Healthy Skin Magazine - Volume 8 Issue 1

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VOLUME 8, ISSUE 1
Free Webinars Improving Quality of Care Based on CMS Guidelines
New Techniques for Pressure Ulcer Prevention,
Hand Hygiene and CAUTI Prevention
PRESSURE ULCER PREVENTION IN LONG-TERM CARE Volume 8, Issue 1
Learn more about continuous quality improvement for the prevention of avoidable pres-
sure ulcers and F-Tag 314 citations, factors leading to pressure ulcers in long-term care
facilities and comprehensive pressure ulcer prevention strategies and solutions.
MARCH APRIL M AY JUNE No More

Skin Tears
4th 12:00 pm - 1:00 pm 6th 12:00 pm - 1:00 pm 6 12:00 pm - 1:00 pm
th 3rd 12:00 pm - 1:00 pm
16th 1:00 pm - 2:00 pm 15th 1:00 pm - 2:00 pm 14th 1:00 pm - 2:00 pm 10th 1:00 pm - 2:00 pm
24th 11:00 am - 12:00 pm 21st 11:00 am - 12:00 pm 20th 11:00 am - 12:00 pm 23rd 11:00 am - 12:00 pm
Sign up at www.medline.com/PUPP-webinar
HAND HYGIENE COMPLIANCE IMPROVEMENT STRATEGIES
As the number one defense against healthcare-acquired conditions, hand hygiene plays
HEALTHY SKIN
an important role in the prevention of infections. Learn how hospitals and healthcare
facilities are combining best-in-class products and education to achieve hand hygiene
compliance while dramatically improving the skin condition of healthcare workers.
MARCH APRIL M AY JUNE

5th 12:00 pm - 1:00 pm 2nd 11:00 am - 12:00 pm 14th 11:00 am - 12:00 pm 14th 11:00 am - 12:00 pm
19th 12:00 pm - 1:00 pm 23rd 11:00 am - 12:00 pm 19th 12:00 pm - 1:00 pm 17th 12:00 pm - 1:00 pm Exclusive:
Sign up at www.medline.com/handhygiene
Diane Krasner
INNOVATION IN THE PREVENTION OF CAUTI on Skin Care
Join your colleagues from around the country to learn more about strategies to prevent At Life’s End Let Us Hear
From You!
catheter-acquired urinary tract infections as well as Medline’s ERASE CAUTI system.
3rd 2:00 pm - 3:00 pm 6th 2:00 pm - 3:00 pm 5th 12:00 pm - 1:00 pm 7th 11:00 am - 12:00 pm
10th 11:00 am - 12:00 pm 8th 11:00 am - 12:00 pm 10th 11:00 am - 12:00 pm 9th 2:00 pm - 3:00 pm
Survey Inside
12th
17th
24th
2:00 pm - 3:00 pm
12:00 pm - 1:00 pm
12:00 pm - 1:00 pm
13th
15th
26th
12:00 pm - 1:00 pm
2:00 pm - 3:00 pm
12:00 pm - 1:00 pm
11th
18th
21st
2:00 pm - 3:00 pm
2:00 pm - 3:00 pm
12:00 pm - 1:00 pm
11th
18th
21st
12:00 pm - 1:00 pm
12:00 pm - 1:00 pm
11:00 am - 12:00 pm
Banish
Bacteria
31th 11:00 am - 12:00 pm 28th 11:00 am - 12:00 pm 24th 11:00 am - 12:00 pm 22nd 2:00 pm - 3:00 pm
Sign up at www.medline.com/erase/webinar.asp
Hosted by Connie Yuska, RN, MS, CORLN

and Lorri Downs, RN, BSN, MS, CIC
www.medline.com
Free CE! Skin Assessment & OASIS-C

MKT210055/LIT575R/25M/SEL5
©2010 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.
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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
To learn more about Ultrasorbs® AP view the
the subject matter on that page relates to one or more of the following national initiatives:
• QIO – Utilization and Quality Control Peer Review Organization online video at www.medline.com/incocare
• 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 10 and 11.
Alts_65262_MedCal:Layout 1 2/12/10 7:31 PM Page 3
HEALTHY SKIN
Improving Quality of Care Based on CMS Guidelines
Survey Readiness
Editor
38 Survey Smarts: An Interview with Dr. Andy Kramer
Sue MacInnes, RD, LD
44 Lessons Learned: One Nursing Homeʼs Winning Quality
Clinical Editor Assurance Strategies
Margaret Falconio-West, BSN, RN, 51 Focus on Infection Control: Understanding the New
APN/CNS, CWOCN, DAPWCA
F-Tag 441 Requirements
Managing Editor 54 Ten Tips for Cleaning and Disinfecting Shared
Alecia Cooper, RN, BS, MBA, CNOR Medical Equipment Page 17
55 Product Spotlight: Dispatch Cleaning Solution for Use on
Senior Writer
Carla Esser Lake
Glucose Meters
Creative Director Prevention

Mike Gotti 13 Do the Math: Nutrient-Based Skin Care = Fewer Skin Tears
Clinical Team
17 No More Skin Tears
Clay Collins, BSN, RN, CWOCN, CFCN,
56 Put Bacteria in its Place
CWS, DAPWCA 59 Changing the Catheter Culture at Your Facility
Lorri Downs, BSN, RN, MS, CIC 65 Performance Under Pressure: The Legal Side of Pressure Page 44
Cynthia Fleck, BSN,MBA, RN, CWS, DNC, Ulcer Prevention
CFCN, DAPWCA, FCCWS
Joyce Norman, BSN, RN, CWOCN, Treatment
DAPWCA
23 Skin Changes At Lifeʼs End (SCALE)
Kim Kehoe, BSN, RN, CWOCN, DAPWCA
Elizabeth OʼConnell-Gifford, BSN, MBA, RN,
Special Features
CWOCN, DAPWCA
7 Medline Healthcare Survey: Letʼs Talk About You!
Jackie Todd, RN, CWCN, DAPWCA
14 Medline Donates Critical Medical Supplies to Haiti
Connie Yuska, RN, MS, CORLN Page 51
29 Unraveling the Pressure Ulcer and Wound Care Sections
Wound Care Advisory Board of OASIS-C
Mary Brennan, MBA, RN, CWON 64 Safe Handling of Residents: Which Technique Would You Use?
Zemira M. Cerny, BS, RN, CWS 76 Medlineʼs Pink Glove Dance: A YouTube Sensation
Patricia Coutts, RN
Cindy Felty, MSN, RN, CNP, CWS Regular Features
Evonne Fowler, MSN, RN, CNS, CWOCN 10 Two Important Initiatives for Improving Quality of Care
Lynne Grant, MS, RN, CWOCN
Diane Krasner, PhD, RN, CWCN, CWS, Caring for Yourself
Page 59
BCLNC, FAAN 70 Nine Habits of Very Happy People
Dea J. Kent, MSN, RN, NP-C, CWOCN 83 Recipe: Cheesy Potatoes
Andrea McIntosh, BSN, RN, APN, CWOCN
Linda Neiswender, BSN, RN, CPN Forms & Tools
Laurie Sparks, BSN, RN,CWOCN 86 OASIS-C: Integumentary Status
Lynne Whitney-Caglia, MSN, RN, CNS, 89 H1N1 (Swine Flu) - Patient Handout (English)
CWOCN 91 H1N1 (Swine Flu) - Patient Handout (Spanish)
Laurel Wiersema-Bryant, RN, ANP, BC 93 Clinical Fact Sheet: Quick Assessment of Leg Ulcers
Linda Woodward, BSN, RN, OCN, CWOCN 95 Infection Prevention and Control: Long-Term Care Audit Page 70
Deborah Zaricor, RN, CWOCN 101 Bariatric Assessment: Home Care/Long-Term Care Facility
About Medline Meeting the highest level of national and international quality standards, Medline
Medline, headquartered in Mundelein, IL, manufactures and distributes more is FDA QSR compliant and ISO 13485 certified. Medline serves on major in-
than 100,000 products to hospitals, extended care facilities, surgery centers, dustry quality committees to develop guidelines and standards for medical
home care dealers and agencies and other markets. Medline has more than 800 product use including the FDA Midwest Steering Committee, AAMI Steriliza-
dedicated sales representatives nationwide to support its broad product line and tion and Packaging Committee and various ASTM committees. For more in-
cost management services. formation on Medline, visit our Web site, www.medline.com.
©2010 Medline Industries, Inc. Healthy Skin is published by Medline Industries, Inc. One Medline Place, Mundelein, IL 60060. 1-800-MEDLINE.
Improving Quality of Care Based on CMS Guidelines 3

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HEALTHY SKIN Letter from the Editor
Dear Reader,
Last week was one to remember! There were several preventing pressure ulcers in their facilities. All of these
peer-reviewed articles recently published, showing presentations are now available for everyone to watch
compelling evidence on the clinical efficacy of Medline’s on Medline University at www.medlineuniversity.com.
Remedy® skin care line. I get so excited because there
is nothing that makes a company like ours prouder than Now, that brings me to another fun activity that we do
to see our products perform with excellence. Anyway, at many of our meetings, and that is a pre-survey. For
we thought it would be really neat to have the industry each conference, we put together a series of questions
experts speak about these studies, film them doing so, and then report the group response at the meeting. I
and make the information available to all of you. As I am always fascinated with the results. So, what do you
was working out the logistics, it occurred to me that if say we try a national survey from you, our Healthy Skin
“
we were going to film these presentations, why not do readers? On page 7, we’ve included a list of questions
it in front of a live audience! So, instead of simple indi- about your workplace. You can take the survey online
I had no idea the
vidual filming, we ended up orchestrating three confer- or you can mail or fax it in. For each survey we receive, number of skin
ences. I called it the “Trifecta.” we will send you a FREE Medline doll. In addition, we’ve tears industry wide
posed a question to find out more about the excep- each year is over
Three meetings, over 200 attendees in a 48-hour period tional work you are doing. Submit your answer to the
”
1.5 million
– now that’s a challenge. But it worked, and I got to question and receive the entire Medline doll series. The
hear firsthand from our customers some excellent in- first place answer will also receive a plaque acknowl-
formation on improving outcomes as they relate to skin edging their efforts.
tears, and improving the skin condition of your hands to
promote better hand hygiene. Our cover shot for this I can’t wait to see your responses and report back to
issue shows Diane Krasner sharing secrets on reducing you in the next edition of Healthy Skin. Based upon your
and treating skin tears with a group of long-term care responses, we are going to focus that edition on
professionals. I had NO idea the number of skin tears addressing some of your issues and finding practical
industry wide each year is over 1.5 million. The next solutions we all can share. Thank you in advance for
meeting was with Dr. Marty Visscher from Cincinnati your participation!
Children’s Hospital. Her study was published in the Jan-
uary 2010 issue of AJIC. She presented to a group of
infection preventionists about improving hand hygiene.
The next day we had a half-day meeting with nursing
leaders of hospitals and WOCNs. What a great combi- Sue MacInnes, RD, LD
nation. There were even four area CNOs who spoke Editor
on a panel discussion on barriers they encounter in
On the cover
Wound care expert Diane Krasner presented
on skin tears to an audience of long-term
care professionals during Medline’s Trifecta
of meetings. See also page 23 for an inter-
view with Dr. Krasner about her experiences
as co-chair of the SCALE Panel.
4 Healthy Skin
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TenderWet Active polyacrylate wound dressings rinse pathogens and keeping the wound moist, TenderWet
and debride necrotic wounds for up to 24 hours! Plus, Active helps create an ideal healing environment.
they won’t stick to the wound bed, reducing patient
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Let’s Talk About

All winne
You!
and submis rs
will be featu sions
upcoming is red in
sues of
Healthy Skin
!
Step 1: Complete the Survey!
?
The first 1000 survey submissions will receive the latest
and greatest addition to our Medline Doll collection.
The doll is Top Secret and will debut in April.
Results of the survey will be published in the next

issue of Healthy Skin!
Step 2: Answer the Bonus Question!

In 50 words or less, describe an innovative program, initiative and/or
solution implemented at your facility or your organization that made a
significant impact on quality and patient/resident care.
First Prize
The entire Medline Doll collection
A plaque awarding the 2010 Contribution to Healthy Skin!
Second Prize
There will be several second place award winners, who
will all receive the entire Medline Doll collection.
Everyone
can be a winner!
You can submit the survey three ways:
1. Complete the survey online at
www.medline.com/healthyskinsurvey
2. Manually complete the survey, tear it out
and fax it to 847-949-3073.
3. Mail it back to us at Medline Industries, Inc.,
One Medline Place, Mundelein, IL 60060
Attn: Marketing Department – Healthy Skin
MEDLINE HEALTHCARE SURVEY Let’s talk about you!

Special Feature
1. Tell us about yourself 5. What are your top three priorities? 10. What is the CNA turnover rate at
Name ________________________________ your facility?
1. __________________________________
Credentials (i.e., RN, LPN, etc.)______________ 2. __________________________________ ❏ < 5% ❏ More than 25%
3. __________________________________ ❏ 6% - 10% ❏ Does not apply
Facility ______________________________
❏ 11% - 25%
Street Address ________________________ 6. Which of the following is most helpful in
improving patient care? 11. Do you see skin tears as a problem in
City/Town ____________________________
❏ Continuing Education your facility?
State/Providence ______________________
❏ Competency ❏ Yes ❏ No
Zip/Postal Code ________________________
Phone ( ) ________________________ 7. How often do you believe education 12. Do you have a facility protocol for
E-mail ______________________________ is transferred by the clinician to skin tears?
bedside practice?
❏ Yes ❏ No
2. Where do you work?
❏ 0% – 20% ❏ 61% – 80%
❏ Nursing Home ❏ 21% – 40% ❏ 81% – 100%
13. What percentage of the time do you
❏ Hospital ❏ 41% – 60%
feel the facility protocol is followed?
❏ Long-Term Care
❏ Long-Term Acute Care 8. Which staff member are you most
❏ 25% ❏ 75%
❏ Home Health Care concerned about when it comes to ❏ 50% ❏ 100%
❏ Hospice implementing the necessary changes
❏ Other (please specify) at your facility to be successful?
❏ Nursing 14. Average number of skin tears at
❏ Aides/Technicians your facility

3. Number of beds at your facility? ❏ Managers
❏ < 100 ❏ 350-499 ❏ Physicians
❏ 101-199 ❏ 500+ ❏ Other (please specify)

15. How much time do you spend on skin
❏ 200-349
tears during new employee orientation?
4. What is your job title? 9. What medium would you like to see
education materials offered in? (Choose
❏ Director of Nursing (DON)
all that apply) 16. Do you currently use treatment
❏ Staff Nurse
❏ Staff LPN ❏ Online (e-Learning)
protocols or algorithms to treat wounds
❏ Nurse Manager ❏ Written after they have been diagnosed?
❏ Aide/Technician ❏ Audio ❏ Yes ❏ No
❏ Treatment Nurse ❏ Video/CD/DVD
❏ Wound Care Nurse ❏ Live Presentation
❏ Clinical Educator ❏ Webinar Continued on page 8
❏ Risk/Quality Manager ❏ Other (please specify)
❏ Restorative Nurse
❏ Other (please specify)

MEDLINE HEALTHCARE SURVEY Let’s talk about you!
17. What is your pressure ulcer incidence? Bonus Question:

(For a chance to win the entire Medline Doll Collection)
Everyone whose answer is chosen for publication in Healthy Skin will
receive the collection.
18. What are your biggest barriers to
pressure ulcer prevention?
In 50 words or less, describe an innovative program, initiative and/or
solution implemented at your facility or your organization that made a
significant impact on quality and patient/resident care.
19. Has your organization ever been

involved in a legal suit involving
pressure ulcers?
❏ Yes ❏ No
20. Have you personally ever been

involved in a legal suit involving
pressure ulcers?
❏ Yes ❏ No
21. Which of the following technologies

do you have? (Check all that apply)
❏ PDA (Blackberry®, Palm®, iPhone®)

❏ Cell phone
❏ iPod®/mp3
❏ DVD player
❏ CD player
❏ Electronic reading device (Kindle®,
Sony®, iPad®)
❏ Computer
22. If you checked PDA, what type do

you have?
❏ iPhone®
Fax or mail completed
❏ Blackberry®
survey to:
❏ Palm®
Blackberry is a registered trademark of Research In
❏ Droid™ Motion Limited Marketing Department –
❏ Other Palm is a registered trademark of Research In Healthy Skin magazine
Motion Limited
iPhone is a registered trademark of Apple Inc. Medline Industries, Inc.
iPod is a registered trademark of Apple Inc.
Kindle is a registered trademark of Amazon
One Medline Place
Technologies, Inc. Mundelein, IL 60060
Sony is a registered trademark of Sony Corporation
Droid is a trademark of Lucasfilm Ltd. Fax (847) 949-3073
8 Healthy Skin
ALL NEW AND UPGRADED CONTENT.

WWW. MEDLINEUNIVERSITY.COM
Easier navigation to find what you need – faster.
Interactive courses and competencies And for facilities participating in the Pressure Ulcer
Continuing education courses are still available, and now Prevention and Hand Hygiene programs, all materials,
you can earn all credits for FREE! In addition, we are pre- and post-tests are now conveniently located
adding online competencies. Courses and competencies online at www.medlineuniversity.com.
are more interactive with more graphics, sound and
animation to make learning more fun. Log on to www.medlineuniversity.com today
and start earning CE credits —FREE.
Facility-specific features
Now each facility has the option of creating a group
account on Medline University. This will help you
and your facility view and keep track of all
completed courses.
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 is a three-year work plan.
Purpose: To carry out statutorily mandated review activities, such as:
• Reviewing the quality of care provided to beneficiaries;
• Reviewing beneficiary appeals of certain provider notices;
• Reviewing potential anti-dumping cases; and
• Implementing quality improvement activities as a result of case review activities.
Goal: In the 9th SOW, the QIO Program has been redesigned with a framework for accountability and also in content. The
content now consists of four themes with the goal to help providers, both in long-term care and acute-care facilities,
prevent illness, decrease harm to patients and reduce waste in health care.
Of note: QIOs will be required to help Medicare promote three overarching themes: adopt value-driven healthcare,
support the adoption and use of health information technology and reduce health disparities in their communities.
Under the direction of the Centers for Medicare & Medicaid Services (CMS), the QIO Program consists of a national
network of 53 QIOs located in each of the 50 U.S. states, the District of Columbia, Puerto Rico and the Virgin Islands.
Quality Improvement Organization Program’s 9th Scope of Work Theme

The official Executive Summaries for the 9th SOW Theme are available at:
http://providers.ipro.org/index/9SOW_summaries
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.
Advancing Excellence
The coalition is meeting to consider the following additions for the next two-year campaign:
1. Improving immunizations as a clinical goal
2. Including target setting in all goals
3. Changes to the order in which the goals are presented
10 Healthy Skin
Regular Feature
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

Happenings on the Hill
FY 2010
Labor HHS-Education
Appropriations Bill Allocates
Funds for Health Care Nursing home and medical facilities inspections
$347 million ($54 million above 2009)
This funding has been allocated within the Centers for
Medicare and Medicaid Services (CMS) for enhanced
state inspections in nursing homes and other medical
facilities where healthcare-associated infections are ris-
ing. The funds will give inspectors greater opportunities
to identify infection control problems. CMS is also urged
to include additional infection control measures in its
hospital performance reporting system, Hospital Com-
pare, and its “pay for performance” and “pay for re-
porting” systems.
Healthcare-associated infections (HAIs)

This funding will help continue an aggressive campaign
to dramatically reduce life-threatening infections patients
acquire while receiving treatment for medical or surgical
conditions. HAIs are among the top 10 leading causes
of death in the United States, accounting for nearly
100,000 deaths, 1.7 million infections and $30 billion in
excess healthcare costs every year.
Nurse training
The substantial increase in funding for nurse training is
essential because the United Sates is in the midst of a
nursing shortage that is expected to intensify as baby
boomers age and the need for health care grows. The
Health Resources and Services Administration (HRSA)
estimates that the nation’s nursing shortage will grow to
more than one million nurses by the year 2020.
Source: Memo – United States Congress Committees

on Appropriations, December 8, 2009. Available at: http://appropri-
ations.house.gov/pdf/FY10_LHHS_Conference_Summary.pdf.
Accessed January 25, 2010.
12 Healthy Skin
Prevention
Do the Math
Nutrient-Based Skin Care = Fewer Skin Tears
A skin care regimen using a phospholipid-based cleanser and a
dimethicone/nutrient-based moisturizing cream resulted in skin
tear likelihood that was 30 times less than in a similar group using
a surfactant-based cleanser and dimethicone/aloe moisturiz-
ing cream.
Just released in the January/February 2010 issue of the Journal

of Wound Ostomy and Continence Nursing, researchers
recommend nutrient-based skin care (NBSC) as one part of a
comprehensive skin tear prevention program, along with other
preventive interventions such as staff education, proper
positioning, protective clothing, turning, lifting and transfer-
The expected cost to treat a skin tear in the NBSC group
ring techniques.
was $287.70 per resident versus $331.80 per resident in
the non-NBSC group. The cost per skin-tear-free day was
The six-month study at a 108-bed convalescent center in south-
$1.60 per resident for treatment with NBSC and $2.14 per resi-
ern Illinois compared outcomes after randomly assigning one half
dent for treatment with non-NBSC products. NBSC was found
of a resident population (n = 100) to a group using Remedy®
to be significantly less costly and more effective than a reginmen
cleanser, moisturizer and skin protectant products (all NBSC
using non-NBSC products.
products). The second group (n = 100) was cared for with a sur-
factant-based cleanser and dimethicone/aloe moisturizer and
A limited number of reprints of the full study are available
a zinc oxide barrier product when indicated.
from your Medline representative or by calling 1-800-Medline.
The Remedy® Advanced Skin Care Line is available through
Incidence of Skin Tears
Medline Industries, Inc.
A group of 100 residents experienced a total of 180 skin tears
during the initial six-month period when non-NBSC products
For additional information, visit www.medline.com/skincare.
were used compared to 1.6 skin tears per resident over six
months when a NBSC was used. The number of expected skin-
tear-free days when skin care was completed using NBSC was
179.7 days as compared to 154.8 days when non-NBSC prod- Remedy is a registered trademark of Medline Industries, Inc.
ucts were used, yielding an incremental effect of 24.9 days.
Source: Groom M, Shannon RJ, Chakravarthy D, Fleck CA. An evaluation of costs and
effects of a nutrient-based skin care program as a component of prevention of skin tears
Cost Implications in an extended convalescent center. Journal of Wound, Ostomy and Continence Nurs-
In addition to a 250 percent greater likelihood of maintaining ing. 2010; 37(1):46–51.
intact skin when the NBSC products were used, the researchers
considered cost of treatment.

