edema below the knee, which resolves area. Marathon Liquid Skin Protectant helps protect
with elevation against irritation and maceration by creating a barrier
• Red or ruddy colored skin, especially around against moisture and chemical assault.
the ankle area
• Wounds or scars that start at the ankle Marathon, a cyanoacrylate, bonds to the skin surface,
integrating with the epidermis on a molecular level to
These are classic signs and symptoms of venous hyper- seal in moisture. While other skin protectants may flake
tension, and can be resolved with elevation, education off, Marathon stays in place, offering robust protection
about proper ambulation and compression. and increased wafer wear time.
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.
Conclusion
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-
Stoma site before Same stoma site after
lem is not resolving despite comprehensive care, some- treatment with Marathon.1 treatment with Marathon.1
thing else may be wrong, and the patient will require
further assessment.
LEARN MORE ABOUT MARATHON SKIN PROTECTANT
2 Launch the QR app
http://www.medline.com/wound-
skin-care/marathon/application.asp
1. Data on file
© 2011 Medline Industries, Inc. Medline and Marathon are registered

trademarks of Medline Industries, Inc.
Ventilator-Associated Pneumonia
can be deadly.
VAPrevent can be easy.
Convenient,
space-saving
packaging
VAPrevent
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
Evidence-based innovation in oral care for ventilator patients
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.
The three parts of the VAPrevent program you’ll want to know:
Product
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.
Clear visuals let

you identify the
right kit quickly
for your patient’s
needs
Program
When your staff knows how to use a product appropriately, its effectiveness
increases greatly. That’s why Medline developed the Medline VAP program,
which helps build knowledge and clinical skills with educational modules
for both novice and experienced clinicians, as well as an online interactive
competency for oral care. A program manager helps you implement your
program and stays active as you progress, providing 90-day reports to
help you track your incidence of VAP.
Price
If you expected a VAP program this innovative would come at a price
premium, you’re in for a pleasant surprise. VAPrevent from Medline
comes to you for five to ten percent lower than competitors. In a tough,
pay-for-performance environment, VAPrevent represents a major value.
LEARN MORE ABOUT THE VAPREVENT SYSTEM

2 Launch the QR app
http://www.medline.com/programs/vap
References
1 Bingham M, Ashley J, De Jong M, Swift C. Implementing a unit-level intervention to reduce the probability
of ventilator-associated pneumonia. Nursing Research. 2010; 59(1): S40-S47.
2 Trouillet J, Chastre J, Vuagnat A, Joly-Guillou M, Combaux D, Dombret M, et al. Ventilator-associated
pneumonia cased by potentially drug-resistant bacteria. Am J Respir Crit Care Med. 1998. 157(2):531-539.
Make Your Facility a Greener Place to Work
92 Healthy Skin
Special Feature
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.
Did You Know? Learn More and Take Action

• The National Institute for Occupational Safety and Join the EnviRN Knowledge Network, the online learning
Health (NIOSH) estimates that eight to 12 percent of resource for nurses concerned about environmental health.
all healthcare workers have become allergic to latex. It is made possible by the Alliance of Nurses for Environ-
The likelihood of nurses developing asthma during mental Health (ANHE), a national organization of nurses and
their career is 2.17 times greater if they used powdered nursing organizations working to promote healthy people
latex gloves. Latex-free gloves offer a safe alternative and healthy environments by educating and leading the
and, with new technology, many feel just like latex.1 nursing profession, advancing research, incorporating
evidence-based research and influencing policy. Here are
• Disinfecting and sterilizing agents and housekeeping just a few things you can do at EnviRN.org:
chemicals can build up on surfaces and in the air each
time cleaning or disinfecting occurs, and may lead to • Take the Nurses Pledge: By making simple changes
asthma, allergies, and other, more serious health in your everyday life, you can live and work in healthier
problems. Besides using alternative products, facilities environments. EnviRN is asking nurses to make three
can increase education and awareness for staff on personal changes and three changes where you work.
proper use and handling of chemicals. When mercury- • Click on “Essentials” for an introduction to the intersection
containing equipment breaks, mercury vapors are of environmental health nursing practice.
spread through the air of a room where nurses work • At “Hazards A – Z” you will find a library on
and breathe. Eliminate mercury-containing equipment environmental hazards and the health concerns they
wherever possible at your facility.1 trigger, along with news articles and educational
resources.
• 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.
For more information on Medline’s Sustainability Program, contact

Francesca Olivier at 847-643-3821 or folivier@medline.com.
Reference
1 Environmental Working Group website. Nurses’ workplace exposures. Available at
http://www.ewg.org/node/28128. Accessed April 26, 2011.