Special Feature
Medline Donates Critical Medical Supplies to
Medline Industries, Inc. has donated more than $250,000 in

initial humanitarian aid to the people of Haiti in response to How you can help
the devastating earthquake that struck the country recently. In order to ensure that relief efforts are conducted in the
The aid includes medical and surgical supplies, as well most effective and efficient manner, individuals interested
as logistics resources and support to both U.S.-based in volunteering or donating to help the people of Haiti
hospital systems and international aid organizations that are are advised to get in touch with a relief organization.
providing medical supplies, doctors and other resources to The following is a list of resources.
the people in Haiti.
American Medical Association
“
http://www.ama-assn.org/ama/pub/news/news/haiti-
We are deeply saddened by the devastation from the earthquake-response/help.shtml
earthquake and the millions of victims left in its wake,” said Bill
Abington, President of Operations for Medline. “As we have American Red Cross
done in past disasters when people are in need, we www.redcross.org
immediately initiated our Disaster Response Plan that
mobilized our distribution and logistics network around the Center for International Disaster Information (CIDI)
country to prepare and stage medical and surgical supplies www.cidi.org/incident/haiti-10a/
that are needed in this type of disaster to assist with the
Department of Health and Human Services
heroic efforts taking place in Haiti.
”
http://www.hhs.gov/haiti/
Abington said the supplies were immediately delivered to Medscape Nurses

aircraft and ships being utilized by Medline’s key healthcare http://www.medscape.com/viewarticle/579888
partners and global relief organizations. Throughout the
coming months Medline will continue providing support to
Source: Medscape. Earthquake in Haiti and the Medical Aftermath
organizations aiding Haiti. of Natural Disasters. Available at:
www.medscape.com/features/slideshow/haiti-earthquake.
Major Infectious Complications Accessed February 4, 2010.
of Haitian Earthquake
Wound infections
Diarrheal illness - Cholera, shigella, Salmonella
Mosquito borne infections - Malaria, dengue fever
Preventable illness eradication disruption
- Lymphatic filariasis, parasites, tuberculosis
Interruption in chronic medication treatments
- HIV/AIDS
14 Healthy Skin
2010
Prevention Above All
Discoveries Grants:
Supporting the adoption
of solutions into everyday
clinical practice
Knowing that clinicians in the field have some of the best ideas
for improving health care, Medline is now accepting applica-
tions for research funding through their Prevention Above All
Discoveries Grant program. Through the grant program,
Medline intends to award up to $1 million in grants for
research on innovative ideas and evidence-based practices
that will improve patient safety and quality of care. PERIOPERATIVE PRESSURE
ULCER EDUCATION.
Healthcare providers interested in submitting letters of intent
can apply for one of two funding categories: pilot grants of up
MORE IMPORTANT
to $25,000 for projects that can be completed within six THAN EVER BEFORE
months or empirical study grants of up to $100,000 for projects
“
completed within 12 months. Pilot study grantees, if
successful, may qualify for future funding through an empirical I have seen an increase in
study grant. the number of legal issues
linking facility-acquired pressure
Expert Review Board ulcers to post-surgical patients.
Recognizing that the grant target groups haven't had much A pressure ulcer program for the
experience in developing research studies, the review board OR is more critical than ever.”
has come up with a creative way to ensure that a rigorous Diane Krasner, PhD, RN, CWCN,
research process is followed. An Expert Review Board (ERB) CWS, BCLNC, FAAN
composed of members who represent a breadth of research
Medline’s Pressure Ulcer Prevention Program
and practice knowledge will independently review each
now has a component designed specifically for the
request. Applicants whose proposals are selected for funding
will then be assigned an ERB member as a mentor to help perioperative services. The easy-to-use interactive
develop a final proposal that will then receive funding. CD addresses the following:
• Hospital-acquired conditions
• CMS reimbursement changes
Deadline for grant applications is March 31, 2010. • Best practices for pressure ulcer prevention
For more information on the grant program visit www.med- • Perioperative assessment tools
line.com/prevention-above-all/grants.asp and for a sample • Critical patient and equipment risk factors
letter of intent visit www.medline.com/prevention-above-
all/pdf/LofI_Example.pdf. To submit a grant contact Toni
Marchinski, grant coordinator, at grantprogram@medline.com To learn more about Medline’s
or call 866-941-1998. Pressure Ulcer Prevention Programs
for long-term care, acute care and
perioperative services, call your
Medline representative or visit
www.medline.com/pupp-webinar.
©2010 Medline Industries, Inc.

Medline is a registered trademark of Medline Industries, Inc.
MEDLINE’S REVOLUTIONARY SHOW-AND-TELL PACKAGING
Each package is a 2-Minute Course

in Advanced Wound Care ™
Medline’s Educational Packaging offers all the information you need, step by step,
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For more information visit www.medline.com/ep.
Prevention
Aging skin, coupled with reliance on others for assistance with

Techniques activities of daily living, puts the elderly at high risk for skin tears.
Firmly gripping delicate elderly skin while offering assistance can
for Prevention lead to tissue trauma and tearing. In fact, an estimated 1.5 million
skin tears occur in institutionalized adults each year,1 with nearly 80
and Treatment percent appearing on the arms and hands.2
Minimizing the occurrence of skin tears begins with an under-

standing of the skin’s structure and common risk factors, followed
by developing a plan of care using the most effective products for
prevention and treatment.

Structure of the skin

The basic structure of the skin has a great deal to do with how Epi der
mis
and why skin tears occur. First, it’s important to know that the
skin consists of three layers:
Derm
is
1. The epidermis — outermost layer
Subc
2. The dermis — the thicker second layer that ut an eo
us ti s
su e
contains hair follicles, sweat glands and nerves
3. The subcutaneous tissue — the fatty layer
that provides cushioning and protection
Between the epidermis and dermis is the basement mem- Category I: Skin tears without tissue loss
brane, a moving junction that both separates and attaches Category II: Skin tears with partial tissue loss
the epidermis and the dermis (also known as the dermal- Category III: Skin tears with complete tissue loss
epidermal junction). This junction provides structural sup-
port and allows for the exchange of fluid and cells between Risk factors
the skin layers. Patients and residents who are completely dependent on
others for activities of daily living, such as dressing, bathing
The epidermis has an irregular shape resembling down- and positioning, are at the highest risk for sustaining skin
ward, finger-like projections called rete ridges or pegs, and tears.2 Often, these individuals are elderly and may have a
the dermis has upward projections. These upward and history of previous skin tears, compromised nutrition, fluid
downward projections fit together like puzzle pieces an- volume deficit, confusion, limitations in mobility, lack of inde-
choring the epidermis to the dermis. This connection helps pendence and bruised skin. Certain medications, including
to prevent the epidermis from sliding back and forth across steroids, also make skin more prone to injury by causing fur-
the dermis with normal movement and skin manipulation. ther thinning as well as suppression of the immune system.
The two move together as one unit in people with healthy,
young skin. As the skin ages – typically by the sixth decade In addition, wound healing progresses more slowly in the eld-
of one’s life – these rete ridges or pegs begin to flatten erly due to several factors, including decreased inflammatory
between that dermal-epidermal junction.3 This diminished response, delayed angiogenesis (i.e., formation of new blood
anchoring between the two layers increases the potential vessels), slower epithelialization, decreased function of
for the epidermis to detach from the dermis, leading to tear- sebaceous glands, decreased collagen synthesis, alternation
ing of the skin, especially in older adults.4 in melanocytes (resulting in skin discoloration) and thinning
of all the skin layers. Less adipose tissue means decreased
Assessment insulation and protection. The subcutaneous tissue also
In the late 1980s Payne and Martin developed the Payne- atrophies in very specific areas: the face, hands and feet.6
Martin Classification System for Skin Tears, which
addresses assessment, prevention and treatment of skin Research has shown that 25 percent of skin tears are caused
tears. The system, which was revised in 1993, defines a by wheelchair/geri-chair injuries. Another 25 percent occur
skin tear as “a traumatic wound occurring principally on the from accidents involving bumping into objects, 18 percent
extremities of older adults as a result of friction alone or involve patient or resident transfers and 12.4 percent are the
shearing and friction forces that separate the epidermis from result of falls.1 These situations increase contact with the skin,
the dermis or separate both the epidermis and the dermis thus increasing the potential for the skin to tear.
from underlying structures.” The Payne-Martin Classification
System places skin tears into three categories:5
18 Healthy Skin
“
“ Residents of a 173-bed, long-term care
facility developed fewer skin tears when an
emollient soap was used during bathing.
Prevention of skin tears long-term care facility developed fewer skin tears when an
The basics. Common sense strate- emollient soap was used during bathing. When comparing the
gies, such as clothing residents in long total rate of skin tears per resident, the rate of skin tears when
sleeves and long pants, the use of gen- emollient soap was used was 34.8 percent lower than when
tle adhesives and staff education on non-emollient soap was used.8
gentle handling of the skin, are all good
first steps toward preventing skin tears.7 Use great care while Plante and Regan conducted a controlled study among 64
providing full or partial assistance with activities of daily living. residents of a long-term care facility to compare the effects of
These tasks increase contact with the skin, thus increasing the using a non-detergent, no-rinse cleanser to bathing with soap
potential for the skin to tear.8 Use of appropriate equipment and water. After 12 weeks, the total number of skin tears de-
(i.e., lifts, walkers, transfer and turn aids, etc.) to assist with toi- creased by 90 percent, with an 82 percent reduction in skin
leting and transferring also can be helpful in decreasing the tears in the treatment group. Annual cost savings for patients
chance of developing skin tears. in the treatment group was $2,446.11
Skin care. Advanced skin care products that deliver ender- Skin Tear Prevention Strategies12
mic nutrition as well as antioxidants can provide for nourished • Perform risk assessments to identify at-risk individuals
skin topically – even if the patient or resident is not receiving ad- • Use moisturizers/emollients daily
equate nutrition from oral, enteral or parenteral nutrition.9 • Make sure vulnerable individuals wear long-sleeved
shirts, pants and stockings
One study looked at skin tear incidence in a 100-bed long- • Use skin sleeves and leg protectors
term care facility and showed a reduction from 180 skin tears • Maintain individuals’ hydration and nutrition
in a six-month period to two skin tears in a six-month time pe-
riod.10 This particular facility used a gentle, advanced skin care Treatment of skin tears
line with pH-balanced soap and surfactant-free cleansers; Despite your best efforts to prevent skin tears, they can still
moisturizers containing amino acids and free radical scav- happen. The primary goals for treating skin tears are to stop
engers like grape seed extract, vitamin C (ascorbic acid), and bleeding, recover skin integrity, prevent infection of the wound,
hydroxytyrosol (from olives); essential fatty acids like omega-3, minimize pain and promote comfort.12 There are several good
-6 and -9; and tenacious skin protectants containing sophisti- topical products that can help alleviate the discomfort of skin
cated combinations of silicones. tears while protecting the area to allow healing. It is also im-
portant to look at your dressing choices and choose products
Similarly, in a four-month prospective crossover study com- that allow you to avoid adhesives, decrease dressing changes
paring the use of emollient soap (containing moisturizers) with and maintain an optimally moist wound healing environment.
non-emollient soap, Mason found that residents of a 173-bed,

Three Steps for Treating Skin Tears12 Conclusion

Overall, when it comes to skin tears, keep it simple. Basic
strategies, such as a comprehensive skincare program that
Cleanse using normal saline, avoids soap and includes nutrient-based moisturizers, con-
1 tap water or wound cleanser
suming plenty of fluids and a nutritious diet, combined with
using extra care to protect patients’ or residents’ skin from in-
Assess according to the Payne-Martin
2 scale or by classifying wounds as partial
jury, will go a long way toward preventing skin tears.
thickness or full thickness
When a skin tear does occur, be sure to keep it protected
3 Dress the wound using recommended products
from infection and further injury. Avoid outdated treatments,
such as telfa-type non-adherent dressings or removal of a vi-
able skin flap. One very effective treatment is use of a hydro-
Hydrogel sheets. Hydrogel sheets are clear or translucent gel sheet kept in place with an elastic net dressing.
water- or glycerin-based products that can be used to main-
tain a moist wound environment.13 They look like a thin slice With these tips and techniques, your facility will be well on its
of sticky gelatin and can handle the initial fluid from a wound way toward eliminating skin tears all together.
for the first 24-48 hours. They vary in thickness and are non- References
adherent to the wound base. The hydrogel sheet may be held 1. Brillhart B. Preventive skin care for older adults. Geriatrics & Aging. 2006;9(5):334-
339.
in place with elastic net dressing or a tubular-type dressing. 2. Baranoski S. How to prevent and manage skin tears. Advances in Skin & Wound
Care. 2003;16(5):268-70.
3. Humbert P, Sainthillier JM, Mac-Mary S. Capillaroscopy and videocapillarsocopy and
Protective sleeves. The use of protective sleeves or elastic assessment of skin microcirculation: dermatologic and cosmetic approaches. J Cos-
tubular support bandages that come on a roll is a good way met Dermatol. 2005;4(3):153-162.
4. Baranoski S, Ayello E. Skin: an essential organ. In: Baraoski S, Ayello E, eds. Wound
to hold dressings in place without irritating sensitive skin with Care Essentials: Practice Principles. Springhouse, Penn.:Lippincott Williams &
Wilkins; 2004.
adhesive tape. They also protect the patient or resident who
5. Baronoski S. Skin tears: the enemy of frail skin. Advances in Skin & Wound Care.
is prone to picking at the dressing. 2000; 13(3 Pt 1):123-126.
6. Thomas-Hess C. Fundamental strategies for skin care. In: Krasner D, Rodheaver G,
Sibbald G., eds. Chronic Wound Care: A Clinical Source Book for Healthcare Pro-
Use caution with adhesive closure strips. Adhesive clo- fessionals. 2nd ed. Wayne, Pa: HMP Communications; 1997.
7. Fleck CA. Ethical wound management for the palliative patient. ECPN. 2005;100:38-
sure strips are common for keeping skin tears closed while 46.
they heal, however, caution is advised. Traction on the frag- 8. Mason SR. Type of soap and the incidence of skin tears among residents of a long-
term care facility. Ostomy Wound Management. 1997;43(8):26-30.
ile epidermis combined with inflammatory action can cause 9. Groom M. Decreasing the incidence of skin tears in the extended care setting with
skin damage. When it’s time to remove the closure strips, use the use of a new line of advanced skin care products containing Olivamine. Pre-
sented at the 18th Annual Symposium on Advanced Wound Care and the 15th An-
extra care, as blood crusts can tear off the epidermis. 14 nual Medical Research Forum on Wound Repair in San Diego, Calif. April 21-24,
2005.
10. Frantz RA, Gardner S. Clinical concerns: management of dry skin. J Gerontol Nurs.
1994;20(9):15-18, 45.
11. Birch S & Coggins C. No-rinse, one-step bed bath: the effects on the occurrence
Outdated Treatments for Skin Tears12 of skin tears in a long-term care setting. Ostomy Wound Management.
• Transparent films (as primary dressing) 2003;49(1):64-67.
12. Krasner D. Prevention and Treatment of Skin Tears in Older Adults. Presented at
• Telfa-type non-adherent dressings Medline’s Prevention Above All Symposium in Oakbrook, Ill. January 26, 2010.
• Sutures 13. Hess CT. When to use hydrogel dressings. Advances in Skin & Wound Care.
2000;13(1):42.
• Removal of a viable skin flap immediately post-injury 14. Meuleneire F. Using a soft silicone-coated net dressing to manage skin tears.
J Wound Care. 2002;11(10):365-369.
20 Healthy Skin
Are Your Physicians Making the Grade?

A recent survey graded physicians’ abil-
ities to recognize, assess and document
Stage III and IV pressure ulcers at a “D”
level. Medline’s new Pressure Ulcer Prevention
Program MD Education CD contains everything physicians
“ The new MD Education component of Medline’s Pressure
Ulcer Prevention Program is critical for acute-care facilities
to ensure that physicians understand their role in recognizing
and accurately documenting POA pressure ulcers.”
Michael Raymond, MD,
Associate Chief Medical Quality Officer,
need to brush up on their skills and comply with the new
NorthShore University HealthSystem,
CMS Inpatient Prospective Payment System (IPPS). Skokie Hospital, Skokie, IL
To learn more about Medline’s Pressure Ulcer Prevention

Programs and FREE webinars for acute care and perioperative
services, call your Medline representative, or visit
www.medline.com/pupp-webinar.
More solutions than any other skin and wound care company.
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do everything you can to protect the periwound area. Marathon Liquid Skin
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Marathon bonds to the skin surface, integrating with the epidermis

on a molecular level. While other skin protectants may flake off,
Marathon stays put, offering robust protection.
For a free trial, visit www.medline.com
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Medline® and Marathon are registered trademarks
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It’s another level of

comfort
and
protection
Restore®/Remedy® briefs provide maximum

dryness with skin nourishment built right in.
Restore®/Remedy® briefs not only keep wetness away from your residents’ skin, they
also help provide protection from skin irritation with a coating of Medline’s Remedy®
Skin Repair Cream on the inner liner. Using a combination of the Remedy skincare line
and the Restore/Remedy brief was shown to keep the pressure ulcer incidence rate
and incontinence-associated dermatitis prevalence rate down according to a retrospective,
cohort study conducted at Meridian Nursing and Rehabilitation in Brick, NJ.1
The brief’s absorbent UltraCare core helps provide maximum dryness for improved
comfort and protection. And the cloth-like outer cover is comfortable against the skin,
helping to minimize rash or irritation.
Purchase a 12 month supply of Restore/Remedy briefs and

receive one month free. For details contact your Medline
representative or call 1-800-MEDLINE.
1 Shannon R., Fisher K. A Nursing and Rehabilitation Center Project in New Jersey: Expected Value of Remedy Skin Care and Restore
Briefs in an At-Risk Resident Population for Pressure Ulcer and Incontinence-Associated Dermatitis Prevention. ©2010 Medline Industries, Inc.
Treatment
Wound care expert Dr. Diane Krasner shares her experiences

as co-chair of the SCALE Panel and corresponding author of
the SCALE Final Consensus Statement.
Skin Changes
At Life’s End
Healthy Skin Editor Sue MacInnes interviews
SCALE Panel Co-Chair Diane Krasner
Diane Krasner, PhD, Sue MacInnes,
RN, CWCN, CWS, RD, LD
BCLNC, FAAN
Sue MacInnes: Sue MacInnes:

What is the SCALE Panel and why was it formed? What process did the SCALE Panel use to
Diane Krasner: reach consensus?
The SCALE Panel was convened to explore the issues Diane Krasner:
surrounding skin conditions associated with dying patients. After reviewing the existing literature on the topic and
The panel reviewed existing literature, best practices and hearing presentations by selected panel members, the
research on the issue. Eighteen participants met for the first SCALE panel worked in three teams, drafting preliminary
panel meeting April 4-6, 2008 in Chicago, which was funded consensus statements. Jim Lutz used audiotapes and notes
by an unrestricted educational grant from Gaymar Industries, from the April 2008 meeting to craft a Preliminary Consensus
Inc. Participants included nurses, physicians, legal experts Statement. This document was reviewed and edited by
and a medical writer. All had an interest in or clinical the entire panel. From September 2008 to June 2009
experience with skin conditions in dying patients. Included the Preliminary Consensus Statement was presented
in the panel were Karen Lou Kennedy, a nurse practitioner internationally at wound conferences, published and
who has published on the Kennedy Terminal Ulcer posted on the SCALE website. Stakeholders were
(www.kennedyterminalulcer.com) and Dr. Diane Langemo, encouraged to circulate the document for comments. All the
who proposed the concept of skin failure. SCALE Panel mem- comments were used to generate a Final Consensus
bers represented the continuum of care from acute care to Statement, which was then returned to the original
hospice. Dr. Gary Sibbald and I served as panel co-chairs. 18-member expert panel and a 52-member reviewer panel.
Cindy Sylvia was the panel facilitator. Jim Lutz served as the The two groups of panel members then voted on each of the
medical writer. Dr. Thomas Stewart conceived the acronym 10 statements for consensus using a modified Delphi Method
SCALE: Skin Changes At Life’s End. approach. A quorum of 80 percent that strongly agreed or

10 statements proposed
by the SCALE Expert Panel:
somewhat agreed with each statement was used as a
Statement 1 ........................................................................
pre-determined threshold for having achieved consensus
Physiologic changes that occur as a result of the dying process may affect
on each of the statements. A consensus based on 52
the skin and soft tissues and may manifest as observable (objective) changes
votes was reached after the first round of the Delphi.
in skin color, turgor, or integrity, or as subjective symptoms such as localized
Numerous comments were made, and a final draft was
pain. These changes can be unavoidable and may occur with the application
written to incorporate the comments. The SCALE Final
of appropriate interventions that meet or exceed the standard of care.
Consensus Statement was released on October 1, 2009.
Statement 2 ........................................................................
Sue MacInnes:
The plan of care and patient response should be clearly documented
How would you describe the SCALE Final
and reflected in the entire medical record. Charting by exception is an
Consensus Statement?
appropriate method of documentation.
Diane Krasner:
The SCALE Final Consensus Statement reflects the
Statement 3 ........................................................................
current evidence and best practices surrounding Skin
Patient centered concerns should be addressed including pain and activities
Changes At Life’s End. The ten statements represent the
of daily living.
expert opinions of thought leaders from around the world.
There is clear agreement that more research needs to be
Statement 4 ........................................................................
undertaken to enhance our understanding of the multiple
Skin changes at life’s end are a reflection of compromised skin (reduced
and complex skin change phenomena that occur during
soft tissue perfusion, decreased tolerance to external insults, and impaired
the dying process. In the meantime, the 10 consensus
removal of metabolic wastes).
statements give practical and focused suggestions for
clinical management. In addition to the 10 consensus Statement 5 ........................................................................
statements, which are reprinted in this issue of Healthy Expectations around the patient’s end of life goals and concerns should be
Skin, the SCALE Final Consensus Statement includes a communicated among the members of the interprofessional team and the
glossary, a reference list and several charts/enablers for patient’s circle of care. The discussion should include the potential for
clinical practice. SCALE including other skin changes, skin breakdown and pressure ulcers.
Sue MacInnes: Statement 6 ........................................................................