Special Feature
San Diego, CA
Congratulations
Dr. Jeter and WOCN!
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.
Experience Katherine’s journey day by day

http://cyclingforscholarships.blogspot.com
94 Healthy Skin
St. Augustine, FL
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, I may be retired, but that doesn’t mean I should sit around
“Has it been worth it?” In other words, have I sacrificed and do nothing. It feels good to work toward growing as
things that I wish I had not? I won’t lie, I have missed some an individual, while giving back.”
things this past year, including entertaining friends at our
mountain home and some of the ski season, but it was all
worth it. Opposite page: Evonne Fowler, MSN, RN, CNS, CWOCN, sends
Katherine off with a smile at the start of the trip in California.
“I’ve grown as a person. I’m working on maintaining a
healthy physique to prevent the recurrence of breast cancer. Above: Medline Clinical Education Specialist Kim Kehoe, BSN,
I have met a whole group of new friends. And I hope I'm RN, CWOCN, DAPWCA congratulates Katherine at the finish line
encouraging young and old alike to be active. in Florida.

How to
ENERGIZE
96 Healthy Skin
by Wolf J. Rinke, PhD, RD, CSP
YOUR TEAM
...the fastest way to achieve peak
performance is to treat all employees
as if they were volunteers
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. Now, stop and think, what would you say to your team mem-
I refer to this as the most important leadership principle of all bers if indeed they were volunteers? How about: "Please."
time. I discovered it while I was a Board member of one of my "Thank you!" "Can I count on you?" "I need your help." "I really
professional associations and the Chair for the Council on appreciate what you’ve done." "Thanks for being on my team!"
Education. In that role the Board looked to me to implement "Thanks for showing up." And now the one that blows the
new Standards of Education, which had been in limbo for autocratic managers away: "Could you do me a favor?" That
countless years. A team of 12 professionals was on my com- one just doesn’t sit well with lots of managers. Here are some
mittee. All highly educated, all volunteers, all having their own of the things they’ve said to me: "What are you talking about?
agenda. I quickly became aware that all the “crutches” that I You’re paying them; they owe you a good job." Or "You’ve got
relied on during my “day job” did not work. For example, one of to be nuts. They are not doing you any favor, it’s their job," and
my committee members, let’s call her Julie, was really gung-ho. so on. All really good arguments, and all really, really incorrect.
Any time there was a project to be done she was the first one (If you agree with any of these, it’s time to wake up and smell the
to volunteer. There was only one problem—Julie seldom deliv- coffee. Because the only thing pay will do is get team members
ered. Forget delivering on time, she just did not deliver. At work, to show up, and stay with you. (Not bad, but certainly not peak
when any of my team members did that, I could counsel them performance.) And the fastest way to achieve peak perform-
and if that did not work I could use the ultimate “crutch”— ance is to treat all employees as if they are volunteers.
I could fire them. Trying that with Julie, however, produced just
the opposite results. Her response: “Hey I don’t need this; I’m 2. Catch team members doing things almost right!
outta here—more time with the family.” Most of us were taught to supervise team members by catch-
ing them making mistakes. Someone even gave it a name:
After banging my head against the proverbial brick wall several management by exception. Unfortunately most team members
times I finally figured out that my autocratic strategies simply will live up or in this case down, to your expectation. To reverse
did not work with volunteers. I had to develop an entirely different this, you will need to learn to catch team members doing things
skill set to motivate these people. And after I had mastered right. No wait, let me modify that, catch team members doing
them, I transferred these new strategies to my “day job.” For things almost right! The problem is that if you are a perfection-
me this was a defining moment that enabled me to transform ist some of your team members just have a tough time getting
myself from an autocratic manager to a highly effective leader. it right, especially if right is defined as the way you would have
What was that concept? Are you ready for it? This is BIG! Drum done it. Then you must compliment or recognize that positive
roll please! Treat all employees as if they are volunteers. performance in some way. In other words, you must learn to
98 Healthy Skin
Changing
your look
just got
more
affordable
New lower prices on all
your favorite brands!
At www.Scrubs123.com, finding quality scrubs in a variety

of brands and styles to match your individual look and
professional style is as easy as 1-2-3! And now it’s more
affordable with new lower prices and low flat rate shipping.
Pay only $6.95 shipping on any size order and get FREE
shipping on purchases over $99.
RECEIVE 15% OFF ALL MEDLINE SCRUBS AT

CHECKOUT WITH PROMO CODE: HEALTHY SKIN 11
2 Launch the QR app
http://www.scrubs123.com
©2011 Medline Industries, Inc. Medline is a registered trademark

of Medline Industries, Inc
I learned a long
time ago that if it’s
fun, it gets done.
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
practice management by appreciation (MBA). Although difficult make donations to your Celebration Team. Example: movie tick-
to master, this is a more powerful strategy than you will ever ets, a weekend for two at a local resort, etc., etc. Just be sure
learn in any university MBA program. Catching team members to give those who donate lots of visibility. Now ask the Cele-
doing things almost right means you use your abundant men- bration Team to get together to identify specific things they are
tal energy to look for your team members moving in the right di- planning to do each month that make work fun. Tell them any-
rection, instead of using the same amount of energy to catch thing goes, provided that they stay within their allocated budget
them messing up. If you look hard enough, you will find that and it does not violate any laws, rules or regulations.
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 4. Be positive and energetic
about it, ideally in public. If you still find yourself slipping back Attitudes, just like colds are
into old habits use the 10 penny system. Put 10 pennies in your catching. Positive attitudes are
left pocket or in case you don’t have pockets, the left side of caught just as easily as negative
your desk. Every time you catch one of your team members attitudes. The only problem is
doing something almost right and let them know about it, trans- that negative attitudes suck the
fer one penny from your left pocket to your right pocket. On the energy out of your team mem-
other hand if you provide negative reinforcement to one of your bers like a giant sponge—some-
team members, reverse the process; but this time move three thing your peak performers are
pennies back to the left pocket. Your goal is to have all pennies just not going to put up with. On
in your right pocket at the end of each day. the other hand, positive attitudes
are like the little Energizer bunny.
They will keep your team mem-
100 Healthy Skin

50%
LESS
FRICTION
than the leading
competitor3
Relieve Pressure on Vulnerable Heels
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-
all.1 According to clinical experts, the most effective aspect of
pressure ulcer prevention for heels is pressure relief, also known
as offloading.1,2 Offloading is achieved with the use of pillows or
Straight-back strapping Criss-cross strapping
heel protection devices that relieve pressure by elevating the heel. provides extra room, isolates the foot and
ventilation and protection floats the hell
The HEELMEDIX Heel Protector is designed to help eliminate against foot drop
pressure, friction and shear on the skin by elevating the heel.
Made of soft, suede-like material on the inside and easy-to-clean
MENTION THIS AD TO RECEIVE A 10% DISCOUNT
nylon on the outside. Adjustable straps are soft against vulnerable
ON YOUR FIRST HEELMEDIX HEEL PROTECTOR ORDER
skin. Includes a mesh laundry bag with patient ID label to simplify
washing and sorting. 1 Download a QR Code Reader app
2 Launch the QR app
heel-and-elbow/
1
Fowler E, Scott-Williams S, McGuire JB. Practice recommendations for preventing heel pressure
ulcers. Ostomy Wound Management. 2008;54(10):42:48.
2
Langemo D, Thompson P, Hunter S, Hanson D, Anderson J. Heel pressure ulcers: stand guard.
Advances in Skin & Wound Care. 2008;21(6):282-292.
Recognize that positive
language energizes you.
bers going, and going, and going (well, you get it.) To build a 6. Get team members to listen to motivational
positive attitude, become aware of your conversations including audio programs.
the ones that you have inside of your head. Recognize that pos- Mary Kay sales associates, or for that matter all highly suc-
itive language energizes you, and negative, cynical, “stinking cessful sales professionals, have this figured out. You must pro-
thinking” conversations de-energize you and your team mem- vide team members with external motivation if you want them
bers. Make it a practice to say positive things, especially about to consistently perform at peak performance. So start building
other people, or say nothing at all. Also recognize that your an audio-program library. Suggest to your team members that
mind can hold only one thought at a time. It can either be pos- they listen to a program every day on their way to work. Meet
itive or negative, it is your choice! So when you catch yourself in brief weekly meetings and have team members share one
thinking positive thoughts, congratulate yourself. On the other powerful principle they learned from each program. That way
hand when you are thinking negative thoughts, catch yourself, everyone can learn from everyone else, and energize each other
change those thoughts, then give yourself credit. Remember at the same time. Supplement these activities by showing a mo-
because of “mirror neurons” your team members take their cue tivational program during your next in-service. (Aren’t your team
from you! You must be the role model for the kind of behaviors members getting tired of the same mandatory training?) Or bet-
you want them to exhibit. (For in-depth strategies of how to ter yet hire a motivational speaker to energize your next "all
make this happen read Make It a Winning Life--Success hands" team meeting. Your team members will be positively
Strategies for Life, Love and Business available at http://wol- surprised, feel honored and energized. And when they are
frinke.com/miwlbook.html.) 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
5. Build on team members' strengths. better faster.
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 © 2011 Wolf J. Rinke
what they do. Typically team members who love what they do
are in jobs that let them build on their strengths. So find out Dr. Wolf J. Rinke, RD, CSP is a keynote
what your team members love to do and do everything in your speaker, seminar leader, management con-
power to assign them to those projects or place them in those sultant, executive coach and editor of the free
positions. What if you end up losing them? Think about it: would electronic newsletter Read and Grow Rich,
you rather have team members who love what they do and available at www.easyCPEcredits.com. In ad-
hence are peak performers, or those who stick with you dition he has authored numerous CDs, DVDs
because they can’t get a job anywhere? Even your most dedi- and books including Make It a Winning Life:
cated team members are going to get burnt out really fast if Success Strategies for Life, Love and Busi-
they are not building on their strengths. So you would be much ness, Winning Management: 6 Fail-Safe Strategies for Building
better served to get team members in positions or projects that High-Performance Organizations and Don’t Oil the Squeaky Wheel
enable them to build on their strengths even if you lose them. and 19 Other Contrarian Ways to Improve Your Leadership Effec-
Just remember that whoever inherits one of your team mem- tiveness; available at www.WolfRinke.com. His company also pro-
bers will be much more likely to reciprocate in the future. Plus duces a wide variety of quality pre-approved continuing
the team member who has left you will become an "ambas- professional education (CPE) self-study courses, available at
sador of goodwill" for you. And in today's competitive health www.easyCPEcredits.com. Reach him at WolfRinke@aol.com.
care industry, good will is a very valuable commodity when you
need to fill your next vacancy.
102 Healthy Skin