How can the SCALE documents be accessed Risk factors, symptoms and signs associated with SCALE have not been fully
and utilized? elucidated, but may include:
Diane Krasner:
Free downloads of the SCALE documents are available ■ Weakness and progressive limitation of mobility.
at the website of the panel sponsor, Gaymar Industries: ■ Suboptimal nutrition including loss of appetite, weight loss, cachexia and
www.gaymar.com. Look under “Clinical Support and wasting, low serum albumin/pre-albumin, and low hemoglobin as well
Education” and “SCALE Consensus Documents.” In as dehydration.
addition to the 19-page final consensus statement, there
■ Diminished tissue perfusion, impaired skin oxygenation, decreased local
is a three-page guide and the SCALE annotated bibliog-
skin temperature, mottled discoloration, and skin necrosis.
raphy. All of these documents can be utilized for educa-
tion and training. The SCALE documents have ■ Loss of skin integrity from any of a number of factors including
relevance across the continuum of care for all members of equipment or devices, incontinence, chemical irritants, chronic exposure
the interprofessional wound care team. For further to body fluids, skin tears, pressure, shear, friction, and infections.
information, contact corresponding author Dr. Diane ■ Impaired immune function.
Krasner at dlkrasner@aol.com.
Statement 7 ........................................................................
Dr. Krasner is a Wound & Skin Care Consultant in York, PA. She A total skin assessment should be performed regularly and document all
works part-time at Rest-Haven York, is the lead co-editor of Chronic areas of concern consistent with the wishes and condition of the patient.
Wound Care (www.chronicwoundcarebook.com) and clinical editor Pay special attention to bony prominences and skin areas with underlying
of Wound Source (www.woundsource.com). cartilage. Areas of special concern include the sacrum, coccyx, ischial
tuberosities, trochanters, scapulae, occiput, heels, digits, nose and ears.
Describe the skin or wound abnormality exactly as assessed.
24 Healthy Skin
SCALE Final Consensus Statement

Determined as a result of a two-day panel discussion and subsequent
panel revisions with input from noted wound care experts using a
modified Delphi Method approach.
Figure 1: The SOAPIE

mnemonic with the
5P enabler.
Evaluate & revise Evaluate & revise

care plan as needed care plan as needed
Statement 8........................................................................
Consultation with a qualified health care professional is recommended for A = Assess and document etiology: An assessment should then be made
any skin changes associated with increased pain, signs of infection, skin of the general condition of the patient and a care plan.
breakdown (when the goal may be healing), and whenever the patient’s
P = Plan of care: A care plan should be developed that includes a decision
circle of care expresses a significant concern.
on skin care considering the 5P’s as outlined in Figure 1. This plan of care
should also consider input and wishes from the patient and the patient’s
Statement 9........................................................................
circle of care.
The probable skin change etiology and goals of care should be determined.
Consider the 5 Ps for determining appropriate intervention strategies: I = Implement appropriate plan of care: For successful implementation, the
■ Prevention plan of care must be matched with the healthcare system resources (avail-
■ Prescription (may heal with appropriate treatment) ability of equipment and personnel) along with appropriate education and
■ Preservation (maintenance without deterioration) feedback from the patient’s circle of care and as consistent with the
■ Palliation (provide comfort and care) patient’s goals and wishes.
■ Preference (patient desires) E = Evaluate and educate all stakeholders: The interprofessional team also
S = Subjective skin & wound assessment: The person at the end of life needs to facilitate appropriate education, management, and periodic reeval-
needs to be assessed by history, including an assessment of the risk for uation of the care plan as the patient’s health status changes.
developing a skin change or pressure ulcer (Braden Scale or other valid and
reliable risk assessment scale). Statement 10......................................................................
Patients and concerned individuals should be educated regarding SCALE
O = Objective observation of skin & wound: A physical exam should iden- and the plan of care.
tify and document skin changes that may be associated with the end of life
or other etiologies including any existing pressure ulcers.

CE Questions
SCALE:
Skin Changes At Life’s End Continuing Education Questions
1. Why was the SCALE Panel convened? 7. The 5P enabler for determining appropriate
A. To discuss weight loss issues intervention strategies consists of:
B. To explore the issues surrounding skin conditions A. Prevention, Prescription, Preservation, Palliative,
associated with dying patients Proactive
C. To develop new treatments for dry, scaly skin B. Potential, Prescription, Pattern, Palliative, Preference
D. None of the above C. Prevention, Perseverance, Panic, Persuade,
Preference
2. When was the SCALE Final Consensus D. Prevention, Prescription, Preservation, Palliative,
Statement released? Preference
A. February 1, 1972
B. September 30, 2008 8. Which of the following might cause loss of skin
C. May 15, 1997 integrity at the end of life?
D. October 1, 2009 A. Infections
B. Binge eating
3. In addition to the 10 consensus statements, C. Incontinence
the SCALE Final Consensus Statement includes D. Both A and C
a glossary, a reference list and _________________.
A. A dictionary 9. Choose the false statement below.
B. A thesaurus A. Expectations around the patient’s end of life goals
C. Several charts/guides for clinical practice and concerns should be kept secret.
D. Free samples of skin care lotion B. Skin changes at life’s end are a reflection of
compromised skin (reduced soft tissue perfusion,
4. Which approach was used by the SCALE Panel decreased tolerance to external insults, and
to reach consensus? impaired removal of metabolic wastes).
A. Modified Delphi Method C. The plan of care and patient response should be
B. Accelerated Apolo Ohno clearly documented and reflected in the entire
C. Prediction Partnership medical record.
D. Phase I Delphi Method D. A total skin assessment should be performed
regularly and document all areas of concern
5. The SCALE Final Consensus Statement reflects consistent with the wishes and condition of
the current evidence and best practices the patient.
surrounding _______________________.
A. Choosing the best bathroom scale 10. Physiologic changes that occur as a result
B. Sunny Climates And Lifelong Eczema of the dying process may affect the skin and
C. Skin Changes At Life’s End soft tissues and may manifest as observable
D. Treatment of dry skin in long-term care residents (objective) changes in skin color, turgor, or
__________________, or as subjective symptoms
6. The letter “A” in the SOAPIE mnemonic stands such as localized pain.
for ___________________. A. Sensitivity
A. Answer all questions B. Density
B. Assess and document etiology C. Texture
C. Accentuate the positive D. Integrity Submit your answers at
D. All of the above www.medlineuniversity.com
and receive 1 FREE CE credit
26 Healthy Skin
1-800-MEDLINE I www.medline.com
©2010 Medline Industries, Inc.
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www.cdc.gov/nchs/pressroom/04facts/patients.htm. Accessed April 12, 2008.
Special Feature
Unraveling the
Pressure Ulcer
and Wound Care
Sections of
OASIS-C
by Clay E. Collins, RN, BSN, CWOCN, CFCN, CWS
It’s finally here! The long-awaited OASIS-C data collection

tool for home care agencies was implemented January 1,
2010, leaving many home care nurses and agencies
scrambling to understand the multitude of additions and
revisions. These changes could significantly affect agency
reimbursement and publicly reported quality measures
while also providing essential guidance for surveyors.
With this in mind, home care agencies are

faced with the daunting task of re-learning
and understanding the new OASIS-C
document. This article will help you make
sense of the changes in the documenta-
tion of pressure ulcers and wound care
that appear under the section of
OASIS-C called “Integumentary
Status.”
History and background

In 1999 the Centers for Medicare and
Medicaid Services (CMS) began requiring
all Medicare-certified home care agencies
to begin collecting and submitting data
related to all adult, non-maternity patients
receiving skilled nursing services under
Medicare and Medicaid. These require-
ments were documented in the Outcome
and Assessment Information Set (OASIS).
Over the years, OASIS has undergone
changes to improve data collection require-
ments, refine items for payment algorithms and
enhance outcome reporting.

Over the past decade CMS has focused on quality improve- 3. To align and “harmonize” OASIS measures with other
ment and evidence-based practice recommendations from care measurement instruments currently being
the Institutes of Medicine (IOM), the National Quality Forum developed across post-acute care settings (i.e., the
(NQF) and the Medicare Payment Advisory Commission nursing home Minimum Data Set [MDS] and the
(MedPAC). Beginning in 2004, with the revision of long-term Continuity Assessment Record Evaluation [CARE]).
care’s F-Tag 314 regarding pressure ulcers and the release of Regarding reason #3, pressure ulcer items on OASIS were
new guidelines to direct surveyors of long-term care facilities, revised to reflect current pressure ulcer assessment guide-
CMS embarked on a journey to bring the providers of long- lines from the National Pressure Ulcer Advisory Panel
term care, acute care and home care into a synergistic rela- (NPUAP) and the Wound, Ostomy and Continence Nurses
tionship focused on improving outcomes and the quality of Society (WOCN) and to collect additional information consid-
patient care. ered to be essential to care planning (i.e., wound length, width
and depth).
Next, as a result of the federal Value Based Purchasing (VBP)
Initiative, came the implementation of the present- Home care agencies also are being encouraged to use
on-admission (POA) indicators for acute care facilities on evidence-based practices, although the care processes
October 1, 2008. It includes a list of hospital-acquired included in OASIS-C are not currently mandated in the Home
conditions, including full thickness pressure ulcers (Stage Health Agency (HHA) Conditions of Participation. Home care
III and IV), which are no longer reimbursable when they occur agencies may choose not to incorporate the care processes
during a hospital stay.1 In home care, the focus on quality and included in OASIS-C, but should be aware that since some of
evidence-based practice has never been more evident than the process items will be utilized to support publicly reported
in the new OASIS-C data collection tool. measures, failure to incorporate the care processes may be
reflected in their Home Health Compare scores. For example,
Development of OASIS-C one measure that will be publicly reported on Home Health
OASIS-C was developed for three reasons: Compare is: “Percentage of home health episodes of care in
1. To address issues raised by home care providers which the patient was assessed for risk of developing pres-
2. To expand home care quality measurement to sure ulcers at start of care/resumption of care.” The data for
include care processes this care process will be obtained from a new question added
30 Healthy Skin
Agencies are now required to screen patients

for risk of developing pressure ulcers.
to the OASIS-C, “M1300 - Pressure Ulcer Assessment: Was with a population with characteristics similar to the patient
the patient assessed for risk of developing pressure ulcers?” who is being evaluated and shown to be effective in identify-
ing people at risk for developing pressure ulcers; and 2)
The goal is clear; CMS expects home care agencies to take includes a standard response scale.” Examples of these
an active role in the prevention and treatment of pressure types of tools include the Braden Scale and the Norton Scale.
ulcers and expects patients’ wounds to improve. This will In place of the Braden or Norton Scale, agencies may choose
challenge agencies to take a closer look at their policies and to develop their own risk assessment tool or assess patients’
procedures guiding delivery of care to ensure that they are in risk based on an evaluation of clinical factors. If an agency
line with OASIS-C and the patient care practices being chooses this method, then they must also define what con-
implemented. Staff training and education on wound healing stitutes risk. These two questions are to be answered at Start
and assessment will be essential in achieving the expertise of Care and Resumption of Care.
necessary to accurately complete the questions included in
the Integumentary Status section of OASIS-C. The inability to (M1306) Does this patient have at least one Unhealed
correctly assess, describe and measure wounds could not Pressure Ulcer at Stage II or Higher or designated as
only result in serious financial implications for a home care “not stageable”?
agency, but also in poor outcome quality measures. The National Pressure Ulcer Advisory Panel (NPUAP) defines
a pressure ulcer as: “Localized injury to the skin and/or
OASIS-C items related to pressure ulcers underlying tissue usually over a bony prominence, as a result
and other wounds2,3,4,5 of pressure, or pressure in combination with shear and/or fric-
With that in mind, let’s take a look at OASIS-C. The first thing tion.”6 It is important for the assessing clinician to make an
you will notice is that the items have been renumbered. The accurate determination of the true causative factors/etiology
items for Integumentary Status are now numbered M1300 of a wound to be sure that it truly is a pressure ulcer. If a
through M1350. For a copy of the Integumentary Status sec- patient’s wound is not a pressure-related injury, then the cor-
tion of OASIS-C, turn to page 86. It will be helpful to follow rect answer would be “0-No.”
along with that document as you read this article.
If it is determined that the wound is a pressure-related injury,
Here is a detailed explanation of each item in the Integumen- the clinician must have a thorough understanding of the
tary Status section of OASIS-C: NPUAP staging system, updated February 2007, as well as
principles of wound healing. Stage I pressure ulcers involve
(M1300) Pressure Ulcer Assessment: Was this patient intact skin, and thus no open wound, so they are not included
assessed for Risk of Developing Pressure Ulcers?
(M1302) Does this patient have a Risk of Developing
Pressure Ulcers?
These are two new questions added to OASIS-C to capture
home care agencies’ use of best practices in the assessment
“ The goal is clear;
CMS expects home care agencies to take an active
role in the prevention and treatment of pressure ulcers
of pressure ulcer risk. Agencies are now required to screen
patients for risk of developing pressure ulcers. They are not,
however, required to use a standardized, validated risk
assessment tool. CMS defines a standardized, validated tool
and expects patients’ wounds to improve.
”
as one that “1) has been scientifically tested and evaluated

in this question. Research regarding wound healing has to exist or suspected to exist, but may not be observable due
revealed that partial thickness wounds such as Stage II pres- to the presence of dressings or devices (e.g., casts) that can-
sure ulcers heal through regeneration of the dermis and epi- not be removed to assess the underlying skin. This question
dermis. Once complete epithelialization occurs, the wound is is to be answered at the following points in time: Start of care,
considered healed and no longer counted as a pressure ulcer. Resumption of care, Follow-up and Discharge from agency –
not to inpatient facility.
Under M1306, if the patient has a healed Stage II pressure
ulcer and no other pressure ulcers, the correct answer would (M1307) Date of Onset of Oldest Unhealed Stage II
be “0-No.” On the other hand, full thickness wounds such as Pressure Ulcer identified since most recent Start of
Stage III and Stage IV pressure ulcers heal differently than par- Care (SOC)/Resumption of Care (ROC) assessment
tial thickness wounds. Full thickness wounds heal through a This item is designed to identify the oldest Stage II pressure
process of granulation, contraction and epithelialization, which ulcer only and is collected upon discharge from the agency.
results in the formation of scar tissue. As a result, full thickness An ulcer that is suspected of being a Stage II, but is
wounds never can be considered “healed.” However, they Unstageable, should NOT be identified as the “oldest” Stage
may be considered “closed” when they have fully granulated, II pressure ulcer. With this question, CMS will be able to tell
and the wound has been resurfaced with new epithelium. how long this ulcer remained unhealed while receiving serv-
ices from the home care agency and identify patients who
So, if a patient presents with a “closed” (or open) Stage III or developed a pressure ulcer while under the care of the home
IV pressure ulcer or if the patient has an Unstageable pressure care agency. Once again, as previously mentioned, CMS
ulcer or suspected deep tissue injury, the correct answer to expects to see healing and not deterioration of patients or
this question would be “1-Yes.” The OASIS-C guidance also their wounds while receiving home care services.
directs clinicians to select “1-Yes” if pressure ulcers are known
Continued on page 34
32 Healthy Skin
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CMS expects to see healing and not deterioration

of patients or their wounds while receiving home
care services.
(M1308) Current Number of Unhealed (M1310) Pressure Ulcer Length, (M1312) Pressure
(non-epithelialized) Pressure Ulcers at Each Stage Ulcer Width, (M1314) Pressure Ulcer Depth
This chart of items requires the clinician to count the number These three questions are new to OASIS data collection and
of current open pressure ulcers and their stage. Completion require the measurement of the largest unhealed Stage III or
of this item requires a sound understanding of the IV or Unstageable pressure ulcer only. To determine the
NPUAP Pressure Ulcer Classification System, available at largest ulcer, measure the length and width of each open
www.npuap.org/resources.htm. Stage III, IV or Unstageable pressure ulcer to determine which
has the largest surface area. The instructions direct the clini-
The clinician must be sure that each pressure ulcer meets the cian how to obtain the measurements: length is measured as
requirements of the definition of each stage. Stage I pressure the longest length from “head to toe,” width is measured as
ulcers and any healed (epithelialized) Stage II pressure ulcers the greatest width measured perpendicular to the length, and
are not counted. Likewise, pressure ulcers that are depth is measured from the visible surface to the deepest
repaired surgically through procedures such as a muscle flap, area of the wound. All measurements are to be recorded in
skin advancement flap or rotational flap, are no longer con- centimeters.
sidered to be pressure ulcers. Instead, the patient now has
a surgical wound. Surgical debridement of a pressure ulcer,
on the other hand, only removes necrotic tissue, so a surgically
debrided wound would still be counted as a pressure ulcer.
When counting Stage III and IV pressure ulcers remember,

W
“once a Stage III always a Stage III; once a Stage IV always
a Stage IV.” Reverse staging of pressure ulcers is clinically
incorrect and inappropriate because the stage only refers to
the level of tissue damage. Stage III and IV pressure ulcers,
as mentioned previously, heal through granulation, L
contraction and epithelialization and do not restore the
previously damaged underlying layers. M1310, M1312 and M1314 require all home care agencies
to measure wounds in the same manner to allow CMS to col-
So, if a Stage III pressure ulcer means a full thickness tissue lect data that directly reflects a home care agency’s wound
loss down to the subcutaneous layer, then this amount of healing efforts as evidenced by either increasing or decreas-
L
damage will always be present even when the wound has ing wound sizes. These items are completed at Start of Care,
granulated to surface level and has been resurfaced with Resumption of Care and upon Discharge from agency – not
new epithelium. As a result, if a patient has a previously to inpatient facility.
closed Stage III or IV that reopens, it is still a Stage III or IV
(even if it only looks like a Stage II). When attempting to stage Measurements may be made using a variety of tools, includ-
a granulating pressure ulcer, challenges arise if the clinician ing a cotton-tipped applicator, disposable measuring device,
did not see the ulcer at its worst. In this case, the assessing a camera or other device that calculates measurements.
clinician should make every reasonable attempt to determine Measurements should always be taken following removal of
the original stage of the ulcer at its worst by contacting the dressing and thorough wound cleansing.
previous providers (i.e., physician, hospital, nursing home).
34 Healthy Skin
The “most problematic pressure ulcer”

does not necessarily mean the largest.
(M1320) Status of Most Problematic (Observable) (M1324) Stage of Most Problematic Unhealed
Pressure Ulcer (Observable) Pressure Ulcer
For this question, the “most problematic pressure ulcer” does This item identifies the stage of the most problematic pressure
not necessarily mean the largest. The most problematic pres- ulcer that was previously determined in item M1320. Again,
sure ulcer could be the largest or the most advanced stage a thorough understanding of the NPUAP Pressure Ulcer Clas-
or the ulcer the clinician is having the most problem access- sification System is required to correctly answer this item.
ing because of location, difficulty with pressure relief or a If the patient has no pressure ulcers or if the most problem-
variety of other factors. atic is Unstageable due to the presence of necrotic tissue or
unobservable due to a non-removable dressing or device,
Once the most problematic pressure ulcer is determined, then the correct answer would be “NA-No observable pres-
the clinician must then make a determination of the healing sure ulcer.”
status. The Wound, Ostomy and Continence Nurses Society
(WOCN) recently issued a new guidance document to assist (M1330) Does this patient have a Stasis Ulcer?
clinicians in making this determination. It’s available at (M1332) Current Number of (Observable) Stasis Ulcer(s)
www.wocn.org/pdfs/GuidanceOASIS-C.pdf. Here are a few These items pertain to stasis ulcers, which are caused by
items of note: venous insufficiency in the lower leg. It is important for clini-
1. Since Stage II pressure ulcers do not granulate, as cians to differentiate stasis ulcers from other lower leg ulcers,
previously explained, the only appropriate answer for such as arterial ulcers and other types of skin ulcers. This
a Stage II pressure ulcer would be “3-Not healing.” requires the clinician to utilize clinical assessment skills and
2. The response “NA-No observable pressure ulcer” only knowledge of various etiologies of lower leg ulcers. These
refers to pressure ulcers that cannot be observed due items are to be completed at Start of Care, Resumption of
to the presence of a dressing or device that cannot Care, Follow-up and Discharge from agency – not to inpa-
be removed. tient facility. Hint: The WOCN produced a “Clinical Fact Sheet
3. Unstageable pressure ulcers or ulcers with necrotic for Assessment of Leg Ulcers” that may be of value in helping
tissue (eschar/slough) would either be scored as with this process. For a copy, turn to page 93 or go to
“2-Early/partial granulation” or “3-Not healing,” www.wocn.org/pdfs/WOCN_Library/Fact_Sheets/C_QUICK
depending on the amount of necrotic tissue present. 1.pdf.
4. If a patient has only one pressure ulcer, then that ulcer
is the most problematic. Stage I pressure ulcers are (M1334) Status of Most Problematic (Observable)
not considered for this item. Stasis Ulcer
This item utilizes the same thought process as item M1320 to
(M1322) Current Number of Stage I Pressure Ulcers determine the most problematic stasis ulcer and describes
A Stage I pressure ulcer is characterized by intact skin with the healing status of the ulcer dependent on the amount of
non-blanchable redness of a localized area usually over a necrotic tissue and granulation tissue based on the WOCN
bony prominence. The area may be painful, firm, soft, warmer guidance.
or cooler as compared to adjacent tissue. This question iden-
tifies the presence of Stage I pressure ulcers at Start of Care,
Resumption of Care, Follow-up and Discharge.

(M1340) Does this patient have a Surgical Wound?