Yes, They’re Genuine.
Y
O
Only Medline’s Pink Pearl™ gloves combine
aloe, nitrile and breast cancer awareness.
a
LEARN MORE ABOUT THE PINK GLOVE DANCE

AND SUPPORT BREAST CANCER AWARENESS
2 Launch the QR app
http://pinkglovedance.com/

Medline is a registered trademark
and Pink Pearl is a trademark of
Medline Industries, Inc.
Special Feature
Countdown to Breast Cancer

Awareness Month!
2011 Things to do
- Schedule ma mmogra m
June - Start working on pink glove dance
video for pinkglovedance.com
Order pink gloves for Breast

July Ca ncer Awareness Month
- Participate in breast cancer walk

August - Visit the National Breast Cancer
Foundation website
- Re me mber to do monthly self

Sept breast exa ms.
- Not too late to order pink gloves!
Oct Celebrate!
104 Healthy Skin

Special Feature
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
Reference
1. Survival rates for breast cancer. American Cancer Society website. Available at:
http://www.cancer.org/cancer/breastcancer/overviewguide/breast-cancer-overview-
survival-rates <http://www.cancer.org/cancer/breastcancer/overviewguide/breast-
cancer-overview-survival-rates>. Accessed April 28, 2011.

Healthy Eating
Nutrition
Information
Servings: 9
Calories: 166
Fat: 15.6 g
Sodium: 159 mg
Fiber: 0.1 g
Aunt Judy’s
Tortilla Roll-Ups
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
Directions: This recipe is Judy’s favorite appetizer, which she inherited from
Mix ingredients together, and spread onto the tortillas. Roll up her Aunt Judy a year ago. It’s a highly requested dish at the
tortillas. Place into a zip lock bag and chill. When ready to serve, many events Judy attends.
slice and serve with salsa.
Judy was also involved in creating Medline’s first and second
Hint: Healthier alternative ~ low fat cheese and low fat sour edition cookbooks, which feature recipes from Medline employ-
cream and whole wheat tortillas may be used. ees. The latest edition is available for purchase, and the pro-
ceeds go to Medline’s Spirit of Giving fund, which helps support
Judy DeSalvo, Marketing Business Manager – Mundelein Medline employees in times of need.
Judy DeSalvo has been working at Medline for nine years. She
basically “does it all” to keep the Marketing Department running
The Medline employee cookbook
efficiently. Judy sees print projects through to completion, mak-
is $10. To purchase your own
ing sure vendor estimates are correct on
copy, please e-mail Judy at
invoices, all the way down to ensuring
jdesalvo@medline.com.
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.
106 Healthy Skin