(M1342) Status of Most Problematic (Observable)
Surgical Wound
This item identifies the presence of any wound caused by a
surgical procedure. Scars and keloids are NOT considered
surgical wounds. Bowel ostomies and all other ostomies are
not considered surgical wounds, either; however, the wound
that results after an ostomy reversal procedure is considered
to be a surgical wound. As mentioned previously, surgical
repair of a pressure ulcer with flap surgery is NOT considered
a pressure ulcer and would instead be included under this
item. Debridement or skin grafting does NOT create a surgi-
cal wound, and these wounds would continue to be consid-
ered the same type of wound as previously identified prior to
the procedure.
The CMS guidance states “For the purpose of this OASIS

item, a surgical site closed primarily (with sutures, staples or
a chemical bonding agent) is generally described in docu-
mentation as a surgical wound until epithelialization has been
present for approximately 30 days, unless it dehisces or pres-
ents signs of infection.” Surgical sites that have been epithe-
lialized for 30 days should be described as a scar, and should
not be included in this item.
Surgical wounds also include: Orthopedic pin sites, central

line sites, wounds with drains, medi-port sites and other types
of implanted infusion devices or venous access devices.
A PICC line is NOT considered a surgical wound since it is
peripherally inserted. Also EXCLUDED are procedures such
as cataract surgery, surgery to mucosal membranes or
vaginal gynecological procedures.
Item M1342 identifies the most problematic surgical wound

and the status of the healing surgical wound based on the
WOCN Guidance Document. CMS encourages clinicians to
follow the guidance suggested in the WOCN Guidance Doc-
ument on "OASIS Skin and Wound Status M0 Items" (revised
July 2006) in the assessment of surgical wounds. The docu-
ment is available at www.wocn.org/pdfs/WOCN_Library
/OASIS_Guidance_rev_07_24_2006.pdf.
36 Healthy Skin
(M1350) Does this patient have a Skin Lesion or Open Item M2250 (plan of care synopsis) asks whether the physi-
Wound, excluding bowel ostomy, other than those cian-ordered plan of care includes interventions to address
described above that is receiving intervention by seven process measures: vital signs and other clinical find-
the home care agency? ings, diabetic foot care, falls prevention, depression, pain and
This final item identifies all other types of wounds or skin pressure ulcer prevention and treatment.
lesions other than pressure ulcers, stasis ulcers and surgical
wounds that are CURRENTLY receiving intervention. On pre- Conclusion
vious versions of OASIS, clinicians identified the presence of As you can see, the new OASIS-C incorporates many new
all skin lesions, including moles, scars, etc. With OASIS-C, ideas and concepts intended to improve patient care. As
however, this item now pertains only to lesions that are overwhelming as it may seem, this should be viewed as a
receiving intervention by the home care agency. PICC lines great opportunity to improve not only your clinical assessment
and IV sites qualify as skin lesions/open wounds under this skills with wounds, but also to improve the care you provide
item. Tracheotomies, urostomies and nephrostomies are also to your patients. With a little time, education and experience,
included here if interventions such as cleansing and dressing you will feel more confident in assessing your patients, and
changes are being provided by the home care agency. your patients will feel more confident with you. I encourage
you to seek out opportunities to further your knowledge base
Two new care process items, M2250 and M2400, also and never stop learning.
include items that directly pertain to the use of best practices
References
in the prevention and treatment of diabetic foot ulcers and 1. Lyder C & Ayello E. Annual checkup: the CMS pressure ulcer present-on-admission
pressure ulcers. As mentioned earlier, CMS is encouraging indicator. Advances in Skin and Wound Care. 2009; 22(10):476-484.
2. Highlights of OASIS-C Changes by Section: Train the Trainer Part 2 of 3. Available at:
home care agencies to use best practice patient care http://www.cms.hhs.gov/HomeHealthQualityInits/02_CMSSponsoredCalls.asp.
processes, and OASIS-C includes data items to measure the Accessed January 11, 2010.
3. OASIS-C Development and Impact on Agency Operations. Available at:
use of these best practices. Clinicians are asked if the plan of
http://www.cms.hhs.gov/HomeHealthQualityInits/02_CMSSponsoredCalls.asp.
care ordered by the physician includes the following: Accessed January 11, 2010.
4. OASIS-C Guidance Manual September 2009 for 2010 Implementation. Centers for
• Diabetic foot care, including monitoring for the presence
Medicare & Medicaid Services. Available at: http://www.cms.hhs.gov/homehealth-
of skin lesions on the lower extremities qualityinits/14_hhqioasisusermanual.asp. Accessed January 11, 2010.
• Patient/caregiver education on proper foot care 5. Wound Ostomy Continence Nurses Society Guidance on OASIS-C Integumentary Items.
Available at: http://www.wocn.org/pdfs/GuidanceOASIS-C.pdf. Accessed January 11, 2010.
• Intervention(s) to prevent pressure ulcers 6. Pressure Ulcers Prevention & Treatment: Clinical Practice Guideline. National Pressure
• Pressure ulcer treatment based on principles of moist Ulcer Advisory Panel & European Pressure Ulcer Advisory Panel. 2009.
7. AHCPR Treatment of Pressure Ulcers: Clinical Guideline Number 15. December 1994.
wound healing: When determining if the wound care is Available at http://www.ncbi.nlm.nih.gov/bookshelf/br.fcgi?book=hsahcpr&part=A5124.
based on the principles of moist wound healing, the Accessed January 11, 2010.
clinician might consider the definition of a moist wound

dressing as published in the “AHCPR Treatment of
Clay E. Collins BSN, RN, CWOCN, CFCN, CWS,
Pressure Ulcers: Clinical Guideline Number 15,”
DAPWCA is a certified wound, ostomy, conti-
December 1994.7 According to this guideline:
nence and foot care nurse through the WOCN
– A moist dressing keeps the ulcer bed continuously Certification Board and a certified wound spe-
moist. Wet-to-dry dressings should be used cialist through the American Academy of
only for debridement and are not considered Wound Management. He currently serves on
continuously moist saline dressings. the Foot Care Exam Committee for the WOCN
– The dressing needs to keep the surrounding intact Certification Board and is a member of the
Wound, Ostomy, Continence Nurses Society,
(periulcer) skin dry while keeping the ulcer bed moist.
Sigma Theta Tau International Nursing Honor Society and a Diplo-
– Pressure ulcers require dressings to maintain their mat of the American Professional Wound Care Association. He has
physiologic integrity. An ideal dressing should protect extensive experience in the home care setting serving as adminis-
the wound, be biocompatible, and provide ideal trator, clinical director and wound program director. He has devel-
hydration. The condition of the ulcer bed and the oped and implemented advanced wound care programs and served
desired dressing function determine the type of as expert reviewer for best practice documents for the WOCN. He
is currently a clinical education specialist for Medline Industries, Inc.
dressing needed.

SURVEY
SMARTS
An Interview with
Dr. Andy Kramer on QIS
Facts & Myths
he transformation of the long-term care (LTC) survey process
QIS SURVEYS
T is under way, with more than 3,100 nursing facilities in 14 states
having experienced at least one Quality Indicator Survey (QIS)
CONDUCTED review. As expected, QIS is bringing much change to the long-term
As of 12/14/2009
care survey process and a new paradigm in the assessment of care
and quality-of-life indicators in LTC facilities.
California.....................36
Connecticut ..............584 The QIS is designed to improve consistency in what surveyors
Delaware.......................9 pinpoint – and possibly cite – and to facilitate surveyor review of the
Florida.......................911 full range of regulations. The QIS methodology utilizes 162 quality
Kansas......................328 of care indicators—far more than those comprising the QIs/QMs.
Louisiana ..................268 The QIS calculates rates for each facility for particular care areas
Maine..........................29 and compares them to specified national thresholds, allowing
Maryland .....................56 that a certain number of those occurrences could be normal. When
Minnesota .................333 a facility’s QIS indicator exceeds the threshold for a particular area,
North Carolina...........186 it will likely prompt surveyors to pay close attention to that area
New Mexico ................44 during the survey process.
Ohio..........................278
Vermont ........................9 Quality Care magazine recently spoke with Dr. Andrew Kramer to
Washington.................51 learn more about how the QIS is affecting the long-term survey
West Virginia ...............17 process. Dr. Kramer led the development of the QIS and is
Total ......................3,139 currently principal investigator in support of CMS to refine the QIS
process and to conduct the training of state survey agencies in
the national rollout of QIS.
38 Healthy Skin
Survey Readiness
Dr. Kramer, a noticeable difference in QIS is that it has Does that make QIS surveys longer than
two stages. Can you briefly describe them? traditional surveys?
Dr. Kramer: Stage 1 is conducted during the first day Dr. Kramer: On average, even though QIS includes
and a half of a Quality Indicator Survey. The survey larger samples of resident and very comprehensive
team conducts resident interviews, family interviews, assessments, they generally require about the same
staff interviews, resident observations and chart amount of time and resources as the traditional survey
reviews. At the end of Stage 1, the team of surveyors process. In a specific sense, however, the length of a
will compile all of the data they have collected from QIS survey is variable depending on how many care
these assessments. The data will be used to calculate areas are “triggered” in the Stage 1 investigation. If
rates that are compared to national thresholds to only a few care areas are triggered, the survey could
determine whether Stage 2 investigations for potential be relatively short. If many care areas are triggered,
compliance concerns are warranted. No compliance the survey could be considerably longer.
decisions are made in Stage 1.
The other factor to consider is that when each new
Stage 2 is the portion of the survey process in which state begins implementing the QIS process, it may
an in-depth investigation is conducted on behalf of take longer than the traditional survey because there
residents within care areas that exceeded thresholds is a learning curve for surveyors. As you would expect,
on indicators identified during the Stage 1 process. efficiency increases substantially once they gain
Compliance decisions are made at the completion of experience with the process.
Stage 2.
Surveyors use both a resident’s CPS score

and a series of screening questions to determine
whether a resident is interviewable.

You mentioned the surveyor’s learning curve—

What do you think is the hardest thing for them Where Stage 2 “trigger”
to adapt to? information comes from:
Dr. Kramer: Surveyors face two primary adaptations
when learning the QIS process. First and most obvi-
16% 21%
ous is the intensive use of computer software and
Resident Resident
technology in the QIS. This isn’t a trivial thing for a lot Observation Interview
of them—the adjustment really does take some time
to get used to. The other challenge is getting to use
11%
the highly structured protocols and larger sample 12%
New MDS Indicators
sizes, and the fact that they have tasks that need Family Interviews
to be completed within a defined timeframe.
13% 8% Staff
So, with all the structured protocols and larger sample QIs/QMs Interviews
8% 11%
sizes, do “zero deficiencies” surveys still occur? Admission
Census
Dr. Kramer: Yes. Zero deficiency surveys still occur. Chart Chart
Are there certain types of deficiencies that are cited

at a higher rate in QIS? What criteria are used to determine a resident
Dr. Kramer: A major change resulting from QIS is that interview candidate?
Stage 2 in-depth investigations of residents are trig- Dr. Kramer: Surveyors use both a resident’s
gered mostly from resident interviews and observa- Cognitive Performance Scale (CPS) score and
tions and family interviews. In contrast, in the a series of screening questions to determine whether
traditional survey, most of the investigation is triggered a resident is interviewable. To determine whether a
by the QIs/QMs. resident can be interviewed, surveyors ask the follow-
ing questions:
The QIS results in resident-centered assessments 1. Are you from around here, the area, etc?
where far more information is derived from 2. Tell me a little about yourself.
residents and families. As a result, F-tags cited 3. How long have you been here?
at substantially higher rates include quality of 4. What is the food like here?
life deficiencies such as choices, dignity and
activities, which are directly assessed in the If the resident provides reasonable answers to these
resident interview and the resident observation; resi- questions, the surveyor marks the resident as inter-
dent behavior and facility practices relating viewable. If the resident provides unreasonable
to abuse, restraints and staff treatment of answers, the surveyor marks the resident as non-
residents; and quality of care deficiencies interviewable. If a surveyor is uncertain, they mark the
relating to providing necessary care for highest prac- resident as interviewable and conduct the interview. If
ticable well being, weight loss and hydration, and a they find the responses unreasonable or inconsistent,
drug regimen that is free from unnecessary drugs. they are able to change the resident’s status to
non-interviewable.
40 Healthy Skin
“ The Quality Indicator Survey is a more resident-centered

survey process designed to improve consistency
and accuracy, enhance documentation and focus survey
resources where they’re needed most.
Can a surveyor add a specific resident that wasn’t

chosen randomly by the computer?
Dr. Kramer: Yes. After the initial random sample is
drawn by the surveyor software tool, the surveyor will
reconcile that sample with the facility census. They will
”
pendent and more able to make choices and
express preferences.
How will a surveyor handle concerns, not related to

a direct question, which are brought up during the
ask for a list of residents admitted within the last 30 resident or family interview?
days and who are still in the facility. If any residents Dr. Kramer: The surveyor will note the concerns in the
from the initial draw of 40 are no longer in the facility, comments section of the interview and then bring the
they will be replaced with one of the newly admitted concerns to the team. If the concerns indicate poten-
residents. tial for non-compliance, the surveyor will initiate that
resident and applicable care area into the Stage
Surveyors can also “surveyor initiate” a resident into 2 sample.
the sample based on resident- or facility-specific
information obtained from ombudsman information, How do you think the QIS will affect residents overall?
off-site complaints, surveyor observation or interviews. Dr. Kramer: The Quality Indicator Survey is a more
resident-centered survey process designed to
How do surveyors go about finding family members improve consistency and accuracy, enhance docu-
to interview? What are they looking for? mentation and focus survey resources where they’re
Dr. Kramer: Surveyors screen all 40 census sample needed most. The QIS can also be used by providers
residents and conduct a resident interview with those as part of a continuous quality improvement process
who are interviewable. Then they select three non- to review and improve quality-of-life and quality-
interviewable residents who have a family member or of-care for residents.
personal representative who is likely to be
able to complete a family interview either in QIS will eventually contribute to the objective
person or over the phone before the end of of aligning the definition of quality among regulatory,
the Stage 1 investigation. They screen the family mem- provider and consumer constituents. Its resident- and
ber or personal representative, asking about their family-centered perspective will have the greatest
knowledge of and the extent of their relationship with impact on quality-of-life and quality-of-care for residents.
the resident. It is desirable that the family member be
familiar with the resident’s care planning, preferences
and daily routines when the resident was more inde-

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Designed for: Nurses and CNAs
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This course covers: Long-Term Care Administrator Boards (NAB),
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• The importance of the CNA in QIS and process evolved to standardize state surveys
resident-centered care in accordance with federal guidelines
• The different aspects of QIS, including the • The top six objectives of the QIS
resident interview, resident observations • How surveyors in all states are being trained
and family interviews in a structured and consistent manner
• How the CNA can help improve the overall • How the QIS differs from traditional
quality of care in long-term care facilities state surveys
42 Healthy Skin
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using abaqis® Stage 1 Suite
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One Nursing Home’s

Winning Quality
Assurance Strategies
By Betty Lou Barron, MSN, MBA
Director of Nursing, Bear Creek Nursing Center
44 Healthy Skin
Survey Readiness
Bear Creek Nursing Center is an 120 bed short-term stay and long-term care health care
facility located in Hudson, Florida.
Our Nursing Home Our Challenge

Bear Creek Nursing Center is located in Hudson, Florida was one of the first states to pilot the new Quality
Florida in the Central West region of the state along Indicator Survey (QIS) for nursing homes. With QIS, we
the Gulf of Mexico. Our mission is to ensure the high- had to change the culture of our nursing home staff.
est quality of care to the residents entrusted in our Compared to the traditional survey, QIS is designed to
care. Residents and their families are our first priority. be more consistent and less subjective, with a resi-
Our focus is to help all residents achieve their highest dent-centered focus.
level of function.
Because QIS is a new and very different process than
Bear Creek has 120 licensed beds and offers the traditional survey, our staff was naturally unsure
an array of services including traditional nursing what to expect and how to prepare for the new
care, which can range from several months to inspection. The idea of having to change the focus of
a long-term stay; rehabilitation care and respite our quality assurance efforts after having the traditional
care – a short-term program designed to give family survey for so many years was unsettling for all of us.
members a much needed break from the
d e mands of caring for the chronically ill at home. Along those same lines, we also realized that our nursing
Whether it’s for a w e e k e n d o r a f e w w e e k s , home was managed with an “institutional” mentality,
we provide a comfortable, secure medical and social meaning all of our residents were on the same sched-
environment. ule, participated in the same activities, went to bed at
the same time, and so on. While we did not know it at
the time, this type of system was not the optimal envi-
“ With the change in the survey process,

we knew we not only had to alter the
ronment for our residents to thrive.
way we prepared for the new QIS, we had

to reassess our entire quality assurance
approach to focus more on the resident.
”
The Solution
With the change in the survey process, we knew we not
only had to alter the way we prepared for the new QIS, we
had to reassess our entire quality assurance approach to
focus more on the resident.
Back in June 2008, I was introduced to a new

quality assurance system for nursing homes called
abaqis®. What got me initially interested in abaqis® was
that it used the same calculations, thresholds and analysis
as the QIS to quickly highlight residents at risk. I wanted
something to help take the guess work out of preparing
for the survey and make our nursing staff feel confident
Facility: Bear Creek Nursing Center
that what they were doing was helping the resident and
Location: Hudson, FL enhancing their chances of getting a good survey.
Size: 120 licensed beds with an array of services The abaqis® Stage 1 Suite examines 125 resident-cen-
including traditional nursing care, rehabilitation care
tered indicators of quality-of-care and quality-
and respite care
of-life that are used to identify care areas for
Challenge: Prepare for the new Quality Indicator a Stage 2 in-depth investigation and possible
Survey and change the culture of the nursing home citations during a QIS. These indicators are contained in
staff to be more resident centered. six modules that exactly replicate the QIS assessments
conducted on-site during the survey, plus one module
that uploads and reviews MDS data. The modules are:
• Resident Interview
• Family Interview
• Staff Interview
• Resident Observation
• Census Sample Record Review
• Admission Sample Record Review
• MDS Data
“ One of the biggest benefits of abaqis®

is that it helps us ask
our residents insightful questions about
Some of the Bear Creek clinical staff their likes and dislikes, and then it
who have helped transform the facility into
statistically analyzes the data to focus
a resident-centered nursing center.
us on our residents’ key issues.
”
46 Healthy Skin
“ Since abaqis® has become an integral part of our QA system,

the patients are noticeably happier now that we are changing things based
on their specific feedback. They appreciate that we have become more
resident-centered and customer friendly — meaning we are asking what they
think about their care and listening to their suggestions and issues.
”
After I was trained on abaqis ®, I identified 13 key needs and suggestions. One of the biggest benefits of
personnel at the facility – our department heads – to train abaqis® is that it helps us ask our residents insightful
and inservice them on abaqis®. At first, they were reluc- questions about their likes and dislikes and then it statis-
tant because this new system was a significant departure tically analyzes the data to focus us on our residents’
from what they had been doing in their current QA key issues. It allows us to uncover trends among our res-
process and they were uncertain if this was really going to idents and see areas where we can change and improve.
help them prepare for the new inspection. For instance, we learned that our planned activities were
not meeting our residents’ needs. The abaqis® system
In early February 2009, we started implementing asks residents for their own suggestions and they came
the abaqis® system in our facility. Although abaqis® is up with movie nights and more activities on weekends
a Web-based system that can be accessed from any and during afternoon shift changes. In fact, we ended up
computer, we have an older facility without wireless overhauling the entire activities schedule as a result of the
capabilities or laptop computers. So, we used a manual feedback we received from the abaqis® interviews. We
process to collect data and then we gave the information also discovered the temperature of the food was not to
to our administrative staff to input into the computer. the liking of many of our residents and some of them
wanted to eat at different times than when we had them
I divided the data collection responsibilities according scheduled.
to each staff member’s strengths and concentration. For
instance, it made sense that our social workers focused Over the next several weeks, we whittled down the number
on the resident interviews, while the administrative staff of focus areas to six and then we did a mock QIS survey
concentrated on record reviews. of the facility at the end of March. Of the six identified
areas, four did not get flagged. The two remaining areas
By the end of February, we had completed all the mod- of concern we fixed during the next three weeks.
ules, interviews and data analysis for our 112 residents.
What we found was that we had 28 areas of concern – With this new QA tool, we felt positive about the progress
areas that abaqis® flagged as red and a possible Stage 2 we were making on improving the quality of our residents’
investigation if we did not correct these deficiencies. experiences. Moreover, we became increasingly more
confident about the impending Quality Indicator Survey.
Specifically, but not surprisingly, many of the areas of con-
cern came from the resident interviews and their specific