FORMS & TOOLS
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
Diabetes
National Diabetes Fact Sheet, 2011................................ 111

FORMS & TOOLS
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
Diabetes
National Diabetes Fact Sheet, 2011................................ 111

What type of wound is it?
WOUND
APPEARANCE
PRESSURE VENOUS
Definition Damage to the skin or underlying struc- Failure of venous valve function in return-
tures as a result of tissue compression and ing blood from the lower extremities to the
inadequate perfusion heart causing venous congestion, leading
to venous hypertension
Location Usually over a bony prominence Gaiter area (ankle to mid calf), often
meedial malleolus, may be circumferential
Wound Margin Usually circular Irregular shaped
Wound Bed Can have viable or necrotic tissue Usually shallow, can have viable or
necrotic tissue
Wound Size Can be very large or very small Usually large
Exudate Can vary from none to heavy Can vary from none to heavy to general-
ized weeping
Edema Can be localized, usually not seen Generalized edema to lower extremity
Limb Staining Usually not present Usually seen
Ankle Brachial Index N/A > 0.8

(ABI)
Pedal Pulses N/A Usually normal, or undetectable due

to edema
Pain Usually, but often undertreated Often in dependent position, with edema
Best Practice • Remove necrotic tissue • Compression

• Maintain optimal moisture • Remove necrotic tissue
• Protect periwound skin • Maintain optimal moisture
• Control bioburden • Protect periwound skin
• Remove pressure • Control bioburden
• Ensure lower extremity moisturization
108 Healthy Skin

ARTERIAL NEUROPATHIC /DIABETIC
Wounds caused by ischemia, related to Neuropathy is often associated with dia-
the presence of arterial occlusive disease betes. Wounds result from damage to the
autonomic, sensory or motor nerves and
have an arterial perfusion deficit
Distal aspect of arterial circulation, can be Can be anywhere on the lower extremity,
anywhere on the leg (i.e. toes and feet) often on the foot
“Punched out,” well defined borders Similar to arterial, usually with a

callous edge
Pale wound bed, little or no granulation, Similar to arterial

necrotic tissue is common
Can be small, often increases due to lack Often small

of arterial perfusion
Minimal to no exudate Similar to arterial
If present, localized Similar to arterial
Usually not present Similar to arterial
< 0.8 Not reliable, sometimes > 1.0 falsely eval-

< 0.5 - indicates inability to heal uated due to calcification
Usually reduced or absent Not reliable
Occurs at rest, nocturnal, or when Due to neuropathy, pain may be absent

extremity is elevated or severe
• If perfusion not adequate, consider • Maintain optimal moisture

vascular consult • Control diabetes, if appropriate
• If perfusion is adequate, follow protocol • Repetitive removal of callous
based on wound assessment and
characteristics • Bioburden control and prevention
of systemic infection
• If dry, stable eschar leave intact
• Remove pressure with appropriate
offloading shoe or other appliance

Forms & Tools One & Only Campaign
1 needle
1 syringe
+ 1 time
0 infections
It’s elementar y!
Patients and healthcare providers must
both insist on nothing less than One Needle,
One Syringe, Only One Time for each and
every injection.
For more information, please visit:

www.ONEandONLYcampaign.org
The One & Only Campaign is a public health

campaign aimed at raising awareness among
the general public and healthcare providers
about safe injection practices.
CDC Diabetes Facts Forms & Tools
National Diabetes Fact Sheet, 2011
FAST FACTS ON DIABETES

Diabetes affects 25.8 million people
8.3% of the U.S. population
DIAGNOSED
18.8 million people
UNDIAGNOSED
7.0 million people
All ages, 2010
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.
Citation In 2005–2008, based on fasting glucose or hemoglobin A1c levels,

Centers for Disease Control and 35% of U.S. adults aged 20 years or older had prediabetes (50% of
Prevention. National diabetes fact adults aged 65 years or older). Applying this percentage to the entire
sheet: national estimates and general
U.S. population in 2010 yields an estimated 79 million American
information on diabetes and prediabetes
in the United States, 2011. Atlanta, GA: adults aged 20 years or older with prediabetes.
U.S. Department of Health and Human
Services, Centers for Disease Control and Diabetes is the leading cause of kidney failure, nontraumatic lower-
Prevention, 2011. 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.
National Center for Chronic Disease Prevention and Health Promotion