The Results Future Opportunities

On August 30, the official reporting agency, the Going forward, abaqis® has become an integral
Agency for Healthcare Administration (AHCA), visited component of our ongoing QA system. We are
our facility and began our first inspection using the implementing two of the modules each month, which
new QIS – and we were ready. The inspection means we will complete one full survey of all of our
resulted in only four citations. (We had 16 during our residents every quarter.
mock survey.) According to the team leader of the
survey at our facility, we had the fewest areas cited This type of comprehensive quality assurance system
for a Stage 2 investigations he had seen so far. impacts our facility in many important and significant
ways. It not only decreases our chances for a Stage
Of the four citations, two were for nurse observations, II investigation, but more profoundly, our residents
which are easier issues to resolve than citations appear happier and more satisfied with their lives.
resulting from residents complaints about a specific And, as a result, our CNAs and other staff have
aspect of their care. I truly believe we had such positive increased job satisfaction with the knowledge that
feedback because we had abaqis® to prepare us. they are making a real and valuable contribution in the
lives of each resident.
At the conclusion of the survey, several of our staff
made the following comments:
About the Author
“You were right, the surveyors asked me Betty Lou Barron is Director of Nursing
the same questions that abaqis® asked.” at Bear Creek Nursing Center in
Hudson, Florida, a 120 bed skilled
nursing facility with emphasis on long-
“It really works.”
term and short-term rehabilitation
residents. Betty has been working in
“I see what you mean when you said the long-term-care industry for almost
it was resident-centered.” 10 years in various capacities. She is a Certified Director of
Nursing and has earned her certification as an Alzheimer’s
From the feedback of the surveyors, clearly trainer for the Department of Elder Affairs. She also has
our staff was less nervous and more prepared earned a masters degree in nursing and health care
for this survey than any other we had had administration. Betty is certified with the QIS system.
This certification enables her to train and educate other
previously, despite the new inspection process.
directors of nursing and administrative staff on the
QIS process.
Similarly, since abaqis® has become an integral part
of our QA system, the patients are noticeably happier
now that we are changing things based on their spe-
cific feedback. They appreciate that we have become
more resident-centered and customer friendly –
meaning we are asking what they think about their
care and listening to their suggestions and issues.
48 Healthy Skin
“ How do we improve
our resident and family-
centered quality of care
and prepare for QIS?
We use abaqis.”
Sherri Dahle, RN, DNS
Director of Nursing
Central Healthcare
LeCenter, MN
The new Quality Indicator Survey (QIS) for nursing homes That gives you a unique advantage in preparing for your
is more resident-centered, with more information obtained survey – and in meeting your resident’s needs.
from direct questioning of residents and families. In fact,
60 percent of facilities have had more deficiencies in QIS abaqis® is sold exclusively through Medline.
than in the prior traditional survey, often in regulatory areas Learn more by signing up for a free webinar
such as quality of life that were not as fully investigated demo at www.medline.com/abaqisdemo.
in the traditional process.
®
abaqis is the only quality assessment and reporting
system for nursing homes that is tied directly to the QIS,
and its quality assessment modules reproduce the same
forms, analysis and thresholds used by State Agency
surveyors. Rich reporting capabilities on 30 care areas
guide you to what surveyors will be targeting in your facility.
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Survey Readiness
Focus on
Understanding the New F-Tag 441 Requirements
By Lorri A. Downs, RN, BSN, MS, CIC
If you’re confused about the Centers for Medicare & Medicaid Services
(CMS) revised F-Tag 441 requirements regarding shared medical devices –
particularly glucose meters – you’re not alone.
Although every infection preventionist, healthcare worker, administrator and

regulatory surveyor certainly would prefer long-term care facilities to provide
dedicated medical equipment for each resident, they also realize this can be
cost prohibitive. Therefore, CMS and the CDC guidelines allow for the
sharing of durable medical equipment – such as glucose meters – as long
as it is properly cleaned and disinfected between every patient use.
Why are the regulatory eyes of CMS looking When devices are shared, staff training and education is
so closely at cleaning and disinfection? crucial to ensure proper infection control. One common
Healthcare-associated infections are a major concern, and barrier is lack of clear delegation of equipment cleaning tasks.
germs are commonly transmitted from person to person via If the responsibility is left to everyone, often no one ends up
medical devices. The new F-Tag 441 states:1 performing the cleaning task. Healthcare workers are busy
and simply assume another staff member completed this
“Infections are a significant source of morbidity and simple but critical task.
mortality for nursing home residents and account for up to
half of all nursing home resident transfers to hospitals. How has F-Tag 441 changed?
Infections result in an estimated 150,000 to 200,000 As mentioned earlier, CMS is especially concerned about
hospital admissions per year at an estimated cost of $673 infection control due to the rising rates of healthcare-acquired
million to $2 billion annually. When a nursing home resident conditions. They have combined all F-Tags related to
is hospitalized with a primary diagnosis of infection, the death infection control (i.e., F-Tag 441, 442, 443, 444 and 445) into
rate can reach as high as 40 percent. It is estimated that an one location under F-Tag 441 to make these guidelines more
average of 1.6 to 3.8 infections per resident occur annually accessible. F-Tag 441 is now the “one-stop-shop” for
in nursing homes.” infection control requirements.
Reducing and/or preventing infections acquired through The revisions to F-Tag 441 are based in part on a Centers for
indirect contact with surfaces or medical equipment requires Disease Control and Prevention (CDC) report describing
decontamination (cleaning, sanitizing or disinfection) prior to separate outbreaks of hepatitis B virus (HBV) linked to the
exposing a different resident to the particular piece of sharing of blood glucose monitoring equipment at long-term
medical equipment. care facilities in Mississippi, North Carolina and California.2

Investigators suggest that recommendations concerning

standard precautions and the reuse of fingerstick devices
have not been adhered to or enforced consistently in
long-term care settings. The potential for devices to carry
bloodborne pathogens and multidrug resistant bacteria and
viruses (if the device is not cleaned between every use) is
well-documented in the CDC report. For a copy of the
report, go to www.cdc.gov/mmwr/preview/mmwrhtml/
mm5409a2.htm. Ultimately the safety of your residents and
employees is at the core of most of the rules and regulations
surrounding infection control. Yet it can be challenging to
keep up with all the regulatory changes. Implementing
routine processes will increase your staff’s knowledge and
awareness, along with the assurance that clean care really is
safer care.
How will this regulatory change affect

long-term care facilities?
Regulatory inspections will be more frequent, and facilities
that are 1.) cited with severe non-compliance with the new
F-Tag 441 requirements and 2.) fail to implement preventative
or corrective measures will no longer be able to participate in
Medicare – a financially devastating prospect.
Non-compliance is categorized into the following levels

according to severity. Note that not cleaning glucose meters
between residents falls under the most severe level of
non-compliance.
52 Healthy Skin
New CMS Infe

ction Control
Requirements
for Long-Term
Care Facilitie
Severity Level 4 – Immediate jeopardy to resident health s
or safety: Non-compliance with one or more requirements
has caused or is likely to cause serious harm, impairment or
death to a resident.
Listed below are the infection control requirements
Example: under F-Tag 441 that long-term care facilities must
“The facility failed to follow standard precautions during the follow in order to be Medicare providers and receive
performance of routine testing of blood sugars. The facility reimbursement from CMS. 1
did not clean and disinfect the glucometers before or after
use and did not use new glucometer lancets on residents “The intent of this regulation is to assure that the
who required blood sugar monitoring. This practice of not facility develops, implements, and maintains an
cleaning and disinfecting glucometers between every use Infection Prevention and Control Program in order to
and re-using glucometer lancets created an Immediate prevent, recognize, and control, to the extent
Jeopardy to resident health by potentially exposing residents possible, the onset and spread of infection within the
to the spread of blood borne infections for multiple residents facility. The program will:
in the facility who required blood sugar testing.” 1
Perform surveillance and investigation to prevent,
to the extent possible, the onset and the spread
Severity Level 3 – Actual harm that is not immediate
of infection.
jeopardy: The negative outcome can include, but may not
be limited to clinical compromise, decline or the residents
Prevent and control outbreaks and cross-
inability to maintain and/or reach his or her highest
contamination using isolation precautions in
practicable well-being.
addition to standard precautions.
Example:
“The facility routinely sent urine cultures of asymptomatic Use records of infection incidents to improve its
residents with indwelling catheters, putting residents with infection control processes and outcomes by
positive cultures on antibiotics, resulting in two residents taking corrective actions, as indicated.
acquiring antibiotic-related colitis and significant weight loss.” 1
Implement hand hygiene practices consistent
Severity Level 2 – No actual harm with potential for more with accepted standards of practice, to reduce
than minimal harm that is not immediate jeopardy: the spread of infections and prevent cross-
Non-compliance that results in a resident outcome of no more contamination.
than minimal discomfort and/or has the potential to compro- Properly store, handle, process, and transport
mise the resident’s ability to maintain or reach his or her high- linens to minimize contamination.”
est practicable level of well being. The potential exists for
greater harm to occur if interventions are not provided.
Example: References
“The facility failed to ensure that their staff demonstrates 1. CMS Manual. Interpretive Guidelines for Long-Term Care Facilities Tag
proper hand hygiene between residents to prevent the F441. Available at: http://www.cms.hhs.gov/transmittals/downloads/
R55SOMA.pdf. Accessed January 21, 2010.
spread of infections. The staff administered medications to a
2. Centers for Disease Control and Prevention. Transmission of hepatitis B
resident via a gastric tube and while wearing the same gloves virus among persons undergoing blood glucose monitoring in long-term
proceeded to administer oral medications to another care facilities: Mississippi, North Carolina and Los Angeles County,
resident. The staff did not remove the used gloves and wash California, 2003-2004. MMWR 2005;54(09): 220-223. Available at:
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5409a2.htm.
or sanitize their hands between residents.” 1 Accessed January 21, 2010.

Survey Readiness
10
Ten Tips for
Cleaning and
Disinfecting
Shared Medical
Equipment
1 Make a list of every piece of shared medical equipment. 6 Clean medical device surfaces when visible blood or bloody
(Assign clinical staff to help identify and generate the fluids are present by wiping with a cloth dampened with
equipment list.) soap and water to remove any visible organic material, and
then disinfect.
2 Assign the cleaning and disinfection responsibility to the
type of healthcare worker who will be performing the task 7 If no visible organic material is present, disinfect the exterior
within your policy. surfaces after each use using a cloth or wipe with either an
EPA-registered detergent/germicide with a turberculocidal
3 Communicate this administrative decision to all members or HBV/HIV label claim, or a dilute bleach solution of 1:10
of your staff, both written and verbally, and document. to 1:100 concentration.
4 Educate and train staff on proper care, maintenance, cleaning 8 Note that alcohol also is not an EPA-registered
and storage of each piece of equipment. At a minimum, detergent/disinfectant.
provide this education upon initial employment, when the
equipment is replaced with a newer model and annually. 9 Disposable professional grade wipes with a short “kill time”
Document that this training has occurred. (60 seconds after application) can make the time spent
cleaning equipment quick and easy.
5 Select easy-to-use, EPA-registered hospital grade
disinfectants and cleaning products. Make sure the products 10 All cleaning should be done in well-ventilated areas with
list which microorganisms and viruses it kills. Common gloves to protect healthcare workers’ hands.
cleaners are sodium hypochlorite (bleach solution) or
quaternary ammonium products. However, to help avoid
warranty issues or equipment damage, be sure to follow
manufacturers’ recommendations regarding which cleaning
products to use.
54 Healthy Skin
Product Spotlight
Dispatch® Cleaning Solution for Use on Glucose Meters
Dispatch is a liquid cleaner that contains a unique deter- Dispatch is available as a liquid or as pre-moistened wipes
gent and bleach dilution strength (5500 ppm sodium in a canister. It meets both Universal and Standard
hypochlorite [NaOCl]) equivalent to the 1:10 bleach solu- Precautions set forth by OSHA and CDC. It is also regis-
tions recommended by the Centers for Disease Control and tered with the EPA.
Prevention (CDC) for disinfecting. It can be used on hard,
non-porous external surfaces such as glucose meters; Germicidal efficacy
however, care must be taken to protect the electrical com- Dispatch kills Mycobacterium bovis (TB) within 30 seconds
ponents of the equipment from any contact with liquid. and the following within 60 seconds: Acinetobacter bau-
Always remember to turn off electrical equipment prior to mannii, Avian Influenza A, Canine Parvovirus, Enterobacter
cleaning it with a liquid product. aerogenes, Enterococcus faecium, Vancomycin resistant
(VRE), Escherichia coli, ESBL, Feline Panleukopenia Virus,
Glucose meters should be stored in their carrying case Hepatitis A Virus (HAV), Hepatitis B Virus (HBV), Hepatitis C
when not in use. After use on a patient, the monitor should Virus (HCV), Herpes Simplex Virus (HSV-2), Human
be wiped down with Dispatch, left on for one minute, and Immunodeficiency Virus Type 1 (HIV-1), Influenza A Virus,
then wiped off with a fabric cloth or paper towel. Klebsiella pneumoniae, Norovirus, Poliovirus Type 1
(Mahoney), Pseudomonas aeruginosa, Rhinovirus,
More stable than bleach solutions Rotavirus, Salmonella enterica (formerly choleraesuis),
Dispatch is more stable than bleach solutions and more Staphylococcus aureus, Methicillin resistant Staphylococ-
pleasant to use. It remains stable through the expiration cus aureus (MRSA), Streptococcus pyogenes and Athlete’s
date (two years from manufacture), unlike bleach solutions, Foot Fungus.
which begin to deteriorate immediately. It is an excellent
cleaner because it contains detergent along with an anti- Dispatch is a registered trademark of Caltech Industries, Inc.
corrosive ingredient that minimizes damage to surfaces and
equipment.

Survey Readiness
Put
Bacteria
in its Place
Microfiber mops Why is Microfiber NICE?
minimize infection. N ew Product to the long-term care market
According to the CDC, there are an es-
I nfection Control
timated two million incidents related to
• One wet mop per room reduces cross-contamination, helping
healthcare-associated infections each
with infection control
year, making infection control one of the
highest priorities for healthcare facilities. • Due to their size, microfiber mops get into the small pores of
Thorough cleaning and disinfection of all the floor, enhancing your cleaning
surfaces, including floors, is one way to • A positive charge is created on the mop as it is pulled across
reduce infection. Microfiber mops are the floor to attract negatively charged dust and dirt particles
particularly useful for infection control • There is a 99 percent reduction in floor surface bacteria after
because they reduce floor surface bac- using a micofiber mop1
teria by 99 percent.1 Cost Savings
• Using microfiber mops reduces water and chemical usage
95 percent1
References
1. Environmental Best Practices for Health Care Facil-
• Microfiber mops weigh less than a traditional loop mop,
ities. Using microfiber mops in hospitals. November saving money in processing costs
2002. Available at: http://www.epa.gov/region09/
waste/p2/projects/hospital/mops.pdf. Accessed on • Because microfiber mops will last about 10 times longer than
February 4, 2010.
2. Sustainable Hospitals Project. 10 Reasons for Mi- a loop mop,2 there is a lower cost per use
crofiber Mops. 2003.
Ergonomics
• The lighter weight of a microfiber mopping system compared
to a traditional mopping system can significantly reduce the
risk of back injuries
• The telescoping handle allows the mop to be placed in an
ideal ergonomic position for each individual employee
56 Healthy Skin
MDT217750 MDT217600
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Prevention
Changing the
Catheter Culture
at Your Facility
Connie M. Yuska, MS, RN, CORLN
Recently my husband was hospitalized following a

10-foot fall at work. We were thankful his injuries were
not life-threatening, but he did have bilateral ankle and heel
fractures. Given the immobility we knew was ahead, I was
discussing the treatment plan with a good friend who is a
nurse. One of her first questions was, “They are going to
put in a catheter aren’t they?” My reply was, “I certainly
hope not. I don’t want him to get a catheter-associated
infection. That is the last thing we need with everything else
that’s going on!”
This conversation verified what I have experienced for the

majority of my career both as a staff nurse and as a chief
nursing officer. More likely than not if a patient was inconti-
nent or having difficulty getting to the bathroom, one of the
first requests would be an order for a urinary catheter. The
nurses believed that their primary intervention of catheter
insertion would maximize the patient’s comfort and avoid
skin breakdown. Today we know that urinary tract infection
is the most common healthcare-associated infection (HAI);
80 percent of these infections are attributable to an
indwelling urethral catheter.1 One in four patients receives
an indwelling urinary catheter at some point during their
hospital stay and up to 50 percent of these catheters are
placed unnecessarily.2,3
So, how do you change the culture at your facility if nurses

still want to place a catheter? We all know that changing
an organization’s culture can feel like turning a cruise ship
around in a wild and stormy sea. The perception of nurses
traditionally has been that putting a catheter in an inconti-
nent patient is the best standard of care. We have to
change that perception. As we begin to collect data, the
evidence is showing that avoiding catheterization protects
the patient from acquiring a catheter-associated urinary

tract infection. And we know that too many indwelling Education and training
urinary catheters are inserted. We also know that indwelling A logical place to start is by designing a comprehensive
urinary catheters stay in too long.4 education and training program. Having a program that
provides the supporting framework for education also helps
Components of Successful Culture Change to organize and publicize the initiative. Medline’s ERASE
Successful culture change consists of many components. CAUTI program will give you all the tools you will need.
The following are some key strategies you can try at your
facility, including use of the new Guideline for Prevention The ERASE CAUTI Program for nurses (RNs and LPNs) is
of Catheter-Associated Urinary Tract Infections 2009, a two-part educational program. Part One is a step-by-step
education and training, engaging front-line staff, a reward product training program on the ERASE CAUTI catheter
program, and finally, being creative, having fun and tracking tray and insertion methodology. Part Two includes the
progress. following four modules:
The Centers for Disease Control Module 1: Indications and Alternatives to Catheterization
and Prevention (CDC) Guideline Module 2: Aseptic Technique and Proper Insertion of
The Healthcare Infection Control Practices Advisory a Foley Catheter
Committee (HICPAC) of the CDC recently published the Module 3: Care and Maintenance, Signs and Symptoms
Guideline for Prevention of Catheter-Associated Urinary of CAUTI
Tract Infections 2009. This is an excellent reference to Module 4: Competency Validation
review prior to initiating a catheter reduction program at
your facility. The document contains recommendations on In addition, current practice guidelines, sample policies and
appropriate urinary catheter use and proper techniques for procedures and competency validation tools are included.
urinary catheter insertion and maintenance. In addition, the You have the opportunity to initiate the training at orientation
guideline outlines strategies for quality improvement and when a new employee joins your organization. This “sets
surveillance programs and summarizes recommendations the stage” for the catheter culture in your facility. You are
for an administrative infrastructure to support a CAUTI setting the expectation that your staff will keep an inconti-
prevention program.5 nent patient clean and dry without exposure to the unnec-
essary risk of acquiring a catheter-related urinary tract
infection. Then during your annual competency reviews for
your staff, you can reinforce the training and the new
“catheter culture.” This gives you a greater chance of hard-
wiring the change into your culture and ensuring that your
staff’s new viewpoint on catheterization is sustained.
Engaging front-line staff

It is also important to identify staff nurse champions at
the beginning of the program. Enlisting their help through a
formalized assignment is one good way to generate enthu-
siasm and support for the new program. Staff nurses have
very good ideas and often know the best answer if we
remember to include them! Getting them involved in the
literature review and in planning the staff education roll-out
will solidify their role as “champions” in the Race to ERASE
CAUTI!
Reward program
In sustaining any long-term change, it is extremely impor-
tant to recognize achievement. Staff work very hard, and
60 Healthy Skin
their efforts need to be recognized. Another part of the References

1. Lo E, Nicolle L, Classen D, Arias A, Podgorny K, Anderson DJ, et al. SHEA/IDSA
ERASE CAUTI Program is a reward component. Everyone practice recommendations: strategies to prevent catheter-associated urinary tract
infections in acute care hospitals. Infect Control Hosp Epidemiol. 2008;29:S41-S50.
who successfully completes the course and achieves at 2. Saint S, Kaufman SR, Thompson M, Rogers MA, Chenoweth CE. A reminder reduces
least an 80% on the post test receives one CE credit, a cer- urinary catheterization in hospitalized patients. Jt Comm J Qual Patient Saf.
2005;31(8):455-462.
tificate of completion and a pin to display on their ID 3. Stokowski, LA. Preventing catheter-associated urinary tract infections. Medscape
badge or uniform. The pin recognizes individual achieve- Nursing Perspectives. February 3, 2009. Available at:
http://www.medscape.com/viewarticle/587464-4. Accessed July 6, 2009.
ment and provides an opportunity for the staff to talk 4. Sulzback-Hoke, Linda M. “Ask the Experts.” Critical Care Nurse. 2002,22:84-87.
about the program with patients, families and other Available at: http.//ccn.accnjournals.org/cgi/content/full/22/3/84. Accessed July 24, 2009.
5. Guideline for Prevention of Catheter-Associated Urinary Tract Infections 2009, Healthcare
healthcare professionals, keeping the program top-of-mind. Infection Control Practices Advisory Committee, Centers for Disease Control. Available
at: http://www.cdc.gov/ncidod/dhqp/pdf/guidelines/CAUTI_Guideline2009final.pdf.
Being creative, having fun and tracking progress

Since this is a Race to ERASE CAUTI, encourage your staff
to post statistics regarding the decline in catheter- associated
About the author
infections. Nursing units in hospitals or hospitals in systems Connie Yuska RN, MS, CORLN began her
can make this a fun, competitive event that results in career as a nurse in the specialty of otorhi-
better patient care. Finally, celebrate when an individual or nolaryngology. Her clinical experience
the entire facility crosses the finish line of achieving zero includes both inpatient and outpatient care
catheter-associated urinary tract infections. of head and neck oncology patients, and she
is certified in otorhinolaryngology and head-neck
nursing. She has held clinical manager and
A Happy Ending director of nursing positions in a large
Although my husband did not have any incontinence, academic medical center and also has experience in the home
he was non-weight bearing and thankfully, none of the care setting as the vice president of operations for a large
nurses actually asked that a catheter be placed prior to sur- academically affiliated home care agency in the Chicago area.
gery. He did have a catheter placed during surgery, but it Connie later joined the executive suite as the chief nursing officer
of a large community hospital in Chicago, and she is currently a
was taken out within 24 hours! The hospital staff did follow
vice president of clinical services for Medline. In all of her leader-
the Guideline for Prevention of Catheter-Associated Urinary ship roles, she has been responsible for ensuring the delivery of
Tract Infections 2009, which states “for operative patients high quality, safe and cost-effective nursing care.
who have an indication for an indwelling catheter, remove
the catheter as soon as possible postoperatively, preferably Connie is a 2003 graduate of the J&J/ Wharton Nurse Executive
within 24 hours, unless there are appropriate indications for Program. She is member of the Board of the Illinois Organization
of Nurse Leaders and a member of the American Organization of
continued use.”5
Nurse Executives. In 2005, she was inducted into the 100 Wise
Women Program sponsored by Deloitte & Touche. In addition, she
I am happy to report that my husband was discharged from has published several articles and chapters in oncology journals
the hospital to a rehabilitation facility, and he was able to and textbooks.
come home for Thanksgiving. This year I was very thankful
that he was in a hospital with an up-to-date catheter
culture, and he is on the road to recovery!
We didn’t just design a

new tray, we designed a
way to make it hard for
healthcare workers to do
the wrong thing.
The new ERASE CAUTI program combines design, education
and awareness to tackle catheter-associated urinary tract
infection – the number one hospital-acquired infection.1
Design
The innovative one-layer tray design guides the clinician through
the process of placing a catheter to ensure aseptic technique.
Education
The acronym ERASE is easy to remember, reminding
the clinician to:
Evaluate indications – Does the patient really require

a catheter?
Design
Read directions and tips – Follow evidence-based Open up the
insertion techniques innovative one-layer
catheter tray and
see the intuitive
Aseptic techniques – Key design solutions support design for
aseptic technique yourself.
Secure catheter – A properly secured catheter will

reduce movement and urethral traction
Educate the patient – Printed materials tell the patient

how to reduce the likelihood of infection
Awareness
Join the Race to ERASE CAUTI! The current state of health
care demands that nurses play a leading role in identifying and
implementing CAUTI risk reduction strategies. Help us reach our
goal to introduce 100,000 nurses to the ERASE CAUTI system.
To sign up for a FREE webinar, “Innovation in the Preven-

tion of CAUTI,” go to www.medline.com/erase/webinar.asp.
Education
Click here for
details on nursing
education materials
that promote
evidence-based
practice. Awareness
Visit this section
to join 100,000
nurses in the
Race to ERASE
CAUTI.
Reference
1. Catheter-related UTIs: a disconnect in preventive strategies.
Physicians Weekly. 25(6), February 11, 2008.
Special Feature
Safe Handling of Residents

Which Technique Would You Use?
Safe handling of residents affects both the caregiver and the resident. Poor technique can result in resident injury or
displeasure in addition to caregiver injury. Nursing is consistently listed as one of the top ten occupations for work-
related musculoskeletal disorders, with incidence rates of 13.5 per 100 nurses in nursing home settings.1 Manual
handling also can be a causal factor in resident falls.
Imagine you are asked to assess the following residents and help develop a care plan for safe patient handling and
transfer, while also considering the caregivers’ risk of injury. Find the best matches below.
1. ____ Mrs. Brown is non-weight-bearing, weighs 475 pounds, and A. Manual stand-assist lift
is transferred between bed and recliner.
B. Low friction lateral transfer device
2. ____ Judy, 205 pounds, has limited upper body strength, is partial with 2-person assist
weight-bearing, and needs help transferring from bed to chair
and from chair to commode. C. 600-pound patient lift
3. ____ Always active, Chuck recently had a stroke and has trouble D. 1 person and gait belt
standing on his own. He is partial weight-bearing and has
some upper body strength. E. 400-pound power stand-assist lift
4. ____ Mr. Anderson is non-weight-bearing, weighs 162 pounds, F. 2-person assist with gait belt
and is transferred between bed, commode and wheelchair.
G. 2-person assist with drawsheet
5. ____ Mrs. Horton is bedbound, 185 pounds, and is completely
H. 400-pound patient lift
non-weight bearing. She is transferred laterally from bed to
shower gurney.
6. ____ 90-pound Ella is fully weight-bearing, uses a walker for part Answers: 1C, 2E, 3A, 4H, 5B, 6D,
of the day, but in the afternoon uses a wheelchair. She is 7F, 8G
unsteady transferring between the two.
Please note that the answers
7. ____ Mrs. Grant, 180 pounds, is on a unit that has no lift. She is provided here are not hard-and-fast
partially weight-bearing and needs assistance between bed, rules. We realize there are many differ-
toilet and chair. ent ways to safely and effectively lift
and handle residents, depending on
8. ____ Mr. Kent, 185 pounds, remains in bed much of the day. individual circumstances.
He is often is found on the lower half of the bed and needs
repositioning regularly. Reference:
1. U.S. Department of Labor. Bureau of Labor
Statistics. Survey of Occupational Injuries and
Illnesses, 2001.
64 Healthy Skin
Prevention
PERFORMANCE
UNDER PRESSURE
The Legal Side of Pressure Ulcer Prevention
mong the tools of the healthcare trade are medicines, dressings, instruments, nutritives and durable
A equipment. The tools of the legal trade are words. When these two professions meet, it’s words that
become the focus of attention. The outcome of a medical litigation is highly dependent on the words used
in a care setting, arguably as important as the care delivered itself.
The concept of the importance of words in a clinical setting was discussed at the Medline
“Prevention Above All” conference in Washington, D.C. by Kevin W. Yankowsky, JD, a partner
in the Health Law–Health Litigation department of Fulbright & Jaworski LLP and Caroline Fife, MD, CWS,
Director of Clinical Research at the Memorial Hermann Center for Wound Healing and Associate Professor–
Division of Cardiology at the University of Texas Health Science Center. They explained the potential for
trouble when words are turned against their original user.
Perhaps nowhere is a facility’s choice of words more important than in the policies and
procedures it creates and expects its employees to follow. “The road to litigation is paved with well-inten-
tioned policies,” explained Mr. Yankowsky. “Policies and procedures are kept in libraries by plaintiff’s attorneys.
They’re shared electronically online.” The implication is that a facility’s own policies may be used to support
a judgment against itself and its workers. Though policies and procedures are not law, a skillful lawyer can
hold them up as standards. Because they’re the facility’s own words, they can be very powerful.

“
Never”
In their single-minded pursuit of improved clinical the “standard of care” was violated. Typically, “stan-
care, policy drafters often fail to consider the legal dard of care” in a medical legal context is unique to
implications of words they choose to insert each resident, very factually specific and generally
in policies. Even more dangerously, they often fail no more than what would be reasonable care
to appreciate the plain, common sense meanings under the same or similar circumstances.
lay people give to those words when they are
jurors in a professional liability trial. However, a policy incorrectly identified as the
definition of the standard of care can fundamen-
For example, never, always, equal, complete and tally change this important question. When a
immediately are absolute words. Absolutes should policy is labeled the “standard of care” a jury can
be used cautiously, as they imply a binary, be asked to simply consider whether or not every
black or white, yes or no state. Suppose one exact detail of the policy, as written, was followed.
particular two-hour turn of a bariatric resident over Put another way, the focus shifts to whether the
a four-day period was not done until three hours policy was strictly adhered to instead of whether
had passed. If your policy stated that residents clinically appropriate care was delivered.
with certain risk factors for pressure ulcers must
be turned every two hours, have you delivered sub- A policy should be a guideline that recognizes
standard care because of that one incident? the uniqueness of each resident, which allows
the sound judgment of the healthcare team to be
Actually, this scenario captures two potential exercised and provides flexibility in implementation.
problems – the imperative must and the implied When “standard of care” is too closely bound to a
linkage between a policy and standard of care. policy, the answer to policy adherence is too closely
In nearly all jurisdictions, jurors in a healthcare bound to the assessment of appropriate care.
liability lawsuit will be asked to decide whether
66 Healthy Skin
“
Stage” “ [silence]”
The word stage means a point in a progression One of the most dangerous
or series of events. When we think of stages, we words in precipitating
usually consider them moving through a usual litigation may well be
set order, such as stages of development or grief. no words at all.
Staging a pressure ulcer, however, does not fit with
that widespread understanding of the term. “We really need to
think about … what
“There is the misconception that if you have a Stage drives residents to
III or IV, it must have begun as a Stage I,” Dr. Fife attorneys,” explained
explained. “Therefore it follows that had it been Mr. Yankowsky. “Some-
identified at Stage I, the Stage IV would never have times it’s greed. Certainly
happened. If that’s true, the fact the Stage IV is there sometimes it’s grief. Sometimes it’s
must mean that there was negligent care.” anger. Most of the time … it’s a search for answers.”
All of these assumptions are false. The current Two typical scenarios lead to litigation. The
NPUAP (National Pressure Ulcer Advisory Panel) first is a resident or family who had questions that
pressure ulcer staging system indicates only the were simply not answered. The second
depth of tissue damage at the time the ulcer is is a question that was answered incompletely,
assessed – it implies nothing about progression. inappropriately, unhelpfully or dismissively.
Furthermore, our current understanding of how
stage 3 and 4 ulcers develop is that they form from “If you don’t provide the answers, your adversary
the inside out, the way an apple rots. As a result, will,” Yankowsky cautioned, “and once they go to
tissue damage has already occurred at the level of the plaintiff’s attorney, the game’s up. You’re past
the muscle by the time skin changes are apparent. the point of being able to prevent the legal risk.”
When communicating with residents and their The role of the apology is a topic of debate. Apol-
families about pressure ulcers, using the staging ogizing is not new; it has been almost
system, while clinically correct, may be more universally taught in homes and classrooms
confusing than helpful. Spending time to educate and liberally applied on sporting fields and in
them – about the development of wounds from the department stores. In a clinical setting, though,
inside out, about the skin as an organ that can fail it is a relatively new phenomenon.
and about the healing process may save you from
trying to educate a jury later on those same points. Current thinking is that this practice may be effica-
cious, but words can be tricky when attached
Of course, you should only answer questions to an apology. Unintended and unexpected
appropriate to your clinical expertise and specific messages may be communicated. A nurse
knowledge of the resident’s case. Otherwise, a wishing to communicate sympathy by saying, “I’m
three-part response is called for: Acknowledge sorry,” may mean, “I’m sorry this has happened
the question and its importance, name the person to you,” but the resident may hear an admission
who can address their question, and promptly of guilt for substandard care. Like many good
notify that person by calling them or leaving them a treatments, apologies must not be dispensed with-
detailed message—and note the action in the chart. out cautious, conscious consideration.

Prevention Above All

Preventative medical care and preventative dentistry tative legal care approach. Far from being an
are concepts we understand conceptually and whose underhanded way of deflecting blame for poor health
effectiveness we can prove empirically. The concept care, it is an open and honest way to improve health
of preventative legal care for healthcare facilities and care while preventing litigation that is preventable and
practitioners is not as widely adopted. Understanding protecting oneself against litigation that may be un-
the potential pitfalls of simple words and responding preventable.
appropriately is one facet of a comprehensive preven-
Available beginning March 22, 2010 1 Contact Hour
LEGAL IMPLICATIONS OF PRESSURE ULCERS
Join us for this webcast presentation as two industry experts bring you critical informa-
tion on how the utilization of the nursing process and proper documentation are vital
components in maintaining the standard of care and avoiding litigation.
Dr. Caroline Fife is the Chief Medical Officer of Intellicure, Inc. and is
an Associate Professor within the Department of Medicine, Division
of Cardiology at the University of Texas Medical School at Houston
and Director of Clinical Research at the Memorial Hermann Center for
Wound Healing and Hyperbaric Medicine. She has served on the
Boards of the American Academy of Wound Management and
the Association for the Advancement of Wound Care. She is the
co-editor of the textbook, "Wound Care Practice" and is the author
of many scientific papers.
Kevin Yankowsky is a partner in the health law litigation group

of Fulbright & Jaworski L.L.P.’s Houston office. A true trial lawyer,
Kevin’s trial practice encompasses virtually all types of civil litigation
facing the healthcare industry. In addition to his extensive courtroom
experience, he advises on Joint Commission investigations, hospital
committee and medical peer review matters.
To pre-register for this special webcast visit

www.medlineuniversity.com
68 Healthy Skin
JOIN THE PROGRAM TO

REDUCE PRESSURE ULCERS
We’ve made pressure ulcer prevention easy.
“
Systematic efforts at education, heightened awareness This has been a great learning experience for
and specific interventions by interdisciplinary healthcare our staff and for our facility as a whole. I am
teams have demonstrated that a high incidence of thankful Medline had this program and that we
pressure ulcers can be reduced.1 The main challenges were able to access it. I can’t imagine recreating
to having an effective pressure ulcer prevention program this wheel!”
are: lack of resources; lack of staff education; behavioral Katrina “Kitty” Strowbridge, RN
challenges; and lack of patient and family education.2 Quality Improvement Coordinator
St. Luke Community Healthcare Network
Medline’s comprehensive Pressure Ulcer Prevention
Ronan, Montana
Program offers solutions to these challenges.
The Pressure Ulcer Prevention Program from Medline

For more information on the Pressure Ulcer
will help you in your efforts to reduce pressure ulcers in
Prevention Program, contact your Medline
your facility. The program includes:
representative, call 1-800-MEDLINE or visit
• Education for RNs, LPNs, CNAs and MDs www.medline.com/pupp-webinar to register
• Teaching materials for you to help train your staff for a free informational webinar.
• Practical tools to help reduce the incidence of
pressure ulcers
• Innovative products supported by evidence-based
information that results in better patient care
References
1
Holmes A, Edelstein T. Envisioning a world without pressure ulcers. ECPN. 2007;122(8):24-29.
2
CMS Roundtable, Omni Hotel, Chicago, Ill. March 10, 2008.
70 Healthy Skin
9
Caring for Yourself
Habits of Very Happy People
By Wolf J. Rinke, PhD, RD, CSP
Economy sputtering; swine flu getting everyone upset;

lots of changes at my facility, and you want me to be
happy? You’re kidding, right?
Actually not! Because no matter how bad things seem to be,

it’s important to remind ourselves that Abraham Lincoln was
absolutely right when he said, “Most people are about as
happy as they make their minds up to be.” Happy people are
not happy because they are endowed with the happiness
gene—although researchers tell us that accounts for about
half of one’s potential for happiness—happy people are happy
because they realize that happiness is something they control
by doing certain things every day. So here are nine things you
can do that will make you happier:
1. Love what you do

I find it ironic that many people deny themselves the joy of their
work. Somehow they assume that work is a dirty four letter
word and that they must escape it as soon and as fast as pos-
sible so that they can get home and plop down in front of the
TV. (This by the way, is a great way to become more unhappy
and depressed.) I suspect it is because they have not found
what they love to do. The key word here is love—not like—
because once you find what you love to do you will not ever
have to “work” another day in your life. (By the way, it took me
36 years to find what I love to do, so don’t give up your search,
because when you find your passion, the quality of your life
will improve dramatically.) If you would like help with this, read
my book Make It a Winning Life: Success Strategies for Life,
Love and Business.

2. Chase your dreams

Happiness is often a byproduct of something that we are
going after—something that juices us. Think of children. When
are they the happiest? About two weeks before the Christmas
or Hanukkah holidays, or when they have ripped all the pres-
ents open? Once we have clearly-defined, specific, fire-
in-the-belly goals, we get turned on, and we become happy.
In other words, if your goal is to be happy—that’s what many
people in my seminars tell me—you won’t necessarily be
happy. You get happy from traveling the journey or reminding
yourself that you are doing something that improves the quality
of someone else’s life. Chasing your dreams cranks up your
internal body chemistry to such an extent that it energizes you
to achieve extraordinary results and may keep or may even
make you healthy.
Want proof? A good example is Lance Armstrong, who after

being diagnosed in 1996 with an advanced form of testicular
cancer that had metastasized to his brains and lungs, was
given only about a 50 percent chance of survival. After
receiving aggressive cancer therapy, including brain and
testicular surgery and extensive chemotherapy, he went on to
win the Tour de France—cycling’s most prestigious and
grueling race—seven times in a row from 1999-2005. (The
previous record was winning it five times.) And just when
everyone thought he was down and out, he returned to
competitive racing after four years of “retirement” to finish third
in the 2009 Tour de France. Not bad for someone who at
age 38 is considered old in the punishing sport of competi-
tive cycling.
3. Nourish an attitude of gratitude
A difficulty for many successful people is that they perpetually
look up the mountain, never down. To feel a sense of grati-
tude you must have goals—look up the mountain—but also
take the time to reflect on all that you have already achieved
and accumulated—look down the mountain.
If you need a bit of help with this, take advantage of the next
holiday season. Instead of buying gifts for people who already
have more than they will ever need, rally the whole family and
serve a meal at a homeless shelter. Or visit a third world coun-
try. For example, when I used to speak in the Pacific Rim, my
sense of gratitude was always renewed. Typically the client
booked me in a five-star hotel, which makes any of our five
star hotels pale in comparison. One of the hotels in Jakarta
even had a marble driveway. Not concrete, not flagstones—
marble. When I looked out of my 29th story window I saw
many other super-modern high-rise buildings. I also saw a
garbage dump several blocks away swarming with people –
people who were living on the dump in cardboard “houses”
and foraging for scraps. Stop right now, and be grateful for all
the love and abundance that surrounds you.
72 Healthy Skin
4. Love someone deeply psychoneuroimmunology, or PNI for short. (Want to know

Barbra Streisand was absolutely more? Read Dr. Pert’s books: Molecules of Emotions: The
right, “people who love people Science Behind Mind-Body Medicine and Everything You
are the luckiest people in the Need to Know to Feel Go(o)d.)
world.” Start by developing a
strong bond and lifetime relation- 6. Laugh more
ship with a significant other. Hav- That’s right – go ahead and
ing been happily married to my laugh right now. Can’t seem to
“Superwoman” for 41 years, I get it going? Go to the bath-
can attest that she by far is room, stick your tongue out,
my biggest source of joy and wiggle your nose and make the
happiness. (She got that name silliest face you can possibly
because she is a one-in-a-million mate, mother, business come up with and get yourself to
partner and confidant.) If you don’t have such a relationship, laugh. If you need more help, join
make it one of your top three fire-in-the belly goals, because a laughter yoga club, popular-
such a partner becomes increasingly more important as you ized in India, and now available
enter the later passages of your life. Extend that same love to all over the world including the
your family and your close friends. The greater your circle of United States (http://www.laughteryoga.org). Or consult with
loving relationships, the greater your happiness. a “certified laughter leader.” (Hey, I’m not making this stuff up!)
A good way to nurture this is to laugh more at yourself. It will
cause you to take yourself less serious—which is a great start
5. Treat your “body- because you are not nearly as important as you think you are.
mind” like a temple (I’m including myself in that statement; so don’t get bent out
Neuroscientist and pharmacolo- of shape). Laughter has innumerable benefits. It turns on your
gist Dr. Candance Pert, who dis- endorphins and other internal “drugs” that are far more pow-
covered the opiate receptor – the erful than anything you can ingest—legal or illegal. In fact, it is
cellular binding site for endor- so powerful that the late Norman Cousins used it as an “anes-
phins in the brain – calls our body thetic” to combat pain associated with his incurable disease.
and mind the “body-mind” be-
cause her work has unequivo- 7. Give more of what
cally demonstrated that the mind you want
and the body are one. Her work A shortcut to happiness is mak-
also shows that thoughts are ing other people feel happy.
things – things that manifest themselves in the body and in Why? Because life is like a mir-
your life. So if you think “bad” or negative thoughts, then that ror—whatever you give—is what
will have a negative impact on your body. And of course the you get. Make people happy and
reverse is true. Since the mind can have only one thought at you will be happier. Hate people
a time, get in the habit of monitoring your thoughts and self- and you will live in a hateful world.
talk by asking, “Is what I’m thinking about right now nega- Love people the way they are,
tive?” (The worst is hate.) If it is, it will move you away from and you will experience more
happiness and optimum health. On the other hand, positive love. You catch my drift. Actually
thoughts, such as love, kindness and appreciation will move you already knew that. And that’s why you are much more
you in a positive direction. This is so powerful that we now anxious to give a gift than get one. Happiness certainly does
have a whole science concerned with this phenomenon— not come from things. Otherwise the happiest people on

Be sure to never give up hope, no matter how bleak

it gets. And even more important, be sure not to
confuse inconveniences with problems.
earth would be lottery winners. They are not. In fact lottery 9. Keep Hope Alive
winners often become discouraged and depressed because Hope is an incredibly powerful
they become so obsessed with “stuff” that most are broke emotion. Without it not only do
three years after they have won the jackpot. “Superwoman” you become unhappy—you die.
and I have come to the realization that less is more. That is to No one has told that story more
say, the more stuff we have, the more problems and stress we powerfully than Dr. Victor Frankl
have. That’s why we evaluate every new opportunity by ask- in his book Man’s Search for
ing ourselves whether taking advantage of the new opportu- Meaning, in which he details the
nity will add to the quality of our lives. If the answer is yes, we role of hope in surviving the Ger-
go for it. If the answer is no, we don’t. man concentration camps. So
be sure to never give up hope, no
8. Develop a Positive matter how bleak it gets. And
Explanatory Style even more important, be sure not to confuse inconveniences
Professor Marty Seligman, of the with problems. Because many of the “problems” that we get
University of Pennsylvania, who ourselves all worked up about are inconveniences, not
has had a tremendous influence tragedies. When you are in the middle of one of these, a great
on getting psychologists to focus diagnostic is to ask yourself: “How will I feel about this five
on the good—what he has years from now?” And then act accordingly. To deal more ef-
dubbed “positive psychology”— fectively with the real tragedies—which will come—turn to the
wrote a number of powerful source of hope and inspiration that works for you. It may be
books addressing this topic religion, spirituality, meditation or listening to a great motiva-
(http://www.authentichappi- tional speech. (Just had to sneak that in there.) It will help you
ness.sas.upenn.edu/seligman.aspx). His research has keep hope alive and make you more optimistic and happier.
demonstrated that we can learn to be more optimistic by de-
veloping a “positive explanatory style” (PES). The way you do © 2009 Wolf J. Rinke
that is by focusing on the good stuff, especially when bad
things happen to you. In other words you learn to fake it until Dr. Wolf J. Rinke, PhD, RD, CSP is a keynote
you make it. Research has shown that people who have de- speaker, seminar leader, management con-
veloped PES, as opposed to a Negative Explanatory Style sultant, executive coach and editor of the free
electronic newsletters Make It a Winning Life
(NES) are able to evaluate “reality” more clearly—just the
and The Winning Manager. To subscribe go
opposite of what most people assume. Process “bad” news to www.WolfRinke.com. He is the author
more effectively, and you are more likely to accept what can’t of numerous books, CDs and DVDs including
be changed and move on. In short, PES enables you to Make it a Winning Life: Success Strategies for
inoculate yourself against the negative attitude “virus” and his Life, Love and Business; Winning Manage-
big cousin—depression. ment: 6 Fail-Safe Strategies for Building High-Performance Organi-
zations and Don’t Oil the Squeaky Wheel and 19 Other Contrarian
Ways to Improve Your Leadership Effectiveness. All are available at
www.WolfRinke.com. His company also produces a wide variety of
quality, pre-approved continuing professional education (CPE) self-
study courses including Beat the Blues: How to Manage Stress and
Balance Your Life, on which this article is based, available at
www.easyCPEcredits.com. Reach him at WolfRinke@aol.com.
74 Healthy Skin
Snug-fitting sheets
for healthier skin.
SoftSpan sheets with spandex fit snugly
on the bed to comfort and protect the skin.
A patented blend of cotton, polyester and spandex
provides softness and a non-abrasive surface, along Call your Medline representative or 1-800-MEDLINE
with better air circulation for skin health. to trial two dozen SoftSpan fitted sheets for the
same price you’re paying for your current sheets.
Independent laboratory studies1 showed that SoftSpan
fitted sheets had 260% stretch in the width and 98%
stretch in the length, compared to a regular knit sheet,
which has 104% stretch in the width and 45% in the
length. Regular woven sheets have no stretch at all.
References
1. Diversified Testing Laboratories, Inc. ASTM D 6614-07, “Standard Test
More stretch means a tighter, smoother fit, and no Method for Stretch Properties of Textile Fabrics – CRE Method.” July 29,
wrinkles. Mayo Clinic and other healthcare experts 2009. Data on file.
2. Mayo Clinic. Bed sores (pressure sores). Available at http://www.may-
recommend keeping the bottom sheet pulled tight oclinic.com/health/bedsores/DS00570. Accessed on February 5, 2010.
to prevent wrinkles and bunching, which can cause 3. Oregon Department of Human Services. Pressure Sores: A Self-Study
Course. 2008. Available at: http://www.oregon.gov/DHS/spd/provtools/nurs-
pressure that contributes to skin breakdown.2,3 ing/study-guides/pressure_sores.pdf3.
MEDLINE’S
PINK GLOVE
Thank You!
Providence St. Vincent
Medical Center
F rom th e h i g h e s t l e v e l s o f y o u r
o r ganization down through your entire
staff, we could not have picked a better
partner for the “Pink Glove Dance,”
video project.
Thank you for taking part in a

cause that touches us all.
76 Healthy Skin
Special Feature
DANCE
Boosting Hearts, Minds
and Support for Breast
Cancer Awareness
A YouTube™ Sensation
One early November morning, when the OR
staff of Providence St. Vincent Medical Center
was approached by Medline to take part in a little
breast cancer awareness video they were doing, little
did they know what an impact their participation
would soon make.
A little more than a month later, over six million people

across the globe have seen the “Pink Glove Dance” video.
The YouTube video phenomenon has been featured on