Division of Diabetes Translation
CS217080A

Forms & Tools CDC Diabetes Facts
Complications of diabetes in the United States
Heart disease and stroke

In 2004, heart disease was noted on 68% of diabetes-related death certificates among people aged 65 years or older.
In 2004, stroke was noted on 16% of diabetes-related death certificates 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.
Hypertension
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
transplant.
Nervous system disease

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
feeling).
Severe forms of diabetic nerve disease are a major contributing cause of lower-extremity amputations.
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.
112 Healthy Skin

C
Complications
omplications of diabetes
diabetes in the United
United States
States ((continued)
continued)
Dental
Dental disease
Periodontal (gum) disease is more common in people with diabetes. Among young adults, those with diabetes have about
twice the risk of those without diabetes.
Adults aged 45 years or older with poorly controlled diabetes (A1c > 9%) were 2.9 times more likely to have severe periodontitis
than those without diabetes. The likelihood was even greater (4.6 times) among smokers with poorly controlled diabetes.
About one-third of people with diabetes have severe periodontal disease consisting of loss of attachment (5 millimeters or
more) of the gums to the teeth.
Complications
Complications of pregnancy
pregnancy
Poorly controlled diabetes before conception and during the first
trimester of pregnancy among women with type 1 diabetes can cause
major birth defects in 5% to 10% of pregnancies and spontaneous
abortions in 15% to 20% of pregnancies. On the other hand, for a
woman with pre-existing diabetes, optimizing blood glucose levels
before and during early pregnancy can reduce the risk of birth defects
in their infants.
Poorly controlled diabetes during the second and third trimesters of
pregnancy can result in excessively large babies, posing a risk to both
mother and child.
Other
Other ccomplications
omplications
Uncontrolled diabetes often leads to biochemical imbalances that can
cause acute life-threatening events, such as diabetic ketoacidosis and
hyperosmolar (nonketotic) coma.
People with diabetes are more susceptible to many other illnesses.
Once they acquire these illnesses, they often have worse prognoses.
For example, they are more likely to die with pneumonia or influenza
than people who do not have diabetes.
People with diabetes aged 60 years or older are 2–3 times more likely
to report an inability to walk one-quarter of a mile, climb stairs, or do
housework compared with people without diabetes in the same age
group.
People with diabetes are twice as likely to have depression, which can
complicate diabetes management, than people without diabetes. Working together, people
In addition, depression is associated with a 60% increased risk of
developing type 2 diabetes. with diabetes, their
As indicated above, diabetes can aff
ffe
ect many parts of the body and support network, and
can lead to serious complications such as blindness, kidney damage,
and lower-limb amputations. Working togetherr,, people with diabetes, their health care providers
their support network, and their health care providers can reduce the
occurrence of these and other diabetes complications by controlling can reduce the occurrence
the levels of blood glucose, blood pressure, and blood lipids, and by
receiving other preventive care practices in a timely manner. of diabetes complications.
9

BioCon™- 500
Bladder Scanner
Safely Measures
Bladder Volume
Minimize unnecessary catheterization
Research has shown that 80 percent of urinary tract
infections acquired at healthcare facilities are associated
with an indwelling urethral catheter.1 This type of infection
is known as CAUTI, or catheter-associated urinary
tract infection.
Avoiding unnecessary catheter use

is a primary strategy for preventing
CAUTI, and clinical guidelines
recommend the consideration of
alternatives to catheterization.2
Bladder scanners accurately
assess bladder volumes,
and many urinary catheterizations
can be avoided.3
LEARN MORE ABOUT BIOCON-500

2 Launch the QR app
bladder-scanner
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. 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.