CNN, ABC World News with Charles Gibson, Fox &
Friends - Fox News Network’s national morning show,
and literally more than 100 local TV newscasts across
the country.
News stories about the video also span the Internet, from
the Huffington Post to the AOL home page. People can’t
stop talking about this video, which showcases more
than 200 hospital workers from the medical center in
Portland, OR. dancing in Medline’s pink gloves. Phone
calls, cards and e-mails are flooding both the hospital
and Medline. And more than 10,000 people have posted
comments about the video on YouTube. It has enter-
tained and inspired laughter and, for many, it has evoked
memories of their own battle with breast cancer or bat-
tles faced by loved ones.
One viewer wrote: “Wonderful! This brought tears to

my eyes as I am a survivor 13 years out and it reminded
me of the wonderful staff at Yale Oncology unit. Thank
you to all in the medical field. Please be sure to share
this with those who are going through treatments. I am
sure this will be helpful.” – mamakawecki55
Another said: “Given the type of work that they do,

it is good to see them having fun for a good cause.
Remember they are the ones who care for those with
cancer.” – seaglassfriends

Birth of an Idea The next few days were a blur of action. The hospital sent
Why would perfectly sane and incredibly busy hospital out a call for employee volunteers to dance in the video.
workers agree to dance in a YouTube video? The short Back at Medline, the wheels were in motion. Jay Sean’s hit
answer is to get people talking about breast cancer. But song “Down” was selected for the video and discussions
there’s more to the story. It all began at Medline’s Corporate took place to coordinate which areas of the hospital would
office when employees were brainstorming ideas to pro- be filmed, the number of staff participating in each shot and
mote their new Generation Pink™ glove (launched in the overall plan of events.
October). To further support Medline’s ongoing breast cancer
awareness campaign (visit www.medline.com/breast-can-
cer-awareness for details), they had already implemented a
promotion to donate $1 of every case purchased to the
National Breast Cancer Foundation to fund mammograms
for individuals who cannot afford them.
But they needed a big idea to help spread the word. So,
they asked, “What if we were to video healthcare workers
dancing in pink gloves? Could we produce a viral video?”
Little did they know. . .
The first step was finding the right hospital to partner with The Making of the Video
Medline to create the video. The Providence Health Sys- A week later, Medline product manager Emily Somers was
tem, a 26-hospital system in the northwest area of the at the hospital with a few boxes of pink gloves and the film
country, proved to be the perfect choice. The health system crew. More than 200 employees of all ages, departments
suggested Medline work with Providence St. Vincent Med- and skill levels answered the call to participate.
ical Center in Portland, which not only was willing to give full
access to each area of the facility for the video shoot, but “We had so many people who said, ‘You know, this
also shared Medline’s passion for breast cancer awareness. disease has touched my life. I want to be a part of it,’” said
78 Healthy Skin
“
I am very honored that Medline and
Providence St. Vincent Medical Center
used my song “Down” to promote and
support Breast Cancer Awareness.
I like that such a fun and light hearted
approach was taken to create aware-
ness for a serious disease that can
”
be cured if caught early.
– Jay Sean

Martie Moore, the chief nursing officer at Providence Monte Crawford, “the
St. Vincent Medical Center. mop man,” has become
one of the more popular
figures in the “Pink Glove
The filming took two days and Emily taught the volunteers
Dance” video.
basic dance moves to showcase the pink gloves. “In an
environment filled with sickness and gloom, the caregivers
brought incredible energy to the making of the video,
expressing their great heart and spirit,” Emily said. From
lab technicians and the kitchen help to surgical teams, they
all let loose, dancing throughout the hospital.
Touching People Around the World

Thousands of people across the globe have posted inspiring
comments about the video — even singer Jay Sean
responded by posting a link to the video on his website.
On his Facebook page he wrote, "The vid is awesome …
medicine will always be close to my heart and this is such
a worthy and important cause. So maybe I could have
been a doctor and a singer at the same time after all then?
Just brilliant."
17,000 Screaming Pink-Gloved Fans

To further spread the “Pink Glove Dance” message, more
than 17,000 passionate fans recently wore Medline’s pink
Emily Somers, Medline product manager – and the choreographer gloves at a live concert held in Chicago. With 34,000 pink
of the “Pink Glove Dance” – teaches the lab staff of Providence gloved hands swaying back and forth to a live performance
St. Vincent some dance moves during the shooting of the video. by Jay Sean singing his hit song “Down,” the arena took on
a surreal appearance of a dense forest of pink trees waving
in the wind. It was an unbelievable sight that brought tears
to the eyes of many in the audience.
80 Healthy Skin
A world without breast cancer is in our hands.
Medline’s Generation Pink latex-free, third-generation vinyl exam gloves

have the comfort, barrier protection and price you love.
Even better, when you choose Generation Pink gloves, you’re helping
Medline support the National Breast Cancer Foundation.
Other ways to show your support:
Become a Facebook fan at: facebook.com/ Watch the “Pink Glove Dance” video at:
medlinebreastcancerawareness YouTube.com/watch?v=OEdvfyt-mLw
For more information on Medline’s exam gloves, please contact your

Medline representative, call 1-800-MEDLINE or visit www.medline.com.
©2010 Medline Industries, Inc. The cross-fingered pink glove hand image is a trademark of
Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.
“Pink
Glove
Dance
Video ”
Goes
• National news – ABC, CNN, FOX, MSNBC
• 17,000 fans donning pink gloves during
a live performance of Jay Sean’s hit
Viral! • Over 6 million views on YouTube
• Over 10,000 comments on YouTube
• More than 120 TV news stories
song, “Down” across the country
Support The Cause. Help fund free mammograms!

When you choose Generation Pink Gloves, a portion of the proceeds will be donated to the
National Breast Cancer Foundation to fund free mammograms for women who cannot afford them.
Depending on who you are (an individual or a facility), there are two sites to choose from
when ordering gloves.
• Individuals visit www.scrubs123.com
• Healthcare facilities visit www.medline.com/breast-cancer-awareness
• If you wish to donate directly to the National Breast Cancer Foundation,
visit the NBCF website www.nationalbreastcancer.org.
82 Healthy Skin
Featured Recipe
Cheesy Potatoes (12 servings) Nutrition

Information
• 16 oz. bag frozen hash brown potatoes Topping: Servings: 12
Calories: 296
(cubed or shredded) • 2 c. corn flakes
Fat: 12.7 g
• 16 oz. container sour cream • ¾ stick melted butter or margarine Sodium: 407.7 mg
• 1 can cream of chicken soup Fiber: 1.2 g
• ½ c. chopped onion
• 8 oz. bag shredded cheddar cheese
Directions: The Shannons regularly host parties at their home, where they
Mix together all ingredients and place in a baking dish. Top with have a fully outfitted game and entertainment room. Dennis
crushed corn flakes mixed with the melted butter. Cover with said his cheesy potatoes dish is a big favorite with guests. “It’s
foil and bake at 350 degrees F for 30 minutes. Remove the foil easy and inexpensive to make, and people really like it.”
and bake an additional 20-30 minutes.
Dennis offers another quick, easy and
Hint: To cut down on salt and fat, use low-sodium soup and reduced inexpensive recipe that’s also a big hit at
fat cheese and sour cream. parties: Spread a thin layer of chive-
flavored cream cheese onto a flour
Shipping employee Dennis Shannon has worked at Medline’s tortilla and then layer it with a slice of
Allentown, Penn. warehouse for 10 years. In his spare time, he turkey breast lunch meat, a piece of red
enjoys cooking and entertaining. He said at his house, “I do the leaf lettuce and pimentos. Roll it up and
cooking and my wife does the baking, so it works out well.” cut into slices for an attractive and deli-
cious snack.

FORMS & TOOLS
The following pages contain practical tools for implementing

patient-focused care practices at your facility.
OASIS-C
Integumentary Status ........................................86
H1N1 (Swine Flu)

Patient Handout (English) ..................................89
Patient Handout (Spanish) ................................91
Leg Ulcers
Clinical Fact Sheet: Quick Assessment
of Leg Ulcers ......................................................93
Infection Prevention and Control

Long-Term Care Audit ........................................95
Bariatrics
Bariatric Assessment: Home Care/Long-Term
Care Facility ....................................................101

Forms & Tools OASIS-C Integumentary Status
This checklist is part of the new OASIS-C guidance from the Centers for Medicare
& Medicaid Services. OASIS-C went into effect at the end of 2009. For a step-by-step
explanation of this portion of OASIS-C, turn to the article on page 29.
OASIS-C
INTEGUMENTARY STATUS
(M1300) Pressure Ulcer Assessment: Was this patient assessed for Risk of Developing Pressure
Ulcers?
0 - No assessment conducted [ Go to M1306 ]
1 - Yes, based on an evaluation of clinical factors, e.g., mobility, incontinence, nutrition, etc.,
without use of standardized tool
2 - Yes, using a standardized tool, e.g., Braden, Norton, other
(M1302) Does this patient have a Risk of Developing Pressure Ulcers?

0 - No
1 – Yes
(M1306) Does this patient have at least one Unhealed (non-epithelialized) Pressure Ulcer at Stage
II or Higher or designated as "not stageable"?
0 - No [ Go to M1322 ]
1 – Yes
(M1307) Date of Onset of Oldest Unhealed Stage II Pressure Ulcer identified since most
recent SOC/ROC assessment:
__ __ /__ __ /__ __ __ __
month / day / year
UK - Present at most recent SOC/ROC assessment
NA - No new Stage II pressure ulcer identified since most recent SOC/ROC assessment
86 Healthy Skin
OASIS-C Integumentary Status Forms & Tools
OASIS-C
INTEGUMENTARY STATUS (cont’d.)
(M1308) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at Each Stage: (Enter
“0” if none; enter “4” if “4 or more”; enter “UK” for rows d.1 – d.3 if “Unknown”)
Stage description – unhealed pressure Number Present Number of these that were
ulcers present on admission
(most recent SOC / ROC)
a. Stage II: Partial thickness loss of dermis
presenting as a shallow open ulcer with red
pink wound bed, without slough. May also
present as an intact or open/ruptured serum-
filled blister.
b. Stage III: Full thickness tissue loss.
Subcutaneous fat may be visible but bone,
tendon, or muscles are not exposed. Slough
may be present but does not obscure the
depth of tissue loss. May include
undermining and tunneling.
c. Stage IV: Full thickness tissue loss with
visible bone, tendon, or muscle. Slough or
eschar may be present on some parts of the
wound bed. Often includes undermining and
tunneling.
d.1 Unstageable: Known or likely but not
stageable due to non-removable dressing or
device
d.2 Unstageable: Known or likely but not
stageable due to coverage of wound bed by
slough and/or eschar.
d.3 Unstageable: Suspected deep tissue
injury in evolution.
Directions for M1310 and M1312: If the patient has one or more unhealed (non-epithelialized)
Stage III or IV pressure ulcers, identify the pressure ulcer with the largest surface dimension
(length x width) and record in centimeters:
(M1310) Pressure Ulcer Length: Longest length “head-to-toe” | ___ | ___ | . | ___ | (cm)
(M1312) Pressure Ulcer Width: Width of the same pressure ulcer; greatest width perpendicular to
the length | ___ | ___ | . | ___ | (cm)
(M1314) Pressure Ulcer Depth: Depth of the same pressure ulcer; from visible surface to the
deepest area | ___ | ___ | . | ___ | (cm)
(M1320) Status of Most Problematic (Observable) Pressure Ulcer:

0 - Re-epithelialized
1 - Fully granulating
2 - Early/partial granulation
3 - Not healing
NA - No observable pressure ulcer

Forms & Tools OASIS-C Integumentary Status
OASIS-C
INTEGUMENTARY STATUS (cont’d.)
(M1322) Current Number of Stage I Pressure Ulcers: Intact skin with non-blanchable redness of a
localized area usually over a bony prominence. The area may be painful, firm, soft, warmer or cooler
as compared to adjacent tissue.
0 1 2 3 4 or more
(M1324) Stage of Most Problematic (Observable) Pressure Ulcer:

1 - Stage I [Go to M1330 at SOC/ROC/FU ] 2 - Stage II 3 - Stage III 4 - Stage IV
NA - No observable pressure ulcer
(M1330) Does this patient have a Stasis Ulcer?

0 - No [ Go to M1340 ]
1 - Yes, patient has one or more (observable) stasis ulcers
2 - Stasis ulcer known but not observable due to non-removable dressing [ Go to M1340 ]
(M1332) Current Number of (Observable) Stasis Ulcer(s):

1 - One
2 - Two
3 - Three
4 - Four or more
(M1334) Status of Most Problematic (Observable) Stasis Ulcer:

3 - Not healing
(M1340) Does this patient have a Surgical Wound?

0 - No [ Go to M1350 ]
1 - Yes, patient has at least one (observable) surgical wound
2 - Surgical wound known but not observable due to non-removable dressing [ Go to M1350 ]
(M1342) Status of Most Problematic (Observable) Surgical Wound:

0 - Re-epithelialized
3 - Not healing
(M1350) Does this patient have a Skin Lesion or Open Wound, excluding bowel ostomy, other
than those described above that is receiving intervention by the home health agency?
0 - No
1 - Yes
88 Healthy Skin
Forms & Tools H1N1 Patient Handout
H1N1 (Swine Flu)

What is H1N1 flu?
H1N1 influenza, or swine flu, is a respiratory
illness caused by type A influenza viruses. This
virus was originally referred to as “swine flu”
because it was thought to be very similar to flu
viruses that normally occur in pigs (swine) in
North America. H1N1 flu was first detected in
people in the United States in April 2009.
How does H1N1 flu spread?

H1N1 flu is contagious and is spreading between people. This virus may be transmitted in similar ways that other flu viruses
spread, through coughing or sneezing. A person may be able to infect another person one day before symptoms develop and
for seven or more days (longer for children) after becoming sick. It is possible that someone may become infected by touching
something with the virus on it and then touching his mouth or nose. Eating pork does not cause swine influenza.
What are the symptoms of H1N1 flu?

The symptoms of H1N1 flu include fever, cough, sore throat, runny or stuffy nose, body H1N1 Symptoms
aches, headache, chills and fatigue. Diarrhea and vomiting may also be associated with
H1N1 flu. Most people with the virus have recovered without needing treatment, but • Headache
hospitalizations and deaths have occurred. • Fever
• Fatigue
What should I do if I think I have H1N1 flu?
If you have flu symptoms, stay home and avoid contact with other people to avoid • Chills
spreading your illness. It is recommended that you stay home for at least 24 hours after • Runny or
your fever is gone, or if possible, until your cough is gone. If you have severe illness or stuffy nose
you are at high risk for flu complications, contact your health care provider.
• Sore throat
He or she will determine whether testing or treatment is needed.
• Cough
Seek emergency medical care for any of the following warning signs: • Body aches
In children: In adults:
• Fast breathing or trouble breathing • Difficulty breathing
• Bluish skin color or shortness of breath
• Not drinking enough fluids • Pain or pressure in the chest or abdomen
• Not waking up or not interacting • Sudden dizziness
• Being so irritable that the child does not want to be held • Confusion
• Flu-like symptoms improve but then return with • Severe or persistent vomiting
fever and worse cough • Flu-like symptoms improve but then return with
• Severe or persistent vomiting fever and worse cough
Page 1 Text courtesy of NursingCenter.com.

Images courtesy of Anatomical Chart Company.
Lippincott Williams & Wilkins | Wolters Kluwer Health Businesses.
nursingcenter.com anatomical.com 5mcc.com

Forms & Tools H1N1 Patient Handout
How is H1N1 flu treated?

The CDC recommends the use of oseltamivir (brand
name Tamiflu) or zanamivir (brand name Relenza) to
treat and/or prevent swine influenza. These antiviral
medications may also prevent serious complications.
For treatment, antiviral drugs work best if star ted
within 2 days of symptoms.
What can I do to prevent H1N1 flu?

You can reduce your risk of contracting and spreading swine influenza
and other influenza viruses by:
• Coughing or sneezing into • Not touching your eyes, nose, or

your arm; avoiding close mouth because this is how germs
contact with people who have get into your body
respiratory symptoms such as
coughing or sneezing
• Staying home when you're sick • Keeping surfaces and objects

and getting as much rest (especially tables, counters, door-
as possible knobs, toys) that can be exposed
to the virus clean
• Washing your hands often • Practicing other good health habits,

with soap and water for including getting plenty of sleep,
15-20 seconds; using staying active, drinking plenty of
alcohol-based hand cleansers fluids, and eating healthy foods
is also acceptable
Check with your healthcare

provider to see if the
Lisa Morris Bonsall, MSN, RN, CRNP H1N1 vaccine is right for you.
Page 2 Text courtesy of NursingCenter.com.

Images courtesy of Anatomical Chart Company.
nursingcenter.com anatomical.com 5mcc.com
90 Healthy Skin
H1N1 Español por los Pacientes Forms & Tools
Virus de la influenza A subtipo H1N1

(anteriormente llamado de la «gripe porcina»)
¿Qué es la gripe por H1N1?
La gripe por H1N1, originalmente llamada
«gripe porcina», es la enfermedad respiratoria que
causa la infección por el virus de la influenza A
subtipo H1N1. A este virus originalmente se le llamó
virus de la «gripe porcina» puesto que se pensó que
era muy similar a los virus que causan gripe en los
cerdos (porcinos) en Norteamérica. El virus de la influenza
A subtipo H1N1 fue detectado por primera vez en humanos
en los Estados Unidos de Norteamérica en abril del 2009.
¿Cómo se propaga la gripe por H1N1?

La gripe por H1N1 es contagiosa y se propaga de persona a persona. El virus puede propagarse de manera similar a otros
virus de la gripe; a través de la tos o de los estornudos. Una persona puede infectar a otra un día antes de presentar síntomas
y durante siete o más días (más tiempo en los niños) después de haber enfermado. Existe la posibilidad de que una persona se
infecte al tocar una superficie contaminada con el virus si esta persona luego se pone las manos sobre la boca o nariz. Comer
carne de cerdo no causa gripe por H1N1.
¿Cuáles son los síntomas de la gripe por H1N1?

Los síntomas de la gripe por H1N1 incluyen fiebre, tos, dolor de garganta, nariz con Síntomas de A(H1N1)
mucosidad o tupida; dolor en el cuerpo, dolor de cabeza, escalofríos y fatiga. La mayoría
de las personas que han tenido el virus se han recuperado sin necesitar tratamiento, pero • Dolor de cabeza
ha habido otras que han necesitado hospitalización, y también otras que han muerto. • Fiebre
• Fatiga
¿Qué debo hacer si pienso que tengo gripe por H1N1? • Escalofríos
Si usted piensa que tiene síntomas de gripe quédese en casa y evite entrar en contacto con
otras personas para no propagar la enfermedad. Es recomendable quedarse en casa por lo • Nariz con
menos durante 24 horas después de que le haya pasado la fiebre, o si es posible, después mucosidad o tupida
de que le haya pasado la tos. Si está gravemente enfermo, o si pertenece a un grupo de alto
riesgo para desarrollar complicaciones, entre en contacto con su proveedor de atención • Dolor de garganta
médica. Él determinará si es necesario que le hagan análisis o que tome tratamiento. • Tos
• Dolores corporales
Busque atención médica de urgencias si presenta cualquiera de los
siguientes signos (señas) de alarma:
En niños: En adultos:
• Respiración acelerada o dificultad para respirar • Dificultad para respirar o sensación de «falta de aire»
• Tonalidad morada en la piel • Dolor o sensación de presión en el pecho o en
• No está tomando suficientes líquidos el abdomen
• No se despierta o no responde a las acciones • Mareo súbito
• Está tan irritable que no quiere que lo alcen • Confusión
• Los síntomas como de gripe mejoran pero • Vómito intenso o persistente
luego reaparecen con fiebre y tos más fuerte. • Los síntomas como de gripe mejoran pero luego
• Vómito intenso o persistente reaparecen con fiebre y tos más fuerte.
Página1 Texto por cortesía del centro NursingCenter.com.

Imágenes por cortesía de Anatomical Chart Company. nursingcenter.com anatomical.com 5mcc.com

Forms & Tools H1N1 Español por los Pacientes
¿Cómo es el tratamiento para la gripe por A(H1N1)?

Los Centros para el Control y la Prevención de Enfermedades de los EE. UU.
(CDC) recomiendan el uso de oseltamivir (nombre de marca Tamiflu) o de
zanamivir (nombre de marca Relenza) para el tratamiento y la infección,
o solamente para prevenir la infección por el virus de la influenza
A(H1N1). Estos medicamentos antivíricos también pueden prevenir
complicaciones graves. Para el tratamiento, los medicamentos antivíricos
funcionan mejor si se comienzan a usar en un lapso de dos días después
de que comienzan los síntomas.
¿Qué puedo hacer para prevenir la gripe por A(H1N1)?

Usted puede disminuir su riesgo de contraer gripe por A(H1N1) y de propagar
otros virus de la influenza de la siguiente manera:
• Tosiendo o estornudando sobre • No tocándose los ojos, nariz o

su brazo y evitando el contacto boca, pues ésta es la manera
cercano con personas que como los gérmenes llegan hasta
presentan síntomas respiratorios nuestro cuerpo.
tales como tos o estornudos.
• Quedándose en casa cuando está • Manteniendo limpias las superficies

enfermo y descansando el mayor y objetos (especialmente mesas,
tiempo que pueda. mesones, cerraduras de puertas)
que puedan estar expuestos al virus.
• Lavándose las manos con • Practicando otros hábitos saludables;

frecuencia con agua y jabón incluso dormir bastante, mantenerse
durante 15 a 20 segundos o activo, tomar líquidos en cantidad y
usando un limpiador para las comer alimentos saludables.
manos con base en alcohol.
Verifique con su proveedor

de atención médica para
determinar si la vacuna
contra el virus de la
Escrito por Lisa Morris Bonsall, MSN, RN, CRNP influenza A(H1N1) es
Traducido por Marcela D. Pinilla, M.H.E., M.T. (ASCP) adecuada para usted.
Página 2 Texto por cortesía del centro NursingCenter.com.

Imágenes por cortesía de Anatomical Chart Company. nursingcenter.com anatomical.com 5mcc.com
92 The OR Connection
Clinical Fact Sheet Quick Assessment of Leg Ulcers
Venous Insufficiency (STASIS) Arterial Insufficiency Peripheral Neuropathy
Advanced Age Arterial Disease Advanced age
CHF Cardiovascular Disease Alcoholism
Lymphedema Diabetes Chemotherapy
Obesity Dyslipidemia Diabetes
Body_65262_MedCal:Layout 1
Orthopedic Procedures Hypertension Hansen’s Disease

Pain reduced by elevation Increased pain with activity and/or elevation Heredity
Pregnancy IIntermittent Claudication HIV, AIDS and related drug therapies
Previous DVT with Phlebitis Obesity Hypertension
2/11/10
Pulmonary Embolus Painful Ulcer Impaired glucose tolerance
History
Reduced mobility Sickle Cell Anemia Obesity
Sedentary Lifestyle Smoking Raynaud’s Disease, Scleroderma
Traumatic Injury Vascular procedures/surgeries Smoking
Vascular Ulcers Spinal Cord Injury and neuromuscular diseases
8:09 PM
Work History
Malleolus Areas exposed to pressure or repetitive trauma, or rubbing of footwear Altered pressure points/sites of painless trauma/repetitive
Page 93
Medial aspect of leg superior to medial malleolus Lateral malleolus stress

Mid tibial Dorsal and distal toes
Phalangeal heads Heels
Toe tips or web spaces Inter-digital
Metatarsal heads
Location
Mid-foot (dorsal and plantar)
Toe interphalangeal joints
WOUND WOUND WOUND

Base: ruddy red; yellow adherent or loose slough; granulation tissue Base: Pale; granulation rarely present; necrosis, eschar, gangrene (wet Base: pink/pale; necrotic tissue variable;
present, undermining or tunneling are uncommon or dry) may be present Depth: variable
Depth: usually shallow Depth: may be deep Edges well defined
Margins: irregular Margins: edges rolled; punched out, smooth and undermining Exudate: usually small to moderate
Exudate: moderate to heavy Exudate: minimal Wound shape: usually rounded or oblong and found over
Infection: less common Infection: frequent (signs may be subtle) bony prominence
SURROUNDING SKIN SURROUNDING SKIN SURROUNDING SKIN

Quick Assessment of Leg Ulcers
Venous dermatitis (erythematic, weeping, scaling, crusting) Pallor on elevation Normal skin tones
Hemosiderosis (brown staining) Dependant rubor Trophic changes
Lipodermatosclerosis; Atrophy Blanche Shiny, taut, thin, dry, Fissuring or callus formation
Temperature: normal; warm to touch Hair loss over lower extremities Edema: with erythema may indicate high pressure
Assessment
Edema: pitting or non-pitting; possible induration and cellulitis Atrophy of subcutaneous tissue Temperature: warm
Scarring from previous ulcers, ankle flare, tinea pedis Edema: variable; atypical
Infection: Induration, cellulitis, inflamed, tender bulla Temperature: decreased/cold NAILS
Infection: Cellulitis Onychomycosis; dystrophic nails; paronychia, hypertrophy
Necrosis, eschar, gangrene may be present
NAILS
Dystrophic Continued on page 94
WOCN 1 5 0 0 0 C o m m e r c e Pa r k wa y, S u i t e C Mount Laurel, NJ 08054 (888) 224-WOCN We b s i t e : w w w. w o c n . o r g

Forms & Tools

Clinical Fact Sheet Quick Assessment of Leg Ulcers
Venous Insufficiency (STASIS) Arterial Insufficiency Peripheral Neuropathy
PAIN PAIN PAIN
Minimal unless infected or dessicated Intermittent claudication Decreased sensitivity to touch; if present, pain may be
94 Healthy Skin
Described as throbbing, sharp, itchy, sore, tender, heaviness Resting; positional; nocturnal superficial, deep, aching, stabbing, dull, sharp, burning or
Worsens with prolonged dependency Painful Ulcer cool; altered sensation not described as “pain” (numbness,
Paresthesias warmth, prickling, tingling)

Forms & Tools
PERIPHERAL PULSES
Present/palpable PERIPHERAL PULSES PERIPHERAL PULSES
Absent or diminished Palpable/present
2/11/10
NON-INVASIVE VASCULAR TESTING

Capillary Refill: normal (less than 3 seconds) NON-INVASIVE VASCULAR TESTING NON-INVASIVE VASCULAR TESTING
ABI to rule out arterial component Capillary refill: Delayed (more than 3 seconds) Capillary refill: Normal
ABI <0.9
MEASURES TO IMPROVE VENOUS RETURN TCPO2 <40mmHG NOTE: LEAD may co-exist with neuropathic disease
8:09 PM
(Provided vascular studies have ruled out significant arterial disease) TP >30mm HG
MEASURES TO ELIMINATE TRAUMA
Surgical obliteration of damaged veins MEASURES TO IMPROVE TISSUE PERFUSION Reduction of shear stress and offloading of neuropathic
Perfusion
Elevation of legs Revascularization if possible wounds (bedrest, contact casting, orthopedic shoes)
Page 94
Medications Medications to improve RBC transit through narrowed vessels Use of assistive devices to provide support, balance and
Exercise Lifestyle changes (avoid tobacco, caffeine, restrictive garments, additional offloading
Education cold temperatures) Appropriate footwear
Compression therapy to provide at least Hydration Tight glucose/glycemic control
Measures to prevent trauma to tissues (appropriate foot wear) Aggressive prevention/treatment of infection (debridement
30mm Hg compression at ankle‘ Maintain legs in neutral or dependent position of callus and necrotic tissue; pharmacologic treatment when
**See WOCN Clinical Practice Guideline for Compression Therapy Pressure reduction for heels and toes appropriate)
Revascularizaton if ischemic
Complications: Cellulitis, osteomyelitis, gangrene, Charcot
fracture
Goals: absorb exudates, maintain moist wound surface DRY, NON-INFECTED, NECROTIC WOUND Use dressings that maintain a moist surface, absorb exudates
Keep dry and allow easy visualization
INFECTED WOUND/DRY OR MOIST NECROSIS Cautious use of occlusive dressings

Referral for potential surgical debridement/antibiotic therapy
Quick Assessment of Leg Ulcers
OPEN WOUND/NON-NECROTIC
Moist wound healing;
Non-occlusive dressings
Aggressive treatment of any infection
Topical Therapy
WOCN 1 5 0 0 0 C o m m e r c e Pa r k wa y, S u i t e C Mount Laurel, NJ 08054 (888) 224-WOCN We b s i t e : w w w. w o c n . o r g
Revised: November 24, 2009
INFECTION PREVENTION AND CONTROL BEST PRACTICES
FOR LONG TERM CARE AND COMMUNITY CARE INCLUDING HEALTH CARE OFFICES AND AMBULATORY CLINICS
APPENDIX III – AUDIT TOOL (A)

LONG TERM CARE AUDIT
AUDIT PERFORMED BY __________________________ DATE:___________________
AREA AUDITED :_______________________________
AREAS AND ITEMS COMMENTS

2/12/10
8:52 PM
FULLY
IMPLEMENTED
PARTLY
IMPLEMENTED
NOT
IMPLEMENTED
N/A
ENTRY TO FACILITY
Page 95
Infection Control Signage at Entry (related to

screening for communicable diseases)
Hand Hygiene Station at entrance
UNIT LEVEL
Client assessed before entry for risk factors (fever,
cough, diarrhea, rash, drainage)
Written policy and procedure for client assessment
Includes: drainage, cough, fever, continence, ability to
follow hygiene measures
Protective equipment available
Gloves
Long Term Care Infection Prevention Audit
Masks
Gowns
Alcohol-based hand rub stations
Goggles/eye protection
Cleaner for client equipment
Written Policies for Dress Code:
Includes no jewellery (rings or bracelets)
No nail enhancements
Forms & Tools
Canadian Committee on Antibiotic Resistance (2007) Infection Prevention and Control Best Practices for Long Term

Care, Home and Community Care including Health Care Offices and Ambulatory Clinics Continued on page 96

LONG TERM CARE AUDIT (CONTINUED)
96 Healthy Skin
Forms & Tools

2/12/10
8:52 PM
FULLY
IMPLEMENTED
PARTLY
IMPLEMENTED
NOT
IMPLEMENTED
N/A
Signage for hand washing
Page 96
Signage for alcohol-based hand rub

Signs showing how to wash hands
Signs showing How to use alcohol-based hand rub
Staff can identify when to use hand hygiene:
Before resident care
Before aseptic practices
After resident care
After contact with body fluids or mucous
membranes
After contact with contaminated equipment
Resident equipment has regular cleaning schedule
Commodes
BP Cuffs
Slings
Glucometers
Cleaners used are appropriate and used according to
manufacturer’s recommendations
concentration contact time
Clean procedures use sterile supplies
e.g. Wound care

Catheterization
Resident Personal Care Equipment is labeled
and stored safely
Care, Home and Community Care including Health Care Offices and Ambulatory Clinics


2/12/10
8:53 PM
FULLY
IMPLEMENTED
PARTLY
IMPLEMENTED
NOT
IMPLEMENTED
N/A
LAUNDRY
Page 97
Laundry is transported in a clean manner

Soiled laundry in sealed bags
Clean in segregated manner
Laundry is sorted by staff wearing PPE
Hand hygiene is available in laundry area
Education is provided to laundry workers on
protective practice
Immunization is offered to laundry workers for
Hepatitis B
WASTE
Puncture Resistant Sharps containers are used
Written policies reflect waste segregation
Sharps containers not more than 3/4 filled
Sharps containers are accessible and safe

HEALTHY WORKPLACE
Documentation of staff tubercline skin tests are kept
Documentation of staff immunization is kept:
Flu Shots
MMR
TDP
Hep B
Forms & Tools

98 Healthy Skin
Forms & Tools

2/12/10
8:53 PM
FULLY
IMPLEMENTED
PARTLY
IMPLEMENTED
NOT
IMPLEMENTED
N/A
Page 98
Written policies outline work exclusions:

Dermatitis on hands
Disseminated shingles
Initial days of a cold
Diarrhea
Eye infection until treated
Written policy outlines Bloodborne Pathogen Follow-
up (Sharps injury or blood splash)
Education is provided to staff annually on Infection
prevention and Control
Education is provided on risk assessment, routine
practices and equipment cleaning
Rate of Staff Flu vaccination year_______
Rate of Resident Flu vaccination
OUTBREAK MANAGEMENT
Written policies identify notification process for
clusters of symptoms or outbreaks
Written policies and procedures exist for managing
outbreaks
Including tools for tracking cases

and a communication plan
MEDLINE’S HAND HYGIENE COMPLIANCE PROGRAM

FOR ALL THE LIVES YOU TOUCH.
Now more than ever, hand hygiene compliance is crucial. The Hand Hygiene Compliance Program includes:
As of October 1, 2008, the Centers for Medicare & Medicaid • An instructor’s manual that takes the guesswork
Services no longer reimburses hospitals for eight hospital- out of planning lessons
acquired conditions, including catheter-associated urinary • A customizable plug-and-play CD that contains
tract infections, surgical site infections and bloodstream presentations, posters and more
infections.1 We know that hand hygiene is the number • Forms and tools to serve as reminders and
one line of defense against hospital-acquired infections.2 reinforcements
• A cost calculator to help you determine the cost
There’s no such thing as of prevention vs. the cost of an infection
“overeducating” when it comes • A rewards program to recognize those who
to hand hygiene. Enhance your complete the course
current strategy with Medline’s • Patient and family education materials
Hand Hygiene Compliance • CE-credit courses for staff
Program! • A how-to guide on enhancing your presentation skills
For an on-site presentation of the Hand Hygiene

Compliance Program and our Healthy Hands
Product Bundle, contact your Medline representative
References
1
or visit www.medline.com/handhygiene.
Centers for Medicare & Medicaid Services. Medicare program; changes to the hospital
inpatient prospective payment systems and fiscal year 2007 rates. Available at:
www.cms.hhs.gov/AcuteInpatientPPS/downloads/CMS-1533-FC.pdf.
Accessed November 20, 2007.
2
Davis D, Sosovec D. The value of products that improve hand hygiene and skin. Health-
care Purchasing News. Available at: http://www.hpnonline.com/inside/2003-11/1103hy-
giene.htm. Accessed November 20, 2007.
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.
In vitro studies show that Puracol Plus has the ability
to reduce the levels of elastase and MMPs from
This is Puracol Plus Micro- surrounding fluid.2
Scaffold as seen through an
electron microscope. Its open,
cellular structure allows easy
fibroblast migration.2 The high
strength of the MicroScaffold2
also assists in establishing a
fresh wound bed. Each Puracol package is
a 2-Minute Course in ™
Advanced Wound Care.
1. Schultz GS, Mast BA. Molecular analysis of the environ- ©2010 Medline Industries, Inc.
ment of healing and chronic wounds: Cytokines, proteases, Puracol is a registered trademark of Medline Industries, Inc.
and growth factors. Wounds. 1998;10 (6 Suppl): 1F-9F. Medline is a registered trademark of Medline Industries, Inc.
2. Data on file.
Bariatric Assessment Forms & Tools
Bariatric Assessment : Homecare / Long Term Care Facility

Is your facility ready to accept bariatric patients or residents? Here's a checklist to help you assess your current equipment and
supplies.
Mobility Equipment Current Desired Comments

Cane Weight Capacity
Walker Weight Capacity
Walker Width
Wheelchair Weight Capacity
Wheelchair Width
Power Chair Weight Capacity
Power Chair Width
Crutch Weight Capacity
Patient Handling Current Desired Comments

Transfer Board Weight Capacity
Patient Lift Weight Capacity
Sling Weight Capacity
Transfer Sheet
Stand Assist Lift
Stand Assist Device
Stretcher
Bathroom Current Desired Comments

Grab Bars
Bath Bench Weight Capacity
Wall Mounted Sink Weight Limit
Toilet Weight Bearing Limit
Toilet Rails/Commode Weight Capacity
Bathtub/Shower Weight Limit
Patient Environment Current Desired Comments

Patient Seating/Chair Weight Limit
Patient Seating/Chair Width
Patient Seating/Chair Seat Height
Dining Facilities Current Desired Comments

Dining Chair Weight Capacity
Dining Chair Width
Dining Table Weight Limit
Dining Table Stability
Pathway Around Table Width
Enteral Feeding, Longer Tubes

Forms & Tools Bariatric Assessment
Bariatric Assessment : Homecare / Long Term Care Facility
Sleeping Facilities Current Desired Comments

Bed Hi-Low Height
Bed Weight Capacity
Bed Sleeping Area Width
Bed Sleeping Area Length
Side Rail Weight Capacity
Bed Scale Weight Capacity
Overbed Table Weight Capacity
Pathway Around Bed Width
Dressing Chair Width
Dressing Chair Weight Cap.
Mattress Weight Capacity
Proper Size/Fit Bedding
Pressure Reducing Mattress
Alternating Pressure Mattress
Entrance, Exit Points Current Desired Comments

Doorframe Width
Shower Door Width
Hallways/Narrow Passages
Emergency Exit Width
Front Stair/Walkway Width
Monitoring Devices Current Desired Comments

Large Blood Pressure Cuffs
Scale Weight Limit
CPAP Therapy
Digital Wrist Cuff Monitor
Synchro Pump
Skin Care Current Desired Comments

Skin Lotions
Powders
Wound Care
Patient Apparel Current Desired Comments

Patient Clothing
Towels
Briefs
102 Healthy Skin

HEALTHY SKIN
Join the team! Soft, non-woven topsheet
– softer against skin for increased comfort
Advanced SuperCore® absorbent sheet

– thermo-bonded to provide better pad
integrity and superior skin dryness
AquaShield film
– traps moisture, providing better
leakage protection
Innovative backsheet
– air permeability means better skin comfort
When it comes to hot THE ULTIMATE ONE

topics in long-term care,
you’re the experts!
Ultrasorbs® AP Premium DryPads
You, our readers, are on the front lines of everything that for writers and contributors. Whether youʼd like to try your With Ultrasorbs® AP, you can count on the Power of One:
happens in the healthcare industry – and we want to hear hand at writing or offer suggestions for future articles, we • One pad for healthy skin: The innovative
from you! Have you ever wished you could write an want to hear what you have to say! You never know – the backsheet allows air to flow through the pad while
article that would be published in a large-circulation next time you open an issue of Healthy Skin, it might be still acting as a barrier to moisture. The result is
magazine? Nowʼs your chance. Healthy Skin is looking to read your own article! optimal skin dryness and comfort.
• One pad for lower cost: Ultrasorbs AP are so
Contact us at healthyskin@medline.com to learn more! strong and absorbent that they eliminate the need
for multiple pads.
• One pad for easy care: Can be used on both
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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
To learn more about Ultrasorbs® AP view the
the subject matter on that page relates to one or more of the following national initiatives:
• QIO – Utilization and Quality Control Peer Review Organization online video at www.medline.com/incocare
• 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 10 and 11.
VOLUME 8, ISSUE 1
Free Webinars Improving Quality of Care Based on CMS Guidelines
New Techniques for Pressure Ulcer Prevention,
Hand Hygiene and CAUTI Prevention
PRESSURE ULCER PREVENTION IN LONG-TERM CARE Volume 8, Issue 1
Learn more about continuous quality improvement for the prevention of avoidable pres-
sure ulcers and F-Tag 314 citations, factors leading to pressure ulcers in long-term care
facilities and comprehensive pressure ulcer prevention strategies and solutions.
MARCH APRIL M AY JUNE No More

Skin Tears
4th 12:00 pm - 1:00 pm 6th 12:00 pm - 1:00 pm 6 12:00 pm - 1:00 pm
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16th 1:00 pm - 2:00 pm 15th 1:00 pm - 2:00 pm 14th 1:00 pm - 2:00 pm 10th 1:00 pm - 2:00 pm
24th 11:00 am - 12:00 pm 21st 11:00 am - 12:00 pm 20th 11:00 am - 12:00 pm 23rd 11:00 am - 12:00 pm
Sign up at www.medline.com/PUPP-webinar
HAND HYGIENE COMPLIANCE IMPROVEMENT STRATEGIES
As the number one defense against healthcare-acquired conditions, hand hygiene plays
HEALTHY SKIN
an important role in the prevention of infections. Learn how hospitals and healthcare
facilities are combining best-in-class products and education to achieve hand hygiene
compliance while dramatically improving the skin condition of healthcare workers.

5th 12:00 pm - 1:00 pm 2nd 11:00 am - 12:00 pm 14th 11:00 am - 12:00 pm 14th 11:00 am - 12:00 pm
19th 12:00 pm - 1:00 pm 23rd 11:00 am - 12:00 pm 19th 12:00 pm - 1:00 pm 17th 12:00 pm - 1:00 pm Exclusive:
Sign up at www.medline.com/handhygiene
Diane Krasner
INNOVATION IN THE PREVENTION OF CAUTI on Skin Care
Join your colleagues from around the country to learn more about strategies to prevent At Life’s End Let Us Hear
From You!
catheter-acquired urinary tract infections as well as Medline’s ERASE CAUTI system.
3rd 2:00 pm - 3:00 pm 6th 2:00 pm - 3:00 pm 5th 12:00 pm - 1:00 pm 7th 11:00 am - 12:00 pm
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Hosted by Connie Yuska, RN, MS, CORLN

and Lorri Downs, RN, BSN, MS, CIC
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Free CE! Skin Assessment & OASIS-C

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Healthy Skin Magazine - Volume 8 Issue 1

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Covers_65262_MedCal:Layout 1 2/12/10 7:22 PM Page 1

PRESSURE ULCER PREVENTION IN LONG-TERM CARE Volume 8, Issue 1

MARCH APRIL M AY JUNE No More

HAND HYGIENE COMPLIANCE IMPROVEMENT STRATEGIES

MARCH APRIL M AY JUNE

Hosted by Connie Yuska, RN, MS, CORLN

Free CE! Skin Assessment & OASIS-C

Advanced SuperCore® absorbent sheet

When it comes to hot THE ULTIMATE ONE

Creative Director Prevention

Improving Quality of Care Based on CMS Guidelines 3

HEALTHY SKIN Letter from the Editor

TenderWet ACTIVE GENTLY REMOVES

We’re confident you’ll find TenderWet Active more effec-

Let’s Talk About

Step 1: Complete the Survey!

Results of the survey will be published in the next

Step 2: Answer the Bonus Question!

MEDLINE HEALTHCARE SURVEY Let’s talk about you!

❏ Nursing 14. Average number of skin tears at

❏ Aides/Technicians your facility

❏ < 100 ❏ 350-499 ❏ Physicians

❏ 101-199 ❏ 500+ ❏ Other (please specify)

Improving Quality of Care Based on CMS Guidelines 7

MEDLINE HEALTHCARE SURVEY Let’s talk about you!

17. What is your pressure ulcer incidence? Bonus Question:

19. Has your organization ever been

20. Have you personally ever been

21. Which of the following technologies

❏ PDA (Blackberry®, Palm®, iPhone®)

22. If you checked PDA, what type do

ALL NEW AND UPGRADED CONTENT.

Easier navigation to find what you need – faster.

Two Important National Initiatives

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

The 9th Scope of Work Content Themes

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 11

Happenings on the Hill

Healthcare-associated infections (HAIs)

Source: Memo – United States Congress Committees

Just released in the January/February 2010 issue of the Journal

Improving Quality of Care Based on CMS Guidelines 13

Medline Donates Critical Medical Supplies to

Medline Industries, Inc. has donated more than $250,000 in

Abington said the supplies were immediately delivered to Medscape Nurses

©2010 Medline Industries, Inc.

MEDLINE’S REVOLUTIONARY SHOW-AND-TELL PACKAGING

Each package is a 2-Minute Course

For more information visit www.medline.com/ep.

Aging skin, coupled with reliance on others for assistance with

Minimizing the occurrence of skin tears begins with an under-

Improving Quality of Care Based on CMS Guidelines 17

Structure of the skin

Improving Quality of Care Based on CMS Guidelines 19

Three Steps for Treating Skin Tears12 Conclusion

Are Your Physicians Making the Grade?

To learn more about Medline’s Pressure Ulcer Prevention