Medline is a registered trademark of Medline Industries, Inc.
P
Preventing
reventing diab
diabetes
etes ccomplications
omplications
Glucose
Glucose control
control
Studies in the United States and abroad have found that improved glycemic control benefits people with either type 1 or
type 2 diabetes. In general, every percentage point drop in A1c blood test results (e.g., from 8.0% to 7.0%) can reduce the risk
of microvascular complications (eye, kidneyy, aand nerve diseases) by 40%. The absolute difference in risk may vary for certain
subgroups of people.
In patients with type 1 diabetes, intensive insulin therapy has long-term beneficial effects on the risk of cardiovascular disease.
Blo od pressure
Blood pressure control
control
Blood pressure control reduces the risk of cardiovascular disease (heart disease or stroke) among people with diabetes by 33%
to 50%, and the risk of microvascular complications (eye, kidneyy, and nerve diseases) by approximately 33%.
In general, for every 10 mmHg reduction in systolic blood pressure, the risk for any complication related to diabetes is reduced
by 12%.
No benefit of reducing systolic blood pressure below 140 mmHg has been demonstrated in randomized clinical trials.
Reducing diastolic blood pressure from 90 mmHg to 80 mmHg in people with diabetes reduces the risk of major cardiovascular
events by 50%.
C
Control
ontrol of blo
blood
od lipids
Improved control of LDL cholesterol can reduce cardiovascular complications by 20% to 50%.
P
Preventive
reventive ccare
are pr
practices
actices ffor
or e
eyes,
yes, ffeet,
eet
e , and k
kidneys
idneys
Detecting and treating diabetic eye disease with laser therapy can reduce the development of severe vision loss by an
estimated 50% to 60%.
About 65% of adults with diabetes and poor vision can be helped by appropriate eyeglasses.
Comprehensive foot care programs, i.e., that include risk assessment, foot-care education and preventive therapy, treatment of
foot problems, and referral to specialists, can reduce amputation rates by 45% to 85%.
Detecting and treating early diabetic kidney disease by lowering blood pressure can reduce the decline in kidney function by
30% to 70%. Treatment with particular medications for hypertension called angiotensin-converting enzyme inhibitors (ACEIs)
and angiotensin receptor blockers (ARBs) is more effective in reducing the decline in kidney function than is treatment with
other blood pressure lowering drugs.
In addition to lowering blood pressure, ARBs and ACEIs reduce proteinuria, a risk factor for developing kidney disease, by about
35%.
Detecting and treating

diabetic eye disease with
laser therapy can reduce
the development of severe
vision loss by an estimated
50% to 60%.
NEW! ULTRASORBS® UF DRYPADS
Dryness & Odor Control In One Ultra-Fresh™ Pad
Drier Patients. Fresher Air.
Ultrasorbs UF provides the same patented* SuperCore® as

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 Our latest Ultrasorbs innovation.
The advanced features of Ultrasorbs AP
• Makes for a fresher room
plus antimicrobial Ultra-Fresh to inhibit
• Clinically shown to help maintain skin integrity as part bacteria and yeast that cause odor**
of an overall pressure ulcer prevention program.1
LEARN MORE ABOUT ULTRASORBS UF
To request a free bag of
Ultrasorbs UF, send an e-mail
2 Launch the QR app

to ultrasorbs@medline.com.


" " " # %
& ( http://www.medline.com/
)* +/ 0
% 7/8 )+ 0
:;;< incontinence/drypads/
ultrasorbs.asp
=0"" " " > >?@ ?;: ==D
G
H
" "
G "G
I:; 0 J" J 0 G /
0 J" J D
/ 0 J" J "(
G / 0K L #% M (
CDC Clinical Reminder Forms & Tools
C
CDC
DC C
CLINICAL
LINICAL REMINDER
REMINDER
Spinal Injection Procedures Performed
without a Facemask Pose Risk for
Bacterial Meningitis
Summary:
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),1 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.2
Background:
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
myelography.
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

Forms & Tools CDC Clinical Reminder
Since facemasks have been shown to limit spread of droplets arising from the oral flora,3 the CDC has
recommended their use by healthcare providers when performing spinal injection procedures.2
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
patient.2
Recommendations:
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.2
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
procedures.2
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:

http://www.cdc.gov/hicpac/2007IP/2007ip_part3.html
References:
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:
http://www.cdc.gov/hicpac/pdf/isolation/Isolation2007.pdf. 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.
1992;69(4):407-8.
NCEZID Atlanta:
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: cdcinfo@cdc.gov Web: www.cdc.gov
118 Healthy Skin

How 4 square inches of Puracol® Plus
changed chronic wound care.
Forever.
Look closely. It’s not a bandage. It’s Puracol™ Plus

MicroScaffold™, made entirely of pure native collagen.
Chronic wounds tend not to heal when unbalanced levels
of elastase and MMPs (inflammatory enzymes) destroy the
body’s own collagen and growth factors.1
But apply Puracol Plus and help restore nature’s balance.
This is Puracol Plus Micro- In vitro studies show that Puracol Plus has the ability
Scaffold as seen through an to reduce the levels of elastase and MMPs from
electron microscope. Its open, surrounding fluid.2
cellular structure allows easy
fibroblast migration.2 The high
strength of the MicroScaffold2
Each Puracol package is
a 2-Minute Course in ™
also assists in establishing a

Advanced Wound Care.
fresh wound bed.
LEARN MORE ABOUT PURACOL PLUS

2 Launch the QR app
wound-skin-care/puracol-plus/
1. Schultz GS, Mast BA. Molecular analysis ©2011 Medline Industries, Inc.
of the environment of healing and chronic Puracol is a registered trademark of Medline Industries, Inc.
wounds: Cytokines, proteases, and growth Medline is a registered trademark of Medline Industries, Inc.
factors. Wounds. 1998;10 (6 Suppl): 1F-9F.
2. Data on file.
Introducing ...
THE NEW REMEDY WEBSITE
www.RemedyAdvancedSkincare.com
Now you and your family can enjoy professional
quality Remedy skin care products at home.
SAVE 15% ON YOUR FIRST ORDER BY USING

PROMO CODE: ISAVED15

2 Launch the QR app
http://www.remedyadvanced-
skincare.com/
©2011 Medline Industries, Inc. Medline and Remedy

are registered trademark of Medline Industries, Inc.
MKT211157/LIT847/35M/RPN5

Healthy Skin Magazine - Volume 9 Issue 2

Diunggah oleh

Informasi Dokumen

Judul Asli

Hak Cipta

Format Tersedia

Bagikan dokumen Ini

Bagikan atau Tanam Dokumen

Opsi Berbagi

Apakah menurut Anda dokumen ini bermanfaat?

Apakah konten ini tidak pantas?

Hak Cipta:

Format Tersedia

Healthy Skin Magazine - Volume 9 Issue 2

Diunggah oleh

Hak Cipta:

Format Tersedia

Improving Quality of Care Based on CMS Guidelines

Get Set for

Contact us at healthyskin@medline.com to learn more!

Clinical Editor Prevention

Clinical Team Treatment

Forms & Tools

Improving Quality of Care Based on CMS Guidelines 3

MEDLINE’S GRANT PROGRAM

Improving Quality of Care Based on CMS Guidelines 5

QIO Utilization and Quality Control Peer Review Organization

Quality Improvement Organization Program’s 9th Scope of Work Theme

2 Advancing Excellence in America’s Nursing Homes

Clinical and Operational/Process Goals

Clinical Goals: Goal Actual Operational/Process Goals: Goal Actual

Trends in Goal Selection

Participating nursing homes: 7,481

Improving Quality of Care Based on CMS Guidelines 7

Source: American Hospital Association

According to the newly

that their organization will

NE1™ Wound Assessment Tool

Wound measurement made easy

LEARN MORE ABOUT THE NE1 WOUND ASSESSMENT

What is hospital value-based purchasing?

This essentially means your hospital will now be in a national

Improving Quality of Care Based on CMS Guidelines 13

TenderWet Active dressings have a “rinsing” effect as

We’re confident you’ll find TenderWet Active more effective

Answering Your Questions About

When will the ACO

Improving Quality of Care Based on CMS Guidelines 15

How ACOs Can Help

• ACOs could potentially save Medicare as much

Epi-clenz™ Gel Instant Hand Sanitizers contain tain

LEARN MORE ABOUT EPI-CLENZ

Also available in a 1 Download a QR Code Reader app

Initially skilled nursing facilities, nursing homes and long-term

Improving Quality of Care Based on CMS Guidelines 19

Strategy Priorities #1 Goal:

and Goals, Safer Care

with Illustrative Opportunities for success:

Opportunities for success:

Improving Quality of Care Based on CMS Guidelines 21

LEARN MORE ABOUT OPTILOCK

2011 Nursing Leadership Priorities:

The top priorities for organizations in 2011 are very simply

• Staff engagement and loyalty (HCAHPS)

Improving Quality of Care Based on CMS Guidelines 23

Each package is a 2-Minute Course

LEARN MORE ABOUT ADVANCED WOUND

1 Download a QR Code Reader app

3 Scan this QR Code or visit

Effects of a Just-in-Time Educational Intervention

A Multicenter Randomized Controlled Trial

Improving Quality of Care Based on CMS Guidelines 25

Improving Quality of Care Based on CMS Guidelines 27

ceived the unfamiliar dressing in a package Control Intervention Group Total

Licensure x2 = 0.1549 N = 173

speak of any part of their experience in the

Conﬁdence with dressing application. Dressing applica-

Improving Quality of Care Based on CMS Guidelines 29

Dea J. Kent, MSN, RN, NP-C, CWOCN, Manager, Wound

The Wound, Stuart Robertshaw, EdD, JD